Race, Ethnicity, Gender and Other Social Characteristics as Factors in Health and Health Care Disparities: Volume 38

Purpose – This study examined the impacts of racial discrimination on the self-reported health among Asian Americans.

Methodology/Approach – This study investigated a subsample of 1,090 Asian Americans from the 2008 National Asian American Survey. Three-category measure of self-reported health was constructed ain. Racial discrimination experiences encompassed (1) interpersonal discrimination, (2) institutional racism, and (3) hate crime. Ordered logistic regression models were employed to test the association between self-reported health and experiences of racial discrimination among Asian Americans.

Findings – With respect to ethnic origin, South Asians showed lower levels of self-reported health than East Asians/Asian Indians. Although the baseline effect of each discrimination indicator was insignificant, there was an interactional effect between ethnic origin and racial discrimination, indicating the more interpersonal discriminatory experiences, the worse health status for South Asians.

Research limitations – There remained some limitations including data and the measures of racial discrimination.

Originality/Value of Paper – Despite the limitations, this study revealed that as a risk factor, how experiences of racial discrimination shape health disparities among ethnic groups in the United States, focusing on the heterogeneity within Asian Americans.

Purpose – Differential racialization experiences influence ethnic and racial self-identification. This research assesses how ethnic self-identification colors perceptions perceived discrimination and how this in turn influences adolescent depressive symptomatology.

Methodology/Approach – We use the second wave of the Children of Immigrants Longitudinal Study (CILS) to examine the children of Caribbean immigrants. This research uses descriptive statistics, bivariate, and multivariate analyses to test hypotheses. The primary statistical method used is linear regression with OLS estimators.

Findings – Variations in the depression score exist among the racial/ethnic groups, with those identifying as non-black Antillean experiencing greater depression than the other three groups, and those identifying as white Cuban experiencing the lowest depression levels. The findings also show that some of this association is due to perceived discrimination.

Research Limitations/Implications – Future research should examine the association between discrimination and mental health longitudinally. We did not explore this option due to the lack of availability of relevant variables across multiple waves of the study.

Originality/Value of Paper – The results have implications for better understanding the second generation and elucidate how race and ethnicity shape adolescent perceptions of discrimination, and how these perceptions, in turn, are associated with mental health.

Purpose – To examine potential sex differences among American Indian and Alaska Native peoples (AIANs) in diabetes prevalence, comorbidities, healthcare utilization, and treatment costs within the Indian Health Services (IHS).

Methodology/Approach – Data were drawn from the IHS Improving Healthcare Delivery Data Project with 437,608 persons in our analytical sample. We described sex and age differences in diabetes, comorbidities, healthcare utilization, and treatment costs among the adults with diabetes. We evaluated the statistical differences between men and women using confidence intervals calculated at the 95% level, with nonoverlapping confidence intervals indicating statistical significance.

Findings – The prevalence of diabetes among females was somewhat higher than that of males (10.82 vs 9.16%, respectively, p < 0.05). Among adults with diabetes, males had statistically higher prevalence of hypertension, cardiovascular disease, and substance use disorders and fewer mental health disorders compared to females. Although males had overall lower average cost of services than females, males had higher utilization for hospital inpatient services than females, and females used more outpatient services.

Research limitations/implications – We are limited to one fiscal year of data and thus cannot predict the influence of healthcare utilization patterns on the overall health of this population. Although a large sample, the findings are only generalizable to the active users of the participating IHS Service Units.

Originality/Value of Paper – This study fills a major gap in our knowledge of sex differences in diabetes prevalence, comorbidities, healthcare utilization, and treatment costs among AIANs. Differences in the comorbidities that characterized the AIAN adult males and females with diabetes in this sample have important implications for mortality and cost of care. Diabetes management that addresses such gender-specific comorbidities, particularly substance use disorders among men and mental health disorders among women, promises to reduce these comorbidities and related complications.

Purpose – This study analyzed individual factors of race and dual eligibility on emergency room (ER) utilization of older adult Medicare patients treated by RHCs in CMS Region 4.

Methodology/approach – A prospective, longitudinal design was employed to analyze health disparities that potentially exist among RHC Medicare beneficiary patients (+65) in terms of ER use. The years of investigation were 2010 through 2012, using mixed multilevel, binary logistic regression.

Findings – This study found that dual eligible RHC patients utilized ER services at higher rates than nondual eligible, Medicare only RHC patients at: 77%, 80%, and 66%, in 2010, 2011, and 2012, respectively; and above the White reference group, Black RHC Medicare patients utilized ER services at higher rates of: 18%, 20%, and 34%, in 2010, 2011, and 2012, respectively.

Research limitations/implications – Regarding limitations, cohort data observations within the window of 3 years were only analyzed; regarding generalizability, in different CMS regions, results will likely vary; and linking other variables together in the study was limited by the accessible data. Future research should consider these limitations, and attempt to refine. The findings support that dual Medicare and Medicaid eligibility, as a proxy measure of socioeconomic status, and race continue to influence higher rates of ER utilization in CMS Region 4.

