Reducing Health Disparities Among African-American

Reducing Health Disparities among African-American Women with Metabolic Syndrome

In the past few years, the increasing number of health disparities among African-American women, specifically those ages 35 to 50 with metabolic syndrome, have raised concern and awareness among health care organizations, policy makers and citizens alike. Racial and ethnic minorities experience higher rates of a variety of health concerns than other populations. Research indicates that just a few years ago, nearly 8% of whites were considered to be in fair or poor health compared to nearly 13% of Hispanics / Latinos, nearly 14% of African-Americans and more than 17% of Native Americans. The proposed research project targets this severe problem affecting women in the African-American community. The specific community to be studied involves African-American women affected by metabolic syndrome, including diabetes and hypertension, residing in Montgomery County, Maryland. The study will examine the current use of technology to promote physical activity among this population and suggest future uses of technology to reduce health disparities.

Defining Health Disparities in the African-American Women Population

Other health disparities among African-American women include a doubled amount of infant death rates than that of whites, a 30% higher cancer death rate among African-Americans than whites, and a higher death rate from breast cancer than white women and Vietnamese. In addition, African-American women have a cervical cancer rate that is nearly five times the rate for white women, and the death rate for HIV / AIDS for African-Americans is more than seven times that for whites. Research indicates that there are several potential reasons for such ethnic and racial health disparities. A prominent reason is that even when racial or ethnic minorities are insured at levels comparable to whites, they tend to receive a lower quality of health care for the same health conditions. Research also indicates that African-American patients are less intelligent, less educated, and more likely to abuse drugs, alcohol and more likely to fail to comply with medical advice. African-Americans face reduces access to care, as they are nearly one and a half times more likely to be denied authorization through their managed care system for care after an emergency room visit than whites.

Trends of increased overweight prevalence in children reflect an accelerated gradient in black and Mexican-American children as compared with white children.

Substantial cultural heterogeneity also exists within each aggregate minority population. Within all populations, obesity prevalence varies by region, socioeconomic status, and other demographic variables. Attitudes about obesity also vary across cultures, as where thinness is associated with extreme poverty, deprivation, or wasting diseases, obesity may be viewed as a symbol of social stature, prosperity, and robustness.17

State-Wide Research on Health Disparities

The role of obesity in predisposing individuals to diabetes, hypertension, and other aspects of cardiovascular disease is well established, and obesity contributes to racial/ethnic disparities in cardiovascular disease risk. A gradient of increasing risk of diabetes, hypertension, and coronary heart disease with increasing body mass index levels can be readily demonstrated in several available data sets for blacks, and some related data also are available for other racial/ethnic groups. In particular, obesity has been identified as a contributor to the excess prevalence of diabetes in minority populations. Benefits of weight loss for reducing hypertension-related risks have been reported for black patients in several clinical trials. Weight gain and retention in association with pregnancy have also been identified as risk factors for obesity in black women.

Other potential causes can be found in macrosocietal changes that accompany economic and nutrition transitions, characteristics of local environments that constrain individual choices with respect to eating and physical activity, and sociocultural influences on lifestyle behaviors related to weight gain and weight control. Research indicates that some of these factors may exert their effects early in life, such as during gestation or in infancy, through maternal weight status, or in parental feeding behaviors.

The serious limitations of current approaches to obesity treatment and particularly the apparent less-than-average success of treatment approaches in racial and ethnic minority populations reveal a need to reduce health disparities.

Metabolic syndrome, also known as the insulin-resistance syndrome, refers to a specific clustering of cardiovascular risk factors in the same individual, including abdominal obesity, elevated blood pressure, and insulin resistance. Patients with the metabolic syndrome are at increased risk for developing diabetes and cardiovascular disease. According to a recent analysis of data from the Third National Health and Nutrition Examination Survey, 23. 7% of Americans have the metabolic syndrome. African-American women had a 57% higher prevalence for the syndrome than did black men, who had the lowest prevalence in this study. As a result of the close relationship of obesity to the metabolic syndrome, the rising prevalence of obesity in the United States is cause for particular concern.

