Perceived discrimination and reported delay of pharmacy prescriptions and medical tests

Prospective Survey of Discrimination in Pregnant Persons and Correlation with Unplanned Healthcare Utilization

OBJECTIVE

To determine the association between lifetime exposure to discrimination and unplanned healthcare utilization in pregnant persons.

METHODS

This was a prospective cohort study of pregnant persons receiving care from 2021 to 2022. Primary data was collected from participants on sociodemographic factors and on Perceived Ethnic Discrimination Questionnaire (PED-Q), a validated 17-item scale measuring perceived lifetime interpersonal racial and ethnic discrimination in four domains: work/school, social exclusion, stigmatization, and threat. The primary outcome was unplanned healthcare utilization, defined as unplanned labor and delivery admissions, triage, Emergency Department, or urgent care visits. Bivariate and multivariate analyses were done to examine the association between lifetime exposure to discrimination and unplanned healthcare utilization.

RESULTS

A total of 289 completed the PED-Q and were included in the analysis. Of these, 123 (42.6%) had unplanned healthcare utilization. Mean (SD) of lifetime racial and ethnic discrimination was significantly higher in people with unplanned healthcare utilization compared to those with planned healthcare utilization [1.67 (0.63) vs 1.48 (0.45), p = 0.003]. Univariate analysis showed that lifetime racial and ethnic discrimination was significantly associated with unplanned healthcare utilization (OR 1.96, 95% CI 0.23-3.11). Significant associations were found between unplanned healthcare utilization and maternal age (p = 0.04), insurance type (p = 0.01), married status (p < 0.001), education (p = 0.013), household income (p = 0.001), and chronic hypertension (p = 0.004). After controlling for potential confounding factors, self-reported lifetime racial and ethnic discrimination remained significantly associated with higher odds of unplanned healthcare utilization (aOR 1.78, CI 95% 1.01-3.11).

CONCLUSION

We found that a higher level of self-reported lifetime racial and ethnic discrimination was associated with increased unplanned healthcare utilization during pregnancy.

Race and ethnicity and self-reported racial/ethnic discrimination in breast cancer patient interactions with providers in the Pathways Study

PURPOSE

To examine the association of race and ethnicity groups with self-reported racial/ethnic discrimination in patient-provider interactions during the diagnosis and treatment for breast cancer.

METHODS

We analyzed data from the Pathways Study, a prospective cohort of women diagnosed with breast cancer from 2006-2013 in the Kaiser Permanente Northern California Health Care System. Racial/ethnic discrimination in patient-provider interactions was assessed with two questions from the Interpersonal Processes of Care survey at baseline and 6-months and 24-months post-diagnosis. Logistic regression was performed to compare women who self-identified as racial or ethnic minorities with Non-Hispanic White (NHW) women. Covariates included age at diagnosis, country of origin, education level, income, marital status, and medical provider's race/ethnicity.

RESULTS

Our sample included 1836 participants: 1350 NHW women and 486 women (87 Black, 208 Asian American, 153 Hispanic, 38 American Indian/Alaskan Native/Pacific Islander [AIANPI]) from racial or ethnic minority groups. In multivariate analysis, minority women were more likely to report racial/ethnic discrimination in patient-provider interactions than NHW women (adjusted odds ratio [aOR]: 4.73; 95% confidence interval [CI] 3.45-6.50). Specifically, Black women were most likely to self-report racial/ethnic discrimination in patient-provider interactions (aOR: 9.65; 95% CI 5.92-15.70), followed by Asian (aOR: 5.39; 95% CI 3.46-8.40), Hispanic (aOR: 2.55; 95% CI 1.54-4.14), and AIANPI (aOR: 1.74; 95% CI 0.58-4.25) women, compared with NHW women.

CONCLUSION

Racial/ethnic discrimination was more likely self-reported from minority women diagnosed with breast cancer. Additional studies are needed to understand the mechanisms and impact of racial/ethnic discrimination in patient-provider interactions on disparities.

Medical Mistrust on Prostate Cancer Screening: A mixed method study among African Americans, Caribbean immigrants and African immigrants

Objectives

The contribution of medical mistrust to healthcare utilization delays has been gaining increasing attention. However, few studies have examined these associations among subgroups of Black men (African Americans, Caribbean, and African immigrants) in relation to prostate cancer (PCa). This study addresses this gap by assessing how medical mistrust affects PCa screening behavior and to further understand perceptions of medical mistrust among subgroups of Black men.

Methods

This research employs a mixed-methods approach comprising two distinct phases. In Phase 1, a cross-sectional examination was conducted to evaluate the influence of medical mistrust toward healthcare organizations on prostate cancer screening among 498 Black men. In Phase 2, a qualitative investigation was undertaken to delve into the nuances of medical mistrust through six focus groups (n=51) and ten key informant interviews (n=10). Logistic regression and grounded theory methods were employed for data analysis.

Results

Quantitative findings unveiled disparities in mistrust among subgroups, with Caribbean immigrants exhibiting higher levels of medical mistrust. Nevertheless, individuals with a family history of PCa showed elevated likelihoods of undergoing screening, despite mistrust. Qualitative results revealed 1) differences in reasons for medical mistrust among Black subgroups, 2) cultural perceptions which influence medical mistrust and medical care seeking, 3) lack of education in relation to PCa that contributes to medical mistrust, 4) negative past experiences and poor provider communication contribute, and 5) when PCa directly affected one's life, either personally or within the family, there was a recognized importance placed on monitoring one's risk despite mistrust.

Conclusion

While medical mistrust may not significantly deter healthcare utilization among individuals with a family history or diagnosis of PCa, it underscores the variability of medical mistrust and its underlying reasons among different Black subgroups.

Racial differences in patient perception of interactions with providers are associated with health outcomes in type II diabetes

OBJECTIVES

Examine the association of patient perceptions of care with hemoglobin A1c (HbA1c), medication adherence, and missed appointments in non-Hispanic Black (NHB) and White (NHW) patients with type 2 diabetes (T2DM).

METHODS

We used linear and logistic regression models to analyze the association of the Interpersonal Processes of Care survey (IPC) with HbA1c, medication adherence, and missed appointments. We then examined how these associations differed by race.

RESULTS

There was no overall association between IPC subdomains and HbA1c in our sample (N = 221). NHB patients perceiving their provider always explained results and medications had a HbA1c on average 0.59 (-1.13, -0.04; p = 0.04) points lower than those perceiving their provider sometimes explained results and medications. No effect was observed in NHWs. Never perceiving disrespect from office staff was associated with an average 0.67 (-1.1, -0.24; p = 0.002) point improvement in medication adherence for all patients. Never perceiving discrimination from providers was associated with a 0.44 (-0.63, -0.25; p < 0.0001) decrease in the probability of missing an appointment for NHB patients.

CONCLUSIONS

These results demonstrate that particular aspects of communication in the patient-provider interaction may contribute to racial disparities in T2DM.

PRACTICE IMPLICATIONS

Communication training for both providers and staff may reduce disparities in T2DM.

The impact of interpersonal racism on oral health related quality of life among Indigenous South Australians: a cross-sectional study

Background

Interpersonal racism has had a profound impact on Indigenous populations globally, manifesting as negative experiences and discrimination at an individual, institutional and systemic level. Interpersonal racism has been shown to negatively influence a range of health outcomes but has received limited attention in the context of oral health. The aim of this paper was to examine the effects of experiences of interpersonal racism on oral health-related quality of life (OHRQoL) among Indigenous South Australians.

Methods

Data were sourced from a large convenience sample of Indigenous South Australian adults between February 2018 and January 2019. Questionnaires were used to collect data on sociodemographic characteristics, cultural values, utilization of dental services, and other related factors. OHRQoL was captured using the Oral Health Impact Profile (OHIP-14) questionnaire. We defined the dependent variable 'poor OHRQoL' as the presence of one or more OHIP-14 items rated as ‘very often’ or ‘fairly often'. Experiences of racism were recorded using the Measure of Indigenous Racism Experiences instrument. Interpersonal racism was classified into two categories (‘no racism’ vs ‘any racism in ≥ 1 setting’) and three categories ('no racism', 'low racism' (experienced in 1–3 settings), and 'high racism' (experienced in 4–9 settings)). Logistic regression was used to examine associations between interpersonal racism, covariates and OHRQoL, adjusting for potential confounding related to socioeconomic factors and access to dental services.

Results

Data were available from 885 participants (88.7% of the total cohort). Overall, 52.1% reported experiencing any interpersonal racism in the previous 12 months, approximately one-third (31.6%) were classified as experiencing low racism, and one-fifth (20.5%) experienced high racism. Poor OHRQoL was reported by half the participants (50.2%). Relative to no experiences of racism in the previous 12 months, those who experienced any racism (≥ 1 setting) were significantly more likely to report poor OHRQoL (Odds Ratio (OR): 1.43; 95% Confidence Interval (CI): 1.08–1.92), after adjusting for age, education level, possession of an income-tested health care card, car ownership, self-reported oral health status, timing of and reason for last dental visit, not going to a dentist because of cost, and having no family support. This was particularly seen among females, where, relative to males, the odds of having poor OHRQoL among females experiencing racism were 1.74 times higher (95% CI: 1.07–2.81).

