hapter C 1 Tuskegee syphilis study Who? What? When? Where? Who: study involved 600 black men. 399 with syphilis and 201 who did not have the disease. Researchers said they were being t reated when in fact t hey were not being t reated correctly. W hat: researchers underestimated the length of the study and were i nvolved in a lawsuit from the NAACP, which entitled all participants to free medical and burial services. The Tuskegee health benefit program was made to provide these services. I t also gave health services for wives, widows, and children who had been infected because of the study. When: 1932 to 1972 Where: Macon County, Alabama Racial Category terms and terminology uses Race/ethnicity refers to the set of categories used to group individuals Minority refers to all of the groups generically Black and African American refer to people of African descent (including A frican Americans, native Africans, and persons from the Caribbean and south America) H ispanic/latino refers to people central and south America (including mexico), the Spanish-speaking Caribbean (Puerto r ico, cuba, and dominican republic), and brazil. American Indian refers to all indigenous Americans from what is now the continental united states. Alaska natives refers to indigenous populations of Alaska. Asian/pacific islander refers to persons having origins in any of the original peoples of the far east, southeast asia, the Indian subcontinent, or the pacific islands. (china, india, japan, korea, the phillippine islands, and samoa) Racial/ethnic minorities health status Generally have worse health status than whites and higher fertili ty r ates than whi te Americans. Why is i t important to study minority health? An aging society combined with increasing proportions of minorities w ill place increasing demands on a health care system that seems illprepared to handle it. Thus i ts important for minori ty health to be a central feature of t raining programs in. Civil Rights Act of 1964
P rohibited discrimination in public accommodations such as mass t ransportation, restaurants, and hotels on the basis of race, color, religion, or national origin. Chapter 2 Nature of race and ethnicity Blumenbach 1775 classified humans into 5-fold classification 1. Caucasian or white 2. Mongolian or yellow 3. Malayan or brown 4. Negro or black 5. American or red Race concept Problems with the race concepts 1. The concept has not been clearly defined no consistently applied 2. There is no consensus definition of race 3. Race is often confounded with other related concepts such as ethnicity and nationality 4. The existence of races has li t t le support from biological or genetic research One-drop rule Means that one-drop of non-white blood makes a person a member of t hat group. Policy for determining racial status Us Policy for racial status Father Mother Child White White White White Black Black White Japanese Japanese Black White Black Black Japanese Black Black Black Black Japanese White Japanese Japanese Black Japanese Japanese Japanese Japanese
Japanese policy for racial status Father Mother White Japanese Black Japanese Japanese White Japanese Black Brazilian policy for racial status Father Mother White White White Black Black White Black Black Differences between race and ethnicity
Child White Black Japanese Japanese
Child White Mulatto Mulatto Black
Race presumes shared biological or genetic t raits. E thnicity connotes shared cultural t raits and a shared group history. Directive 15 Set standards for collection of data on race and ethnicity. Set 5 categories for data on race. 1.American Indian or Alaska native 2. Asian or Pacific Islander 3. Black 4. White 5. H ispanic The directive instructed that race and ethnicity be captured by separate questions. One asking race, and the other asking ethnicity (Hispanic o rigin or not H ispanic origin) Conceptual models of race/ethnicity and health In the model, race is viewed as latent factor in which skin color is the most commonly used manifest indicator. Social r isk factors include racism, sexism, socioeconomic status, social support, population density, housing quality, racial segregation, stress, or residence in a neighborhood with high c rime rate. Race and ethnicity are social categories, not biological ones. Left s ide of the model is the social pathway and r ight side is the behavioral pathway.