Originality/value – In terms of ER utilization disparities, persistently, as recent as 2012, Black, dual eligible RHC Medicare beneficiary patients age 65 years and over may be twice as likely to utilize ER services for care than their counterparts in the Southeastern United States.

Native American (NA) women's health needs in general are underresearched, and use of holistic, community-informed, and resilience-based approaches are rare. Despite extensive documentation of the continuing health inequalities between NA women and the general US population, little research examines what healthcare infrastructure and healthcare provider factors most impact, and exacerbate, these health disparities. The purpose of the study was to provide insight into the healthcare experiences of NA women. A qualitative descriptive research methodology with “hues” of an ethnographic life-history approach was used. Data were collected through qualitative semi-structured life-history interviews with 31 NA women from the Gulf Coast region of the United States. All women identified healthcare obstacles and barriers. These barriers were predominately comprised of Healthcare Infrastructure Barriers, which entailed: (1) Cost and Insurance Barriers; (2) Concerns about Western Medication; (3) Language Barriers; (4) Distance to Medical Facilities or Specialists; and (5) Long-wait Times, and Negative Provider Relationships, which included: (1) Rushed or Rude Provider Interactions; (2) Providers not Listening, or Ignoring Patient Concerns; (3) Poor, Inaccurate, or Inadequate Care or Diagnosis; (4) Discrimination in Healthcare; and (5) The need for Personal Relationships with Providers. These findings suggest that healthcare infrastructure issues and poor healthcare provider relationships are important structural issues that contribute to health disparities. The findings from this study have important implications for the type of training those working in healthcare services receive to be more sensitive to the needs of NA women and suggest that NA women may need unique support when accessing healthcare.

Purpose – In this chapter, I set out to unexcise the messiness of maternalisms and disparities in women's health care by addressing narratives about reproductive trauma. I ask, what might it mean to analyze the interaction between the medical industrial complex and women who experience reproductive trauma as a social practice, one that is constitutive of gender socialization and the medicalization of women's bodies in the American nation-state? I accomplish responding to the question by addressing a vastly underresearched and underaddressed pregnancy complication Hyperemesis Gravidarum (HG).

Methodology/Approach – First, I thread posts from supportive online reproductive trauma forums to weave thematic narratives about and the impacts of HG. Next, I review biomedical literature in order to probe potential etiology. Third, I share my debilitating experiences with HG – reproductive traumas – to interrogate dominant androcentric biomedical discourse of pregnancy culture, maternalisms, maternal ideology, and epistemic violence.

Findings – Our knowledge about HG continues to be murky and unresolved, leaving many pregnant people – namely women – untreated.

Research limitations/implications – I call on the absence of contemporary protective sociocultural structures that provide support and care – gendered health-care disparities – for women during pregnancy, labor and delivery, and postpartum in order to advocate reproductive trauma is a viable and normal expression in the context of misogynist social scripts.

Originality/Value of the Chapter – My hope is to raise the volume on narratives of pregnancy trauma and reproductive experience using HG as a case study and my intention is to argue gender is a salient factor in health-care disparities.

Purpose – Although recent work has made significant contributions to our theoretical understanding of white fragility, more empirical work is needed to establish the social causes of this particular form of racial stress. Our chapter builds on previous research by assessing gender and socioeconomic variations in white fragility.

Methodology/Approach – Data come from the 2018 Survey of White Fragility, a convenience sample of 279 non-Hispanic white undergraduate students aged 18 years and over attending two large public universities in the southeastern and southwestern United States.

Findings – Results indicate that women tend to exhibit higher levels of remorse fragility (feeling sad, guilty, and angry). There were no gender differences in depletion fragility (feeling drained/exhausted, unsafe, attacked, and confused). Parental education was unrelated to levels of white fragility. Overall parental socioeconomic status was initially associated with lower levels of remorse and depletion fragility, but these associations were confounded by a general measure of nonspecific psychological distress.

Research Limitations/Implications – Research limitations include a nonprobability sampling design and low external validity.

Originality/Value of Paper – This study contributes to previous work by establishing gender variations in white fragility. We also reveal that socioeconomic variations in white fragility may be confounded by the broader social distribution of psychological distress.

Objectives – Given the multitude of barriers faced by incarcerated and formerly incarcerated individuals, we contribute to prior literature through our exploration of the relationship between Social Determinants of Health (SDOH) and Adverse Childhood Experiences (ACE) scores among a sample of incarcerated individuals (women) in San Bernardino County.

Methods – We performed a secondary data analysis on the original, self-reported data collected in 2011 from 336 female participants serving sentences in the San Bernardino County Jail System. Multivariate linear regression analysis was performed to examine the association between ACE scores and select covariates.

Result – Higher ACE scores were associated with participants characterized as younger, low income, and unemployed and were significant among incarcerated women whose biological father has been in trouble with the law and those with an incarcerated household member. Additionally, participants with higher ACE scores were raised in more unstable neighborhoods.

