April 2001
Submitted by: Gem P. Daus, M.A., Legislative and Governmental Affairs Coordinator
Introduction
In accordance with Title II of the Minority Health and Health Disparities Research and Education Act of 2000 (P.L. 106-525), the Agency for Healthcare Research and Quality (AHRQ) is developing an annual report to Congress on prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations. AHRQ will develop quality of care measures that assess such factors as access to care, cultural competence and health outcomes for minority and underserved populations. AHRQ has requested guidance on the conceptual framework of the report, the types of measures that might be included, and possible data sources. The Institute of Medicine’s “Committee for Guidance in Designing a National Health Care Disparities Report” and the public will provide this guidance to AHRQ.
Asian and Pacific Islander American Health Forum (APIAHF) supports the development of this national disparities report. H owever, federal datasets are woefully inadequate for Asian American and Pacific Islander populations. In order for the report to be useful to policy makers, health care providers, and communities, AHRQ must look beyond federal sources of data.
Definition
The National Institutes for Health defines health disparities as : “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.” “Other adverse health conditions” may include differences in access to care and quality of care. “Specific population groups” may be defined by race and ethnicity, gender, education, income, disability, geographic location, and sexual orientation (Healthy People 2010).
In the case of racial and ethnic health disparities, comparisons are often made between a particular minority group and non-Hispanic Whites, or a minority group and the national average . For example, 56% of elderly Asian Americans with Medicare received the flu vaccine in 1996, compared to 65% for Whites (Commonwealth Fund, 1999); Asian Americans and Pacific Islanders (AAPI) have the highest rates of tuberculosis of all race/ethnic groups in the United States (NCHS, 2002).
Disparities also exist between U.S.-born and foreign-born populations of the same ethnic group. For example, second generation Japanese Americans suffer from diabetes at approximately twice the rate of the White population, and four times the rate seen in Japan.
Why racial and ethnic health disparities exist is not clearly understood. They may be related to socioeconomic status or cultural beliefs and practices. Disparities in mortality may be related to disparities in quality. Disparities in incidence or prevalence may be related to access issues, or they could be related to the environment, genetics, or discrimination. More research needs to be done to identify the causes of disparities and understand the interaction of the many factors that influence health.
A complete picture of the health status of any racial/ethnic population includes data on access to care, quality of care, and health outcomes. In addition, data for race/ethnic populations must be contextualized or cross-referenced with data on socioeconomic status, geography, age, and gender. For AAPI, data on immigration status, nativity, and language proficiency of the population should be also presented. Finally, data should be presented for distinct Asian American and Pacific Islander ethnic groups such as Hawaiian, Vietnamese and Asian Indian.
Eliminating Racial and Ethnic Health Disparities
While the causes of disparities are not fully understood, there are nevertheless many efforts underway to reduce and/or eliminate health disparities. Healthy People 2010, the nation’s strategic plan for health, has as one of its goals the elimination of health disparities by 2010. Each of the Institutes and Centers of the National Institutes of Health have produced strategic plans to “reduce and ultimately eliminate health disparities.”
We must be clear, however, that eliminating racial and ethnic health disparities is more than improving health status until it is equal to that of Whites. This is an important point because disparities are usually cast as comparisons between non-Hispanic Whites and a particular minority group. However, this comparison does not mean that the level of performance for Whites is the ideal health outcome. Regardless of the disparity or population, we can define a standard of care and a desired health outcome for all people. Progress in improving health status can then be measured against these standards.
Data collection, analysis and dissemination
Documentation of health disparities experienced in Asian American and Pacific Islander populations is limited by the lack of AAPI-specific research, the incomparability of federal and industry datasets, and the lack of statistically significant samples in those datasets. The paucity of data is glaringly evident in the Health People 2010 objectives. Of the 22 objectives that will be used to measure the Leading Health Indicators, only five have separate data for Asians and for Native Hawaiians and Other Pacific Islanders. Another six objectives only have aggregated Asian and Pacific Islander data. Two have both aggregated data and data for Asians but not for Native Hawaiians and Other Pacific Islanders. Nine of the 22 objectives do not even have statistically reliable aggregated Asian and Pacific Islander data.
Healthy People 2010 does not contain any data for specific Asian American or Pacific Islander subpopulations such as Korean or Filipino. Aggregate data on AAPI can be highly misleading because it obscures important differences. Severe health disparities among sub-populations such as Southeast Asians and Native Hawaiians will only be illuminated when data are disaggregated. Disaggregated and statistically-significant samples are essential for identifying and understanding the causes of health disparities among AAPI, as well as for developing appropriate programs and interventions and making decisions about resource allocations.
