Educating primary care clinicians about health disparities
© Cardarelli and Chiapa; licensee BioMed Central Ltd. 2007
Received: 02 June 2006
Accepted: 01 February 2007
Published: 01 February 2007
Racial and ethnic health disparities inarguably exist in the United States. It is important to educate primary care clinicians regarding this topic because they have the ability to have an impact in the reduction of health disparities.
This article presents the evidence that disparities exist, how clinicians contribute to these disparities, and what primary care clinicians can do to reduce disparities in their practice. Clinicians are able to impact health disparities by receiving and providing cross-cultural education, communicating effectively with patients, and practicing evidence-based medicine. The changes suggested herein will have an impact on the current state of health of our nation.
The U.S. racial and ethnic minority population will grow from 28% in 1998 to nearly 40% in 2030 . According to the Institute of Medicine (IOM), health disparities inarguably exist among racial and ethnic minorities . It is important to address health disparities because consequences include poorer health, increased suffering, and higher mortality . Many racial and ethnic minorities have higher mortality rates from cancer, diabetes, and cardiovascular disease . African Americans have a higher cancer mortality rate (243.1 vs. 193.9 per 100,000, respectively) and twice the cardiovascular mortality rate compared to white Americans [4, 5]. Among Hispanics, the diabetes death rate ranges from 47–172 per 100,000 depending on nationality (Cuban, Mexican, Puerto Rican, etc.), more than twice the rate of white Americans (23 per 100,000) . Furthermore, Hispanic women have the highest cervical cancer incidence rate .
Health disparities have a financial toll as well. The higher burden of disease affects the health of the nation as a whole. Poorer health requires increased expenditure, especially when complications arise from uncontrolled or undetected disease. For example, African American women are more likely to have late-stage breast cancer at the time of diagnosis, more often requiring intensive treatment and hospitalization, and leading to more disability . Loss of individual productivity also contributes to national health care costs, impacting all individuals regardless of race or ethnicity.
Despite concerted efforts to address and eliminate health disparities, many complicated, interrelated factors still need to be overcome. According to the IOM report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, health disparities occur at different levels, including health care systems and their administration, clinicians and their practices, and patients themselves . At the clinical level, there are several factors that may contribute to racial and ethnic health inequity . Clinicians, patients, and the clinical encounter all impact health disparities. For example, a person's interaction with the clinician may lead to non-adherence, distrust, and misunderstandings that lead to poor health. Therefore, primary care clinicians have an important role and the ability to decrease health disparities [8, 9].
The purpose of this paper is to expose primary care clinicians to the current state of health inequality and to describe how they may positively impact health disparities in their practice.
How are health disparities and primary care related?
There are a variety of factors that lead to disparities in care, such as access to care, socioeconomic position, and social factors. In addition, there is evidence that clinic interactions (front desk, medical assistant, etc.) and clinician-patient encounters may lead to health disparities [2, 10–12].
Primary care is the gateway to accessible health care in the United States, especially since the growth of managed care. Primary care has been defined as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of health care needs, developing a sustained partnership with patients, and practicing in the context of family and community [13, 14]. The importance of receiving quality care from primary care clinicians is reflected in a recent review . First, health is better in areas with more primary care clinicians. Better health is characterized by lower rates of mortality, improved health outcomes, and increased lifespan. Second, people who identify a primary care clinician as their usual source of care have better health outcomes as well. Third, the characteristics of primary care are associated with better health. These characteristics are first-contact access for each need; long-term person focused care; comprehensive care; and coordinated care . However, primary care access is inequitable and factors associated with the clinical encounter are related to various health inequalities which interact at different levels [12, 16]. Minorities have reported poorer care compared to whites in several domains of care, such as communication, trust, accessibility to clinics, and continuity of care [17, 18].
Evidence and potential sources of health disparities
Factors that contribute to health disparities can be divided into two sets. The first set involves the operation of healthcare systems and the environment in which they operate. These factors affect access to care. Health insurance has been the most studied factor that affects access to health care. There are about 39.2 million uninsured people in the country, and minorities comprise more than 60% of that population . Availability of services also affects access. Whites are the group with the highest percentage of a usual source of care, while Hispanics are the group with the lowest percentage .
