Running head: HEALTH CARE DISPARITIES

Health Care Disparities among Minority Groups !RS ""# Primary Care o$ the Adult%&lder Adult Linda gameduru' R ()S Coppin State !ni*ersity Helene +uld S,hool o$ ursing Mar,h -.' -#/01

HEALTH CARE DISPARITIES Elimination o$ health disparities among di$$erent segments o$ the population 2as one o$ the goals o$ Healthy People -#/#1 Healthy People -#/# a,3no2ledged that health disparities ,an a$$e,t population groups 4ased on age' so,ioe,onomi, status' ethni,ity' gender' disa4ility' or spe,ial health ,are need' geography' se5ual orientation1 The determinants o$ health' missed diagnoses' dis,repan,ies in treatment and pri*ilege help e5plain 2hy minority groups e5perien,e poorer health than others1 The determinants o$ health su,h as a person6s 4eha*ior' an indi*idual6s so,ial en*ironment7 in,luding' neigh4orhood' housing' personal relationship' transportation' and a person6s geneti,s and $amily history ,an impro*e health status' or disposition indi*idual at ris3 $or in8ury and diseases1 In,onsisten,y and ine9uity o$ ,are should 4e eliminating 4e,ause health disparities are ,ostly' it impa,ts a 9uality o$ li$e' mor4idity' and mortality :Diggs' -#/-;1 The ad*an,ed nurse pra,titioners are $a,ed 2ith the ,hallenge o$ pro*iding this population 2ith primary ,are 2ith the emphasis on ris3 assessment' health maintenan,e' health promotion' and disease pre*ention through health edu,ation' 4eha*ioral ,hanges' and pre*enti*e treatment $or indi*iduals' and health ,are system1 In the !nited States' minority groups in,lude Hispani,s' A$ri,an(Ameri,an' ati*e Ameri,ans' Pa,i$i, Islanders' Asian Ameri,ans' and ati*e Alas3ans1 More minorities la,3 health insuran,e than the general population and higher ,osts and lo2er 2ages $or minority groups ma3e it di$$i,ult to rise out o$ po*erty :Saha et al1' -##<;1 Most $amilies 2ith ra,ially or ethni,ally di*erse 4a,3grounds ha*e a lo2er so,ioe,onomi, status than does the population at large1 The poor also su$$er more than the population as a 2hole $or nearly e*ery measure o$ health1 Considera4le disparities remain in health insuran,e ,o*erage $or ,ertain populations1 Among the non(elderly population' appro5imately 0-1/= o$ Hispani, persons' as 2ell as' Ameri,an Indian and Alas3a ati*e persons la,3ed health insuran,e ,o*erage in -##.7 $or

HEALTH CARE DISPARITIES 0 A$ri,an(Ameri,ans' the per,entage o$ uninsured in -##. 2as />1?1 La,3 o$ health ,are ,o*erage has ma8or impli,ations $or health :!1S Department o$ Health and Human Ser*i,es @!SDHHSA' -##<;1 Bith the in,rease in minority population so are the in,iden,es o$ illnesses su,h as o4esity' dia4etes' hypertension' ,an,er' ,hroni, o4stru,ti*e pulmonary diseases' and stro3e' as 2ell as' the ra,ial' ethni,' and ,ultural di$$eren,es in health ser*i,es' treatment pro*ided' and a,,ess to health ,are pro*iders1 +or instan,e' ,ardio*as,ular disease inter*ention pro,edures are o$$ered less to A$ri,an(Ameri,an men1 The tas3 $or,e on 4la,3 and minority health' minority populations is less 3no2ledgea4le a4out spe,i$i, health pro4lems than our 2hites1 A$ri,an(Ameri,ans and Hispani,s re,ei*e less in$ormation a4out ,an,er and heart disease than do nonminority groups1 A$ri,an(Ameri,ans tend to underestimate the pre*alen,e o$ ,an,er' gi*e less ,reden,e to the 2arning signs' o4tain $e2er s,reening tests' and are diagnosed at later stages o$ ,an,er than our 2hites :Saha et al1' -##<;1 Gi*en the re,ent $o,us on the litera,y rates o$ the Ameri,an population and their e$$e,ts on health and health ,are ha*e ma8or impli,ations $or the patient and ,aregi*er tea,hing1 Patients 2ith limited litera,y ha*e in,reasing trou4le understanding and a,ting on health in$ormation' leading to health illitera,y1 Ad*an,ed nurse pra,titioners ,an use the Single(Item Litera,y S,reener :SILS; to identi$y adults 2ho need help 2ith reading' sin,e study ha*e sho2n that using SILS help predi,t di$$i,ulty 2ith reading printed health(related material :Diggs' -#/-;1 Su,,ess$ul programs to in,rease pu4li, a2areness a4out health pro4lems are 4eing o$$ered to minority groups' 4ut ad*an,ed nurse pra,titioners must ,ontinue the e$$ort to rea,h more o$ the population1 Community organiCations' ,hur,hes' $amilies' and employers need to 4e in*ol*ed in assisting 4eha*ior modi$i,ations that 2ill result in impro*ed li$estyles1 Edu,ation programs ha*e