K now all key terms as listed at the end of the chapter Race- Persons who are relatively homogeneous with respect to b iological inheritance. Ethnicity- refers to cultural commonality Species- a class of individuals having some common characteristics or qualities; distinct sort or kind OMB directive 15- established standards for the collection of data on r ace and ethnicity. Goal was to provide consistent and comparable data on r ace and ethnicity throughout the federal govt for an array of statistical and administrative programs. Physiognomy- the art of judging human character from facial features Chapter 3 T he US demographics by 2050 American population will be 400 million. By 2020 there will be more than 50 million American seniors. Increase in # of seniors can be a tt r ibuted to r ising life expectancy, surge of births after WWI I -- the anticipated movement in to the ranks of the elderly of the baby boom generation. US population is 75% white, 12% black, 12% H ispanic, and 4% Asian. Doesnt add up to 100 because of rounding. The region with the largest population is t he south. The region with the smallest population is the northeast. Minority population distribution African Americans are largest minority group in northeast, Midwest, and south. Hispanics are the largest minority group in the west. H ispanics a re the 2nd l argest group in US. Fertili ty rates and birth rates Each minority group has a higher fertili ty rate than whites. The total U.S. fertili ty rate is declining. H ispanics have the highest fertility rate. Fertility rates are the total # of live births per 1000 women of childbearing age Bir th rates are (the # of live births in a year within a given age group/ total # of women in that age group) M inority-Majori ty shift Minority populations are younger with more persons in the childbearing ages. White population is a rapidly aging population
Teen childbearing (# of teen births/all births) X 100 Puerto Ricans have the highest % of births to teen mothers follow by b lacks, and American Indians, the other H ispanic, Hawaiians, Mexicans, and H ispanics. For each of these groups, between 15-20 percent of the live births in the year 2000 were to mothers below the age 20. Know all the key terms as listed at the end of the chapter Fertility - refers to the # of offspring produced by a population. Crude mortali ty rate- (# of deaths in a given year/ midyear # of persons i n the population of the age group) X 1000 = # of deaths in a year per 1000 of t he midyear population Age-specific mortality rate- (# of deaths among persons of a given age d uring a year/ midyear # persons in the population of the age group) X 1000 = # of deaths of persons of a given age during a year per 1000 of the midyear population at that age Age-adjustment (age-standardization)- a p rocedure for adjusting various rates, such as birth and death rates, to minimize the effects of d iffering age distributions when comparing difference populations. Chapter 4 Epidemiology Key terms Rate- (# of events in specified period/average population during specified time period) X 10^n L ife expectancy- # of years a given individual can expect to live. Prevalence- the # number of occurrences of a given disease or condition w ithin a given population at a given point in time. Typically expressed as a r ate (prevalence rate). The # of instances of a given disease or other condition i n a given population at a designated time. Incidence- the # of new cases of a given disease or condition within a g iven population of persons who are at r isk of getting the disease at a given point in time. Incidence rate is the # of new cases of the disease or condition d ivided by the number of persons exposed o r isk during the time period being examined. Tools
E xamining Mortali ty Crude death rate, age-adjusted death rate, infant mortality rate, low bir th weight, maternal mortality rate, life expectancy, and years of potential life lost. Examining Morbidity Prevalence rates Incidence rates
Mortali ty/Morbidity Mortali ty When comparing populations i t is important to refer to relative s ize of the population. Men have higher mortality rates. Blacks have higher mortali ty rates. For both male and female blacks have the highest ageadjusted mortality rate and Asians have the lowest. Morbidity Morbidity is defined as any departure, subjective or objective, f rom a state of physiological or psychological well-being. I t is the state of being sick or ill or having a disease, either physical or mental. Surveys p rovide best data. N H IS is the principal source of info on the health of the noninstitutionalized civilian population of the US. I t is one of the major data collection programs of the NCHS. The main objective of the N H IS is to monitor the health of the US population th rough the collection and analysis of data on a broad range of health topics. A major strength is the ability to d isplay these health characteristics by many demographic and socioeconomic characteristics L ife expectancy L ife expectancy is hypothetical and can be calculated from any age. L ife expectancy at birth is greatly in fluenced by infant mortality. Black women and whi te males had relatively equal life expectancy. White females have the h ighest life expectancy. Of the countries Japan has the highest life expectancy. 3 factors contribute to life span 1. Socioenvironmental factors -refer to characteristics in the physical environment that impact individuals.