Evidence exists of the differences in the quality of care that is received . Three mechanisms by which healthcare disparities can occur at the clinical encounter are: 1) bias (or prejudice) against minorities; 2) greater clinical uncertainty when interacting with minority patients; and 3) beliefs (stereotypes) held by clinicians about the behavior or health of minorities .
Healthcare provider bias can occur unconsciously. Research has found that prejudicial attitudes still remain common in America , and that clinicians' diagnostic and treatment decisions may be influenced by the patients' race or ethnicity. For example, physicians were found to be less likely to recommend catheterization procedures to African American females compared to white males and females, and African American males . Physicians were also found to rate African American patients as less intelligent, less educated, more likely to abuse drugs and alcohol, more likely to not follow medical advice, and less likely to participate in cardiac rehabilitation than white counterparts . Although there are many factors influencing clinician decisions, subtle factors such as bias may have an effect on the patients and their health outcomes. Primary care clinicians need to become aware of unconscious and unintentional actions or decisions in order to make changes in the way they provide care.
Clinical uncertainty occurs when clinicians make decisions about the severity of an illness based on prior beliefs or experience . These prior beliefs and experiences will be different depending on the age, gender, socioeconomic status, race and ethnicity of the patient. If the clinician does not have the information needed to make a diagnostic decision, (for example, if the clinician has difficulty understanding the symptoms), then the clinician will be more likely to use prior beliefs and experiences to make diagnostic and treatment decisions. As a consequence, the patient's needs may not be met.
Stereotypes can be defined as categories that people use (sex, race, etc.) to process and recall information about others . People then use the information in these categories to understand and simplify complex situations. Although explicit stereotyping is rarely seen these days, it still exists in more implicit and subtle ways. Even people who do not believe they are prejudiced often demonstrate implicit or unconscious bias or stereotypes.
Clinicians must become aware that they are not exempt from unintentional (or intentional) bias or discrimination when caring for patients. Most clinicians strongly refute the idea that they provide differential care to ethnic and racial minorities . However, it is usually small recurrent unintentional acts during the clinician-patient encounter that may contribute to existing health disparities . Awareness by the clinic staff and clinicians is one of many concerted efforts that are needed to reduce health disparities in this country.
Quality medical care is often influenced by system factors outside of the clinician's control, such as time restrictions, cost-containment pressures, insurance status and ability to pay. However, it is important for primary care clinicians to be vigilant and address these issues in order to provide equal and comprehensive medical care regardless of an individual's age, race, ethnicity, gender, and socioeconomic position .
What can primary care clinicians do to address health disparities?
There are several things that primary care clinicians can do in their practice to aid in national efforts to reduce health disparities. Clinicians can receive and provide cultural competence/cross-cultural education, learn how to communicate effectively with patients, and practice evidence-based medicine.
Stages of Cultural Competence
Characterized by attitudes, policies, structures, and practices that are destructive to other cultures. They are dehumanizing of other people, and assumptions of superiority are prevalent. This stage occurs consciously.
This stage occurs when there is unintentional cultural destructiveness, bias, paternalism, ignorance, and/or fear.
Involves a philosophy of being unbiased, treating all people the same, belief that culture, class or color does not make a difference. People in this stage are well-intentioned; however, it is still ethnocentric.
Characterized by the realization of weaknesses and gaps that are missing when working with other cultures. There is a desire for inclusion, a commitment to civil rights, and a desire to implement training. However, there may be a danger of false accomplishment.
Characterized by an acceptance and respect for differences. There is a continual inquiry about other cultures and an expansion of knowledge.
Last stage where all cultures are held in high esteem and there is a responsibility taken for constant development of new knowledge and approaches to interaction. This stage assumes responsibility to transfer skills and advocate cultural competence to others within a system or an organization.