Management of the metabolic syndrome consists primarily of 2 strategies: modification or reversal of the root causes, including weight reduction and increased physical activity, and direct treatment of the metabolic risk factors. All of the components of the metabolic syndrome may be improved with weight reduction and increased physical activity. Treatment of several of the individual risk factors associated with the metabolic syndrome has been shown to decrease cardiovascular disease risk, although no randomized clinical trials are yet available to show a decrease in clinical events or increased survival following treatment of the metabolic syndrome.

Importantly, recognition, diagnosis, and treatment of the metabolic syndrome have the potential to contribute importantly to the reduction of health disparities. Research indicates that although data on other racial and ethnic minorities is limited, the high morbidity and mortality rates from cardiovascular disease in African-Americans can be explained in part by the high prevalence and severity of modifiable risk factors. Thus, patients who are at high risk for the metabolic syndrome, such as those with multiple risk factors, should be targeted for intensive risk-reduction measures.

As a result, reduction in racial and ethnic health disparities requires targeting for vigorous prevention and risk-reduction measures.

Health Disparities in Montgomery County, Maryland

Montgomery County, Maryland is a county that represents an increased population of health disparities among African-American women. In the past few years, the Montgomery County Department of Health and Human Services attempted to increase awareness of the disparity in infant mortality between African-American and other County residents. The community identified reducing African-American infant mortality as a priority and established the African-American Health Initiative to work toward eliminating the disparity in infant mortality as well as other health status disparities. Other Montgomery County focus areas include increasing access to care for low-income, uninsured residents; reducing substance abuse, reducing family violence by providing support to high-risk families, reducing asthma hospitalizations among minority children, reducing incidence and complications of diabetes among African-Americans and increasing access to health care.

Infant mortality, or deaths occurring any time between the date of birth and the first birthday, is a cause of concern that illustrates the health disparity in Montgomery County, Maryland. Deaths occurring between 29 days and one year of age are due to a wider variety of causes, including Sudden Infant Death Syndrome and infection, in addition to the causes of neonatal mortality. From 1990 to 1998, the infant mortality rate among African-Americans in Montgomery County was about four times greater than among white infants. In addition, the County's African-American infant mortality rate has frequently exceeded the statewide rate. Access to care, or lack of prenatal care is strongly associated with an increased risk for low birth weight infants, preterm delivery, and maternal and infant mortality.

Montgomery County, through a partnership with Holy Cross Hospital, provides prenatal care for low-income, uninsured women not eligible for Medical Assistance. A smaller percentage of African-American women in Montgomery County, entered prenatal care in the first trimester compared to white women. These problems in infant mortality are a variety of causes, many of which are preventable, such as infection, inadequate prenatal care and poor nutrition. Excluding teenagers, a larger percentage of African-American women in all age groups had low birth weight babies compared to white women in Montgomery County.

The Use of Shared Decision Making to Reduce Health Disparities

Research indicates that shared decision making is an important aspect of making a difference in health disparities among African-American women. It is also clear that interventions to improve access to medical care and reduce behavioral risks must be combined with broader efforts to increase socioeconomic status and reduce racial and ethnic discrimination in eliminating health disparities. Shared decision making could be promoted through collaboration and increased communication among local public health departments, state and local government officials, non-government agencies and organizations, such as voluntary agencies, community-based organizations and philanthropic groups. Additionally, valid, available, and reliable health data must be available on each population category.

Furthermore, African-American community members must be able to design strategies and activities relevant to their cultures, traditions, customs, and beliefs. It should be a priority to promote health and prevent health problems before risks are apparent and problems occur. Community-determined, culturally-relevant strategies that enhance, promote, and improve the health status of communities must also be implemented as well. Community resources must be identified and brought together to meet needs. Actions can be developed to prevent poor health outcomes by: appropriately identifying, collecting, and reporting racial/ethnic group-specific data; identifying where data are lacking and developing appropriate tools to collect those data; and linking poor health status indicators to social conditions and influences, as well as personal behaviors and genetics.