Conclusion

Our findings indicate that the experience of interpersonal racism has a negative impact on OHRQoL among Indigenous Australians. The association persisted after adjusting for potential confounding factors. Identifying this link adds weight to the importance of addressing OHRQoL among South Australian’s Indigenous population by implementing culturally-sensitive strategies to address interpersonal racism.

A qualitative analysis of pharmacists' responses to naloxone inquiries in rural Georgia

Given their critical gatekeeper function regarding naloxone access in rural areas, the purpose of the current study was to examine rural pharmacists’ knowledge and attitudes regarding naloxone use and access (Georgia, 2019), all 364 rural community pharmacies in Georgia were contacted using “secret shopper” methodology and asked about the availability, accessibility, and use of naloxone. A script provided specific questions for data collection. Callers recorded general notes about the call, including the dispositions and impressions of the pharmacists. Thematic analysis was conducted to identify key themes. Rural pharmacists exhibited two classes of attributes: Active Facilitators and Passive Hindrances. Active facilitators supported callers in their search for naloxone, but passive hindrances discouraged callers in a way that was not perceived to be malicious or intentional. Three types of active facilitators emerged: positive approach, helpful suggestions, and knowledgeable and informed. Two types of passive hindrances emerged: negative attitudes and insufficient knowledge. Community pharmacies are sometimes the only formal healthcare access point in rural communities. It is vital for pharmacists to be active facilitators of naloxone access for maximized public health impact. Specific interventions are needed to increase the ability of rural pharmacists to support access to naloxone.

Clinician-Patient Movement Synchrony Mediates Social Group Effects on Interpersonal Trust and Perceived Pain

Pain is an unfortunate consequence of many medical procedures, which in some patients becomes chronic and debilitating. Among the factors affecting medical pain, clinician-patient (C-P) similarity and nonverbal communication are particularly important for pain diagnosis and treatment. Participants (N = 66) were randomly assigned to clinician and patient roles and were grouped into C-P dyads. Clinicians administered painful stimuli to patients as an analogue of a painful medical procedure. We manipulated the perceived C-P similarity of each dyad using groups ostensibly based on shared beliefs and values, and each patient was tested twice: Once with a same group clinician (concordant, CC) and once with a clinician from the other group (discordant, DC). Movement synchrony was calculated as a marker of nonverbal communication. We tested whether movement synchrony mediated the effects of group concordance on patients' pain and trust in the clinician. Movement synchrony was higher in CC than DC dyads. Higher movement synchrony predicted reduced pain and increased trust in the clinician. Movement synchrony also formally mediated the group concordance effects on pain and trust. These findings increase our understanding of the role of nonverbal C-P communication on pain and related outcomes. Interpersonal synchrony may be associated with better pain outcomes, independent of the specific treatment provided. PERSPECTIVE: This article demonstrates that movement synchrony in C-P interactions is an unobtrusive measure related to their relationship quality, trust toward the clinician, and pain. These findings suggest that interpersonal synchrony may be associated with better patient outcomes, independent of the specific treatment provided.

Experiences of Perceived Gender-based Discrimination Among Women Veterans: Data From the ECUUN Study

BACKGROUND

Experiences of discrimination are associated with poor health behaviors and outcomes. Understanding discrimination in health care informs interventions to improve health care experiences.

OBJECTIVE

Describe the prevalence of, and variables associated with, perceived gender-based discrimination in the Veterans Affairs (VA) Healthcare System among women Veterans.

DESIGN

A cross-sectional, telephone-based survey of a random national sample of young female Veterans.

PARTICIPANTS

Female VA primary care patients aged 18-45 years.

MAIN MEASURES

The primary outcome was perceived gender-based discrimination in VA health care. Logistic and linear regression models were used to determine associations between any perceived discrimination and cumulative perceived discrimination with patient and health service characteristics.

KEY RESULTS

Among 2294 women Veterans, 33.7% perceived gender-based discrimination in VA. Perceiving gender-based discrimination was associated with medical illness [adjusted odds ratio (aOR)=1.67, 95% confidence interval (CI)=1.34, 2.08], mental illness (aOR=2.06, 95% CI=1.57, 2.69), and military sexual trauma (aOR=2.65, 95% CI=2.11, 3.32). Receiving most health care from the same VA provider (aOR=0.73, 95% CI=0.57, 0.94) and receiving care at a VA site with a women's health clinic (aOR=0.76, 95% CI=0.61, 0.95) were associated with reduced odds of any perceived gender-based discrimination. Among those who perceived gender-based discrimination (n=733), perceived discrimination scores were higher among women with increased age, medical illness, or history of military sexual trauma and lower among those who saw the same VA provider for most medical care.

CONCLUSIONS

One third of women Veterans perceived gender-based discrimination in VA. Obtaining most medical care from the same VA provider and having a women's health clinic at one's VA were associated with less perceived discrimination.

Perceived Discrimination Based on Criminal Record in Healthcare Settings and Self-Reported Health Status among Formerly Incarcerated Individuals

Perceived discrimination based on criminal record is associated with social determinants of health such as housing and employment. However, there is limited data on discrimination based on criminal record within health care settings. We examined how perceived discrimination based on criminal record within health care settings, among individuals with a history of incarceration, was associated with self-reported general health status. We used data from individuals recruited from 11 sites within the Transitions Clinic Network (TCN) who were released from prison within the prior 6 months, had a chronic health condition and/or were age 50 or older, and had complete information on demographics, medical history, self-reported general health status, and self-reported perceived discrimination (n = 743).Study participants were mostly of minority racial and ethnic background (76%), and had a high prevalence of self-reported chronic health conditions with half reporting mental health conditions and substance use disorders (52% and 50%, respectively), and 85% reporting one or more chronic medical conditions. Over a quarter (27%, n = 203) reported perceived discrimination by health care providers due to criminal record with a higher proportion of individuals with fair or poor health reporting discrimination compared to those in good or excellent health (33% vs. 23%; p = .002). After adjusting for age and reported chronic conditions, participants reporting discrimination due to criminal record had 43% increased odds of reporting fair/poor health (AOR 1.43, 95% CI 1.01-2.03). Race and ethnicity did not modify this relationship.Participants reporting discrimination due to criminal record had increased odds of reporting fair/poor health. The association between perceived discrimination by health care providers due to criminal record and health should be explored in future longitudinal studies among individuals at high risk of incarceration.Clinical Trial Registration: NCT01863290.

Discrimination and disability: Types of discrimination and association with trust, self-efficacy and life satisfaction among older Australians

OBJECTIVE

To examine the prevalence, context and types of discrimination reported by older Australians (aged 55 years and over) and associations between outcomes (trust, self-efficacy and life satisfaction) and exposure to discrimination.

METHODS

The 2014 General Social Survey was used to measure discrimination. Multivariable logistic regression was used to examine associations between levels of trust, self-efficacy and life satisfaction and exposure to discrimination.

RESULTS

A sizeable minority of older Australians with a disability reported discrimination (15%), with higher exposure for those with more severe or multiple disabilities. In addition to disability, age and nationality, race or ethnic group were cited as reasons for discrimination. Discrimination was reported across a variety of contexts, including everyday social interactions. Lower levels of trust, self-efficacy and life satisfaction were associated with exposure to disability discrimination.

CONCLUSIONS

Focusing on disability discrimination alone underestimates the level of exposure to discrimination. Discrimination may reinforce social exclusion by reducing trust and self-efficacy in familial and community contexts.

Pharmacy practitioners' lived experiences of culture in multicultural Australia: From perceptions to skilled practice

OBJECTIVES

The Code of Ethics of pharmacy practitioners in Australia recognises the obligation to provide care to patients in a culturally safe and responsive manner. The aim of this exploratory study was to examine how Australian community pharmacists understand and experience the concept of 'culture' in their everyday practice environment.

METHODS

Voluntary, semi-structured interviews were conducted at community pharmacy placement sites in South-East Queensland, Australia. Pharmacists were asked to recall an incident that evoked their cultural awareness during the course of their practice. The question stated, verbatim: "We are preparing our students to be pharmacists in a highly multicultural community. Can you think of an incident where you learnt something about another person's culture or it made you more aware of your own culture? Please briefly describe the incident." Reportable responses were collected from 59 of the 92 visited pharmacists. These responses were audio-recorded and transcribed. The data were collated and analysed through iterative, reflexive, thematic analysis using constant comparison.

