The topic of health disparities has continued to garner much attention, primarily due to a steady stream of research, which has documented disparities, or gaps, in mortality rates, health conditions, access and utilization of health care, among others. Such disparities have been found to exist in a myriad of population subgroups, including racial and ethnic groups, socioeconomic positioning, gender, age, disability, and geographic location, among others. Certainly, these populations experiencing disparities are not mutually exclusive—individuals may experience health disparities or encounter disparities in access to care due to a confluence of social, cultural, environmental, and economic factors.

Because one of the overarching goals of the Healthy People 2010 initiative is to eliminate health disparities, a crucial step in reaching that goal is identification—through data collection, analysis, and dissemination. The following article presents information on disparities in three areas—health conditions, access to care, and environmental and behavioral factors—among adults (18+) from PHMC’s 2004 Household Health Survey residing in the five-county Southeastern Pennsylvania (SEPA) area. Also included in this article is a brief overview of disparities for selected average annualized (1999-2002) mortality rates (100,000), provided by the Pennsylvania Department of Health, Division of Health Statistics, and the Philadelphia Department of Public Health.

MORTALITY DISPARITIES, SEPA

Disparities in mortality, as reflected in average annualized (1999-2002) rates (per 100,000), reveal that African-American adults die, disproportionately, of the following selected conditions, compared to the aggregate for SEPA as well as their racial and ethnic counterparts.

·  Among women residing in SEPA, the average annualized mortality rate for female breast cancer is 30.7, per 100,000 women. More specifically, the mortality rate is highest for African-American women (39.8), followed by White (29.3), Latina (20.7), and Asian (11.7) women in SEPA.

·  While the average annualized mortality rate for lung cancer in SEPA is 58.4, per 100,000 adults, the mortality rate is highest among African-American adults (76.6), followed by White (55.9), Latino (30.1), and Asian (23.5) adults in SEPA.

·  In SEPA, the average annualized mortality rate for heart disease is 176.9, per 100,000 adults. However, the mortality rate among African-American adults (221.8) far exceeds the rate for SEPA, as well as their racial and ethnic counterparts: White (169.9), Latino (138.6), and Asian (97.3) adults.

·  The average annualized mortality rate for stroke in SEPA is 61.1, per 100,000 adults. The mortality rate is highest among African-American adults (81.3), followed by White (57.2), Latino (55.9), and Asian (54.8) adults in SEPA.

·  While the average annualized mortality rate for homicide in SEPA is 9.6, per 100,000 adults, the mortality rate is three times greater among African-American adults (32.9), followed by Latino (14.3), Asian (2.3), and White (2.8) adults in SEPA.

HEALTH CONDITION DISPARITIES, SEPA

Disparities in mortality rates are, more often than not, related to a convergence of disparities in health conditions, access to care, as well as environmental and behavioral factors. Disparities in health conditions can manifest in areas of general health status as well as specific chronic conditions. The information below, culled from PHMC’s 2004 Household Health Survey, highlights some of these disparities among population subgroups in Southeastern Pennsylvania.

Age Group
·  An increase in age group is met with a steady increase in the percentage of adults in fair or poor health: 11.6% (18-29 years), 11.7% (30-39 years), 19.0% (40-49 years), 22.0% (50-59 years), and 31.7% (60+ years).

·  An increase in age group is also marked by an increase in being either overweight or obese: 41.2% (18-29 years), 55.5% (30-39 years), 62.2% (40-49 years), 65.2% (50-59 years), and 65.7% (60+ years).

Gender
·  While similar percentages of men (19.2%) and women (20.3%) are in fair or poor health, women (15.7%) are more likely than men (9.5%) to have been diagnosed with a mental health condition in their lifetime.

Race/ethnicity
·  Nearly one-third of Latino (31.6%) and African-American (30.4%) adults is in fair or poor health, compared to White (16.4%) and Asian (12.8%) adults.

·  One-in-seven Latino (14.3%) and African-American (14.0%) adults has ever been diagnosed with diabetes, compared to White (7.5%) and Asian (3.9%) adults.

Poverty Status
·  Adults living in poverty (43.0%) are more than twice as likely as adults not living in poverty (17.0%) to be in fair or poor health.