Conclusions – The study demonstrates strong evidence that ACE scores are interrelated with individual-level characteristics, family stability, and SDOH, and impact the health outcomes and life experiences of vulnerable populations.

Purpose – Patient safety and adverse events continue to present significant challenges to the US health care delivery system. Mandated reporting of adverse events can be a mechanism to “coerce” hospitals to identify, evaluate, and ultimately improve the quality and safety of patient care. The objective of this study is to determine if the coercion of mandated reporting impacts hospital patient safety scores.

Methods – We utilize the US News and World Report 2012–2013 Best Hospital Rankings which includes patient safety data from US teaching hospitals. The dependent variable is a composite measure of six indicators of patient safety during and after surgery. The independent variable is state mandated reporting of hospital adverse events. Three control variables are included: Magnet accreditation status, surgical volume, and the percentage of surgical admissions.

Findings – Using ordered logistic regression (n = 670 hospitals) we find a positive, but not significant, relationship between state mandated reporting and better patient safety scores.

Implications – This finding suggests that regulatory policy may not actually prompt performance improvement, and our data point to the need for further study of both formal and informal processes to manage patient safety within the hospital.

Originality – While increased reporting of adverse events has been linked to hospitals providing safer care, no research to date has examined whether or not state-level mandates actually lead to improvements in patient safety.

Purpose – To assess the claim of moral hazard proponents that individuals insulated from paying for the health care they use tend to demand more, often unnecessary, services, or engage in unhealthier behaviors than they otherwise would, collectively driving up demand and increasing health care spending (HCS).

Methodology/Approach – To test the hypothesis that moral hazard increases rather than decreases HCS, I apply a multivariate analysis to examine data from 21 OECD countries over a 20-year period, using out-of-pocket spending (OPS) as a proxy for moral hazard and as the key variable predicting HCS, controlling for other potential drivers of spending.

Findings – OPS is independently associated with HCS, yet in the direction opposite to what moral hazard theory predicts – about $13 higher HCS per additional $10 OPS (p = 0.000).

Research limitations – As with other cross-national studies, limitations include (1) inability to assess differences in health care delivery and quality within and across countries; (2) differences in the measurement and availability of variables across countries; (3) lack of access to data of potential significance, and (4) hard to evaluate cross-national political and cultural differences with implications for health policy.

Policy implications – At least in the United States, unless a fully publicly financed system to cover medically necessary services is implemented, the policy goals of extending adequate health insurance to a national population and controlling HCS nationally will not be met.

Originality/Value of Paper – Most research on moral hazard in US health care has drawn from comparisons within rather than among national health systems. Therefore, the originality and value of this cross-national study lies in its ability to identify variables that could not be included in single nation studies and which have the ability to inform policy and political action.

Purpose – Academic campuses in India in recent years have witnessed an increase in the proportion of older people due to the rise in the age of superannuation of faculty and their cohabitation with older parents. However, such campuses continue to have a skewed program which favor the needs of the younger population. For the present study, a residential academic campus equipped with a health care facility was selected to understand the challenges of the family caregivers of older people residing in it.

Methodology/Approach – Exploratory in-depth interviews were conducted with 154 family caregivers. Secondary data were obtained from the campus hospital records.

Findings – Data revealed that family caregivers experienced various challenges in providing older care in the campus due to unavailability of paid supportive caregivers, lack of community support, and inadequate housing. Though the academic campus has a health care facility, the entitlement rights to it varies among the older people in campus. While the campus health facility was not congenial for family caregiving, it was utilized as a space for providing long-term care. This chapter suggests the need to extend a public heath model of family caregiving in campus.

Research limitations/implications – The study has implication for modifying similar academic campuses in India for facilitating family caregivers of older people.

Originality/Value of Paper – This is the first study of its kind which explored the challenges of family caregiving for older people in academic campuses in India.

Purpose – This study investigates the sociodemographics, late entry to antiretroviral therapy (ART), and clinical markers associated with AIDS-related mortality.

Methodology/Approach – Applying retrospective cohort design, 960 medical records of people who died of AIDS, from October 2006 to December 2014, were accessed from the ART center at tertiary health care center of Ranchi (India).

Findings – With useable data from 889 medical records revealed that the majority of people who died of AIDS consisted of married males in the age group of 19–40 years who were truck drivers, migrant laborers, and of rural origins. The median survival period was below 3 months following the ART. Males and people on the pre-ART group had a shorter survival period than their counterparts. Early mortality was associated with lower CD4+ T cell counts, the third or fourth clinical stage, ambulatory or bed-ridden functional status, and poor medication adherence.

Research limitations/implications – This study was limited to the analysis of AIDS deceased people only; it did not compare the survival duration with living people on ART. The lower CD4+ T cell counts and medication adherence, being strong predictors of mortality, can be addressed to attain higher survival rates of people who have AIDS.

Originality/Value of Paper – This is the first study conducted in the tribal-populated region, covering a large sample of 889 cases. Unique findings of this study update the existing data on AIDS-related mortality.