2. Behavioral factors -refer to actions that an individual takes that may affect health and life span. 3. Biological inheritance -refers to the degree to which an i ndividuals genetic endowment predisposes that individual to long life. Mortali ty crossover The reversal of mortality rates between advantaged and disadvantaged populations. Just beyond age eighty blacks actually have a higher life expectancy than whites. Some believed that the crossover was merely a data anomaly resulting from low quality birth records during the early twentieth century. The consistency of this finding and i ts replication using many d ifferent research designs has led to a general consensus today that the mortali ty crossover is a real phenomenon. I t is now generally accepted that t he mortality crossover is cause by selective survival of the healthiest older A frican Americans. Survival curve Survival curve shows the proportion of a birth cohort projected to be a live as the population ages. The curve begins at 100% and the percent living declines as the population ages. For persons above 80 the curve begins to converge and the tails off above age 100. Infant mortali ty Used as a marker of the general health status of a population, and t hese rates are often used to conduct analysis comparing across societies. B lacks have highest infant mortality rate. Asians/pacific islanders have the lowest infant mortality rates. 2/3 of infant deaths occur during the neonatal period and the other third in the postneonatal period. Blacks have the highest neonatal mortality rate and Asians/pacific islanders have the lowest. Of the H ispanic/Latino subgroups Puerto Ricans have the highest infant mortali ty r ate and Cubans the lowest. The COUNTRY with the lowest infant mortality r ate is Japan and Russia has the highest. B ir th weight is the strongest predictor of infant death. Blacks have the h ighest low birth weight rate and very low birth weight rate. Asian/pacific islander has lowest very low birth weight rate. And H ispanics have the lowest low bir th rate. Self-assessed health status
I t is increasingly being recognized as a valid measure for predicting f uture health outcomesespecially survivalamong older people. Can also p rovide info on projected use of health services, which is useful in planning and policy development. Measured by survey. African Americans had the l argest percentage indicating that they have fair or poor health. Asians have t he lowest percent of persons indicating fair or poor health. Asians/pacific islanders tend to have the best health status. I ncidence/prevalence African Americans have the highest prevalence rate of hypertension. T he lowest prevalence rates were found among Central Americans. Native A mericans have the highest diabetes prevalence rate. Lowest diabetes p revalence rate are among Central Americans and Asians. And prevalence r ate of dental pain is highest among Native Americans. Know all key terms as listed at the end of the chapter Health disparities- differences in the incidence, prevalence, mortality, and burden of disease and other adverse health conditions that exist among specific population groups in the US Health care disparities- differences in access, utilization, quality of care, or outcomes form use of health care services. Epidemiology- the study of the distributions and determinants of mortali ty (death) and morbidity (illness) in human populations. Age-adjusting- allows us to estimate the differences in mortali ty rates t hat would exist between two states if each state had the same age d istr ibution. Survival curve- a way in which we can compare differences in death r ates across populations. Infant mortali ty - calculated as the total # of infant deaths divided by t he total # of live births times 1000. Neonatal mortality - refers to deaths within the fi rst 28 days of birth Post neonatal mortality - refers to deaths between 29 days and one year a fter birth. Low birth weight - below 5.5lbs. Very low birth weight - below 3.31 lbs Maternal mortality - death of the mother while pregnant. Blacks have t he highest maternal mortali ty rate.