The Office of Minority Health published the Culturally and Linguistically Appropriate Services Standards (CLAS) in 2000 . One of the main themes of the standards is culturally competent care. Cultural competence is defined as a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations . Culture refers to the patterns of behavior in humans that include language, thoughts, communication, actions, customs, beliefs, values, and institutions of race, ethnicity, religion, or social groups . Culture not only refers to race, ethnicity, and religion, but also refers to gender, sexual orientation, age, disability, and socioeconomic status . Educational programs should have a patient-centered focus, where the patient is the center of attention, rather than the patient's cultural group characteristics, or the disease itself.
Carrillo JE, Green AR, Bethancourt JR: Cross-cultural primary care: A patient-based approach. Annals of Internal Medicine 1999, 130: 829–834.
Culhane-Pera KA, Reif C, Egli E, Baker NJ, Kassekert R: A curriculum for multicultural education in family medicine. Family Medicine 2006, 29: 719–723.
Kristal L, Pennock PW, Foote SM, Trygstad CW: Cross-cultural family medicine residency training. Journal of Family Practice 1983, 17: 683–687.
Clark L, Thornam C: Healthcare in multicultural environments. Boulder, CO: University of Colorado School of Nursing; 1998.
Galanti G: Caring for patients from different cultures. 3rd ed. Philadelphia: University of Pennsylvania Press; 2004.
Purnell LD, Paulanka BJ: Transcultural health care: a culturally competent approach, 2nd Edition edn. Philadelphia: F.A. Davis; 2003.
Gropper RC: Culture and the clinical encounter: An intercultural sensitizer for the health profession. Yarmouth, ME: Intercultural Press; 1996.
Rundle A, Carvalho M, Robinson M: Cultural Competence in Health Care: A practical Guide. San Francisco CA: Jossey-Bass; 1999.
Spector R: Cultural Diversity in Health and Illness, 6th ed. Prentice Hall; 2003.
Patient-Centered Interview Questions
What do you call the illness?
What do you think has caused the illness?
Why do you think the illness started when it did?
What problems do you think the illness causes? How does it work?
How severe is the illness? Will it have a long or short course?
What kind of treatment do you think is necessary?
What are the most important results you hope to receive from this treatment?
What are the main problems the illness has caused you?
What do you fear most about the illness?
Adapted from Kleinman et al 
Complex language can have a negative effect on successful communication between a clinician and patient. A report by the IOM found that the complex language that clinicians use to communicate with patients, either verbally or written, is a problem for many patients, not just recent immigrants or those with a low level of education . Termed "health literacy," this important concept must be taken into account when communicating with patients.
Health literacy is defined by the National Library of Medicine and Healthy People 2010 as the "degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" [38–41]. Many factors affect health literacy, such as the patient's level of education, cultural background, and native language. The clinician's ability to effectively and appropriately communicate with the intended audience is also important . Even people with strong health literacy skills have difficulty understanding written information from clinicians, such as patient information sheets and prescription drug labeling . If patients have difficulty understanding instructions given by a clinician, they may not be able to understand their health condition, may have difficulty with treatment decision making, and may not take their medications correctly . A patient centered approach, as shown in Table 3, where the patient's perspectives, values, beliefs, and behaviors are taken into account may reduce these communication barriers.
Clinicians and patients who do not speak the same language substantially complicate communication issues. Using trained interpreters is the best way to ensure that patients understand information that is given to them. If non-trained interpreters are used, such as family members or employees who are pulled from their regular job to interpret who are not aware of the potential problems that may arise, problems of lost information, misunderstandings, and miscommunication may occur. This may result in patients not having their needs addressed, requiring returned clinic visits, ordering unnecessary tests, or even misinterpretations regarding prescribed drugs. The Cross Cultural Health Care Program (CCHCP) developed guidelines to help clinicians work through an interpreter . These guidelines state that the decision to use an interpreter is made whenever the clinician feels that language or cultural differences may cause a barrier to clear communication, or whenever a patient requests an interpreter. Choosing an interpreter may also be a challenge. The CCHCP makes several suggestions as to how to choose an interpreter. First, make sure that the interpreter is fluent in both languages; testing may be needed. Second, make sure the interpreter is trained as an interpreter. The fact that a person is bilingual does not make her or him an interpreter; there are special skills involved. Third, do not use a family member. Family members often edit the patient's message, add their own opinions, and answer for the patient. Fourth, never use a child. This creates role reversal and power reversal, and it should not be the responsibility of a child to relay bad news to parents or family members.
