HSPH research on broad determinants of health disparities featured in health affairs

For immediate release: Tuesday, March 11, 2008

Four papers by research faculty at the Harvard School of Public Health (HSPH) are featured in the March/April issue of the journal Health Affairs, which focuses on racial, ethnic, and other social determinants of inequalities in health status.

Among the findings:

• An important cause of health disparities is that many minority children live in segregated neighborhoods with fewer resources — from education to safe recreation to choice of healthy diets — than do white children. Health gaps could be reduced by giving minority families more access to “opportunity neighborhoods.”

• Insurance coverage is lower and state variation in coverage is higher for children in immigrant families where at least one parent was a non-citizen compared to children in “all-citizen” families. The authors discuss state strategies for increasing coverage for children of immigrants, including targeted outreach and enrollment and public/private features of health care insurance reform.

• Four years after the Institute of Medicine report Unequal Treatment documented significant disparities in the rates of medical procedures by race — even when insurance status, income, age, and severity of conditions were comparable — minority populations continue to report a more negative perception of their health care than do whites.

• In a study to examine where elderly Hispanics receive hospital care, researchers found that care is extremely concentrated in a small number of U.S. hospitals that provide a modestly lower quality of care for the common medical conditions of heart attacks, congestive heart failure, and pneumonia.

The array of studies in the journal’s March/April issue represents new findings and perspectives made possible by improved data collection methods and by extending the search for causes — and potential interventions — into broader social dimensions.

The inclusion of several contributions from HSPH reflects the authors’ prominence in the field of health disparities research and the urgency with which the School’s researchers are addressing the problem.

“Toward a Policy-Relevant Analysis of Geographic and Racial/Ethnic Disparities in Child Health”

One such analysis, lead by Dolores Acevedo-Garcia, HSPH Associate Professor of Society, Human Development, and Health, and David Williams, Florence Sprague Norman and Laura Smart Norman Professor of Public Health at HSPH, highlights patterns of racial and ethnic residential segregation that trap minority children in neighborhoods with poor schools, recreational space, and limited dietary choices. Such children often lack access to “opportunity neighborhoods” where there are better social and health resources. The authors note that black and Hispanic children are more likely than white children to live both in poor neighborhoods and in poor families — a form of “double jeopardy.”

The researchers call for interventions that go beyond what is conventionally considered health policy. They consider, for example, the use of litigation to enforce laws against discrimination in housing, helping families move to better neighborhoods, and offering counseling to aid them in housing searches and relocations. They cited a plan in Baltimore that identifies and ranks “communities of opportunity” based on school performance, employment, transportation, child care, health care, and other factors; in this voluntary plan, families can choose to move out of public housing into such communities. Another suggested goal is providing incentives to grocery chains to open stores in poorer neighborhoods to improve access to healthy foods.

“Not only are minority children more likely to live in poor families than white children, but also the spectrum of neighborhoods they live in is entirely different, worse, than the spectrum of neighborhoods where white children live,” said Acevedo-Garcia. “This is a pervasive pattern that repeats itself across the 100 largest metropolitan areas we examined. On average, about 76 percent of black and 69 percent of Latino children live in neighborhoods with poverty rates higher than those found in the neighborhoods of the 25 percent worst-off white children — that is, even the worst-off white children live in lower-poverty neighborhoods than the vast majority of minority children.”

“State Variation in Health Insurance Coverage for U.S. Citizen Children of Immigrants”

In another paper, Acevedo-Garcia and Lisa Cacari Stone, Research Fellow in the HSPH Department of Society, Human Development, and Health, compare health insurance coverage for children whose parents were both U.S. citizens (all-citizen families) to those born into “mixed” situations, where one or both parents lacked citizenship. Their analysis included the 15 states with the highest share of children in mixed families.

The mixed-family children who were U.S. citizens were less likely to have insurance coverage, mainly because their parents were less likely to have employer-sponsored health insurance. The rate of coverage for mixed-family children varied much more widely from state to state than the rate for children in all-citizen families.