·  Poor adults (38.9%) are twice as likely as non-poor adults (23.3%) to have a chronic condition.  More specifically, poor adults are more likely than non-poor adults to have ever been diagnosed with diabetes (18.4% versus 7.9%, respectively), heart problems (14.9% versus 9.3%, respectively) or high blood pressure (38.0% versus 25.9%, respectively).

·  More than one-fifth of poor adults (22.4%) has been diagnosed with a mental health condition in their lifetime, compared to approximately one-tenth (11.7%) of non-poor adults.

ACCESS TO CARE DISPARITIES, SEPA

Disparities in access to care can range from health insurance coverage to preventive cancer screenings; such disparities exist among population subgroups, as highlighted below, and culled from the 2004 Household Health Survey for Southeastern Pennsylvania.

Age Group
·  Younger adults are more likely than older adults to not have a regular source of care: 21.8% (18-29 years), 13.8% (30-39 years), 9.2% (40-49 years), 6.7% (50-59 years), and 6.6% (60+ years)

·  Younger adults are also more likely than older adults to not have health insurance coverage: 17.3% (18-29 years), 9.0% (30-39 years), 7.9% (40-49 years), 5.5% (50-59 years), and 1.1% (60+ years).

Gender
·  Men (15.1%) are nearly twice as likely as women to not have a regular source of care (8.1%).

·  Men (20.9%) are also more likely than women (13.2%) to not have visited a health care professional within the past year.

·  However, men (8.9%) are only slightly more likely than women (6.9%) to not have health insurance coverage.

Race/ethnicity
·  One-fifth of Latino adults (20.0%) does not have health insurance coverage, followed by Asian (17.4%), African-American (12.2%), and White (5.2%) adults.

·  While the majority of women have had a PAP test, mammogram, and clinical breast exam within the past year, Asian women are more likely than their racial and ethnic counterparts to have never had a PAP test, mammogram, or clinical breast exam. Similarly, Asian men are more likely than their racial and ethnic counterparts to have never had a prostate exam (Figure 1).

·  Among adults with a regular source of care, Asian adults are two to three times more likely than their racial and ethnic counterparts to have encountered translation service barriers at the location of their health care provider. Two-fifths of Asian adults (40.2%) have not had someone that speaks their language at their source of health care, compared to White (27.8%), African-American (19.7%), and Latino (14.7%) adults.
o Among Asian adults who have experienced barriers in translation services, 86.2% cite the doctor’s office as the location of their regular source of care.

Poverty Status
·  Poor adults (17.2%) are twice as likely as non-poor adults (6.6%) to not have health insurance coverage. In addition, poor adults (20.5%) are more likely than non-poor adults (12.8%) to not have prescription medical coverage.

·  Moreover, three-tenths of poor adults (30.3%), compared to 12.2% of non-poor adults, were not able to fill a prescription in the past year due to cost factors. Additionally, three-tenths of poor adults (29.9%) were not able to receive dental care due to the cost, compared to 17.3% of non-poor adults.

·  Poor adults (22.2%) are nearly three times as likely as non-poor adults (8.2%) to have been faced with an illness but could seek care due to the costs associated with health care.

·  While poor adults are equally likely as non-poor adults to have a regular source of care—approximately 88%—the location of that regular source of care often differs. Less than three-quarters of poor adults (70.4%) receive their care from a Doctor’s office, compared to 91.3% of non-poor adults. Instead, poor adults are more likely than non-poor adults to receive their care from a community health center or clinic (16.9% versus 2.7%, respectively) or a hospital outpatient clinic (7.9% versus 3.6%, respectively) (Figure 2).

·  More than two-fifths of poor women (42.3%), compared to more than one-third of non-poor women (35.0%), did not have a mammogram in the past year. Similarly, nearly three-fifths of poor men (56.7%), compared to two-fifths of non-poor men (40.5%), did not have a prostate exam in the past year.

ENVIRONMENTAL AND BEHAVIORAL DISPARITIES, SEPA

While disparities are observed in both health conditions as well as access to health care services, disparities are also found in environmental and behavioral factors, as outlined below and based on an analysis of the 2004 Household Health Survey for Southeastern Pennsylvania.

Age Group
·  Generally, as age group increases, the percentage of adults who smoke cigarettes either every day or some days decreases: 30.4% (18-29 years), 23.3% (30-39 years), 27.4% (40-49 years), 22.7% (50-59 years), and 12.4% (60+ years).