RESULTS AND SIGNIFICANCE

The responses provided a rich selection of lived experiences within Australian multicultural pharmacy practice, describing professional dilemmas, fears and the strategies employed to overcome practice challenges. Six main response categories were identified: (i) Language/communication challenges, (ii) Cultural attitudes and behaviours, (iii) Exposure to culture due to pharmacy location, (iv) Religion, gender, and age, (v) Prejudiced/perceived racist attitudes and discrimination towards 'other' cultures, (vi) Perceived 'sameness' of different cultures. The study has provided valuable insights into community pharmacists' experiences of culture in their day-to-day professional practice, also highlighting the associated strategies used to maintain a high standard of practice. There is merit in ensuring that the pharmacy curriculum and professional development programs are designed to respond to the ethical obligation of pharmacists to practise in a culturally safe, responsive manner that acknowledges and incorporates the importance of culture, cultural differences and intercultural relations, while addressing culturally unique needs in a skilled and professional manner.

Racial Discrimination and Uptake of Dental Services among American Adults

This study examined the relationship between racial discrimination and use of dental services among American adults. We used data from the 2014 Behavioral Risk Factor Surveillance System, a health-related telephone cross-sectional survey of a nationally representative sample of adults in the United States. Racial discrimination was indicated by two items, namely perception of discrimination while seeking healthcare within the past 12 months and emotional impact of discrimination within the past 30 days. Their association with dental visits in the past year was tested in logistic regression models adjusting for predisposing (age, gender, race/ethnicity, income, education, smoking status), enabling (health insurance), and need (missing teeth) factors. Approximately 3% of participants reported being discriminated when seeking healthcare in the past year, whereas 5% of participants reported the emotional impact of discrimination in the past month. Participants who experienced emotional impact of discrimination were less likely to have visited the dentist during the past year (Odds Ratios (OR): 0.57; 95% CI 0.44-0.73) than those who reported no emotional impact in a crude model. The association was attenuated but remained significant after adjustments for confounders (OR: 0.76, 95% CI 0.58-0.99). There was no association between healthcare discrimination and last year dental visit in the fully adjusted model. Emotional impact of racial discrimination was an important predictor of use of dental services. The provision of dental health services should be carefully assessed after taking account of racial discrimination and its emotional impacts within the larger context of social inequalities.

Monitoring Californians' Mental Health: Population Surveillance Reveals Gender, Racial/Ethnic, Age, and Regional Disparities

Data from the California Health Interview Survey can facilitate the state, regional, and county tracking of key mental health indicators, including mental health services, service use, unmet need for services, and mental health-related functioning.

The Importance of Language in Behavior Change

Communication between health care providers and patients is important for behavioral treatment in lifestyle medicine. Ineffective communication can lead to patient dissatisfaction, demotivation, and discontinuation of treatment. It is important for health care providers to understand their biases, praise patients' behaviors rather than health outcomes, and use language to prevent dichotomous thinking. These strategies may lead to sustained lifestyle behavior changes and better treatment outcomes among patients.

Perceived discrimination in medical settings and perceived quality of care: A population-based study in Chicago

Perceived discrimination in medical settings remains prevalent within the U.S. health care system. However, the details of these experiences and their associations with perceived quality of care are not well understood. Our study assessed multiple measures of perceived racial/ethnic discrimination in medical settings and investigated the locations and purported perpetrators of the discriminatory experiences within a population-based sample of 1,543 Black, White, Mexican, Puerto Rican, and Other adults. We used logistic regression to estimate associations between perceived discrimination in the medical setting and three quality of care indicators. Overall, 40% of the sample reported one or more types of perceived discrimination in a medical setting, with significant differences by race/ethnicity. Discrimination was perceived across health settings and from a variety of providers and staff. In adjusted logistic regression models, individuals reporting discrimination had more than twice the odds of reporting fair or poor quality of care (OR = 2.4 [95% CI: 1.4-4.3]). In addition, perceived discrimination in medical settings was significantly associated with report of not having enough time with the physician and not being as involved in decision-making as desired. These findings expand our understanding of perceived discriminatory experiences in health care and the consequences of it for patients, providers, and health care systems. This information is essential for identifying future provider interventions and improving the training of health care professionals.

Using Values Affirmation to Reduce the Effects of Stereotype Threat on Hypertension Disparities: Protocol for the Multicenter Randomized Hypertension and Values (HYVALUE) Trial

Background

Medication nonadherence is a significant, modifiable contributor to uncontrolled hypertension. Stereotype threat may contribute to racial disparities in adherence by hindering a patient’s ability to actively engage during a clinical encounter, resulting in reduced activation to adhere to prescribed therapies.

Objective

The Hypertension and Values (HYVALUE) trial aims to examine whether a values-affirmation intervention improves medication adherence (primary outcome) by targeting racial stereotype threat.

Methods

The HYVALUE trial is a patient-level, blinded randomized controlled trial comparing a brief values-affirmation writing exercise with a control writing exercise among black and white patients with uncontrolled hypertension. We are recruiting patients from 3 large health systems in the United States. The primary outcome is patients’ adherence to antihypertensive medications, with secondary outcomes of systolic and diastolic blood pressure over time, time for which blood pressure is under control, and treatment intensification. We are comparing the effects of the intervention among blacks and whites, exploring possible moderators (ie, patients’ prior experiences of discrimination and clinician racial bias) and mediators (ie, patient activation) of intervention effects on outcomes.

Results

This study was funded by the National Heart, Lung, and Blood Institute. Enrollment and follow-up are ongoing and data analysis is expected to begin in late 2020. Planned enrollment is 1130 patients. On the basis of evidence supporting the effectiveness of values affirmation in educational settings and our pilot work demonstrating improved patient-clinician communication, we hypothesize that values affirmation disrupts the negative effects of stereotype threat on the clinical interaction and can reduce racial disparities in medication adherence and subsequent health outcomes.

Conclusions

The HYVALUE study moves beyond documentation of race-based health disparities toward testing an intervention. We focus on a medical condition—hypertension, which is arguably the greatest contributor to mortality disparities for black patients. If successful, this study will be the first to provide evidence for a low-resource intervention that has the potential to substantially reduce health care disparities across a wide range of health care conditions and populations.

Trial Registration

ClinicalTrials.gov NCT03028597; https://clinicaltrials.gov/ct2/show/NCT03028597 (Archived by WebCite at http://www.webcitation.org/72vcZMzAB).

International Registered Report Identifier (IRRID)

DERR1-10.2196/12498

Knowledge, Attitudes, and Beliefs about HIV/AIDS and People Living with HIV among Medical Students at Qassim University in Saudi Arabia

BACKGROUND

Human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) is a global health problem. Since Saudi Arabia is becoming more open to the world, it is important to assess future doctors' knowledge, attitudes, and practices (KAPs) regarding HIV/AIDS and people living with HIV (PLHIV).

MATERIALS AND METHODS

This cross-sectional study included 204 male medical students of Qassim University who answered a self-administered questionnaire about HIV KAPs.

RESULTS

The mean HIV knowledge (HK) and attitude scores were 11.62 (64.5%) and 37.82 (67.5%), respectively. Positive correlations were observed between HK and attitude (r = 0.266) and HK and academic year (r = 0.277). No significant correlation was found between attitude and academic year (r = 0.097). More than half of the students exhibited ignorance about some modes of transmission such as deep kissing and vertical transmission. Around 81% of the students stated that they would not visit the homes of friends with HIV-infected members. Furthermore, 73.1% of the participants indicated that they would not provide care to HIV-positive relatives in their own homes.

CONCLUSIONS

The findings show a modest level of HK and negative attitudes toward PLHIV. The study identified the main knowledge gaps in the transmission and prevention of HIV. Educational institutions should tailor their educational approach based on the identified gaps, which might help to ease the stigma and negative attitudes.

Discrimination and avoidance due to disability in Australia: evidence from a National Cross Sectional Survey

BACKGROUND

Across most high-income countries, populations are ageing. With this demographic change is an increase in the number of people living with disabilities. In this context, we sought to examine the prevalence of disability discrimination and disability avoidance in Australia, the demographic and health correlates of exclusion and the contexts in which disability discrimination and avoidance are experienced.

METHODS

Utilising newly released measures from the 2015 ABS Survey of Disability, Ageing and Carers, we calculate the prevalence of people living with a disability who have experienced discrimination and engage in avoidance behaviours, and the contexts in which they occur. Logistic regression models were fitted to examine the correlates of discrimination and avoidance behaviours, once controls and complex survey design were accounted for.

RESULTS

Approximately 9% (95% CI = 8.1, 9.2) of people with a disability experienced disability discrimination in 2015 and 31% (95% CI = 30.9, 32.9) engaged in avoidance behaviours because of their disability. With controls included, the prevalence of avoidance and discrimination declined with age, was higher for divorced people (versus married), the unemployed (versus employed) and was lower for people with lower levels of education (versus a degree) and those born overseas. Having a psychosocial or physical disability significantly increased the odds of experiencing discrimination or avoidance, as did having an increasing number of long-term health conditions. We further find that disability discrimination and avoidance occurs in contexts critical to human capital, such as the workforce, education and healthcare.

CONCLUSIONS

Despite protections in legislation and international accords, significant proportions of Australians with a disability experience discrimination or engage in avoidance behaviours in various settings with potentially important human capital implications. Recently, sectoral responses (eg., in education and the workplace) have been offered by Government reports, providing direction for future research and evaluation.

