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We explored how clinicians assisting low-income US Latino patients with diabetes and limited English proficiency (LEP) made sense of language-discordant care in the context of the social determination of health.

We interviewed 14 physicians in an urban teaching hospital, recorded and transcribed the interviews, and read transcripts to identify themes and interpret meanings. We used a mixed qualitative approach and drew from the Marxian tradition that illuminates how the dynamic of the clinical encounter tends to reproduce the social order by excluding its critical appraisal.

Participants believed that language barriers undermine the quality of the clinical encounter and diabetes outcomes, were eager to serve disadvantaged patients, and were well schooled in the social determination of health and its role in diabetes inequalities. However, they appeared unable to conceptualize macro-level changes that may achieve greater health equity.

The structure of medical discourse appears to limit the ability of individual clinicians to conceptualize and engage in social change on behalf patients. Recent debates in primary care indicate that this limitation is currently being challenged. Health services for persons with diabetes and limited English proficiency in the United States and elsewhere require significant improvements in interpreter services. At a broader level, clinicians should consider stepping beyond the limited, traditional role of medical/behavioral advisor to engage in political action toward greater social equity, which would result in better health.

Research in the various dimensions of language discordance is largely quantitative thus the need for qualitative studies to inform practice and policy.

To shed light on how gender norms are reproduced in medical training and practice through an exploration of representations of the problem of “work–life balance.” Women physicians and women physician-researchers (WPs/WPRs) in Canada and in the United States experience social and health inequities when compared to their men colleagues. Despite current medical school acceptance parity, upon entering the medical workforce, women work harder than men to succeed within the historically male-dominated structures and value system of the medical profession.

We performed a critical discourse analysis of articles retrieved from academic databases and leading Anglo-American journals that discussed “work–life balance,” to investigate how the discourse contributed to, or challenged, the reproduction of gender norms in medicine.

While the medical literature acknowledges that the social and health inequities experienced by WP/WPR result from discriminatory norms and practices, it neglects to challenge built-in gendered inequities in benchmarks for success in the profession. Instead, proposed solutions require that WP/WPR themselves learn to cope and make better lifestyle choices, including downloading domestic responsibilities on socially disadvantaged – racialized and poor – women. Authors’ gender appears to make no difference.

Our search was limited to the Anglo-American literature, often retrieved articles inaccessible via our university library, excluded informal venues (e.g., blogs), and did not include cases of same-sex couples or interviews of WP/WPR. All these may have challenged components of our argument by revealing more nuanced debates, occurring under different political, cultural, and economic contexts.

While individual choices of WP/WPR are important to the protagonists, to successfully address the very real problem of work–life balance experienced by WP/WPR, patriarchal norms should be challenged, failure to comply with these norms should be rejected as explanations for work–life balance challenges, and norms themselves should become the focus of analysis and intervention.

The medical language used by physicians of both genders normalizes gendered inequities, favoring the success of medical men over women, and reproducing the professional and personal disadvantages experienced by the latter, further burdening socially disadvantaged women.

Since World War II, rates of type 2 diabetes (henceforth diabetes) have skyrocketed, leading to talk of an “epidemic,” believed to result from formerly “adaptive” genotypes colliding with “affluent” postindustrial societies – largely their food excesses and physically undemanding jobs. Hence, experts describe diabetes as a struggle between biology and behaviors – “genes-as-destiny” and “lifestyles-as-choice” – said to have spared no social group. However, racial and ethnic minorities and the poor are affected disproportionately.

In this paper I challenge the “genes–lifestyle” framework and argue that the epidemic, particularly its distribution, is produced not by affluence but by poverty. The cumulative effect of malnutrition or hyperglycemia during pregnancy, of stunting in young children, of structural constraints over healthy lifestyles, and of the lack of a right to adequate medical care, which are all the results of poverty, leads to diabetes and its complications, and to disparities in their distribution among social groups. Hence, diabetes disparities are not mere differences but differences that are avoidable, unnecessary, and unjust. I also highlight selected conceptual problems of the genes–lifestyle framework that mislead about the potential contributions of genetics to human health.

I conclude that because the roots of the diabetes epidemic lie in inequities in social power, the solutions required are not medical but political, and ought to concern a sociologically informed bioethics. I also conclude that insofar as dominant accounts of the diabetes epidemic ignore or downplay these roots, they will legitimize research and policies that reproduce or even increase diabetes disparities. The paper is part of a larger project on the political ecology of diabetes.

Professional interpreter use improves care in patients with limited English proficiency (LEP) but inequalities in outcomes remain. We explore the experience of US Latinos with LEP and diabetes in language discordant care.

We conducted in-depth interviews of 20 low-income Latino patients with diabetes and LEP. We interviewed participants in Spanish, digitally recorded and transcribed interviews, and read transcripts to identify themes and interpret meanings using interpretive phenomenology as theoretical framework.

While patients preferred, and experienced greater trust in, language concordant clinical encounters, they did not believe that language discordance affected outcomes because they felt that these depended largely on their compliance with physicians’ recommendations. Patients also downplayed structural barriers to care and outcomes. Self-blame was paradoxically encouraged by physicians’ praise vis-à-vis favorable outcomes.

Limitations include small and convenience sample and limited generalizability. However, findings illustrate communicational dynamics between patients and clinicians with important implications for health care practice and policy. They support the perception that trust develops best within language concordant care, which underscores the importance of recruiting clinicians with diverse language skills. They highlight the importance of sensitizing clinicians to the social determinants of health, which may be overlooked when treating patients with conditions requiring substantial self-management, like diabetes. Language barriers in health care must be understood in the broader context of structural inequalities in health care. The necessary emphasis on self-management may (inadvertently) strengthen the hegemonic view that places responsibility for diabetes outcomes on patients’ ability to self-manage their condition to the neglect of social/political determinants of diabetes.

Studies have quantitatively examined the effects of language discordant care on diabetes outcomes, yet few have done so qualitatively. To our knowledge, no study has attempted to understand the experience of language discordance from the perspective of LEP patients with diabetes and how this experience may explain observed differences in outcomes.

Over the last few decades, information technology (IT) has significantly altered the nature of work and organizational structures in many industries, including health care. The purpose of this analysis is to compare how system-level differences affect IT implementation in health care (HIT) and the implications of these differences for health care equity.

We critically analyzed selected claims concerning the capacity of HIT to provide better care to more individuals at lower costs, thus contributing to health care equity, in the context of current health care reform efforts in the United States. We used the case of HIT implementation in Taiwan’s National Health Insurance system as a contrasting case.

We argue that however much HIT may yield in quality improvements or savings in the context of a universal and publicly financed single payer system, such savings simply cannot be accrued by a system of multiple health plans competing for better customers (i.e., less costly patients) and driven by profit.

It is important to define the level of analysis in debates about the potential of HIT to produce better health care at lower costs and the equity implications of this potential. In these debates, US policy makers should consider the commitment to health care equity that informed the design of Taiwan’s health care system and of HIT implementation in that country. HIT merely provides enabling tools that are of little value without major systemic changes

To our knowledge, the health IT expert literature has overlooked when not ignored the ethical principles informing health care systems, an omission which makes it difficult if not impossible to evaluate the potential of HIT to increase equity in health care.

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.