“Children of immigrants represent one-fifth of all U.S. children, and the vast majority of these children are American citizens because they were born in the United States,” noted Acevedo-Garcia. “Yet they have more limited access to health insurance than other children.”

The authors wrote that, “given that employer-sponsored coverage has declined overall and that immigrants are less likely than citizens to hold jobs that offer health insurance, subsidizing private insurance premiums might not be the best option to address the needs of children in mixed families. Other policy options include incentives or mandates for small, low-wage firms to offer insurance, and expanding public insurance through either automatic enrollment based on eligibility for nutrition programs (for example, free school lunches) or allowing families to buy into Medicaid/SCHIP. However, children in mixed families will benefit from strategies to address employer coverage to the extent that such strategies include immigrant eligibility and outreach.”

“Disparities in Physician Care: Experiences and Perceptions of a Multi-Ethnic America”

Robert Blendon, HSPH Professor of Health Policy and Political Analysis, and colleagues report the results of a 2007 survey of 4,334 randomly selected U.S. adults to compare perceptions of the quality of physician care among 14 racial and ethnic groups with those of whites. The survey was conducted by HSPH and the Robert Wood Johnson Foundation and was designed to capture opinions from subgroups within the major ethnic populations of African Americans, American Indians/Alaska Natives, Hispanic Americans, and Asian Americans.

Respondents were asked to rate overall quality of their health care from physicians and six others factors, such as wait time for appointments, amount of time spent with patients, how well the doctors listened carefully to them, and their degree of comfort in the interaction.

The study found that on each of the measures, at least five and as many as 11 of the minority subgroups perceived their care to be significantly worse than care for whites.

“Four years after the Institute of Medicine report Unequal Treatment documented numerous disparities in care, this survey found that racial and ethnic minorities perceived the care they received from their physician to be worse than whites,” said Blendon. “Problem areas remained even after taking into account income differences and the role language plays in health care.” The publication year of Unequal Treatment is 2003; the HSPH/RWJF survey was undertaken in 2007.

“The Characteristics and Performance of Hospitals that Care for Elderly Hispanic Americans”

One reason for disparities in health outcomes might be that members of minority groups may receive care in different, inferior settings compared to whites. Ashish Jha, HSPH Assistant Professor of Health Policy and Management, led a study that found that U.S. health care remains segregated along racial lines in some respects. Arnold Epstein, chair of the HSPH Department of Health Policy and Management, is senior author.

The researchers examined the five percent of U.S. hospitals with the highest proportion of elderly Hispanic patients and found that these hospitals cared for more than half of elderly Hispanics. These hospitals were more likely to be for-profit and less likely to have medical or cardiac ICUs. The hospitals cared for more Medicaid patients and had much lower nurse-staffing levels. They provided a modestly lower quality of care for the common medical conditions of heart attacks, congestive heart failure, and pneumonia.

The study has important implications: given the concentration of ethnic minorities in a small number of hospitals, interventions to improve care and outcomes that target these facilities can have a disproportionate impact on the health of Hispanic Americans.

Please note:
Two additional HSPH faculty members are publishing a paper in the March/April issue of Health Affairs. Chi-Man “Winnie” Yip, Adjunct Associate Professor of International Health Policy and Economics, and William Hsiao, K.T. Li Professor of Economics in the Departments of Health Policy and Management and of Population and International Health, have written about, “The Chinese Health System at a Crossroads.”

Christina Roache

Harvard School of Public Health is dedicated to advancing the public’s health through learning, discovery, and communication. More than 400 faculty members are engaged in teaching and training the 1,000-plus student body in a broad spectrum of disciplines crucial to the health and well being of individuals and populations around the world. Programs and projects range from the molecular biology of AIDS vaccines to the epidemiology of cancer; from risk analysis to violence prevention; from maternal and children’s health to quality of care measurement; from health care management to international health and human rights. For more information on the school visit: https://www.hsph.harvard.edu