HEALTH CARE DISPARITIES D the greatest e$$e,t on diseases that are a$$e,ted *ia li$estyles' su,h as hypertension' o4esity' and dia4etes1 +or instan,e' i$ patients 2ith dia4etes ,ould impro*e their sel$(management s3ill' .#= o$ ,ompli,ations ,ould 4e pre*ented' sa*ing human su$$ering and health ,are dollars :)ra*eman et al1' -#//; The human dimension o$ ,aring is an ordinary day(to(day situations o$ ,aring that many ad*an,ed nurse pra,titioners $ind the most important and trou4lesome 9uestions1 )asi, notions o$ indi*idual and so,ial 8usti,e are *ie2ed in terms o$ $airness and 2hat is deser*ed1 An indi*idual has 4een treated 8ustly 2hen he or she has 4een gi*en 2hat is due or o2ed7 there$ore' any denial o$ something to 2hi,h a person has a right or entitlement is an a,t o$ in8usti,e :Diggs' -#/-;1 Handling in8usti,e has 4een a part o$ nursing sin,e the days o$ +loren,e ightingale' 4ut as health ,are deli*ery has shi$ted to a managed ,are system' ne2 9uestions o$ in8usti,es ha*e sur$a,ed :)ra*eman et al1' -#//;1 The system has 4e,ome more sele,ti*e in the amount and type o$ treatment o$$ered1 Some population group may not ha*e a $ull range o$ diagnosti, testing a*aila4le to them 2hen see3ing ans2ers $or perple5ing illnesses1 Ea,h insuran,e ,ompany may ha*e di$$erent 4ene$it pa,3age' 2hile one ,ompany may ha*e a limited in s,ope o$ ser*i,es than a 4ene$it pa,3age o$$ered through another ,ompany1 T2o $amilies li*ing side 4y side in a typi,al su4ur4an neigh4orhood may 4e entitled to di$$erent health,are ser*i,es 4ased on 2here they are employed1 Perhaps one $amily has a,,ess to health ,are' and the other does not1 Bhat right to health ,are do people ha*eE Is ea,h person entitled to the same health ,are pa,3ageE Should a4ility to pay e$$e,ts the spe,i$i, le*el o$ entitlement o$ an indi*idualE Ho2 ethi,al is the reality o$ gate3eeping in the managed ,are systemE In resol*ing su,h 9uestions' it has to 4een 4ased largely on the do,trine o$ 8usti,e' 2hi,h states that li3e ,ases should 4e treated ali3e and e9uals ought to 4e treated e9ually :)ra*eman et al1' -#//;1 Su,h issues grip at the ,ore

HEALTH CARE DISPARITIES ? o$ nursing pra,ti,e 2herein a,,ess to health ,are and a respe,t $or human dignity are paramount1 Fusti,e 4e,omes a 4ioethi,al issue at the point that it a$$e,ts 2hether' 2hen' 2here' and ho2 a patient 2ill re,ei*e health ,are :Diggs' -#/-;1 The ad*an,ed nurse pra,titioners must ,ommit themsel*es to ta3e a ,ourageous position $or 2hat is right and against 2hat is 2rong1 They should $eel empo2ered through their roles as primary patient ad*o,ates to *oi,e their morality in the $a,e o$ a ne2 ,entury that promises s2eeping ,hanges in health ,are deli*ery :Diggs' -#/-;1 Ad*an,ed nurse pra,titioner em4odies a ,ommitment' not 8ust to thin3 and a,t 2isely in the administration o$ therapeuti, nursing inter*entions' 4ut also to thin3 and a,t in a,,ordan,e 2ith spe,i$ied *alues and 4asi, prin,iples o$ right and 2rong1 Ad*an,ed nurse pra,titioners may display some ,ertain 4eha*iors and 4iases that ,an ,ontri4ute to health disparities1 Health ,are G see3ing 4eha*ior in minority populations ,an 4e a$$e,ted through $a,tors su,h as pre8udi,e1 Hospital' outpatient ,lini,' or pu4li, health department' may also ,ontri4ute to health disparities' $or instan,e' a large outpatient ,lini, lo,ated in a large immigrant population Hispani,s or Hietnamese that do not pro*ide translators or edu,ational materials and $inan,ial $orms in Spanish or Hietnamese may limit the a4ility o$ immigrant $amilies to understand ho2 to a,,ess health ,are :)ra*eman et al1' -#//;1 Sometimes dis,rimination at institutional le*el is di$$i,ult to identi$y' 4ut o*ert dis,riminatory 4eha*ior on the part o$ a health ,are pro*ider may not 4e immediately e*ident to the patient or pro*ider' and so may 4e di$$i,ult to ,on$ront1 Resear,h 4y Saha et al' -##< has sho2n that e*en 2ell( intentioned pro*iders 2ho try to eliminate 4ias in their ,are demonstrate their pre8udi,es through non*er4al ,ommuni,ation' and dis,rimination still e5ists e*en 2ith many poli,ies that are in pla,e $or its elimination :Saha et al1' -##<;1