Racial Discrimination in Health Care and Utilization of Health Care: a Cross-sectional Study of California Adults

BACKGROUND

Racial and ethnic discrimination in health care have been associated with suboptimal use of health care. However, limited research has examined how facets of health care utilization influence, and are influenced by, discrimination.

OBJECTIVE

This study aimed to determine if type of insurance coverage and location of usual source of care used were associated with perceptions of racial or ethnic discrimination in health care. Additionally, this study examined if perceived racial or ethnic discrimination influenced delaying or forgoing prescriptions or medical care.

DESIGN

Data from the 2015-2016 California Health Interview Survey were used. Logistic regression models estimated odds of perceiving racial or ethnic discrimination from insurance type and location of usual source of care. Logistic regression models estimated odds of delaying or forgoing medical care or prescriptions.

PARTICIPANTS

Responses for 39,171 adults aged 18 and over were used.

MAIN MEASURES

Key health care utilization variables were as follows: current insurance coverage, location of usual source of care, delaying or forgoing medical care, and delaying or forgoing prescriptions. We examined if these effects differed by race. Ever experiencing racial or ethnic discrimination in the health care setting functioned as a dependent and independent variable in analyses.

KEY RESULTS

When insurance type and location of care were included in the same model, only the former was associated with perceived discrimination. Specifically, those with Medicaid had 66% higher odds of perceiving discrimination, relative to those with employer-sponsored coverage (AOR = 1.66; 95% CI 1.11, 2.47). Race did not moderate the impact of discrimination. Perceived discrimination was associated with higher odds of delaying or forgoing both prescriptions (AOR = 1.97; 95% CI 1.26, 3.09) and medical care (AOR = 1.84; 95% CI 1.31, 2.59).

CONCLUSIONS

Health care providers have an opportunity to improve the experiences of their patients, particularly those with publicly sponsored coverage.

Is disability exclusion associated with psychological distress? Australian evidence from a national cross-sectional survey

OBJECTIVE

To examine the association between disability exclusion and psychological distress.

DESIGN

Cross-sectional study.

SETTING

Population-based study of individuals living in households across Australia.

PARTICIPANTS

Respondents were persons aged 15 and over living with a disability.

PRIMARY OUTCOME MEASURES

Reporting an experience of discrimination or avoidance behaviour due to a respondent's disability. High or very high levels of psychological distress measured using the Kessler K10 instrument.

METHODOLOGY

Using the Survey of Disability, Ageing and Carers, we calculated the prevalence of persons with a disability experiencing psychological distress, disaggregated by experiences of disability exclusion, including discrimination and avoidance. Logistic regression models were fitted to examine the association between disability exclusion and psychological distress, once extensive controls and adjustments for survey design and presence of psychosocial disabilities were considered.

RESULTS

About 62% of persons citing an experience of disability discrimination were in psychological distress, compared with 27% of those citing no discrimination. Furthermore, 53% of those who actively avoided social, familial or economic activities because of their disability experienced psychological distress, compared with 19% of those who did not avoid these situations. After controlling for demographic characteristics and disabling conditions, reporting an experience of disability discrimination or disability avoidance increased the odds of psychological distress by 2.2 (95% CI 1.74 to 2.26) and 2.6 (95% CI 2.28 to 2.97) times, respectively. Those who experienced both avoidance and discrimination were 3.7 (95% CI 2.95 to 4.72) times more likely to be in psychological distress than those experiencing neither. Avoidance and discrimination in healthcare settings were also found to be strongly associated with experiencing psychological distress.

CONCLUSIONS

Given new policy initiatives to improve disability care, coupled with the increasing speed of population ageing, the onus is on governments and its citizenry to address disability exclusion to offset potential mental health impacts.

Disparities in Initiation of Direct-Acting Antiviral Agents for Hepatitis C Virus Infection in an Insured Population

OBJECTIVES

The cost of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) infection may contribute to treatment disparities. However, few data exist on factors associated with DAA initiation.

METHODS

We conducted a retrospective cohort study of HCV-infected Kaiser Permanente Northern California members aged ≥18 during October 2014 to December 2016, using Poisson regression models to evaluate demographic, behavioral, and clinical factors associated with DAA initiation.

RESULTS

Of 14 790 HCV-infected patients aged ≥18 (median age, 60; interquartile range, 53-64), 6148 (42%) initiated DAAs. DAA initiation was less likely among patients who were non-Hispanic black (adjusted rate ratio [aRR] = 0.7; 95% confidence interval [CI], 0.7-0.8), Hispanic (aRR = 0.8; 95% CI, 0.7-0.9), and of other minority races/ethnicities (aRR = 0.9; 95% CI, 0.8-1.0) than among non-Hispanic white people and among those with lowest compared with highest neighborhood deprivation index (ie, a marker of socioeconomic status) (aRR = 0.8; 95% CI, 0.7-0.8). Having maximum annual out-of-pocket health care costs >$3000 compared with ≤$3000 (aRR = 0.9; 95% CI, 0.8-0.9) and having Medicare (aRR = 0.8; 95% CI, 0.8-0.9) or Medicaid (aRR = 0.7; 95% CI, 0.6-0.8) compared with private health insurance were associated with a lower likelihood of DAA initiation. Behavioral factors (eg, drug abuse diagnoses, alcohol use, and smoking) were also significantly associated with a lower likelihood of DAA initiation (all P < .001). Clinical factors associated with a higher likelihood of DAA initiation were advanced liver fibrosis, HCV genotype 1, previous HCV treatment (all P < .001), and HIV infection ( P = .007).

CONCLUSIONS

Racial/ethnic and socioeconomic disparities exist in DAA initiation. Substance use may also influence patient or provider decision making about DAA initiation. Strategies are needed to ensure equitable access to DAAs, even in insured populations.

The Role of Discrimination in Care Postponement Among Trans-Feminine Individuals in the U.S. National Transgender Discrimination Survey

PURPOSE

This study examines the associations between discrimination experiences (types and locations) and care postponement among trans-feminine individuals in the United States.

METHODS

This secondary, cross-sectional study utilized a subset of the data from the National Transgender Discrimination Survey (n = 2248), specifically for trans-feminine individuals. In this analysis, we examined the relationship between discrimination and primary care postponement.

RESULTS

Twenty-six percent (26.25%) of the study sample reported delaying preventive care due to fear of discrimination; 23.98%-46.66% of respondents reported past experiences of discrimination (setting dependent). Discrimination in health and non-health settings and different types of discrimination-being denied services, verbally harassed, or physically assaulted-were all significantly associated with delaying care; respondents reporting discrimination were up to 20 times more likely to postpone care. While discrimination at a health location had the strongest association with care postponement (adjusted odds ratio = 9.65, confidence interval = 7.60-12.24), discrimination in all non-health-related locations was also important. Individuals reporting discrimination in greater numbers of locations and multiple types of discrimination were more likely to postpone care.

CONCLUSION

To promote preventive care-seeking, these results affirm the importance of interventions that promote discrimination-free environments for gender minorities.

Is Perceived Discrimination in Pregnancy Prospectively Linked to Postpartum Depression? Exploring the Role of Education

Objectives The role of perceived discrimination in postpartum depression is largely unknown. We investigate whether perceived discrimination reported in pregnancy contributes to postpartum depression, and whether its impact varies by education level. Methods Prospective data are a part of European Longitudinal Study of Pregnancy and Childhood, the Czech Republic. Surveys were collected in mid-pregnancy and at 6 months after delivery. Depression was measured using Edinburgh Postnatal Depression Scale. Generalized linear models were estimated to test the effects of perceived discrimination on postpartum depression. Results Multivariate models revealed that among women with low education, discrimination in pregnancy was prospectively associated with 2.43 times higher odds of postpartum depression (p < .01), after adjusting for antenatal depression, history of earlier depression, and socio-demographic background. In contrast, perceived discrimination was not linked to postpartum depression among women with high education. Conclusions Perceived discrimination is a risk factor for postpartum depression among women with low education. Screening for discrimination and socio-economic disadvantage during pregnancy could benefit women who are at risk for mental health problems.

Rural-Urban Differences in Access to Preventive Health Care Among Publicly Insured Minnesotans

PURPOSE

Reduced access to care and barriers have been shown in rural populations and in publicly insured populations. Barriers limiting health care access in publicly insured populations living in rural areas are not understood. This study investigates rural-urban differences in system-, provider-, and individual-level barriers and access to preventive care among adults and children enrolled in a public insurance program in Minnesota.

METHODS

This was a secondary analysis of a 2008 statewide, cross-sectional survey of publicly insured adults and children (n = 4,388) investigating barriers associated with low utilization of preventive care. Sampling was stratified with oversampling of racial/ethnic minorities.

RESULTS

Rural enrollees were more likely to report no past year preventive care compared to urban enrollees. However, this difference was no longer statistically significant after controlling for demographic and socioeconomic factors (OR: 1.37, 95% CI: 1.00-1.88). Provider- and system-level barriers associated with low use of preventive care among rural enrollees included discrimination based on public insurance status (OR: 2.26, 95% CI: 1.34-2.38), cost of care concerns (OR: 1.72, 95% CI: 1.03-2.89) and uncertainty about care being covered by insurance (OR: 1.70, 95% CI: 1.01-2.85). These and additional provider-level barriers were also identified among urban enrollees.