The CCHCP also provides suggestions on how to work through an interpreter . First, request interpretation of everything, and in the first person. Second, speak directly to the patient, not to the interpreter. Third, insist that everything you say is interpreted, as well as everything that the patient says, or that family members say. Fourth, be patient. Providing care through an interpreter often takes longer. However, this will avoid wasted time, misunderstandings, or unnecessary tests.
Some organizations or clinicians' offices may be too small to hire a full time interpreter or there may be barriers to hiring bilingual staff. In such cases, another option would be using the American Telephone and Telegraph (AT&T) language line . The service may be used by a subscribed client or company, or may be used by an unsubscribed individual for less frequent use. Although at first glance the price for this service may seem quite expensive (ranging from $2.20 per minute to $7.25 per minute), it becomes cost-efficient in the long run because clinicians will have a better understanding of the patients' symptoms, conditions, and life styles. Patients will also have a better understanding of their condition and their medications, and will be less likely to return due to misunderstandings.
Practicing Evidence-Based Medicine
Useful Evidence-based Medicine Web Sites
Agency for Healthcare Research and Quality Guideline Resources
American College of Physicians Journal Club
Database of Abstracts of Reviews of Effects (DARE)
Evidence-based Medicine Journal
Evidence Syntheses and Systematic Evidence Reviews (USPSTF)
Guide to Clinical Preventive Services, 2005 (USPSTF)
National Guideline Clearinghouse
Although the recommendations provided may not be simple to implement, primary care clinicians can have a significant role in reducing health disparities through incremental changes. Education is the key to understanding patients' perspectives and providing a higher quality of care. Other steps that can be taken are conscious efforts to communicate with patients more clearly and using trained interpreters when needed. Also, communication style, such as asking questions in a more caring manner or validating a patient's concern, may have a positive impact on the health of patients. The use of EBM may be beneficial, not only for the populations that experience health disparities, but also for the patient population as a whole, reducing costs and increasing equity. The sum of our small changes, taken together, will make a significant impact.
American Telephone and Telegraph
Cross Cultural Health Care Program
Culturally and Linguistically Appropriate Services Standards
Database of Abstracts of Reviews of Effects
Institute of Medicine
This manuscript was supported in part by the National Institutes of Health/National Center on Minority Health and Health Disparities grant 1-P20-MD001633-010003.
- United States Census. [http://www.census.gov]
- Institute of Medicine: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Edited by: Brian D Smedley, Adrienne Y Stith, Alan R Nelson. 2003, Washington, DC, National Academies PressGoogle Scholar
- Agency for Healthcare Research and Quality: National Healthcare Disparities Report. 2003, Rockville MDGoogle Scholar
- Centers for Disease Control and Prevention: Fact Sheet: Racial/Ethnic Health Disparities. United States Department of Health and Human Services. 2004Google Scholar
- Henry J, Kaiser Family Foundation: Key Facts: Race Ethnicity and Medical Care. 2003, Washington, DCGoogle Scholar
- National Cancer Institute: Cancer Health Disparities Fact Sheet. U.S. Department of Health and Human Services. National Institutes of Health. 2006Google Scholar
- O'Malley CD, Le GM, Glaser SL, Shema SJ, West DW: Socioeconomic status and breast carcinoma survival in four racial/ethnic groups: a population-based study. Cancer. 2003, 97: 1303-1311. 10.1002/cncr.11160.View ArticlePubMedGoogle Scholar
