Medical Education and Minority Health
(Fam Med 1998;30(3):162-7.)

Training Family Medicine Faculty
to Teach in Underserved Settings
Joshua Freeman, MD; Ronald Loewe, PhD;
Janice Benson, MD

Background and Objectives: Because minority physicians are more likely to practice in minority or medically underserved communities, meeting the health care needs of underserved populations requires that programs not only train such physicians but train minority faculty to act as teachers and role models. The Faculty Development Center in Family Medicine at Cook County Hospital has had more than 120 graduates, most of whom are teaching and practicing in underserved settings. Nearly half have been minorities, the result of the priority given to recruitment of minority fellows. The curriculum is specifically geared to prepare faculty to work in underserved settings and nurture future physicians for these settings. Workforce diversity can be achieved only by major changes in the institutional culture of medical education, which federal policy can encourage by setting high standards for grant funding preferences and supporting centers of excellence for training minority physicians and faculty.

Medical Education and Minority Health
(Fam Med 1998;30(3):168-72.)

Knowledge and Care of Chronic Illness in Three Ethnic Minority Groups
Gay Becker, PhD; Yewoubdar Beyene, PhD; Edwina M. Newsom; Denise V. Rodgers, MD

Background and Objectives: Despite advances in medical approaches to the management of chronic illnesses, relatively little is known about how older members of ethnic minority groups view their chronic illnesses or how they manage them in daily life.

Methods: We recruited 35 African-Americans, 61 Latinos, and 55 Filipino-Americans, all over age 50. Criteria for entry into the study was the presence of one or more chronic illnesses. Findings are based on structured and semi-structured questions in one in-depth interview. Qualitative data on transcribed interviews with 151 respondents was analyzed.

Results: Comparison of the three groups revealed social and cultural differences and similarities that affected the management of chronic illness. The extent to which respondents demonstrated an understanding of their illnesses as chronic varied considerably, with discernible differences among groups about knowledge of illness and self-care practices.

Conclusions: Our findings showed that although major chronic illnesses were, for the most part, the same for all three groups, each group differed in its response to and management of its illnesses. These findings have implications for the education of physicians in training.

Cultural Competence
(Fam Med 1998;30(3):173-8.)

Hmong/Medicine Interactions: Improving Cross-cultural Health Care
Bruce Barrett, MD, PhD; Kathleen Shadick, RN, MSN; Rae Schilling, PhD, PsyD; Liz Spencer RD, MS; Salvador del Rosario; Ka Moua; May Vang

Background and Objectives: There are now more than 100,000 Hmong (Southeast Asian) refugees in the United States. This study examined interactions between Hmong patients and their health care providers and identified specific factors that either enable or obstruct health care delivery.

Methods: We used semistructured interview techniques to investigate patients’ and providers’ experiences, looking for attitudes, ideas, or behaviors that could be modified to improve health care delivery. Interviews with 23 Hmong patients, 18 health care providers, and six translators were audiotaped, transcribed, and analyzed by a multidisciplinary team. Methods included text analysis, theme identification, rank ordering, participant observation, immersion-crystallization, and open-ended discussion.

Results: Hmong patients and their US-trained health care providers have different health belief systems. Both linguistic and cultural translation were seen as problematic. Additionally, an overwhelming number of patients identified kindness, caring, and a positive attitude as important provider characteristics. Providers noted difficulties in understanding Hmong conceptions of acute versus chronic diseases, illness prevention, and pain, both physical and psychological. Many respondents gave suggestions for improvement: 1) learn more about each other’s cultures, 2) be patient, kind, and positive, 3) avoid negative statements or predictions, 4) improve translation quality, 5) explain medical terms using visual aids, 6) respect Hmong family-centered decision making, 7) increase the time allotted for translated clinical encounters, and 8) train Hmong health care providers.

Conclusions: Many basic issues in relations between clinicians and Hmong patients must be addressed to improve health care communication.

Cultural Competence
(Fam Med 1998;30(3):179-84.)

Sudanese Refugees in a Minnesota Family Practice Clinic
David V. Power, MD, MPH; Dianna J. Shandy, MA

Background and Objectives: During the 1990s, African refugees from the southern Sudan were resettled in Minnesota. This research characterizes the health care utilization of a small sample of these recently arrived refugees and describes their health histories. Methods: Data were abstracted from the medical charts of all identified Sudanese patients in an urban, Midwestern family practice residency unit.

Methods: Data were abstracted from the medical charts of all identified Sudanese patients in an urban, Midwestern family practice residency unit.

Results: A small sample of Sudanese refugees were found to have high rates of prior infectious illness and experienced communication difficulties in accessing health care.

Conclusions: Information about this sample’s demographic variables, health behavior, health histories, and communication difficulties are documented. Some descriptors of the Nuer ethnic group are provided, and issues are raised that may help health care workers provide more culturally competent care to this Sudanese refugee population.