CONCLUSIONS

Discrimination, cost of care, and uncertainty about insurance coverage inhibit access in both the rural and urban samples. These barriers are worthy targets of interventions for publicly insured populations regardless of residence. Future studies should investigate additional factors associated with access disparities based on rural-urban residence.

"Down in the Sewers": Perceptions of Depression and Depression Care Among African American Men

Depression is one of the most common, costly, and debilitating psychiatric disorders in the United States. One of the most persistent mental health disparities is the underutilization of treatment services among African American men with depression. Little is known about appropriateness or acceptability of depression care among African American men. The purpose of this study was to examine perceptions of depression and determine barriers to depression treatment among African American men. A series of four focus groups were conducted with 26 African American men. The average age of the sample was 41 years and most participants reported that they had completed high school. Nearly half of the participants reported that they are currently unemployed and most had never been married. The most common descriptions of depression in this study were defining depression as feeling down, stressed, and isolated. A small group of participants expressed disbelief of depression. The majority of participants recognized the need to identify depression and were supportive of depression treatment. Nonetheless, most men in this sample had never sought treatment for depression and discussed a number of barriers to depression care including norms of masculinity, mistrust of the health care system, and affordability of treatment. Men also voiced their desire to discuss stress in nonjudgmental support groups. Research findings highlight the need to increase the awareness of symptoms some African American men display and the need to provide appropriate depression treatment options to African American men.

Racism and health service utilisation: A systematic review and meta-analysis

Although racism has been posited as driver of racial/ethnic inequities in healthcare, the relationship between racism and health service use and experience has yet to be systematically reviewed or meta-analysed. This paper presents a systematic review and meta-analysis of quantitative empirical studies that report associations between self-reported racism and various measures of healthcare service utilisation. Data were reviewed and extracted from 83 papers reporting 70 studies. Studies included 250,850 participants and were conducted predominately in the U.S. The meta-analysis included 59 papers reporting 52 studies, which were analysed using random effects models and mean weighted effect sizes. Racism was associated with more negative patient experiences of health services (HSU-E) (OR = 0.351 (95% CI [0.236,0.521], k = 19), including lower levels of healthcare-related trust, satisfaction, and communication. Racism was not associated with health service use (HSU-U) as an outcome group, and was not associated with most individual HSU-U outcomes, including having had examinations, health service visits and admissions to health professionals and services. Racism was associated with health service use outcomes such as delaying/not getting healthcare, and lack of adherence to treatment uptake, although these effects may be influenced by a small sample of studies, and publication bias, respectively. Limitations to the literature reviewed in terms of study designs, sampling methods and measurements are discussed along with suggested future directions in the field.

Associations Between Perceived Race-based Discrimination and Contraceptive Use Among Women Veterans in the ECUUN Study

OBJECTIVE

To describe perceived race-based discrimination in Veterans Affairs (VA) health care settings and assess its associations with contraceptive use among a sample of women Veterans.

METHODOLOGY

This study used data from a national telephone survey of women Veterans aged 18-44 receiving health care in VA who were at risk of unintended pregnancy. Participants were asked about their perceptions of race-based discrimination while seeking VA health care and about their contraceptive use at last heterosexual intercourse. Logistic and multinomial regression analyses were used to examine associations between perceived race-based discrimination with use of prescription contraception.

RESULTS

In our sample of 1341 women Veterans, 7.9% report perceived race-based discrimination when receiving VA care, with blacks and Hispanics reporting higher levels of perceived discrimination than white women (11.3% and 11.2% vs. 4.4%; P<0.001). In logistic and multinomial regression analyses adjusting for race/ethnicity, age, income, marital status, parity, and insurance, women who perceived race-based discrimination were less likely to use any prescription birth control than women who did not (odds ratio, 0.65; 95% confidence interval, 0.42-1.00), with the largest difference seen in rates of intrauterine device or implant use (odds ratio, 0.40; 95% confidence interval, 0.20-0.79).

CONCLUSIONS

In this national sample of women Veterans, over 10% of racial/ethnic minority women perceived race-based discrimination when receiving care in VA settings, and perceived racial/ethnic discrimination was associated with lower likelihood of prescription contraception use, especially intrauterine devices and implants. VA efforts to enhance respectful interactions may not only improve patient health care experiences, but also represent an opportunity to improve reproductive health outcomes for women Veterans.

Discrimination in Health Care: Correlates of Health Care Discrimination Among Black Males

Using data from the Indiana Black Men's Health Study ( N = 455), a community-based sample of adult Black men, the primary aim of this study was to explore factors of health care discrimination, and to examine if such reports differed by age and the frequency of race thoughts. Approximately one in four men reported experiencing discrimination in the health care setting. Results from the multivariable logistic regression models suggested that frequent race thoughts (odds ratio [ OR]: 1.89, p < .05), not having health insurance ( OR: 1.80, p < .05), and increased depressive symptomology ( OR: 1.06, p < .01) were positively associated with reports of health care discrimination. A multiplicative interaction coefficient of age and frequency of race thoughts was included to determine if health care discrimination differed by age and frequency of race thoughts ( OR: 1.03, p = .08). Results from the predicted probability plot suggested that the likelihood of experiencing health care discrimination decreases with age ( OR: 0.97, p < .05). In particular, results suggested that between the ages of 33 and 53 years, Black men who experienced frequent race thoughts were more likely to report experiences of discrimination in the health care setting than men of the same age that did not experience frequent race thoughts. These results highlight the need for empirical work to better understand the experiences of Black men, a group less likely to utilize health care services than most adult groups within the health care setting.

Perceived discrimination among racial and ethnic minority drug users and the association with health care utilization

People who use drugs (PWUDs) are at increased risk for several medical conditions, yet they delay seeking medical care and utilize emergency departments (EDs) as their primary source of care. Limited research regarding perceived discrimination and PWUDs' use of health care services exists. This study explores the association between interpersonal and institutional racial/ethnic and drug use discrimination in health care settings and health care utilization among respondents (N = 192) recruited from methadone maintenance treatment programs (36%), HIV primary care clinics (35%), and syringe exchange programs (29%) in New York City (n = 88) and San Francisco (n = 104). The Kaiser Family Foundation Survey of Race, Ethnicity, and Medical Care questionnaire was utilized to assess perceived institutional racial/ethnic and drug use discrimination. Perceived institutional discrimination was examined across race/ethnicity and by regular use of ERs, having a regular doctor, and consistent health insurance. Perceived interpersonal discrimination was examined by race/ethnicity. Perceived interpersonal drug use discrimination was the most common type of discrimination experienced in health care settings. Perceptions of institutional discrimination related to race/ethnicity and drug use among non-Hispanic Whites did not significantly differ from those among non-Hispanic Blacks or Hispanics. A perception of less frequent institutional racial/ethnic and drug use discrimination in health care settings was associated with increased odds of having a regular doctor. Awareness of perceived interpersonal and institutional discrimination in certain populations and the effect on health care service utilization should inform future intervention development to help reduce discrimination and improve health care utilization among PWUDs.

Perceived Discrimination and Privilege in Health Care: The Role of Socioeconomic Status and Race

INTRODUCTION

This study examined how perceived racial privilege and perceived racial discrimination in health care varied with race and socioeconomic status (SES).

METHODS

The sample consisted of white, black, and Native American respondents to the Behavioral Risk Factor Surveillance System (2005-2013) who had sought health care in the past 12 months. Multiple logistic regression models of perceived racial privilege and perceived discrimination were estimated. Analyses were performed in 2016.

RESULTS

Perceptions of racial privilege were less common among blacks and Native Americans compared with whites, while perceptions of racial discrimination were more common among these minorities. In whites, higher income and education contributed to increased perceptions of privileged treatment and decreased perceptions of discrimination. The pattern was reversed in blacks, who reported more discrimination and less privilege at higher income and education levels. Across racial groups, respondents who reported foregone medical care due to cost had higher risk of perceived racial discrimination. Health insurance contributed to less perceived racial discrimination and more perceived privilege only among whites.

CONCLUSIONS

SES is an important social determinant of perceived privilege and perceived discrimination in health care, but its role varies by indicator and racial group. Whites with low education or no health insurance, well-educated blacks, and individuals who face cost-related barriers to care are at increased risk of perceived discrimination. Policies and interventions to reduce these perceptions should target structural and systemic factors, including society-wide inequalities in income, education, and healthcare access, and should be tailored to account for racially specific healthcare experiences.