L ife expectancy- hypothetical, measures the expect number of years t hat average person within a given birth cohort can expect to live if present t rends in mortali ty rates do not change. Mortali ty crossover - that in old age the death rate for black Americans is lower than the rate for whi te Americans. Chronic condition - a health condition with a long duration. Leading causes of death in the US. Not cured once acquired. Acute condition - a type of illness or injury that ordinarily lasts less t han 3 months Years of potential life lost - average number of years of life lost per 100,000 person assuming that every person would otherwise live to age seventy five. Younger people are responsible for a greater number of potential year of life lost. Activity of daily living- basic tasks of everyday life, such as eating, bathing, dressing, toileting, and t ransferring (getting in and out of bed, or chair.) Chapter 5 Various mental illnesses & disorders Diagnoses of mental disorders and difficulties A formal diagnosis of a mental disorder made is by clinicians and h inges upon 3 components. 1. a patients description of the nature, intensity, frequency, patterning, and duration of symptoms. 2. A developmental history and signs from a mental status examination. 3. A clinicians observation and in terpretation of the patients behavior, including a global assessment of functional i mpairment. In the end diagnosis is based on judgment of psychiatrist, clinical or counseling psychologist, or clinical social worker. If the provider is not knowledgeable about the cultural context in w hich the patient lives, it may be difficult to make judgments about t he appropriateness of the patients behavior or the degree to which t he behavior will impair functioning at home, school, or work, or in the community.
Definitions, symptoms, r isk, & protective factors Box 5.4 below Major depressive disorder - restlessness, thoughts of death or suicide, feelings of guilt, worthlessness, helplessness, sad, decreased energy, i nsomnia. Dysthymic disorder - chronic symptoms that dont disable but keep one f rom peak functioning. Chronically depressed mood that occurs often in an i ndividual for at least two years. Bipolar disorder - manic-depressive illness, cycling mood changes that i nclude presence of one or more manic episodes, or periods of abnormally and persistently elevated, expansive, or i r r i table modd, and one or more major depressive episodes. Suicide- usually has a mental disorder, white men have the highest suicide rate at all ages. Schizophrenia- delusions, hallucinations in any sensory modality, d isorganized speech, grossly disorganized behavior, and catatonic motor behaviors that significantly impair social and occupational functioning. Panic disorder - recurrent panic attacks, or discrete periods of in tense ter ror or discomfort, in the absence of real th reat and danger. Sweating, t rembling, dizziness, and nausea. Obsessive-compulsive disorder - int rusive anxious thoughts and i mpulses and engagement in r i tualized, repetitive behaviors or mental acts to p revent or reduce anxiety or distress. Posttraumatic stress disorder - intense fear, helplessness, horror, or d isorganized, agitated behavior that develops following exposure to an extreme t raumatic event. Social phobia- persistent and chronic fear of being watched and judged by others and of being embarrassed or humiliated by their own actions. Specific phobia- specific phobias are centered around animals or i nsects, specific situations, objects in the natural environment, injuries i nvolving blood, invasive medical procedures, or other stimuli. Generalized anxiety disorder - fatigue, restlessness, muscle tension concentration difficulties, i r r i tabili ty, and sleep disturbances. Anorexia nervosa- compulsive exercise, vomiting, enemas, laxatives d iuretics.
B ulimia nervosa- eating an excessive amount of food and then vomiting to prevent weight gain. ADHD - scurry about, talk incessantly, or find i t impossible to perform a s imple task like sitting still though a classroom lesson or a presentation at work. May blurt out inappropriate comments, interrupt others, and i mpatience. Autistic disorder - qualitative impairments in their communication, evidenced by a delay or total lack of development of spoken language, and i nability to use multiple nonverbal behaviors. Individuals appear locked into repetitive, stereotyped patterns of behavior, in terests, and activities, and r igid patterns of thinking. Alzheimers disease- memory loss and personality changes. Be able to identify the various types of disorders and what illnesses are i ncluded in that category 5 categories. Mood, anxiety, eating, childhood, and cognitive disorders. See Box 5.4 Racial and ethnic differences Mental disorders among Mexican American immigrants were s ignificantly lower than the rates for US-born Mexican Americans. Results from CAPES showed that Chinese Americans have moderate levels of depressive disorders. Mental disorder classification system used both nationally and i nternationally. ICD-10- international classification of disease. DSM-IV-TR- most widely used classification system both nationally and
I dioms of distress and culture-bound syndromes Somatization
Culture bound syndromes are clusters of symptoms more common in some cultures than in others. Researchers have not yet determined whether Culture bound syndromes are indicative of one or more of the following. Culture bound syndromes are distinct disorder that exist on in those cultures. Culture bound syndromes reflect different ways in which individuals from d ifferent cultures express mental illness. Culture bound syndromes reflect d ifferent ways in which the social and cultural environment interact with genes to produce disorders. Difficulties in diagnosing mental illnesses from a cultural and medical perspective Complaints of nerves and headaches may express depressive experiences of Latino and Mediterranean cultures; problems of the heart or weakness or imbalance may represent depressive symptoms of Middle E astern and Asian cultures. Mental health services- utilization, barriers, obstacles, etc Primary reason for underutilization Health insurance. Biggest obstacle for t reatment The social stigma attached to it.