Cultural Competence
(Fam Med 1998;30(3):185-9.)

Health Status of American Indians/Alaska Natives: General Patterns of Mortality
Martin C. Mahoney, MD, PhD; Arthur M. Michalek, PhD

Background and Objectives: Investigations of American Indian and Alaska Native (AI/AN) populations suggest patterns of mortality that differ from the general population. Mortality data reveal excess overall mortality among AI/ANs, as well as excesses for specific causes of death, including accidents, diabetes, liver disease, pneumonia/influenza, suicide, homicide, and tuberculosis. A relative deficit of deaths has been noted for heart disease, cancer, and HIV infections. It is important that physicians demonstrate cultural competence so they may provide quality medical care for the populations they serve. Activities such as provider education, risk assessment, and emphasis on preventive services are offered to facilitate integration into teaching curricula. Knowledge of distinctive mortality patterns among AI/ANs will help clinicians recognize the unique needs of these patients.

Clinical Issues in Minority Health
(Fam Med 1998;30(3):190-5.)

Barriers to Health Care Access
for Latino Children: A Review
Glenn Flores, MD; Luis R. Vega

Background and Objectives: More than 9 million Latino children currently live in the United States. Latinos will soon be the largest minority group in the country, but little is known about access barriers to health care faced by Latino children. We reviewed the literature to define specific barriers to care for Latino children, identify methodologic problems, and highlight the clinical and research implications of the identified barriers.

Methods: We did a MEDLINE search, using combinations of the key words Hispanic, children, and access. Study exclusion criteria included “not an original research article,” “enrolled only adult subjects,” “no separate data analysis for children,” and “dental care focus.”

Results: The search yielded 497 citations, of which 27 met the inclusion criteria. Of the 32 potential barriers identified, 21 had good supportive evidence. Lack of health insurance was a consistent barrier; recent data revealed that 26% of Latino children are uninsured, compared with 10% of white children and 14% of African-American children. Latino children also are at greater risk for episodic insurance coverage, low rates of private insurance, and loss of employee-based coverage. Parent beliefs about the etiology and treatment of their child’s illness, use of home remedies, choice of sources of advice, and folk medicine practices may also influence how health care is obtained. Few data are available on differences in access among major Latino subpopulations, and no studies focused primarily on barriers as perceived by Latino parents. Evidence is equivocal or lacking that the following are barriers for Latino children: immigration status, duration of parent residency in the United States, and acculturation. Several barriers were identified that originate with practices and behaviors of health care providers, including reduced screening, missed vaccination opportunities, decreased likelihood of receiving prescriptions, and poor communication.

Conclusions: Lack of health insurance and lack of a regular source of care are major access barriers for Latino children, but many other barriers were identified that also can have a substantial effect on health care. In addition, the behaviors and practices of both health care providers and parents can affect access to care. Too little is known about what parents perceive to be the major barriers, access differences among Latino subpopulations, the roles of language and culture, and the causes of obstacles resulting from the actions of providers.

Clinical Issues in Minority Health
(Fam Med 1998;30(3):196-205.)

Filling the Gap: Equity and Access to Oral Health Services for Minorities and the Underserved
M. Ann Drum, DDS, MPH; D.W. Chen, MD, MPH; Rosemary E. Duffy, DDS, MPH

Background and Objectives: Family physicians and other primary care providers play a pivotal role in preventing oral disease, especially among minority and underserved populations who have limited access to dental services and poorer oral health status. Oral diseases/conditions, such as caries, baby bottle tooth decay, gingivitis, periodontitis, oral pharyngeal malignancies, and orofacial trauma, are prevalent and costly, yet largely preventable. Given their role in promoting and protecting overall health and their historical role in serving minority and underserved families, family physicians occupy a unique position to assure equity, access, and improvement in oral health for all Americans.

Clinical Issues in Minority Health
(Fam Med 1998;30(3):206-9.)

Panic Disorder in Hispanic Patients
David A. Katerndahl, MD, MA; Janet P. Realini, MD, MPH

Background and Objectives: This study determined the proportion of community-dwelling Hispanics who present for medical care for their panic attacks and identified factors associated with seeking care. We also compared characteristics of Hispanic subjects with those of non-Hispanic white panic sufferers.

Methods: In this community-based study, subjects with panic attacks completed a structured interview concerning health care utilization, panic characteristics, coexisting psychiatric problems, and illness attitudes. Hispanics were self-identified and completed the Cuellar acculturation scale for Mexican-Americans.

Results: Twenty-nine (53.7%) of 54 Hispanic subjects had sought medical care for their panic attacks. Care seeking in non-Hispanic whites was not dependent on these factors.

Conclusions: Half of the Hispanics with panic attacks seek no medical care for their attacks. Predictors of seeking care among Hispanics in San Antonio included coping style, symptom perceptions, and access to transportation.