The Social Determinants of Chronic Disease

This review article addresses the concept of the social determinants of health (SDH), selected theories, and its application in studies of chronic disease. Once ignored or regarded only as distant or secondary influences on health and disease, social determinants have been increasingly acknowledged as fundamental causes of health afflictions. For the purposes of this discussion, SDH refers to SDH variables directly relevant to chronic diseases and, in some circumstances, obesity, in the research agenda of the Mid-South Transdisciplinary Collaborative Center for Health Disparities Research. The health effects of SDH are initially discussed with respect to smoking and the social gradient in mortality. Next, four leading SDH theories-life course, fundamental cause, social capital, and health lifestyle theory-are reviewed with supporting studies. The article concludes with an examination of neighborhood disadvantage, social networks, and perceived discrimination in SDH research.

Dimensions of Racial Identity and Perceived Discrimination in Health Care

OBJECTIVE

Perceived discrimination is an important risk factor for minority health. Drawing from the scholarship on multidimensionality of race, this study examines the relationships between perceived discrimination in health care and two dimensions of racial identity: self-identified race/ethnicity and perceived attributed race/ethnicity (respondents' perceptions of how they are racially classified by others).

METHODS

We used Behavioral Risk Factor Surveillance System data collected in 2004-2013 and we specifically examined the data on perceived racial discrimination in health care during the past 12 months, perceived attributed race/ethnicity, and self-identified race/ethnicity.

RESULTS

In models adjusting for sociodemographic and other factors, both dimensions of racial/ethnic identity contributed independently to perceived discrimination in health care. After controlling for self-identified race/ethnicity, respondents who reported being classified as Black, Asian, Hispanic, and Native American had higher likelihood of perceived discrimination than respondents who reported being classified as White. Similarly, after taking perceived attributed race/ethnicity into account, self-identified Blacks, Native Americans, and multiracial respondents were more likely to report perceived discrimination than counterparts who self-identified as White. The model using only perceived attributed race/ethnicity to predict perceived discrimination showed a superior fit with the data than the model using only self-identified race/ethnicity.

CONCLUSION

Perceived attributed race/ethnicity captures an aspect of racial/ethnic identity that is correlated, but not interchangeable, with self-identified race/ethnicity and contributes uniquely to perceived discrimination in health care. Applying the concept of multidimensionality of race/ethnicity to health disparities research may reveal understudied mechanisms linking race/ethnicity to health risks.

The Link Between Everyday Discrimination, Healthcare Utilization, and Health Status Among a National Sample of Women

BACKGROUND

Research has not adequately examined the potential negative effects of perceiving routine discrimination on general healthcare utilization or health status, especially among reproductive-aged women. We sought to evaluate the association between everyday discrimination, health service use, and perceived health among a national sample of women in the United States.

MATERIALS AND METHODS

Data were drawn from the Women's Healthcare Experiences and Preferences survey, a randomly selected, national probability sample of 1078 U.S. women aged 18-55 years. We examined associations between everyday discrimination (via a standardized scale) on frequency of health service utilization and perceived general health status using chi-square and multivariable logistic regression modeling.

RESULTS

Compared with women who reported healthcare visits every 3 years or less (reference group), each one-point increase in discrimination score was associated with higher odds of having healthcare visits annually or more often (odds ratio [OR] = 1.36, confidence interval [95% CI] = 1.01-1.83). Additionally, each one-point increase in discrimination score was significantly associated with lower odds of having excellent/very good perceived health (OR = 0.65; 95% CI = 0.54-0.80).

CONCLUSION

Perceived discrimination was associated with increased exposure to the healthcare setting among this national sample of women. Perceived discrimination was also inversely associated with excellent/very good perceived health status.

Masculinity and Race-Related Factors as Barriers to Health Help-Seeking Among African American Men

Men's tendency to delay health help-seeking is largely attributed to masculinity, but findings scarcely focus on African American men who face additional race-related, help-seeking barriers. Building principally on reactance theory, we test a hypothesized model situating racial discrimination, masculinity norms salience (MNS), everyday racism (ERD), racial identity, sense of control (SOC), and depressive symptomatology as key barriers to African American men's health help-seeking. A total of 458 African American men were recruited primarily from US barbershops in the Western and Southern regions. The primary outcome was Barriers to Help-Seeking Scale (BHSS) scores. The hypothesized model was investigated with confirmatory factor and path analysis with tests for measurement invariance. Our model fit was excellent [Formula: see text] CFI = 0.99; TLI = 1.00; RMSEA = 0.00, and 90% CI [0.00, 0.07] and operated equivalently across different age, income, and education strata. Frequent ERD and higher MNS contributed to higher BHHS scores. The relationship between ERD exposure and BHHS scores was partially mediated by diminished SOC and greater depressive symptomatology. Interventions aimed at addressing African American men's health help-seeking should not only address masculinity norms but also threats to sense of control, and negative psychological sequelae induced by everyday racism.

How Does Managed Care Improve the Quality of Breast Cancer Care Among Medicare-Insured Minority Women?

PURPOSE

The aim of this study is to investigate if evidence-based clinical guidelines are implemented equitability among ethnic minority breast cancer patients using Medicare Advantage and investigate if presumed advantages of managed care over fee-for-service are greater for minorities than for Whites.

METHODS

Data from the Surveillance, Epidemiology, and End Results and Medicare were used to examine 70,755 women over age 65 diagnosed with early stage breast cancer between 2005 and 2009. Implementation of two clinical guidelines was assessed: receipt of radiation therapy after breast conserving surgery and estrogen receptor status documentation. Multilevel logistic regression and inverse propensity weighting controlled for confounding.

RESULTS

African Americans are still less likely than Whites to receive radiation therapy after breast-conserving surgery, whether they use Medicare fee-for-service (OR 95 % CI) = 0.90 (0.83, 0.98) or managed care (OR 95 % CI) = 0.87 (0.76, 1.00). Differences between receipt of radiation therapy by insurance plan type was nonexistent. Relative to FFS, the use of managed care improved the odds of having estrogen receptor status documented by 44 % in African Americans, (OR 95 % CI) = 1.44 (1.15, 1.83) and by 42 % in Latina patients (OR 95 % CI) = 1.42 (1.17, 1.78).

CONCLUSIONS

Compared to Medicare fee-for-service, ethnic and racial disparities among Medicare Advantage users were reduced. We observed fewer disparities, but not an elimination of disparities, among Medicare Advantage enrollees receiving breast cancer care with an organizational and patient component of care. This suggests managed care may still need to focus on minority patient empowerment and involvement in care.

Discrimination in Healthcare Settings is Associated with Disability in Older Adults: Health and Retirement Study, 2008-2012

BACKGROUND

As our society ages, improving medical care for an older population will be crucial. Discrimination in healthcare may contribute to substandard experiences with the healthcare system, increasing the burden of poor health in older adults. Few studies have focused on the presence of healthcare discrimination and its effects on older adults.

OBJECTIVE

We aimed to examine the relationship between healthcare discrimination and new or worsened disability.

DESIGN

This was a longitudinal analysis of data from the nationally representative Health and Retirement Study administered in 2008 with follow-up through 2012.

PARTICIPANTS

Six thousand and seventeen adults over the age of 50 years (mean age 67 years, 56.3 % female, 83.1 % white) were included in this study.

MAIN MEASURES

Healthcare discrimination assessed by a 2008 report of receiving poorer service or treatment than other people by doctors or hospitals (never, less than a year=infrequent; more than once a year=frequent). Outcome was self-report of new or worsened disability by 2012 (difficulty or dependence in any of six activities of daily living). We used a Cox proportional hazards model adjusting for age, race/ethnicity, gender, net worth, education, depression, high blood pressure, diabetes, cancer, lung disease, heart disease, stroke, and healthcare utilization in the past 2 years.

KEY RESULTS

In all, 12.6 % experienced discrimination infrequently and 5.9 % frequently. Almost one-third of participants (29 %) reporting frequent healthcare discrimination developed new or worsened disability over 4 years, compared to 16.8 % of those who infrequently and 14.7 % of those who never experienced healthcare discrimination (p < 0.001). In multivariate analyses, compared to no discrimination, frequent healthcare discrimination was associated with new or worsened disability over 4 years (aHR = 1.63, 95 % CI 1.16-2.27).

CONCLUSIONS

One out of five adults over the age of 50 years experiences discrimination in healthcare settings. One in 17 experience frequent healthcare discrimination, and this is associated with new or worsened disability by 4 years. Future research should focus on the mechanisms by which healthcare discrimination influences disability in older adults to promote better health outcomes for an aging population.

Discrimination and Depression among Urban Hispanics with Poorly Controlled Diabetes

OBJECTIVES

We had three objectives for our study: 1) to describe the prevalence and burden of experiences of discrimination among Hispanics with poorly controlled diabetes; 2) to evaluate associations among discrimination experiences and their burden with comorbid depression among Hispanics with poorly controlled diabetes; and 3) to evaluate whether discrimination encountered in the health care context itself was associated with comorbid depression for Hispanic adults with diabetes.

DESIGN

We conducted a cross-sectional analysis of baseline data of a randomized controlled trial (RCT).

SETTING

We collected data in the context of an RCT in a clinical setting in New York City.

PARTICIPANTS

Our sample comprised 221 urban-dwelling Hispanics, largely of Caribbean origin.

MAIN OUTCOME MEASURES

The main outcome measure was major depression, measured by the Euro-D (score > 3).