K now all key terms as listed at the end of the chapter Mental health - a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and cope with adversity. Mental health problems- signs and symptoms of insufficient intensity or duration to meet the criteria for any mental disorder. Mental illness- the term that refers collectively to all mental disorders, w hich are health conditions characterized by alternations in thinking, mood, or behavior associated with distress and/or impaired functioning. Mental disorder - impairs the individuals ability to function psychologically, socially, academically, or occupationally. Psychosocial functioning- r efers to one's psychological development in and interaction with a social environment . ICD-10- international classification of disease. DSM-IV-TR- most widely used classification system both nationally and internationally. Diagnostic and Statistical Manual of Mental Disorders. L ife event - example is the death of a close friend or relative. Somatization - the expression of distress through physical symptoms. (abdominal pain, heart palpitations, and chest pain) Idioms of distress- different cultures express, experience, and cope with feelings of distress in different ways. Culture-bound syndromes- distinct disorders that exist only in those cultures Stigma- negative atti tudes and beliefs
Chapter 6 Health care Health care disparity vs. health status disparity Health care disparity - differences in quality of care that are not due to clinically appropriate t reatment decisions or patient preferences. Health status disparity - differences among racial/ethnic groups, gender g roups, socioeconomic groups, and other groupings. IOM report
Focused on subsection of health care disparities: racial/ethnic d ifferences in the quality of care received. Described scope of report as racial or ethnic differences in quality of health care that are not due to accessrelated factors or clinical needs, preferences, and appropriateness. Access and use Differences in ACCESS to and use of health care services are largely caused by socioeconomic inequities, such as discrimination or differences in health insurance coverage. Differences in USE of health care services are also i nf luenced by differences in need for services and in patient preferences. Populations with the greatest need are also the populations with the lowest r ates of health care use. Mexican Americans are most likely to not have had any medical visits. Behavioral model of health services utilization Model categories factor that contribute to use of health services in to 3 g roups 1.) Enabling factors 2.) Predisposing factors 3.) Patient need for health care. Enabling and predisposing factors Most common enabling factor is health insurance. Predisposing factors are often measured as a persons attitude (satisfaction with care, m istrust of health care, perceived discrimination, and provider attitudes). Health insurance & health services Private health insurance The majority of Americans have private health insurance. Gained through their employer. Medicare Federally run program for people over 65. Costs are borne i n part by the insured individual who pays a monthly premium, and in part by taxpayers and corporate taxes. Medicaid Fed run program for low-income people. The costs are split between the federal and state governments. Largest percentage covered by it is Blacks. Quality of care Providing patients with appropriate services in a technically competent manner, with good communication, shared decision-making, and cultural
sensitivity. Racial differences in access to surgical and medical management of heart disease are perhaps the most studied health care disparity. Physicians were twice as likely to recommend hormone replacement therapy for white patients than for African Americans. Health care systems used by active mili tary personnel found no racial/ethnic differences in quality of care.