Clinical Issues in Minority Health
(Fam Med 1998;30(3):210-4.)

Patient Ethnicity and Diagnosis of Emotional Disorders in Women
Shae Graham Kosch, PhD; Mary Ann Burg, MSW, PhD;
Shifa Podikuju

Background and Objectives: Ethnic background and family resources have not been sufficiently examined in relation to emotional disorders and their treatment in primary care settings. This study examined the diagnosis and management of psychological disorders in family practice patients to explore how ethnicity may affect the diagnosis and treatment of emotional disorders.

Methods: A random sample of family practice patients was selected from 1 year of office visits. The charts of 100 African-American and 100 Caucasian women were audited for primary and secondary diagnoses, presenting symptoms, prescriptions, psychotherapy referrals, history of domestic violence and substance use, and family and demographic characteristics. Chi-square tests of association and multiple regression were used to analyze the data.

Results: Ethnic background was significantly associated with a diagnosis of a psychiatric disorder; 44% of Caucasian patients were diagnosed with an emotional disorder, compared with 24% of African-Americans. Proportionately more Caucasian patients with psychiatric diagnoses were treated with psychotropic medications. Patient race, marital status, and insurance status explained 15% of the variance in psychiatric diagnoses.

Conclusions: Women’s ethnicity is significantly associated with the diagnosis of emotional disorders and their treatment.

Clinical Issues in Minority Health
(Fam Med 1998;30(3):215-9.)

Supplemental Fitness Activities and Fitness in Urban Elementary School Classrooms
Mark B. Stephens, MD, MS; Susan W. Wentz, MD, MS

Background and Objectives: The physical activity levels of US children are declining. Opportunities for physical activity within city schools are constrained by time and space limits. This study determined whether a supplemental program of physical activity would significantly alter the fitness levels of low-income, minority, urban elementary schoolchildren.

Methods: Ninety-nine students from two Cleveland Public Schools served as subjects. One school received a 15-week intervention program where teams of two medical students met with urban elementary schoolchildren three times a week for physical activity sessions. The other school served as a control and received no supplemental activity other than a regularly scheduled physical education class held once a week. We obtained field measurements of skinfold thickness, heart rate response to submaximal exercise, and sit and reach flexibility.

Results: The supplemental activity group showed significant improvements in flexibility, body composition, and heart rate response to submaximal exercise.

Conclusions: This investigation indicates that a program of fitness activities conducted within the classroom can significantly improve levels of fitness in urban elementary schoolchildren.

Clinical Issues in Minority Health
(Fam Med 1998;30(3):220-3.)

Race and Ethnicity in Research
on Infant Mortality
Matthew R. Anderson, MD; Susan Moscou, FNP, MPH

Background and Objectives: Race and ethnicity are variables frequently used in medical research. However, researchers employ race and ethnicity in different ways and with differing intent. This leads to confusion over the interpretation of racial or ethnic differences. This study sought to determine how race and ethnicity are used in research on infant mortality.

Methods: We did a structured literature review of original research related to infant mortality published between January 1995 and June 1996 and indexed in the Core Contents section of MEDLINE.

Results: The supplemental activity group showed significant improvements in flexibility, body composition, and heart rate response to submaximal exercise.

Conclusions: There are several problems and ambiguities in the use of race and ethnicity in clinical research. Researchers who use racial or ethnic categories should do so for specified reasons and adopt clear definitions of the categories used.

Methodologic Issues in Minority Health Research
(Fam Med 1998;30(3):224-7.)

Disaggregating the Effects of Race
on Breast Cancer Survival
Daniel L. Howard, PhD; Roy Penchansky, DBA;
Morton B. Brown, PhD

Background and Objectives: This study examines differences in breast cancer survival between African-American and white women to determine whether there is a racial difference in survival after accounting for established influences on outcome, such as stage of cancer, health status, health behavior, utilization patterns, access to care, quality of care, and the doctor-patient relationship.

Methods: This study is a retrospective review of clinical records. The sample consists of 246 patients of three staff model HMOs who had mastectomies at stage II or above. Data on patient demographics, stage of cancer, health status, and health behavior and utilization, including preventive care, were extracted from patient records. Multivariate logistic regression was used to predict the determinants of advanced stage of cancer. Cox survival analysis was used to predict the determinants of survival.

Results: Missed appointments and stage of cancer were the key determinants of survival. The effect of race on survival was marginal after adjusting for these factors. Race, patients who missed appointments, and patients who delayed in reporting breast cancer symptoms were determinants of advanced stage. African-Americans were overrepresented among patients who missed appointments.

Conclusions: Missed appointments was a determinant of both advanced stage and shorter survival. This measure is an important component of how race affects survival. Compliance with appointment keeping and alleviating reasons for noncompliance must be considered as factors in breast cancer survival.

Methodologic Issues in Minority Health Research
(Fam Med 1998;30(3):228-35.)