Health Disparities: Social workers helping communities move from statistics to solutions
National Public Health Week April 5-11, 2004
By Elizabeth J. Clark, PhD, ACSW, MPH
Americans are living longer than ever before, and despite an increased awareness of preventive health and advances in medicine there are still segments of the U.S. population who face higher than average mortality and morbidity rates. These individuals — racial and ethnic minorities, people with low incomes, and residents of rural areas — are among the medically underserved populations whose plight is the focus of the U.S. Department of Health and Human Services' initiative, Healthy People 2010.
Launched in 2000, the initiative has two overarching goals: to increase the number of years and improve the quality of healthy life, and to eliminate racial and ethnic disparities in health care. Over the past several years, health disparities has become a catch-phrase in the legislative and health arenas, but the meaning of the term is not always clear. According to the National Institutes of Health, Health disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.
Among other problems, health disparities result in:
- Higher rates of infant mortality
- Decreased access to appropriate cancer screening and management
- Higher rates of cardiovascular disease, HIV Infection/AIDS, and diabetes
- Less access to necessary immunizations
The Office of Minority Health Resource Center (OMHRC) also reports that, as a result of disparities in medical care, African Americans, Asian Americans/Pacific Islanders, Hispanics, and American Indians/Alaska Natives are more likely to have poor health and to die prematurely. For example, the OMHRC released the following:
- In 1999, rates of death from cardiovascular disease were about 30 percent higher among African American adults than among white adults. Heart disease is the leading cause of death for all racial and ethnic groups.
- Overweight and obesity are higher among female members of racial and ethnic minority populations than in non-Hispanic white women. Mexican American men have a greater prevalence of obesity than non-Hispanic men (though African American men have a lower prevalence than non-Hispanic white men).
- American Indians and Alaska Natives have a rate of diabetes more than twice that of the rest of the U.S. population, and the Pima Indians of Arizona have the highest rate of diabetes in the world. Additionally the prevalence of diabetes among African Americans is more than 70 percent higher — and among Hispanics nearly 100 percent higher — than among whites.
- In 2000, 67 percent of older white persons were vaccinated for influenza, while only 48 percent of African Americans, and 56 percent of Hispanics, received the vaccines. Disparities for pneumococcal vaccination were even wider.
- African Americans and Hispanics accounted for approximately 75 percent of all adult AIDS cases — and 81 percent of all pediatric AIDS cases — in 2000, though they comprise only 25 percent of the nation's population.
To make matters worse, racial and ethnic minorities are far less likely to undergo treatment for high blood pressure, despite the fact that they tend to develop hypertension at an earlier age. They are also less likely to receive regular screenings for cholesterol. And, the NIH reports, while infant mortality rates in the U.S. have declined steadily in recent decades, infant death rates among African Americans, American Indians, Alaska Natives, and Hispanics in 1995 and 1996 were all above the national average.
Disparities also abound in utilization of mental health treatment services, according to a 2001 report from the Surgeon General, which shows that race and ethnicity continue to affect the incidence, prevalence, severity, course, and treatment of mental health problems. Mental health disorders like schizophrenia, bipolar disorder, depression, and panic disorder occur across all racial and ethnic groups worldwide. However, the Surgeon General's report states that, compared to Caucasians, racial and ethnic minorities have less access to, and availability of, mental health services; are less likely to receive needed mental health services; often receive a poorer quality of mental health care when they are in treatment; and are under-represented in mental health research.
Poverty is one — but not the only — indicator for health disparities and inequities in health care. The Intercultural Cancer Council ( http://icc.bcm.tmc.edu ), a multicultural coalition, lists five reasons for disparities in health status for racial and ethnic minorities and medically underserved populations:
- Unequal socioeconomic status, resulting in unequal availability, accessibility, and use of health services;
- Unequal diagnostic workup and treatment after entering into the health care system;
- Unequal scientific research, resulting in unequal data collection and unequal understanding of their medical needs;
- Social, racial, and environmental injustice; and
- Individual and institutional prejudices and discrimination.