Reasons for the large number of uninsured Americans Health insurance is linked to employment. The US is the only i ndustrialized nation that does not provide health care access to all citizens. Most Americans obtain health insurance through their employment, but t here are many jobs that dont provide i t. Know all the key terms as listed at the end of the chapter Health care disparity - refers to differences in the access, use, quality, or outcomes of health care services received by racial/ethnic minorities. Health disparity - differences in the incidence, prevalence, mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the US. Health care dissimilarity - refers to racial/ethnic differences that are not caused by underlying inequities; for example, differences produced by patient cultural preferences or patient choice. Health status disparity - refers to differences among racial/ethnic g roups in health status (that is morbidity, mortali ty, functional status, or d isability). Predisposing factor - measure the patients inclination to use health services; this includes the patients attitude toward using care, which are i nf luenced by cultural beliefs, prior experiences, and perceptions. Enabling factor - relates to structural or material resources that can be bar riers or facilitators in seeking care. Cultural competence- the demonstrated awareness and integration of t hree population-specific issues: health-related and cultural values, disease i ncidence and prevalence and t reatment efficacy. C hapter 7 Determinants of health and health status
Socioenvironmental factors- outside exposure. Distal causes are those f ur ther removed from disease manifestation Psychosocial or behavioral factors- habits like smoking, substance abuse, or inactivity. Transitional causes are factors that mediate distal causes or factors that are closer to disease manifestation. Biophysiological i nherited. Proximal causes refer to biological factos t hat ultimately lead to disease. Socioenvironmental theories of health Index of dissimilarity (IOD) is a widely used measure of racial residential segregation within geographic areas. African Americans are more segregated from whites than any other minority group. Racial segregation has been shown to be a consistent predictor of health outcomes and a partial explanation for race dispari ties in health. Psychosocial/behavioral theories of health disparities Racism Exposure to racism has been associated with negative mental health outcomes, physical health outcomes, and health behavior.
H ispanic epidemiological paradox Describes a pattern among mortality and morbidity rates in which H ispanics/Latinos tend to have more favorable health outcomes than nonH ispanic/Latinos. 4 possible hypotheses to explain this pattern. 1. Poor data quality 2. Salmon bias hypothesis 3. The healthy migrant hypothesis 4. Differences in certain r isk factors related to acculturation. Biogenetic and physiological theories of health disparities 3 possible ways in which biogenetic factors may play a role in explaining health disparities. 1. There may be biological or genetic differences among racial and ethnic groupsdifferences that lead to varying levels of susceptibility to diseases. 2. There may be biogenetic or environmental interactions that account for different levels of disease.
3. Because salt deprivation during the Atlantic slave t rade and the excessive mortality rate of Africans who were enslaved, the A fricans who survived were those with a genetic predisposition t o salt retention. Know all key terms as listed at the end of the chapter Psychosocial - causes associated with characteristics of the individual, such as behavior or psychological factors. Context theory - causes associated with social factors or environmental exposures. Racial/ethnic segregation - separate and unequal. Has been shown to be a consistent predictor of health outcomes and a partial explanation for race d isparities in health. Risk exposure theory - states that a high prevalence of social or environmental health r isks in predominantly minority communities leads to a h igher prevalence of disease and death. Resource deprivation theory - minorities are more likely than white to l ive in communities that are lacking in the necessary infrastructure to support a health lifestyle. Weathering hypothesis- states that the health statuses of minorities begin to prematurely deteriorate in young adulthood. John henryism - individuals with lower social status are routinely exposed to psychological and socioeconomic stressors. Immigration and acculturation - as the number of years that the foreign-born person lives in the US increases, the persons health status begins to approximate the health status of US born counterparts. Racial discrimination - beliefs, attitudes, institutional arrangements, and acts that tend to denigrate individuals or groups because of phenotypic characteristics or ethnic group affiliation. Racism Biopsychosocial model - racism is a stressor and as such leads to negative health outcomes. H ispanic epidemiology paradox- describes a pattern among mortality and morbidity rates in which H ispanics/Latinos tend to have more favorable health outcomes than non-Hispanic/Latinos. Biogenetic-environmental interactions- social inequality leads to d ifferential environmental exposures, and these different environmental
factors interact with genes to produce health disparities. No scientific evidence exists to either support or refute this hypothesis. Slave hypertension hypothesis- argues that the higher prevalence of hypertension among African Americans is a result of selective survival.