Given the critical role that the Leading Health Indicators will play in monitoring the nation’s progress on the Healthy People 2010 objectives, it is vital to address the serious lack of data for Asian Americans and Pacific Islanders. The amount and quality of health data on AAPI should be increased to a level that makes it possible to assess the achievement by AAPI of Healthy People 2010 objectives. However, since these datasets are woefully inadequate for Asian American and Pacific Islander populations, alternate sources of data must be considered. For the purpose of developing a national report on health disparities experienced by AAPI, AHRQ must look beyond federal data.
BACKGROUND: AAPI Health Disparities
Disparities in Access to Care
Access to care is the ability of an individual or population to get needed health services. The most common means for obtaining access to care is health insurance. This insurance may come through employers or through public assistance programs such as Medicaid or State Child Health Insurance Program (SCHIP). However, a substantial number of people remain uninsured. According to the Census Bureau, an estimated 38.7 million people (14% of the population) went without health insurance for the entire year in 2000.1 The Census estimated 18% of AAPI are uninsured, and an earlier study by UCLA estimated 21%. 1,2 However, as the table below shows, there is wide variation by ethnicity, age, generation, income and citizenship.
Population |
% uninsured |
|---|---|
AAPI Overall 2 |
21% |
Korean |
34% |
Southeast Asian |
27% |
South Asian |
21% |
Chinese |
20% |
Filipino |
20% |
Japanese |
13% |
3rd generation or more AAPI |
8% |
Citizen |
17% |
Children (0-17) |
15% |
Non-Latino White 2 |
14% |
By Citizenship3 |
|
Non citizen child / noncitizen parent |
23% |
Citizen child / non citizen parent |
12% |
Citizen child / US born parent |
7% |
There are severe health consequences to being uninsured. In comparison to those with insurance, the uninsured are not only more likely to go without care for serious medical conditions, they are also more likely to go without routine care. The uninsured are also less likely to have a regular source of care, less likely to use preventive services, and have fewer visits per year.4 For example, 52% of uninsured Japanese do not have a usual source of care; and 29% of uninsured South Asian children do not meet the recommended number of physician visits for their age group. 2
Disparities in Quality of Care
While health insurance is the key to accessing care, it is not a guarantee of quality health care. Even when access is equal, disparities may exist. Disparities do exist in the quality of care AAPIs receive.
According to the Institute of Medicine, quality of care is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”5 Disparities in quality care can generally be characterized as under-, over-, or mis- utilization of medical services.6 Screening, diagnostic tests, therapeutic interventions, prescription medication and preventive services are all areas where disparities occur.
Data on utilization rates for various medical procedures would be most useful in measuring disparities in quality of care. For example, what proportion of AAPI diabetics has had a foot or eye exam? However, such data is rarely collected, analyzed or disseminated for AAPI populations. Other measures of quality are indirect. For example, prolonged recovery time, disease that is diagnosed in the late stages, or premature death suggests a possible lapse in quality. A study of Asian American AIDS patients in New York revealed that Asians died of pneumocystis carinii pneumonia at a higher rate than other populations suggesting that a fairly treatable opportunistic infection remained untreated.7 Patient satisfaction is another indirect measure of quality.
Examples of disparities in quality of care for AAPI populations are:
- 16.9% of AAPI women had no prenatal care in first trimester of pregnancy in 1998. This is a significant decrease from the 1990 rate of 24.9%, but still higher than the rate for non-Hispanic Whites (12.1%).8
- 61% of Asian women aged 40 years and older have received a mammogram in the past two years, compared to 67% for non-Hispanic White women.9
- Only 30% of APIs with diabetes perform a self-blood-glucose-monitoring at least once a day, compared to 53% for American Indians/Alaska Natives. 9
- 56% of elderly Asian Americans with Medicare received the flu vaccine in 1996, compared to 65% for Whites.10
- Asian Americans are less likely to receive physician counseling about smoking cessation, healthy diet and weight, exercise and mental health.11
Culturally and Linguistically Appropriate Services
As with all disparities, the cause of quality disparities is not fully understood. However, as it relates to AAPI and many other populations i n the health setting, linguistically appropriate and culturally competent services are fundamental to the delivery of quality services. A recent study by the Commonwealth Fund revealed that Asian Americans were less likely than the overall population to rate their care highly, less likely to be confident about their care, and more likely to indicate having a communication problems with their doctor. 11 Many Asian Americans believe their doctor does not understand their background and values. The lack of culturally and linguistically appropriate services can also be a barrier to accessing care in the first place.
