Racial/ethnic disparities, social support, and depression: examining a social determinant of mental health.

OBJECTIVE: We examined the risk of depression as it relates to social support among individuals from African American, Caribbean black, and non-Hispanic White backgrounds. METHODS: 6,082 individuals participated in the national survey of American life (NSAL), a nationally representative, psychiatric epidemiological, cross-sectional survey of household populations. The survey is designed to explore racial and ethnic differences in mental disorders. NSAL survey questions were used as a proxy for social support. Logistic regression analysis was used to examine the correlates between having a DSM-IV diagnosis of major depressive disorder in the past year, demographic variables, and social support. RESULTS: African American race/ethnicity was associated with decreased odds of depression when compared to non-Hispanic whites, even when controlling for social support variables and demographics (OR = 0.51, 95% CI = 0.43-0.60). We found a three-fold increase in risk of depression among individuals who reported feeling "not very close at all" with family members compared to those who reported feeling "very close" to family (OR = 3.35, 95% CI = 1.81-6.19). CONCLUSIONS: These findings reinforce previous research documenting the important relationship between social support and depression, and perhaps should lead us to reexamine the individualistic models of treatment that are most evaluated in United States. The lack of evidence-based data on support groups, peer counseling, family therapy, or other social support interventions may reflect a majority-culture bias toward individualism, which belies the extensive body of research on social support deficits as a major risk factor for depression.

Paths to success: optimal and equitable health outcomes for all.

Abstract:U.S. health disparities are real, pervasive, and persistent, despite dramatic improvements in civil rights and economic opportunity for racial and ethnic minority and lower socioeconomic groups in the United States. Change is possible, however. Disparities vary widely from one community to another, suggesting that they are not inevitable. Some communities even show paradoxically good outcomes and relative health equity despite significant social inequities. A few communities have even improved from high disparities to more equitable and optimal health outcomes. These positive-deviance communities show that disparities can be overcome and that health equity is achievable. Research must shift from defining the problem (including causes and risk factors) to testing effective interventions, informed by the natural experiments of what has worked in communities that are already moving toward health equity. At the local level, we need multi-dimensional interventions designed in partnership with communities and continuously improved by rapid-cycle surveillance feedback loops of community-level disparities metrics. Similarly coordinated strategies are needed at state and national levels to take success to scale. We propose ten specific steps to follow on a health equity path toward optimal and equitable health outcomes for all Americans.

Health care access and utilization among US-born and foreign-born Asian Americans.

Despite efforts to eliminate inequality in health and health care, disparities in health care access and utilization persist in the United States. The purpose of this study was to compare the access to care and use of health care services of US-born and foreign-born Asian Americans. We used aggregated data from the National Health Interview Survey (NHIS) from 2003 to 2005, including 2,500 participants who identified themselves as Asian. Associations between country of birth and reported access and utilization of care in the previous 12 months were examined. After controlling for covariates, being foreign-born was negatively related to indicators of access to care, including health insurance (OR = 0.29, 95%CI = 0.18-0.48), routine care access (OR = 0.52, 95%CI = 0.36-0.75), and sick care access [OR = 0.67, 95%CI = 0.47-0.96)]. Being foreign-born was also negatively related to all indicators of health care utilization (office visit: OR = 0.58, 95%CI = 0.41-0.81; seen/talked to a general doctor: OR = 0.69, 95%CI = 0.52-0.90; seen/talked to a specialist: OR = 0.42, 95%CI = 0.28-0.63) but ER visit (OR = 0.84, 95%CI = 0.59-1.20). There are substantial differences by country of birth in health care access and utilization among Asian Americans. Our findings emphasize the need for developing culturally sensitive health services and intervention programs for Asian communities.

Overweight in school-aged children associated with emotional and behavioral difficulties: results from a national sample.