- Smith JH: Eliminating health disparities: our mission, our vision, our cause. American Family Physician. 2001, 64 (8): 1333-4.PubMedGoogle Scholar
- Hixon AL, Chapman RW: Healthy People 2010: The Role of Family Physicians in Addressing Health Disparities. American Family Physician. 2006, 62:Google Scholar
- Williams DR, Jackson PB: Social Sources of Racial Disparities in Health. Health Affairs. 2005, 24: 325-334. 10.1377/hlthaff.24.2.325.View ArticlePubMedGoogle Scholar
- DeVoe JE, Fryer G, Phillips R, Green L: Receipt of Preventive Care Among Adults: Insurance Status and Usual Source of Care. American Journal of Public Health. 2003, 93: 786-791.PubMed CentralView ArticlePubMedGoogle Scholar
- Shi L, Forrest CB, Von Schrader S, Ng J: Vulnerability and the Patient-Practitioner Relationship: The Roles of Gatekeeping and Primary Care Performance. American Journal of Public Health. 2003, 93: 138-144.PubMed CentralView ArticlePubMedGoogle Scholar
- Institute of Medicine: A Manpower Policy for Primary Health Care. National Academy of Sciences. 1978, Washington, DCGoogle Scholar
- Donaldson MS, Yordy KD, Lohr KN, Vanselow NA: Primary Care: America's Health in a New Era. 1996, Washington, DC: National Academy PressGoogle Scholar
- Starfield B, Leiyu S, Macinko J: Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly. 2005, 83: 457-502. 10.1111/j.1468-0009.2005.00409.x.PubMed CentralView ArticlePubMedGoogle Scholar
- Stewart A, Napoles-Sprnger A, Perez-Stable E: Interpersonal Processes of Care in Diverse Populations. The Milbank Quarterly. 2006, 77: 305-339. 10.1111/1468-0009.00138.View ArticleGoogle Scholar
- Cooper L, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR: Patient-Centered Communication, Ratings of Care, and Concordance of Patient and Physician Race. Annals of Internal Medicine. 2003, 139: 907-915.View ArticlePubMedGoogle Scholar
- Cooper LA, Powe NR: Disparities in Patient Experiences, Health Care Processes, and Outcomes: The Role of Patient-Provider Racial, Ethnic, and Language Concordance. The Commonwealth Fund. 2004Google Scholar
- National Center for Health Statistics: Health, United States. 2003, 52 (3):Google Scholar
- Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ, et al: The effect of race and sex on physicians' recommendations for cardiac catherization. New England Journal of Medicine. 1999, 340: 618-626. 10.1056/NEJM199902253400806.View ArticlePubMedGoogle Scholar
- van Ryn M, Burke JE: The effect of patient race and socio-economic status on physician's perceptions of patients. Social Science and Medicine. 2000, 50: 813-828. 10.1016/S0277-9536(99)00338-X.View ArticlePubMedGoogle Scholar
- Abreu JM: Conscious and nonconscious African American stereotypes: impact on first impression and diagnostic ratings by therapists. J Consult Clin Psychol. 1999, 67: 387-393. 10.1037/0022-006X.67.3.387.View ArticlePubMedGoogle Scholar
- Cross TBBDK & IM: Towards a Culturally Competent System of Care. 1989, CASSP Technical Assistance Center, Center for Child Health and Mental Health Policy Georgetown University Child Development Center. Washington, DCGoogle Scholar
- Office of Minority Health: 2001, National Standards for Culturally and Linguistically Appropriate Services in Health Care. Washington, DC
- Cross TL, Bazron BJ, Dennis KW, Isaacs MR: Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. 1989, Washington, DC, National Technical Assistance Center for Children's Mental Health, Georgetwon University Child Development CenterGoogle Scholar
- Carrillo JE, Green AR, Bethancourt JR: Cross-cultural primary care: A patient-based approach. Annals of Internal Medicine. 1999, 130: 829-834.View ArticlePubMedGoogle Scholar
- Culhane-Pera KA, Reif C, Egli E, Baker NJ, Kassekert R: A curriculum for multicultural education in family medicine. Family Medicine. 2006, 29: 719-723.Google Scholar