Studies of limited-English proficient populations in health care settings reveal many disparities in quality care. While some of these studies are not AAPI specific, it is clear that not speaking English highly impacts the quality of care. The lack of language services results in an impaired exchange of information, loss of language cues that may aid in diagnosis, incomplete patient education, lack of informed consent, less access to services and thus a lower level of preventative care.12 Without interpreters, physicians may order inappropriate or unnecessary tests and patients may not understand their diagnosis, medication instructions or follow-up care plans. Misunderstanding medication instructions can have fatal consequences.
Disparities in Health Status
There are racial and ethnic health disparities in how often a disease occurs in a given population (prevalence), the rate at which new cases of disease arise in a population (incidence), and causes of death (mortality). These disparities may be independent of or related to disparities in access or quality. All Asian American and Pacific Islander populations experience disparities in many of the leading health indicators.
- AAPIs have the highest TB case rates: ten times more than that of Whites. 8
- AAPIs, similar to Blacks and Hispanics, have a higher suicide rate than Whites. 8
- Women of Vietnamese origin suffer from cervical cancer at nearly five times the rate for white women. 9
- Cambodians in California had four times the rate of stroke as the white population in the sate (107 per 100,000 vs. 28).13
- Native Hawaiians have extremely high rates of diabetes. They are over five times as likely as non-Hawaiians to experience diabetes between the ages of 19 and 35, and twice as likely between the ages of 36 and 64.14
- Heart disease is the leading cause of death for Hawaiian and Filipino men. It is the second leading cause of death for Japanese and Chinese men.15
Moreover, there are disparities between U.S.-born AAPIs and foreign-born AAPIs suggesting an environmental influence and underscoring the need for population specific research. For example:
- Rates of primary liver cancer were higher for foreign-born Filipino men than American-born Filipino men (11.4% to 6.5%), and both were higher than whites (3.4%).16
- Second generation Japanese Americans suffer from diabetes at approximately four times the rate seen in Japan.17
- Higher rates of coronary artery disease have been found in South Asians who have migrated to other countries, relative to those who did not immigrate.18
Many factors influence these outcomes including quality of care, behavior, environment, genetics and discrimination.
1 Mill RJ. Health Insurance Coverage: 2000. Washington, DC: U.S. Census Bureau; 2001.
2 Brown ER, Ojeda VD, Wyn R, etal. Racial and Ethnic Disparities in Access to Health Insurance and Health Care. Los Angeles, CA: UCLA Center for Health Policy Research; 2000.
3Immigrant’ Health Care: Coverage and Access. Washington, DC: Kaiser Family Foundation; 2000.
4Coverage Matters: Insurance and Health Care. Washington, DC: Institute of Medicine; 2001.
5 Lohr KN, ed. Medicare: A Strategy for Quality Assurance. Washington, DC: National Academy Press; 1990.
6The Challenge & Potential for Assuring Quality Health Care for the 21 st Century. Washington, DC: U.S. Dept Health and Human Services; 1999.
7 Eckholdt H, Chin J. Pneumocystis carinii Pneumonia in Asians and Pacific Islanders. Clin Infect Dis. 1997; 24:1265-67.
8 Keppel KF, Pearcy JN, Wagener DK. Trends in racial and ethnic-specific rates for the health status indicators: United States, 1990-98. Health People Statistical Notes, no. 23. Hyattsville, Maryland: National Center for Health Statistics; 2002.
9Health People 2010. Conference edition. Washington, DC: US Dept Health and Human Services; 2000
10 Collins KS, Hall A, Neuhaus C. U.S. Minority Health: A Chartbook. New York, NY: The Commonwealth Fund; 1999.
11 Collins KS, Hughes DL, Coty MM, etal. Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans. New York, NY: The Commonwealth Fund; 2002.
12 Woloshin S, et al. Language Barriers in Medicine in the United States. J Am Med Assoc. 1995; 273: 9.
13 Dumbauld S, etal. Analysis of Health Indicators for California’s Minority Populations. Minority Health Improvement Project No. 180M-5-92. Sacramento, CA: California Dept Health Services; 1994.
14Hawaii Health Surveillance. Honolulu, HI: Hawaii Dept Health; 1990.
15 Hoyert DL, Kung HC. Asian or Pacific Islander mortality, selected states. Monthly vital statistics report Vol 46, No.1, Supp. Hyattsville, MD: National Center for Health Statistics; 1997.
16 Rosenblatt KA, Weiss NS, Schwartz SM. Liver cancer in Asian migrants to the United States and their descendants. Cancer Causes and Control. 1996; 7(3): 345-50.
17 Fujimoto WY, et al. Prevalence of diabetes mellitus and impaired glucose tolerance among second generation Japanese American men. Diabetes. 1987; 36:721-9.
18 Dhawan J. Coronary heart disease risks in Asian Indians. Current Opinions in Lipidology. 1996; 7(4): 196-8.