OBJECTIVE: To determine whether there is an association between perceived pediatric overweight and emotional/behavioral difficulties among children ages 4 to 17 years in the United States. DESIGN: A cross-sectional study SETTING: Interview of an adult knowledgeable about a child's emotional and physical health. All statistical analyses were completed using SPSS 17.0. PARTICIPANTS: A total of 7096 noninstitutionalized children aged 4 to 17 years identified in the 2007 National Health Interview Survey. OUTCOME MEASURES: Included in the 2007 National Health Interview Survey were 7096 noninstitutionalized children aged 4 to 17 years. After controlling for age, gender, race, poverty status, education of mother, family structure, and health status, this study found that 7.4% of the children appeared to be overweight and 5.2% had emotional/behavioral difficulties. It also found that caregivers who indicated that their child had a problem with being overweight were more likely to report that the child experienced emotional/behavioral difficulties compared to caregivers who did not report perceived overweight in their child. Characteristics of the children most frequently reported to be overweight included Hispanic race, older children (ages 15-17 years), and those with higher poverty rates and poorer health status. CONCLUSION: The continual increase in pediatric overweight and associated emotional/behavioral difficulties suggests a need for replicable interventions that teach child caregivers to recognize and prevent overweight among vulnerable populations.

United States black:white infant mortality disparities are not inevitable: identification of community resilience independent of socioeconomic status.

INTRODUCTION: U.S. disparities in Black:White infant mortality are persistent. National trends, however, may obscure local successes. METHODS: Zero-corrected, negative binomial multivariable modeling was used to predict Black infant mortality (1999-2003) in all U.S. counties with reliable rates. Independent variables included county population size, racial composition, educational attainment, poverty, income and geographic origin. Resilient counties were defined as those whose Black infant mortality rate residual score was < 2.0. Mortality data was accessed from the Compressed Mortality File compiled by the National Center for Health Statistics and found on the CDC WONDER website. Demographic information was obtained from the US Census. RESULTS: The final model included the percentage of Blacks, age 18 to 64 years, speaking little or no English (P < .008), a socioeconomic index comprising educational attainment, poverty, and per capita income (P < .001), and household income in 1990 (P < .001). After accounting for these factors, a stratum comprising Essex and Plymouth Counties, Mass.; Bronx, N.Y.; and Multnomah, Ore. was identified as unusually resilient. Percentage of Black poverty and educational attainment in Black women in the resilient stratum approximated the average for all 330 counties. In 1979, Black infant mortality in the resilient stratum (23.6 per 1000 live births) exceeded Black US infant mortality (22.6). By 2001, Black infant mortality in the resilient stratum (5.6) was below the corresponding value for Whites (5.7). Resilient county neonatal mortality declined both early and late in the observation period, while post-neonatal declines were most marked after 1996. CONCLUSIONS: Models for reduction/elimination of racial disparities in US infant mortality, independent from county-level contextual measures of socioeconomic status, may already exist.

E-mail in patient-provider communication: a systematic review.

OBJECTIVE: To review systematically the role of e-mails in patient-provider communication in terms of e-mail content, and perspectives of providers and patients on e-mail communication in health care. METHODS: A systematic review of studies on e-mail communication between patients and health providers in regular health care published from 2000 to 2008. RESULTS: A total of 24 studies were included in the review. Among these studies, 21 studies examined e-mail communication between patients and providers, and three studies examined the e-mail communication between parents of patients in pediatric primary care and pediatricians. In the content analyses of e-mail messages, topics well represented were medical information exchange, medical condition or update, medication information, and subspecialty evaluation. A number of personal and institutional features were associated with the likelihood of e-mail use between patients and providers. While benefits of e-mails in enhancing communication were recognized by both patients and providers, concerns about confidentiality and security were also expressed. CONCLUSION: The e-mail is transforming the relationship between patients and providers. The rigorous exploration of pros and cons of electronic interaction in health care settings will help make e-mail communication a more powerful, mutually beneficial health care provision tool. PRACTICE IMPLICATIONS: It is important to develop an electronic communication system for the clinical practice that can address a range of concerns. More efforts need to be made to educate patients and providers to appropriately and effectively use e-mail for communication.