- Kristal L, Pennock PW, Foote SM, Trygstad CW: Cross-cultural family medicine residency training. Journal of Family Practice. 1983, 17: 683-687.PubMedGoogle Scholar
- Clark L, Thornam C: Healthcare in multicultural environments. 1998, Boulder, CO: University of Colorado School of NursingGoogle Scholar
- Naish J, Brown J, Denton B: Intercultural consultations: investigation of factors that deter non-English speaking women from attending their general practitioners for cervical screening. BMJ. 1994, 309 (6962): 1126-1128.PubMed CentralPubMedGoogle Scholar
- Hampers LC, Cha S, Gutglass DJ, Binns HJ, Krug SE: Language barriers and resource utilization in a pediatric emergency department. Pediatrics. 1999, 103: 1253-1256. 10.1542/peds.103.6.1253.View ArticlePubMedGoogle Scholar
- Flores G, Fuentes-Afflick E, Barbot O, Carter-Pokras O, Claudio L, Lara M, et al: The health of Latino children: urgent priorities, unanswered questions, and a research agenda. JAMA. 2002, 288: 82-90. 10.1001/jama.288.1.82.View ArticlePubMedGoogle Scholar
- Manson A: Language concordance as a determinant of patient compliance and emergency room use in patients with asthma. Med Care. 1988, 26: 1119-1128. 10.1097/00005650-198812000-00003.View ArticlePubMedGoogle Scholar
- Baker DW, Parker RM, Williams MV, Coates WC, Pitkin K: Use and effectiveness of interpreters in an emergency department. JAMA. 1996, 275: 783-788. 10.1001/jama.275.10.783.View ArticlePubMedGoogle Scholar
- Woloshin S, Bickell NA, Schwartz LM, Gany F, Welch HG: Language barriers in medicine in the United States. JAMA. 1995, 273: 724-728. 10.1001/jama.273.9.724.View ArticlePubMedGoogle Scholar
- Stewart AL, Napoles-Springer AM, Perez-Stable EJ: Interpersonal Processes of Care in Diverse Populations. The Milbank Quarterly. 1999, 77: 305-339. 10.1111/1468-0009.00138.PubMed CentralView ArticlePubMedGoogle Scholar
- Kleinman A, Eisenberg L, Good B: Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine. 1978, 88: 251-258.View ArticlePubMedGoogle Scholar
- Institute of Medicine: Health Literacy: A prescription to end confusion. Edited by: Nielsen-Bohlman L, Panzer AM, Kindig DA. 2004, Washington, DC, National Academies PressGoogle Scholar
- Selden CR, Zorn M, Ratzan SC, Parker RMN, Selden CR, Zorn M, Ratzan SC, Parker RM: National Library of Medicine Current Bibliographies in Medicine: Health Literacy. NLM Pub. No. CBM 2000-1. 2000, Bethesda, MD, National Institutes of Health, U.S. Department of Health and Human ServicesGoogle Scholar
- U.S.Department of Health and Human Services: Healthy People 2010: Understanding and Improving health. Edited by: . 2000, Washington, DC, U.S. Department of Health and Human ServicesGoogle Scholar
- Ratzan SC, Parker RM: Introduction. National Library of Medicine Current Bibliographies in Medicine: Health Literacy. NLM Pub. No. CBM 2000-1. Edited by: Selden CR, Zorn M, Ratzan SC, Parker RM. 2000, Bethesda, MD, National Institutes of Health, U.S. Department of Health and Human ServicesGoogle Scholar
- The Cross Cultural Health Care Program: Guidelines to Providing Health Care Service Through and Interpreter. 2006, Seattle, WA. 4-24-0006Google Scholar
- The Cross Cultural Health Care Program. [http://www.xculture.org]
- Language Line Services. [http://www.languageline.com]
- What is EBM? University of Toronto Center for Evidence-Based Medicine. 2006
- Straus SE, Richardson WS, Glasziou P, Haynes RB: Evidence-based Medicine: How to Practice and Teach EBM. 2006, Churchill Livingston, Edinburgh, England: Harcourt Brace & Co. Ltd, ThirdGoogle Scholar
- Xu KT, Moloney M, Phillips S: Economics of suboptimal drug use: cost-savings of using JNC-recommended medications for management of uncomplicated essential hypertension. Am J Manag Care. 2003, 9: 529-536.PubMedGoogle Scholar
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