Studies show that stereotypes, bias, and clinical uncertainty may influence clinicians' diagnosis and treatment decisions, but according to a March 2002 report from the Institute of Medicine (IOM), they also show that responses of racial and ethnic minority patients to health care providers are also a potential source of disparities. Racial and ethnic minorities may experience understandable reactions — possibly resulting in response to what the IOM calls negative racial experiences in other contexts, or to real or perceived mistreatment by providers — such as mistrust, poor compliance with treatment, and a lack of engagement in the treatment process. Thus, the IOM report states, physician and patient attitudes may play off — and influence — each other to the detriment of the patient's medical outcome.
The news about the health disparities that exist in our country, in an era of exciting medical breakthroughs and widespread activism against intolerance and injustice, may be discouraging. The good news, though, is that health care and mental health care providers, together with the nation's legislative bodies, are working to identify and implement solutions. Social work will play a key role in this effort, since the socioeconomic and cultural aspects of health disparities require a holistic approach to their elimination.
Cultural competence, research, and education of health care providers and the public will all be necessary elements in eliminating racial/ethnic and geographical health disparities in health and mental health care. Social workers must make certain that they are culturally competent in their areas of practice, and should post the NASW Standards for Cultural Competence in Social Work Practice in their workplaces and social work classrooms. They also should speak out, whenever possible, leading or joining in the efforts to bring interpretation services to health care centers when the needs exists; to implement policy and regulatory strategies that address fragmentation of health plans along socioeconomic and geographical lines; and to link their practices to important policy issues such as mental health parity and health services for immigrants.
For social workers conducting research in health disparities, opportunities abound. On Nov. 22, 2000, President Clinton signed the Minority Health and Health Disparities Research and Education Act; NASW successfully lobbied for the inclusion of the behavioral health community as one of the beneficiaries of the legislation, which provided more than $150 million to create a National Center on Minority Health and Health Disparities at the National Institutes of Health; increased funding for health disparity research; created a program to attract minority health disparity researchers into the field; and supported funding of training for health care professionals on reducing health disparities.
More recently, in September 2003, Health and Human Services Secretary Tommy G. Thompson announced the creation of eight Centers for Population Health and Health Disparities to support cutting-edge research to understand and reduce differences in health outcomes, access, and care. Four NIH institutes (the National Institute of Environmental Health Sciences, the National Cancer Institute, the National Institute on Aging, and the Office of Behavioral and Social Sciences Research) will support this research.
Because social workers are uniquely positioned to participate on, and lead, health disparity research teams, these new grants, totaling $60.5 million over the next five years, provide the profession with a challenging new responsibility. Our participation in this effort extends beyond our adherence to our Code of Ethics and our sense of each having a personal calling to help right the social injustices that remain entrenched in our society. Our participation will also directly reflect on our profession, illuminating the benefits of our specialized, rigorous training and education, the value of our holistic approach to health and mental health care, and the strength of our belief in the essential rights of every individual, regardless of his or her race or ethnicity, gender, sexual orientation, geographical location, or socioeconomic background.
While focusing on addressing and meeting the needs of society's most vulnerable and protecting those at greatest risk, we can also chart a new course for the social work profession, both at home and overseas. Through our thoughtful and well-publicized studies, our active involvement in policymaking and legislation, and our championing of cultural competence in the education of health care and mental health care providers, we can finally claim our position among the nation's — and the world's — health and mental health care leaders.
References
Institute of Medicine (IOM). (2002, March). Unequal treatment: What healthcare providers need to know about racial and ethnic disparities in healthcare [Online]. Retrieved from http://www.iom.edu/includes/dbfile.asp?id=4175 on October 15, 2003.
National Institutes of Health (NIH). (n.d.) What are health disparities [Online]. Retrieved from http://healthdisparities.nih.gov/whatare.html on October 15, 2003.
U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity — A supplement to Mental health: A report of the Surgeon General [Online]. Retrieved from http://www.surgeongeneral.gov/library/mentalhealth/cre/ on October 22, 2003.
Resources
National Association of Social Workers
http://www.socialworkers.org
U.S. Department of Health and Human Services (HHS)
Office of Minority Health Research Center
Fact Sheet: Protecting the Health of Minority Communities
http://www.omhrc.gov
Healthy People 2010
http://www.healthypeople.gov/
Closing the Health Gap
http://www.healthgap.omhrc.gov
National Institutes of Health
Addressing Health Disparities: The NIH Program of Action
http://healthdisparities.nih.gov/
Institute of Medicine
http://www.iom.edu
Intercultural Cancer Council
http://iccnetwork.org/