Context of clinical care: the case of hepatitis C in underserved communities--a report from the Primary Care Multiethnic Network (PRIME Net) Consortium.

BACKGROUND: The importance of Hepatitis C (HCV) as a public and individual health concern is well established. However, national groups differ in their recommendations to primary care clinicians about screening people at high risk for HCV. The purpose of this study was to explore the context of care within which primary care clinicians decide to detect and initially manage HCV. METHODS: The Primary Care Multiethnic Network conducted a web- and paper-based survey of primary care clinicians who largely practice in low-income, medically underserved communities in 3 regions across the country. RESULTS: A total of 494 clinicians participated, for a response rate of 61%. Most (68%) clinicians view HCV as an important problem; more than half (59%) consider screening for HCV to be important when compared with other conditions they screen for in practice. With regard to reported screening habits for risk factors, 54% of clinicians routinely ask new patients whether they have used intravenous drugs and 28% inquire about blood transfusions before 1992. Sixty-one percent order an alanine aminotransferase test when patients present with other risk factors for HCV. The majority of clinicians (54%) refer 75% or fewer of their patients with HCV for treatment; nearly one-fifth (18%) provide antiviral treatment themselves. Key factors influencing clinician HCV decision making are patient comorbidities (74% reported this as a factor), access to treatment (55% reported this as a factor), and tolerance (44% reported this as a factor) of treatment. CONCLUSIONS: In the face of conflicting national guideline recommendations about screening people at high risk for HCV, clinicians have varied views and practice habits influenced by multiple patient, access, and treatment issues.

Role of the primary care safety net in pandemic influenza.

An influenza pandemic would have a disproportionately adverse impact on minority populations, the poor, the uninsured, and those living in underserved communities. Primary care practices serving the underserved would face special challenges in an influenza pandemic. Although not a formalized system, components of the primary care safety net include federally qualified health centers, public hospital clinics, volunteer or free clinics, and some local public health units. In the event of an influenza pandemic, the primary care safety net is needed to treat vulnerable populations and to provide health care surge capacity to prevent the overwhelming of hospital emergency departments. We examined the strength, capacity, and preparedness of key components of the primary care safety net in responding to pandemic influenza.

The clinical content of preconception care: care of psychosocial stressors.

In the period before conceiving, many women are under considerable psychosocial stress, which may affect their ability to conceive and to carry a pregnancy successfully to term. Thus, health care providers who interact with women in the preconception and interconception period should ask their patients about possible psychosocial risks. It is no longer sufficient to wait until the woman mentions a problem or seeks advice; the provider must be proactive, because many women do not realize the potential impact of stressors on their pregnancy outcomes nor are they always aware that their provider is interested in their psychosocial as well as their physical health. An income that puts women below or near the federal poverty level is one such stress. If a woman's economic situation can be improved before the pregnancy, she is more likely to be healthy after conception, because increased income can reduce financial stress, improve food security, and improve well-being in other ways. Therefore, all women should be asked about their economic status and those who appear to be struggling financially should be referred to an agency that can check their eligibility for various types of financial assistance. Many women of childbearing age have difficulty accessing the primary care services needed for preconception care. Usually this is due to lack of insurance, but it may also be caused by living in an area with an insufficient number of providers. Certainly all women who are uninsured, and possible many who are on Medicaid and have difficulty finding providers who will accept Medicaid, have access problems. All women should be asked about their health insurance coverage and their usual source of care. If they do not have health insurance, they should be referred to an agency that can determine their eligibility. If they do not have a usual source of care, one should be established that will accept their insurance coverage or provide care free of charge or on a sliding fee basis. Intimate partner violence, sexual violence outside of an intimate relationship (usually rape), and maltreatment (abuse or neglect) as a child or adolescent place a woman at elevated risk during a pregnancy, as well as having possible adverse impacts on the fetus, the infant, and the child. Studies show that women believe it is appropriate for health care providers to ask about interpersonal violence, but that they will not report it spontaneously. Therefore, screening for ongoing and historical interpersonal violence, sexual violence, and child maltreatment should be incorporated into routine care by all health care providers.