HEALTH CARE DISPARITIES " The ,on,epts o$ alternati*e treatment and a,3no2ledging un,ertainty is di$$i,ult $or today6s health ,are pro*ider1 As ne*er 4e$ore' it seems that pro*iders need to present themsel*es as ,on$ident' 3no2ledgea4le' and sensiti*e to their patients' 2ho may see them as arrogant' dogmati,' and insensiti*e1 A,3no2ledging un,ertainty may 4e 2orth the e$$ort1 +or the diagnosti,ian' it may lighten the 4urden *ia a4sol*ing him or her o$ the responsi4ility $or impli,itly ma3ing de,isions $or 2hi,h there may 4e ,on$li,ting ans2ers :Staurt(Shor' )erra' Iamau J Iumanyi3s' -#/-;1 +or the patient' 3no2ing a4out the un,ertainty may gi*e him or he greater *oi,e in de,ision ma3ing and' in the e*ent o$ treatment $ailure' may lea*e him or her 4etter in$ormed and more trust$ul o$ the ,aregi*er1 An e5,hange 4et2een patient and pro*ider 2ith open ,ommuni,ation a4out the patient6s 2ant and needs is optimal health ,are results' and the pro*ider6s 8udgment and ad*i,e1 The passage o$ The Health Care and Edu,ation A$$orda4ility Re,on,iliation A,t o$ -#/# has made the histori, health ,are re$orm legislation 4e,ome a reality1 Health ,are re$orm is health poli,y initiati*es to a$$e,t su4stantial ,hanges in ho2 health ,are is pro*ided and paid $or in the !nited States1 Many Ameri,ans and pro$essional health ,are organiCations su,h as the Ameri,an urses Asso,iation :A A; support 4old health ,are re$orm to address a ,riti,al pro4lem $a,ing our health ,are system: a gro2ing uninsured population' a,,ess to ,are' rapidly rising ,osts' health pro$essional shortages' and ongoing ,on,erns a4out the 9uality and sa$ety ,are :)ra*eman et al1' -#//;1 !ninsured minority populations ,reate un,ompensated or indigent ,are ,osts and 4ad de4t $or health ,are pro*iders re9uiring pro*iders to in,rease ,harges to pu4li, and pri*ate insurers and ma3ing it e*en more di$$i,ult $or households and 4usinesses to a$$ord ,o*erage :Diggs' -#/-;1 !nder this health ,are re$orm legislation' most Ameri,ans 2ill ha*e health insuran,e 4y -#/D1 Depending on in,ome' people 2ill 4e eligi4le $or Medi,aid' 2hi,h 2ill 4e

HEALTH CARE DISPARITIES . greatly e5panded 4eginning in -#/D' and $or those not eligi4le $or Medi,aid may 4e 9uali$ied $or go*ernment su4sidies to help pay $or pri*ate insuran,e1 Ro4ert Bood Fohnson +oundation :-#/#; initiati*e 2or3 on +inding Ans2ers: Disparities Resear,h $or Change' sho2s that so,ial determinants o$ health' su,h as edu,ation' po*erty' and a,,ess to ,are' are signi$i,ant 4arriers to e9uita4le ,are and must 4e addressed to eliminate disparities and that these $a,tors may 4e 4eyond the s,ope and ,ontrol o$ the primary pro*iders1 This initiati*e proposes a $rame2or3 $or pro*iders and health,are organiCations to understand disparities6 solutions' and posits that positi*e intera,tions 4et2een patients and primary pro*iders' in a system that a,3no2ledges indi*idual ,hara,teristi,s' ,ommunity *alues' and so,ietal norms' ,an lead to impro*ed pro,esses o$ ,are' 2hi,h in turn lead to impro*ed out,omes1 Ad*an,ed nurse pra,titioners must 4e po2er$ul ad*o,ates $or health ,are $or all1 )y understanding the poli,y and politi,al pro,esses' ad*an,ed nurse pra,titioners ,an ma3e su4stantial in$luen,es to the impro*ement o$ health poli,ies that uphold a healthier so,iety1 A simple pro$essional o4ligation is to 4e tangled in pro$essional nursing organiCations and to 4e a politi,ally a,ti*e nurse pra,titioner' +loren,e ightingale' used health poli,y to ma3e a re$orm so ,an 2e ma3e a trans$ormation in the li*es o$ people 2e ,are' in our o2n li*es' and $or the $uture o$ our pro$ession1 urses denote a 3ey pro$i,ient $or,e in the deli*ery o$ health ,are ser*i,es in the !nited States and are un,onditionally ,ru,ial to the deli*ery o$ e5,ellent and ,ompetent health ,are1 ModerniCation and distin,tion in all nursing pra,ti,e is ne,essary to ,omprehend ,ost 2hile a,,omplishing optimisti,' 9uanti$ia4le out,omes1 urses are at the ,enter o$ ensuring positi*e

