Health Disparities Forum

Please read required readings and write your responses and upload to the CLE by 12 pm February 7.

1)         Structural issues within health care delivery are implicated in health care disparities.  Please brainstorm four structural issues that might contribute to these disparities.

1. Language barriers. The study by Fernandez et al., 2010 highlights how limited English proficiency Latinos have poor glycemic control when compared to whites and other English proficient Latinos. While practicing back home in Kenya, I worked in a rural mission hospital that was run by American missionaries who undertook a one month Swahili course and then landed in the community to practice and adamantly refused to use the translators to “fit in”. While we appreciated the effort to speak Swahili, they spoke too loudly, had wrong pronunciation and intonation and were oblivious to certain diseases that our culture required that we don't/never name but describe. Every time we would do a ward round and ask – who has not been attended to, all patients raised their hands, they were waiting for local doctors to interpret what the white man had said.
2. Time pressures on physicians may hamper their ability to accurately assess presenting symptoms of minority patients: Almost similar to the above, due to time pressures, physicians are under pressure to stick to 30-minute windows to see the patients. In my first experience here in America, I was surprised at how curt and short the physician was and her constant reminder that we only had 30 minutes for my visit and she needed to get on with it. As an African (not African American- I was appalled and thought how rude. 30 minutes is what I need to say hello, talk about my family and the doctors family – I barely made it through salutations than my time was up. Needless to say, she did not make a diagnosis, sent me for buzillion tests and referred me to a specialist. I was mortified yet I am an educated black woman. It took me forever to go for the tests, I missed my appointment and finally requested for a different physician- preferably female and black. I can definitely see how these time pressures can be intimidating. 
3. Geographic availability of health care institutions.  I used to think that health access was an LMIC issue. In my reading, I have come to understand that blacks in this country have a higher physician to patient ratio, have access to smaller less well-equipped hospitals and in fact, those hospitals are far (distance-wise). Lack of access to quality health services means that people have a less regular source of care, use health services less appropriately even for curative services and have fewer opportunities for screening and preventive services. It is no wonder that the inequality persists over the years rather than converge.
4. Health care financing and health insurance: Apart from physical access to health services, is the cost of the services. Minority tribes who form the largest portion of the lowest wealth quartile have less access to insurance or are underinsured and have got more out of pocket expenses which further entrenches their poverty in a negative and synergistic manner.

2)         Which of these are relevant to your particular area of research, and how?

My current focus right now is on adolescents and their sexual reproductive health, HIV and psychological well-being. I think the biggest factor is access to youth friendly health facilities  – none of the health facilities are tailored towards adolescents. The facilities are run by older and male physicians to home the adolescent girls cannot relate with. Moreover, the insurance cover is structured in such a way that only the people who are wealthy or are in formal employment to be insured and the insurance does not cover pre-existing conditions, oral or mental health issues. Pregnancy is seen as a pre-existing condition and is not covered well by most insurances let alone when you are a minor. Until recently, contraceptives could not be given to a girl below the age of 18 years without parental permission leaving girls with no option but backstreet abortions as the only “contraceptive method.” Despite policy changes, providers still hesitate to provide these services and the system has no way of enforcing this policy change. Adolescent reproductive health is a neglected component of care. On a lighter Moreover, mental health care is a neglected component of care. In my area where I worked with a population of close to 2 million, we did not have a psychiatrist physician. We had a nurse psychiatrist who worked as the ophthalmic nurse, an example of an unfocused and unprioritized health system.

3)         How do individual physicians contribute to health care disparities? 

1. Prejudice either known or unknown or what Hoffman et al. term as  Ingroup favoritism rather than outgroup hostility. This still amazes me
2. Uncertainty when interacting with minorities or people from one racial group – I have found that here in America, as an African from Kenya, (I guess I qualify as black), it goes without saying that I automatically get the infectious disease, HIV, TB check and a lecture on obesity and diet and physical activity regardless of what I have presented with. The doctor is not listening! As the authors in the article say – the consequence is that treatment decisions and patients needs are potentially less well matched and it is indeed a struggle to keep doctors appointments or go for labs. It creates a reluctance by the minorities to engage in care for curative or preventive services which further worsens their outcomes.
3. Beliefs or stereotypes held by the provider about the behavior or health of minorities –the article by Hoffman et al. talks about the racial bias in pain assessment and treatment for African Americans because white providers think that blacks have a high threshold for pain or are more likely to abuse drugs. I get amused by this stereotypes. I had one person tell me of why Africans were colonized and not them and s/he explained (innocently) that it is because of our brute strength and capacity to do hard manual labor. That was four years ago – I would dread to have her as an attending physician.  

4)         Thinking about an area of health care of particular interest to you, what research do you think could be done to either understand the effect of individual physicians on health disparities or to decrease this effect?

My work has focused on sexual reproductive health and HIV and adolescents and young women. In this region adolescents and young women are nearly four times as likely as their male counterparts to be HIV infected (11% vs. 3%). The region also has the highest teenage pregnancy rate of 27% and with as many as 12% of girls having delivered before the age of 15⁷. Among adolescents and young women who are not married, or in a stable union, contraceptive prevalence is ~ 12%. Unfortunately, provider preferences and practices around service provision for contraceptives to adolescents and young unmarried women are very rigid. Despite the supportive policy, they still prescribe abstinence and refuse or cannot give contraceptives to teenage girls or young unmarried women and when they do, they have specific methods that they have designated for this group!

I would really like to see

1. Research that is centered around providing comprehensive youth friendly services, experimenting with younger health care providers or peer providers who speak the local language, different hours of opening of the facilities e.g. moonlight clinics or weekend clinics
2. Implementation research on how to enforce the policies that support provision of contraceptive provision for adolescent girls
3. Research that expands service provision beyond the clinic into the community, that is gender synchronized and fosters intergenerational dialogue
4. Research that leverages information technology to collect data from adolescents on provider and health facility preferences, reasons for non-adherence or non-utility of services