Diversity in academic medicine no. 6 successful programs in minority faculty development: ingredients of success.

This article describes the ingredients of successful programs for the development of minority faculty in academic medicine. Although stung by recent cuts in federal funding, minority faculty development programs now stand as models for medical schools that are eager to join the 140-year-old quest for diversity in academic medicine. In this article, the ingredients of these successful faculty development programs are discussed by experts in minority faculty development and illustrated by institutional examples. Included are descriptions of program goals and content, mentoring and coaching, selecting participants, providing a conducive environment, managing the program, and sustaining support. This article is a companion to another article, "Successful Programs in Minority Faculty Development: Overview," in this issue of the Mount Sinai Journal of Medicine.

Diversity in academic medicine no. 1 case for minority faculty development today.

For the past 20 years, the percentage of the American population consisting of nonwhite minorities has been steadily increasing. By 2050, these nonwhite minorities, taken together, are expected to become the majority. Meanwhile, despite almost 50 years of efforts to increase the representation of minorities in the healthcare professions, such representation remains grossly deficient. Among the underrepresented minorities are African and Hispanic Americans; Native Americans, Alaskans, and Pacific Islanders (including Hawaiians); and certain Asians (including Hmong, Vietnamese, and Cambodians). The underrepresentation of underrepresented minorities in the healthcare professions has a profoundly negative effect on public health, including serious racial and ethnic health disparities. These can be reduced only by increased recruitment and development of both underrepresented minority medical students and underrepresented minority medical school administrators and faculty. Underrepresented minority faculty development is deterred by barriers resulting from years of systematic segregation, discrimination, tradition, culture, and elitism in academic medicine. If these barriers can be overcome, the rewards will be great: improvements in public health, an expansion of the contemporary medical research agenda, and improvements in the teaching of both underrepresented minority and non-underrepresented minority students.

Diversity in academic medicine no. 3 struggle for survival among leading diversity programs.

Since efforts to increase the diversity of academic medicine began shortly after the Civil War, the efforts have been characterized by a ceaseless struggle of old and new programs to survive. In the 40 years after the Civil War, the number of minority-serving institutions grew from 2 to 9, and then the number fell again to 2 in response to an adverse evaluation by the Carnegie Foundation for the Advancement of Teaching. For 50 years, the programs grew slowly, picking up speed only after the passage of landmark civil rights legislation in the 1960s. From 1987 through 2005, they expanded rapidly, fueled by such new federal programs as the Centers of Excellence and Health Careers Opportunity Programs. Encompassing majority-white institutions as well as minority-serving institutions, the number of Centers of Excellence grew to 34, and the number of Health Careers Opportunity Programs grew to 74. Then, in 2006, the federal government cut its funding abruptly and drastically, reducing the number of Centers of Excellence and Health Careers Opportunity Programs to 4 each. Several advocacy groups, supported by think tanks, have striven to restore federal funding to previous levels, so far to no avail. Meanwhile, the struggle to increase the representation of underrepresented minorities in the health professions is carried on by the surviving programs, including the remaining Centers of Excellence and Health Careers Opportunity Programs and new programs that, funded by state, local, and private agencies, have arisen from the ashes.

Diversity in academic medicine no. 5 successful programs in minority faculty development: overview.

Despite recent drastic cutbacks in federal funding for programs to diversify academic medicine, many such programs survive and continue to set examples for others of how to successfully increase the participation of minorities underrepresented in the healthcare professions and, in particular, how to increase physician and nonphysician minority medical faculty. This article provides an overview of such programs, including those in historically black colleges and universities, minority-serving institutions, research-intensive private and public medical schools, and more primary care-oriented public medical schools. Although the models for faculty development developed by these successful schools overlap, each has unique features worthy of consideration by other schools seeking to develop programs of their own. The ingredients of success are discussed in detail in another article in this theme issue of the Mount Sinai Journal of Medicine, "Successful Programs in Minority Faculty Development: Ingredients of Success."