RESULTS

Of 221 participants, 58.8% reported at least one experience of everyday discrimination, and 42.5% reported at least one major experience of discrimination. Depression was associated significantly with counts of experiences of major discrimination (OR = 1.46, 95% CI = 1.09 - 1.94, P = .01), aggregate counts of everyday and major discrimination (OR = 1.13, 95% CI = 1.02 - 1.26, P = .02), and the experience of discrimination in getting care for physical health (OR = 6.30, 95% CI= 1.10-36.03).

CONCLUSIONS

Discrimination may pose a barrier to getting health care and may be associated with depression among Hispanics with diabetes. Clinicians treating Caribbean-born Hispanics should be aware that disadvantage and discrimination likely complicate a presentation of diabetes.

Using quantile regression to assess disparities in medication adherence

OBJECTIVE

To examine racial/ethnic disparities in medication adherence between Asian and Pacific Islander Americans and Whites.

METHODS

This retrospective data analysis included diabetes patients enrolled in a health plan in Hawaii (N = 43,445). For anti-diabetic, lipid-lowering, and anti-hypertensive medications, quantile regression was estimated at 25(th), 50(th), and 75(th) quantiles to examine the association with race and ethnicity, controlling for other patient characteristics.

RESULTS

Consistently, Filipinos, Native Hawaiians, and other Pacific Islanders were significantly less adherent than Whites. The greatest disparities were found for other Pacific Islanders using lipid-lowering medications, with adjusted differences in medication adherence, with reductions relative to Whites of as much as 19% for lipid-lowering medications for the 25(th) quantile of adherence.

CONCLUSION

Whereas the large sample size undoubtedly contributed to the statistical significance, the large magnitude of the disparities, particularly for Filipinos, Native Hawaiians, and other Pacific Islanders, which suggests that these are meaningful differences that need to be addressed. The largest disparities were found at the lowest quantile suggests that they may be occurring among the most vulnerable populations with potentially poor access to care.

Reported racial discrimination, trust in physicians, and medication adherence among inner-city African Americans with hypertension

OBJECTIVES

We sought to determine if reported racial discrimination was associated with medication nonadherence among African Americans with hypertension and if distrust of physicians was a contributing factor.

METHODS

Data were obtained from the TRUST project conducted in Birmingham, Alabama, 2006 to 2008. All participants were African Americans diagnosed with hypertension and receiving care at an inner city, safety net setting. Three categories of increasing adherence were defined based on the Morisky Medication Adherence Scale. Trust in physicians was measured with the Hall General Trust Scale, and discrimination was measured with the Experiences of Discrimination Scale. Associations were quantified by ordinal logistic regression, adjusting for gender, age, education, and income.

RESULTS

The analytic sample consisted of 227 African American men and 553 African American women, with a mean age of 53.7 ± 9.9 years. Mean discrimination scores decreased monotonically across increasing category of medication adherence (4.1, 3.6, 2.9; P = .025), though the opposite was found for trust scores (36.5, 38.5, 40.8; P < .001). Trust mediated 39% (95% confidence interval = 17%, 100%) of the association between discrimination and medication adherence.

CONCLUSIONS

Within our sample of inner city African Americans with hypertension, racial discrimination was associated with lower medication adherence, and this association was partially mediated by trust in physicians. Patient, physician and system approaches to increase "earned" trust may enhance existing interventions for promoting medication adherence.

Socially-assigned race, healthcare discrimination and preventive healthcare services

BACKGROUND

Race and ethnicity, typically defined as how individuals self-identify, are complex social constructs. Self-identified racial/ethnic minorities are less likely to receive preventive care and more likely to report healthcare discrimination than self-identified non-Hispanic whites. However, beyond self-identification, these outcomes may vary depending on whether racial/ethnic minorities are perceived by others as being minority or white; this perception is referred to as socially-assigned race.

PURPOSE

To examine the associations between socially-assigned race and healthcare discrimination and receipt of selected preventive services.

METHODS

Cross-sectional analysis of the 2004 Behavioral Risk Factor Surveillance System "Reactions to Race" module. Respondents from seven states and the District of Columbia were categorized into 3 groups, defined by a composite of self-identified race/socially-assigned race: Minority/Minority (M/M, n = 6,837), Minority/White (M/W, n = 929), and White/White (W/W, n = 25,913). Respondents were 18 years or older, with 61.7% under age 60; 51.8% of respondents were female. Measures included reported healthcare discrimination and receipt of vaccinations and cancer screenings.

RESULTS

Racial/ethnic minorities who reported being socially-assigned as minority (M/M) were more likely to report healthcare discrimination compared with those who reported being socially-assigned as white (M/W) (8.9% vs. 5.0%, p = 0.002). Those reporting being socially-assigned as white (M/W and W/W) had similar rates for past-year influenza (73.1% vs. 74.3%) and pneumococcal (69.3% vs. 58.6%) vaccinations; however, rates were significantly lower among M/M respondents (56.2% and 47.6%, respectively, p-values<0.05). There were no significant differences between the M/M and M/W groups in the receipt of cancer screenings.

CONCLUSIONS

Racial/ethnic minorities who reported being socially-assigned as white are more likely to receive preventive vaccinations and less likely to report healthcare discrimination compared with those who are socially-assigned as minority. Socially-assigned race/ethnicity is emerging as an important area for further research in understanding how race/ethnicity influences health outcomes.

Relationships between discrimination in health care and health care outcomes among four race/ethnic groups

Discrimination has been found to be detrimental to health, but less is known about the influence of discrimination in health care. To address this, the current study (1) compared levels of racial/ethnic discrimination in health care among four race/ethnic groups; (2) determined associations between this type of discrimination and health care outcomes; and (3) assessed potential mediators and moderators as suggested by previous studies. Multivariate logistic regression models were used within a population-based sample of 1,699 White, African American, Mexican, and Puerto Rican respondents. Overall, 23% of the sample reported discrimination in health care, with levels varying substantially by race/ethnicity. In adjusted models, this type of discrimination was associated with an increased likelihood of having unmet health care needs (OR = 2.48, CI = 1.57-3.90) and lower odds of perceiving excellent quality of care (OR = 0.43, CI = 0.28-0.66), but not with the use of a physician when not sick or use of alternative medicine. The mediating role of mental health factors was inconsistently observed and the relationships were not moderated by race/ethnicity. These findings expand the literature and provide preliminary evidence that can eventually inform the development of interventions and the training of health care providers.

Unhealthy interactions: the role of stereotype threat in health disparities

Stereotype threat is the unpleasant psychological experience of confronting negative stereotypes about race, ethnicity, gender, sexual orientation, or social status. Hundreds of published studies show how the experience of stereotype threat can impair intellectual functioning and interfere with test and school performance. Numerous published interventions derived from this research have improved the performance and motivation of individuals targeted by low-ability stereotypes. Stereotype threat theory and research provide a useful lens for understanding and reducing the negative health consequences of interracial interactions for African Americans and members of similarly stigmatized minority groups. Here we summarize the educational outcomes of stereotype threat and examine the implications of stereotype threat for health and health-related behaviors.

A study of national physician organizations' efforts to reduce racial and ethnic health disparities in the United States

PURPOSE

To characterize national physician organizations' efforts to reduce health disparities and identify organizational characteristics associated with such efforts.

METHOD

This cross-sectional study was conducted between September 2009 and June 2010. The authors used two-sample t tests and chi-square tests to compare the proportion of organizations with disparity-reducing activities between different organizational types (e.g., primary care versus subspecialty organizations, small [<1,000 members] versus large [>5,000 members]). Inclusion criteria required physician organizations to be (1) focused on physicians, (2) national in scope, and (3) membership based.

RESULTS

The number of activities per organization ranged from 0 to 22. Approximately half (53%) of organizations had 0 or 1 disparity-reducing activities. Organizational characteristics associated with having at least 1 disparity-reducing effort included membership size (88% of large groups versus 58% of small groups had at least 1 activity; P = .004) and the presence of a health disparities committee (95% versus 59%; P < .001). Primary care (versus subspecialty) organizations and racial/ethnic minority physician organizations were more likely to have disparity-reducing efforts, although findings were not statistically significant. Common themes addressed by activities were health care access, health care disparities, workforce diversity, and language barriers. Common strategies included education of physicians/trainees and patients/general public, position statements, and advocacy.

CONCLUSIONS

Despite the national priority to eliminate health disparities, more than half of national physician organizations are doing little to address this problem. Primary care and minority physician organizations, and those with disparities committees, may provide leadership to extend the scope of disparity-reduction efforts.

Elucidating the role of place in health care disparities: the example of racial/ethnic residential segregation

OBJECTIVE

To develop a conceptual framework for investigating the role of racial/ethnic residential segregation on health care disparities.

DATA SOURCES AND SETTINGS

Review of the MEDLINE and the Web of Science databases for articles published from 1998 to 2011.

STUDY DESIGN

The extant research was evaluated to describe mechanisms that shape health care access, utilization, and quality of preventive, diagnostic, therapeutic, and end-of-life services across the life course.