As indicated by other counties, the populations experiencing these disparities have many strengths and traditions to draw upon for solutions. In the African-American communities, churches provide connections and leadership on community issues. Other models have provided the use of community engagement principles encouraged throughout any state and local processes addressing eliminating health disparities, whether funded by this initiative or not. Such community engagement principles include fostering openness and participation in the planning process, ensuring that those representing a specific community truly represent that community's values, norms, and behaviors, and using strategies that insure inclusion, representation, and equality in the planning process. For example, ensuring that those representatives who are included in the process participate in a meaningful way and share fully in the decision making process; and offering orientation and skill building opportunities so that everyone will have an equal voice in voting and other decision making activities.

Other possible shared decision making processes include developing cultural competence in the organization's staff, and communicating with and involving the community in the planning process. Other general solutions include addressing issues of unequal access to affordable, nutritious food, working to improve community environments that promote physical activity and wider mental well-being and quality of life, advocating for good quality, affordable housing and promoting education, literacy, and employment. The lessons and specific effective strategies should be shared with other communities so that successful approaches can be promoted and additional new approaches tried.

Members of communities must also be intricately involved in assessing the strengths, resources, and needs of the community, and in planning for and overseeing activities toward improved health status. Community members must become actively involved in designing and implementing strategies, as that will likely lead to more effective approaches. Relationships that lead to increased mutual knowledge, comfort, familiarity and trust must be built before launching into major new efforts. Finally, research indicates that money spent on prevention of sickness, chronic conditions, and injuries is an investment in preventing or reducing more serious and expensive health crises later.

The Use of Technology to Reduce Health Disparities

High technology medical innovation remains implicated as one of the most significant driving forces behind the high costs of health care in the United States. In addition, health care organizations are faced with an increasingly complex and uncertain environment. Research indicates that these factors interrelate to affect decisions made to acquire high cost medical technology. One recent study of hospitals in three states assessed the manner in which environmental variables affect technology acquisition decision making. The results revealed that among the important criteria are physician recruitment and retention and perceived competitive pressure. An analysis of the data reveals that technology is acquired as one means of reducing environmental uncertainty. Within a growing number of integrated health systems, collaboration acts to both control costs and reduce duplicative technology. However, research also indicates that in order for collaboration to be successful, a strong bond of trust must exist between decision makers in addition to any economic benefit derived from the union.

Decision making in health care involves two sets of related decisions, those concerning appropriate service provision on the basis of existing information and those concerned with whether to fund additional research to reduce the uncertainty relating to the decision. The model becomes the vehicle of health technology assessment, managing and directing future research effort on an iterative basis over the lifetime of the technology. This ensures consistency in decision making between service provision, research and development priorities and research methods. Research effort can then be focused on those areas where the cost of uncertainty is high and where additional research is potentially cost-effective.

Health promotion and care information systems and technology adopt different roles and characteristics, depending on multiple determinants, such as the goals pursued by the health care delivery systems. The importance of information in health services relates to its support to the aspects of management and operation: Included in the management and operation aspects is the use of technology. This technology usually sustains the day-to-day operation and management of health services and health care network, and support of diagnostic and therapeutic functions.

In health services, information systems and their associated technological infrastructure are oriented to the support of two functional levels; the logistics of healthcare; flow, registry, processing, and recovery of clinical and administrative data, and the administrative operation, accounting, financing, and human and physical resources management.

Thus, systems that utilize operational data arising from the operation of health systems and services in support of decision functions, are an extremely important element of healthcare. Different levels of care and management require distinct aggregation and display of processed data. A necessary proposal involving the use of technology to promote physical activity among African-American women would be successful. Such a technological program could entail such elements as a mandatory weight, heart rate, and fat index on a regular basis. A technological mandate such as this would provide knowledge regarding diseases such as diabetes or cardiovascular disease that the individual was not previously aware of.