Trends in mental health and substance abuse services at the nation's community health centers: 1998-2003.

OBJECTIVE: We examined trends in delivery of mental health and substance abuse services at the nation's community health centers. METHODS: Analyses used data from the Health Resources and Services Administration (HRSA), Bureau of Primary Care's (BPHC) 1998 and 2003 Uniform Data System, merged with county-level data. RESULTS: Between 1998 and 2003, the number of patients diagnosed with a mental health/substance abuse disorder in community health centers increased from 210,000 to 800,000. There was an increase in the number of patients per specialty mental health/substance abuse treatment provider and a decline in the mean number of patient visits, from 7.3 visits per patient to 3.5 by 2003. Although most community health centers had some on-site mental health/substance abuse services, centers without on-site services were more likely to be located in counties with fewer mental health/substance abuse clinicians, psychiatric emergency rooms, and inpatient hospitals. CONCLUSIONS: Community health centers are playing an increasingly central role in providing mental health/substance abuse treatment services in the United States. It is critical both to ensure that these centers have adequate resources for providing mental health/substance abuse care and that they develop effective linkages with mental health/substance abuse clinicians in the communities they serve.

Black-White mortality from HIV in the United States before and after introduction of highly active antiretroviral therapy in 1996.

OBJECTIVES: We sought to describe Black-White differences in HIV disease mortality before and after the introduction of highly active antiretroviral treatment (HAART). METHODS: Black-White mortality from HIV is described for the nation as a whole. We performed regression analyses to predict county-level mortality for Black men aged 25-84 years and the corresponding Black:White male mortality ratios (disparities) in 140 counties with reliable Black mortality for 1999-2002. RESULTS: National Black-White disparities widened significantly after the introduction of HAART, especially among women and the elderly. In county regression analyses, contextual socioeconomic status (SES) was not a significant predictor of Black:White mortality rate ratio after we controlled for percentage of the population who were Black and percentage of the population who were Hispanic, and neither contextual SES nor race/ethnicity were significant predictors after we controlled for pre-HAART mortality. Contextual SES, race, and pre-HAART mortality were all significant and independent predictors of mortality among Black men. CONCLUSIONS: Although nearly all segments of the Black population experienced widened post-HAART disparities, disparities were not inevitable and tended to reflect pre-HAART levels. Public health policymakers should consider the hypothesis of unequal diffusion of the HAART innovation, with place effects rendering some communities more vulnerable than others to this potential problem.

Trends in Mental Health and Substance Abuse Services at the Nation's Community Health Centers: 1998-2003.

OBJECTIVE: We examined trends in delivery of mental health and substance abuse services at the nation's community health centers. METHODS: Analyses used data from the Health Resources and Services Administration (HRSA), Bureau of Primary Care's (BPHC) 1998 and 2003 Uniform Data System, merged with county-level data. RESULTS: Between 1998 and 2003, the number of patients diagnosed with a mental health/substance abuse disorder in community health centers increased from 210,000 to 800,000. There was an increase in the number of patients per specialty mental health/substance abuse treatment provider and a decline in the mean number of patient visits, from 7.3 visits per patient to 3.5 by 2003. Although most community health centers had some on-site mental health/substance abuse services, centers without on-site services were more likely to be located in counties with fewer mental health/substance abuse clinicians, psychiatric emergency rooms, and inpatient hospitals. CONCLUSIONS: Community health centers are playing an increasingly central role in providing mental health/substance abuse treatment services in the United States. It is critical both to ensure that these centers have adequate resources for providing mental health/substance abuse care and that they develop effective linkages with mental health/substance abuse clinicians in the communities they serve.

Pediatricians' knowledge, training, and experience in the care of children with fetal alcohol syndrome.