PRINCIPAL FINDINGS

The framework describes the influence of racial/ethnic segregation operating through neighborhood-, health care system-, provider-, and individual-level factors. Conceptual and methodological issues arising from limitations of the research and complex relationships between various levels were identified.

CONCLUSIONS

Increasing evidence indicates that racial/ethnic residential segregation is a key factor driving place-based health care inequalities. Closer attention to address research gaps has implications for advancing and strengthening the literature to better inform effective interventions and policy-based solutions.

Patient-reported racial/ethnic healthcare provider discrimination and medication intensification in the Diabetes Study of Northern California (DISTANCE)

BACKGROUND

Racial/ethnic minority patients are more likely to report experiences with discrimination in the healthcare setting, potentially leading to reduced access to appropriate care; however, few studies evaluate reports of discrimination with objectively measured quality of care indicators.

OBJECTIVE

To evaluate whether patient-reported racial/ethnic discrimination by healthcare providers was associated with evidence of poorer quality care measured by medication intensification.

RESEARCH DESIGN AND PARTICIPANTS

Baseline data from the Diabetes Study of Northern California (DISTANCE), a random, race-stratified sample from the Kaiser Permanente Diabetes Registry from 2005-2006, including both survey and medical record data.

MAIN MEASURES

Self-reported healthcare provider discrimination (from survey data) and medication intensification (from electronic prescription records) for poorly controlled diabetes patients (A1c ≥9.0%; systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg; low-density lipoprotein (LDL) ≥130 mg/dl).

KEY RESULTS

Of 10,409 eligible patients, 21% had hyperglycemia, 14% had hyperlipidemia, and 32% had hypertension. Of those with hyperglycemia, 59% had their medications intensified, along with 40% with hyperlipidemia, 33% with hypertension, and 47% in poor control of any risk factor. In adjusted log-binomial GEE models, discrimination was not associated with medication intensification [RR = 0.96 (95% CI: 0.74, 1.24) for hyperglycemia, RR = 1.23 (95% CI: 0.93, 1.63) for hyperlipidemia, RR = 1.06 (95% CI: 0.69, 1.61) for hypertension, and RR = 1.08 (95% CI: 0.88, 1.33) for the composite cohort].

CONCLUSIONS

We found no evidence that patient-reported healthcare discrimination was associated with less medication intensification. While not associated with this technical aspect of care, discrimination could still be associated with other aspects of care (e.g., patient-centeredness, communication).

Depression and medication adherence in the treatment of chronic diseases in the United States: a meta-analysis

OBJECTIVE

To conduct a meta-analysis of the association between depression and medication adherence among patients with chronic diseases. Poor medication adherence may result in worse outcomes and higher costs than if patients fully adhere to their medication regimens.

DATA SOURCES

We searched the PubMed and PsycINFO databases, conducted forward searches for articles that cited major review articles, and examined the reference lists of relevant articles.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

We included studies on adults in the United States that reported bivariate relationships between depression and medication adherence. We excluded studies on special populations (e.g., substance abusers) that were not representative of the general adult population with chronic diseases, studies on certain diseases (e.g., HIV) that required special adherence protocols, and studies on interventions for medication adherence.

STUDY APPRAISAL AND SYNTHESIS METHODS

Data abstracted included the study population, the protocol, measures of depression and adherence, and the quantitative association between depression and medication adherence. Synthesis of the data followed established statistical procedures for meta-analysis.

RESULTS

The estimated odds of a depressed patient being non-adherent are 1.76 times the odds of a non-depressed patient, across 31 studies and 18,245 participants. The association was similar across disease types but was not as strong among studies that used pharmacy records compared to self-report and electronic cap measures.

LIMITATIONS

The meta-analysis results are correlations limiting causal inferences, and there is some heterogeneity among the studies in participant characteristics, diseases studied, and methods used.

CONCLUSIONS

This analysis provides evidence that depression is associated with poor adherence to medication across a range of chronic diseases, and we find a new potential effect of adherence measurement type on this relationship. Although this study cannot assess causality, it supports the importance that must be placed on depression in studies that assess adherence and attempt to improve it.

Impact of perceived discrimination in healthcare on patient-provider communication

BACKGROUND

The impact of patients' perceptions of discrimination in healthcare on patient-provider interactions is unknown.

OBJECTIVE

To examine association of past perceived discrimination with subsequent patient-provider communication.

RESEARCH DESIGN

Observational cross-sectional study.

SUBJECTS

African-American (N=100) and white (N=253) patients treated for osteoarthritis by orthopedic surgeons (N=63) in 2 Veterans Affairs facilities.

MEASURES

Patients were surveyed about past experiences with racism and classism in healthcare settings before a clinic visit. Visits were audio-recorded and coded for instrumental and affective communication content (biomedical exchange, psychosocial exchange, rapport-building, and patient engagement/activation) and nonverbal affective tone. After the encounter, patients rated visit informativeness, provider warmth/respectfulness, and ease of communicating with the provider. Regression models stratified by patient race assessed the associations of racism and classism with communication outcomes.

RESULTS

Perceived racism and classism were reported by more African-American patients than by white patients (racism: 70% vs. 26% and classism: 73% vs. 53%). High levels of perceived racism among African-American patients was associated with less positive nonverbal affect among patients [β=-0.41, 95% confidence interval (CI)=-0.73 to -0.09] and providers (β=-0.34, 95% CI=-0.66 to -0.01) and with low patient ratings of provider warmth/respectfulness [odds ratio (OR)=0.19, 95% CI=0.05-0.72] and ease of communication (OR=0.22, 95% CI=0.07-0.67). Any perceived racism among white patients was associated with less psychosocial communication (β=-4.18, 95% CI=-7.68 to -0.68), and with low patient ratings of visit informativeness (OR=0.40, 95% CI=0.23-0.71) and ease of communication (OR=0.43, 95% CI=0.20-0.89). Perceived classism yielded similar results.

CONCLUSIONS

Perceptions of past racism and classism in healthcare settings may negatively impact the affective tone of subsequent patient-provider communication.

Self-reported racial discrimination in health care and diabetes outcomes

BACKGROUND

Self-reported racial discrimination in healthcare has been associated with negative health outcomes, but little is known about its association with diabetes outcomes.

METHODS

We used data from the Behavioral Risk Factor Surveillance System to investigate associations between self-reported healthcare discrimination and the following diabetes outcomes: (1) quality of care, (2) self-management and (3) complications.

RESULTS

In unadjusted logistic regression models, significant associations were found between self-reported healthcare discrimination and most measures of quality of care [diabetes-related primary care visits odds ratio (OR), 0.38; 95% confidence interval (CI), 0.21-0.66), HbA1c testing (OR, 0.42; 95%CI, 0.21-0.82), and earlier eye examination interval (OR, 0.48; 95% CI, 0.24-0.93)] and health outcomes [foot disorders (OR, 2.32, 95%CI: 1.15, 4.68) and retinopathy (OR, 2.26; 95%CI, 1.24-4.12)], but not the number of provider foot examinations (P=0.48) or diabetes self-management (self glucose monitoring, P=0.42; self foot examinations, P=0.74; diabetes class participation, P=0.37). The effects of self-reported discrimination were attenuated or eliminated after controlling for sociodemographics, health status, and access to care.

CONCLUSIONS

Self-reported racial/ethnic discrimination in healthcare was associated with worse diabetes care and more diabetes complications, but not self-care behaviors, suggesting that factors beyond patients' own behaviors may be the main source of differential outcomes. The relationships between self-reported discrimination and diabetes outcomes were eliminated once adjusting for sociodemographics, health status, and access to care. Our findings suggest that other factors (ie, race, insurance, health status) may play equally or more important roles in determining diabetes health disparities, and that a comprehensive strategy is needed to effectively address health disparities.

Insurance-based discrimination during prenatal care, labor, and delivery: perceptions of Oregon mothers

The purpose of this study was to improve understanding of who experiences insurance-based discrimination during prenatal care, labor, and delivery and how their health care may differ from that of other women. We pooled data from the 1998-1999, 2000, and 2001 Oregon Pregnancy Risk Assessment Monitoring System and conducted univariate, bivariate, and multivariate analyses. The women who perceived that they had been treated differently by health care providers during prenatal care, labor, or delivery based on their insurance status were largely a lower income group. Insurance-based discrimination was significantly associated with lower annual household incomes, being unable to pay bills during pregnancy, and being without employer-sponsored insurance for their baby's delivery, when adjusted for other factors. Insurance-based discrimination was less likely among Hispanic mothers. With respect to the relationship between insurance-based discrimination and receipt of health care, our findings were mixed. Insurance-based discrimination was not significantly associated with the number of topics covered by providers during prenatal care. In contrast, insurance-based discrimination was significantly associated with fewer breastfeeding support actions taken at the hospital and with having had a provider discuss birth control after delivery among women with employer sponsored insurance. These findings draw attention to the need to better understand women's experiences and perceptions of insurance-based discrimination during prenatal care, labor, and delivery.