HEALTH CARE DISPARITIES < patient out,omes and ma5imiCing reim4ursement1 Care deli*ered ought to 4e 4esieged to2ard primary ,are to lesser re9uirement on ,ostly se,ondary and tertiary ,are1 urse pra,titioners ha*e demonstrated their aptitude and a4ilities to deli*er ,ustomer($o,used primary ,are at sensi4le 4udgets as a ,ost(e$$e,ti*e su4stitute to physi,ian ser*i,es1 Prospe,ts $or ad*an,ed pra,ti,ed nurses in,lude primary ,are' utiliCation management' 9uality impro*ement' ,ase management' triage' a patient ad*o,ate' edu,ation' and resour,e management1 Ad*an,ed nurse pra,titioners must ta3e the lead in *alidating the 2orth o$ 2ellness and tea,hing health ,ons,iousness all their patients espe,ially the minority populations1 Briting materials $or all le*els o$ edu,ation 2ill 4e needed' pro*iding yet another opportunity $or ad*an,ed nurse pra,titioners 2ho 2ant to pu4lish1 Implementing e$$ort targeting ad*an,ed nurse pra,titioners and their system o$ deli*ering 4eha*ioral inter*entions are important to a,hie*ing sustaina4le system(2ide impro*ement in out,omes1 In ,on,lusion' as a ,ountry i$ 2e are to a,hie*e the goal o$ the re,ent Ameri,an Heart Asso,iation :AHA; strategi, impa,t goal 4y -#-#' to impro*e the ,ardio*as,ular health o$ all Ameri,ans 4y -#= 2hile redu,ing deaths $rom ,ardio*as,ular diseases and stro3e 4y -#=' health,are organiCations and the ad*an,ed nurse pra,titioners 2ill need to de*i,e approa,hes to lessen ,ardio*as,ular diseases ris3 in underser*ed and ra,ial%ethni, populations that 4ear a disparate en,um4ran,e o$ disease :Stuart(Shor' )erra' Iamau J Iumanyi3a' -#/-;1 Thus ad*an,ed nurse pra,titioners are ,hallenged to meet this goal *ia 2iden their pre*enti*e perspe,ti*es 4eyond primary and se,ondary pre*ention to in,lude primordial pre*ention a,ross the li$espan' a ,hallenge that 2ill re9uire multidis,iplinary teams ,olla4orating ,are1 The redu,tion o$ health disparities also re9uire resour,es to enhan,e ,ultural ,ompeten,e' impro*e health poli,ies' impro*e health ,are deli*ery' and a,,ess to health ,are1

HEALTH CARE DISPARITIES > Re$eren,es )ra*eman' P1 A1' Iumanyi3a' S1' +ielding' F1' LaHeist' T1' )orrell' L1 1' Manders,heid1' J Troutman' A1 :-#//;1 Health disparities and health e9uity: The issue is 8usti,e1 American Journal of Public Health' /#/:/;' /D>(/??1 Diggs' S1 1 :-#/-;1 Health disparities and health ,are $inan,ing: Restru,turing the Ameri,an health ,are system1 Journal of Health Care Finance' 0< :D;' ."(>#1 Ro4ert Bood Fohnson +oundation :-#/#;1 Finding answers: Disparities research for change1 Retrie*ed $rom http:%%2221sol*ingdisparities1org Saha' S1' +reeman' M1' Toure' F1' Tippens' I1 M1' Bee3s' C1' J I4rahim' S1 :-##<;1 Ra,ial and ethni, disparities in the HA health ,are System: A systemati, re*ie21 Journal of General Internal Medicine' !:?"' "?D("./1 Stuart(Shor' E1 M1' )erra' I1 A1' Iamau' M1 B1' J Iumanyi3s' S1 I1 :-#//;1 Re,ent ad*an,ed in pre*enti*e ,ardiology and li$estyle medi,ine: )eha*ioral strategies $or ,ardio*as,ular ris3 redu,tion in di*erse and underser*ed ra,ial%ethni, groups1 Journal of American Heart Association' /-? :/;' /./1 !1S Department o$ Health and Human Ser*i,es :-##<;: #he $$% HH& Po'ert( Guidelines' Bashington' D1C: !1S1 Go*ernment Printing &$$i,e1

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