OBJECTIVES: Prenatal exposure to alcohol interferes with fetal development and is the leading preventable cause of birth defects and developmental disabilities. The purpose of this study was to identify current knowledge, diagnosis, prevention, and intervention practices related to fetal alcohol syndrome and related conditions by members of the American Academy of Pediatrics. METHODS: This study was developed collaboratively by the American Academy of Pediatrics and the Centers for Disease Control and Prevention. Questionnaires were mailed to a 3% random sample (n = 1600) of American Academy of Pediatrics members in the United States. General pediatricians, pediatric subspecialists, and pediatric residents were included. RESULTS: Participation rate was 55% (n = 879). Respondents almost universally knew the teratology and clinical presentation of fetal alcohol spectrum disorders. However, they were less likely to report comfort with routine pediatric care of these children. Whereas 62% felt prepared to identify and 50% felt prepared to diagnose, only 34% felt prepared to manage and coordinate the treatment of children with fetal alcohol spectrum disorders. Even fewer (n = 114 [13%]) reported that they routinely counsel adolescent patients about the risks of drinking and pregnancy. CONCLUSIONS: The survey confirms that pediatricians are knowledgeable about fetal alcohol syndrome but do not feel adequately trained to integrate the management of this diagnosis or prevention efforts into everyday practice. Furthermore, the respondents were not active in routine anticipatory guidance with adolescents for prevention of alcohol-affected pregnancies. The development, dissemination, and implementation of best practice tools for prevention, diagnosis, and referral of fetal alcohol syndrome that are specific for general and subspecialist pediatricians are recommended.

A crash-course in cultural competence.

America is a multi-cultural society. Yet, there are cultural dimensions to the clinician-patient relationship that have not been systematically addressed in medical education or in clinical practice. Lack of diversity and lack of cross-cultural skills in the medical profession may contribute to health disparities in America. Cultural competence for the medical profession represents a core set of skills that can be learned to respectfully and effectively communicate healthcare information with diverse patient populations. The authors blended their extensive literature review with the knowledge and experience of a culturally diverse medical team to develop the CRASH-Course in Cultural Competency training program for medical professionals. CRASH is a mnemonic for the following essential components of culturally competent health care--consider Culture, show Respect, Assess/Affirm differences, show Sensitivity and Self-awareness, and do it all with Humility. The goal of the CRASH-Course in Cultural Competency is to build confidence and competence in the clinician's ability to communicate effectively with diverse patient populations.

Sexual history-taking among primary care physicians.

BACKGROUND: Because many people seek sexual healthcare in settings where they seek primary healthcare, the extent to which primary care physicians take sexual histories is important. We surveyed Atlanta-area primary care physicians to estimate the extent to which they take sexual histories as well as the components of those histories and the circumstances under which they are taken. METHODS: Four-hundred-sixteen physicians in four specialties (obstetrics/gynecology, internal medicine, general/family practice, pediatrics) responded to a mail survey conducted during 2003-2004. Respondents answered whether they asked about sexual activity at all, including specific components of a comprehensive sexual history such as sexual as sexual orientation, numbers of partners and types of sexual activity, during routine exams, initial exams, complaint-based visits or never. Respondents also reported their opinions on whether they felt trained and comfortable taking sexual histories. RESULTS: Respondents (51% male, 58% white) saw an average of 94 patients per week. A majority (56%) felt adequately trained, while 79% felt comfortable taking sexual histories. Almost three in five (58%) asked about sexual activity at a routine visit, but much smaller proportions (12-34%) asked about the components of a sexual history. However, 76% of physicians reported asking about sexual history (61-75% for various components) if they felt it would be relevant to the chief complaint. CONCLUSIONS: Most physicians report feeling comfortable taking sexual histories and will do so if the patient's apparent complaint is related to sexual health. But sexual histories as part of routine and preventive healthcare are less common, and many physicians miss essential components of a comprehensive sexual history. Structural changes and suggestions for training to enhance sexual history-taking are discussed.