Health Care Services, Racial and Ethnic Minorities and Underserved Populations: Patient and Provider Perspectives: Volume 23

This chapter provides an introduction to the volume and reviews some issues related to provision of health care services to racial and ethnic minorities and other underserved population. In addition to this review of some of the material on underserved populations and what has often been called in the US “health care disparities” concerns, this chapter also serves as an introduction to the volume. As such, the chapter explains the organization of the volume and briefly comments on each of the chapters included in the volume.

Racial/ethnic minority, low-income teens represent a significantly underserved group in terms of reproductive health care including birth control and prenatal care. This paper provides patients’ perspectives through analysis of in-depth interviews with 51 African American teen mothers about their reproductive health care and focuses on the influence of gender ideologies and behavior expectations on teens’, and their perceptions of their mothers’, decisions around these issues. The findings suggest that attention to cultural influences of gender on teens’ decisions around sexuality and reproduction is critical to our theoretical and practical approaches to expanding health care services to underserved populations.

Disparities in health care for underserved populations have raised questions about the quality of decisions made by these patients. We explored the decision-making experiences and reactions to a decision aid in focus groups of African American, Hispanic, and Rural breast cancer survivors. All groups were taped, transcribed, and thematic analysis was performed. Individual differences were more common than differences among demographic groups. Decision aids appear to be acceptable without extensive targeting to specific groups. However, translating the decision aid would increase its usefulness for Hispanic populations.

To investigate the role of social factors, health status, and psychiatric disorders (DSM-III-R) on mental health services use, we utilized the National Comorbidity Survey (NCS), a nationally representative household survey (1990–1992) of the US (n=5877). Multivariate logistic regression allowed estimation of the adjusted odds ratios and 95% confidence intervals on the likelihood of visiting the health or the specialty mental/addictive service sectors. Significant determinants included: gender, race, household income, work status, and quality of community-level health care resources. Those with greater socioeconomic resources or comorbid psychiatric disorders were more likely to visit the specialty mental health sector.

Drawing on closed and open-ended interview data (n=79), this paper explores the health care experiences of a purposive sample of sex industry workers in a medium-sized metropolitan area of British Columbia, Canada. The respondents reported high average health care utilization and many reported satisfactory access to health care, including a positive relationship with a regular health provider. However, several respondents reported feeling intimidated and shamed in health care settings (felt stigma) and many choose to withhold information relevant to their health care due to fear of discrimination (enacted stigma) by health professionals.

Older women living in medically underserved areas (MUA) might have particular problems with access to health care. This is an in-depth report of the accessibility issues raised by six frail older women (age 82–93 years) during a longitudinal descriptive phenomenological study of the experience of home care. Three White women lived in the same rural MUA, and three Black women lived in the same urban MUA. The need for health service was understood subjectively and prospectively as the personal perception of a situation requiring relief or supply. Some women reported presenting needs for accessibility to providers, whereas others reported needs for their future accessibility to providers or services. Some intentions were likely linked to residence location, and residence in a rural MUA was relevant to the phenomenon of securing the help that I might need down the road. Feasibility was proposed as a new parameter of access. Research and practice implications were proposed.

A random sample of insured adults (n=134) tests the effects of insurance on respondents’ emotional and physical health. Results showed that being married and being widowed improved physical health while having no religious identification heralded less emotional distress. Preferred Provider Organization services satisfaction was related to better physical health. Respondents in households that restructured themselves to acquire or maintain health coverage also reported more emotional distress than those in households without such problems. Implications of our results regarding improving insurance programs and the effects of marital status and the lack of religious affiliation upon adults’ health are discussed.

This paper investigates the informal learning processes through which family physicians develop an understanding of the social context shaping the health of marginalized patients. The paper is based on the results of a qualitative study, informed by institutional ethnography, involving individual interviews with 10 family physicians working in and around Halifax, Nova Scotia, Canada. The analysis explores what knowledge of social context is for family physicians, emphasizing its hybrid, socio-clinical character. We also explore key aspects of the informal processes through which this knowledge is developed including learning about ‘the other,’ the reflexive unlearning of medical school training, and learning from clinical doing where we discuss patient-based epiphanies and learning from other health care providers.

The purpose of this paper is to draw on previous work in multiple disciplines to establish a theoretical framework for clinical decision-making that incorporates non-medical factors, such as race/ethnicity, into the way physicians make decisions in the practice of medicine. The proposed Rapid Clinical Decision in Context (RCDC) model attempts to understand the influence of various contextual elements on physicians’ decision-making process. The RCDC model provides a basis for future studies to move beyond documentation of areas where disparities exist to understand the causes of the disparities and designing interventions to address those causes. The paper concludes with a discussion on possible studies to test the proposed model.

This study examines the impact of one of President Johnson's “War on Poverty” programs on Native American control over current health care management. This program has been widely credited as a huge success – a tool that prompted tribes to increase their drive for self-determination. However, no one has ever empirically validated this claim. The results provided here do not support this contention. Participation in the program as a whole proved detrimental for tribal self-determination. The primary component within the program actively discouraged tribal development. However, another component did have the desired impact, encouraging capacity-building and supporting local input and control. This study contributes to both the international development and Native American literatures by demonstrating support for “bottom-up” development models and thereby offering a better option for self-determination and long-term sustainability.

Health promotion programs in global health systems need to incorporate culturally competent care and provide linguistic access. This article describes the challenges in one country, the United States, and reports on research studies, which articulate the current gaps in meeting the above goals. Health care providers are bound by both legal and ethical standards to provide such care. Legal standards are cited. Regardless of legal standards, health care providers are also bound ethically to provide such care. An analysis of basic ethical concepts of principalism is described for the importance of these aspects of care.

The premise of this article is that one cannot have a successful health system without inclusion of culturally competent health promotion programs. And, one cannot have such health promotion programs without an understanding of the role that cultural and linguistic competence plays in the provision of clinically competent and cost-effective services. Not only is there a need for culturally competent care that is legally mandated in some countries, such care is ethically necessary. The first part of this paper will address the need for culturally and linguistically appropriate care and applicable laws and standards. The latter part of the paper will provide an ethical analysis. However, before doing that, one global perspective of health care concerns for underserved populations will be presented as well as a discussion of the importance of the use of ethical frameworks.

Through content analysis, the study traces the relative prominence of “biomedical” and “public health” approaches in congressional bills aimed at improving the health of racial and ethnic minorities over a 28-year period. It documents a surge of interest in minority health during the late 1980s and early 1990s and highlights the dominance of biomedical initiatives during this period. Drawing on historical methods and interviews with key informants, the paper explains these patterns by detailing the ways in which policy legacies shaped the interests, opportunities, and ideas of interest groups and policy-makers.

The striking number of persons with low levels of literacy in the United States is a major public-health concern. This study examines the relationship between literacy levels and both (1) access to health care and (2) use of specific health care services among adults. The data are collected from in-person interviews with a representative sample of adults aged 18–44 in Portland, Oregon, who are proficient English speakers, and have not completed high school nor have a GED. Adults with lower levels of literacy are less likely to have a usual provider, to have health insurance, and they have trouble understanding written medical directions, more difficulty getting needed care, and poorer health. They also use physician services, overnight hospital stays, and emergency rooms more frequently, controlling for education, access, health, and sociodemographic characteristics. Literacy is conceptually distinct from education and independently affects the way in which adults seek health care.