·  Similarly, younger adults tend to be more likely than older adults to have experienced extreme stress in the past year: 29.6% (18-29 years), 25.0% (30-39 years), 30.2% (40-49 years), 24.7% (50-59 years), and 12.3% (60+ years).

Gender
·  While relatively similar percentages of men (24.6%) and women (21.2%) smoke cigarettes either every day or some days, a larger percentage of women (56.6%), compared to men (48.6%), have never smoked cigarettes.

·  Women (28.1%) are more likely than men (19.1%) to have experienced extreme levels of stress in the past year.

Race/ethnicity
·  Three-tenths of Latino (30.2%) and African-American (29.4%) adults, compared to 22.5% of White adults and 13.8% of Asian adults, have experienced extreme stress in the past year.

·  African-American (8.3%) and Latino (6.1%) adults are more likely than White (2.7%) and Asian (2.5%) adults to find it difficult or very difficult to locate fruits or vegetables in their neighborhood.

·  Furthermore, African-American (29.3%) and Latino (22.1%) adults are more likely than Asian (12.0%) and White (6.8%) adults to rate the quality of groceries in their neighborhood as fair or poor.

·  Two-fifths of Latino (40.1%) and African-American (39.7%) adults, compared to approximately three-tenths of Asian (30.2%) and White (27.2%) adults, have had to travel outside of their neighborhood to reach a supermarket.

Poverty Status
·  In addition to facing economic obstacles in accessing health care, poor adults also face economic obstacles in obtaining food: poor adults (29.4%) are nearly five times as likely as non-poor adults (6.2%) to have had to either reduce the size of a meal or skip a meal entirely to due other budgetary demands in the past year. Furthermore, poor adults (19.5%) are also approximately five times as likely as non-poor adults (3.7%) to have been hungry but did not eat because of cost factors in the past year.

·  Nearly one-third of poor adults (32.4%), compared to more than one-fifth of non-poor adults (21.6%), smokes cigarettes either every day or some days; however, poor adults (69.6%) are more likely than non-poor adults (52.1%) to have tried to quit smoking in the past year.

·  Nearly two-thirds of poor adults (63.2%), compared to one-half of non-poor adults (49.8%), eat fewer than three servings of fruits and vegetables on a typical day.

·  Poor adults (9.6%) are three times more likely than non-poor adults (3.4%) to find it difficult or very difficult to locate fruits or vegetables in their neighborhood.

·  Poor adults (28.1%) are nearly three times more likely than non-poor adults (10.5%) to rate the quality of the groceries in their neighborhood as fair or poor.

·  Furthermore, more than two-fifths of poor adults (44.0%), compared to nearly three-tenths of non-poor adults (28.9%), have had to travel outside of their neighborhood to reach a supermarket.

·  Poor adults (10.3%) are more than twice as likely as non-poor adults (4.0%) to have avoided a place during the day because of feelings of safety.

·  Two-fifths of poor adults (41.6%) have experienced extreme stress in the past year, compared to approximately one-fifth of non-poor adults (21.8%).

SUMMARY

Findings presented in this article provide a picture of disparities, as they exist in Southeastern Pennsylvania. For example, younger adults are more likely than older adults to lack both health insurance coverage and a regular source of care. While men and women are equally likely to have health insurance coverage, men are more likely than women to not have a regular source or care. African-American and Latino adults are more likely than their racial and ethnic counterparts to be diagnosed with diabetes. Finally, poor adults are more likely than non-poor adults to have been diagnosed with diabetes, heart disease, or high blood pressure in their lifetime; poor adults are also more likely than non-poor adults to lack health insurance coverage and prescription coverage. 

As the Healthy People 2010 deadline approaches, identifying health disparities, especially among specific segments of the population, becomes imperative. Only through identification can health disparities be tracked, monitored, and therefore, ultimately addressed—ensuring that the overall goal of the Healthy People 2010 initiative is achieved: that life expectancy is increased and quality of life is improved among all persons.

For more information on health disparities, please visit the Centers for Disease Control and Prevention’s (CDC) Office of Minority Health’s website: http://www.cdc.gov/omh/AboutUs/disparities.htm.

For more information on the findings presented in this article, please contact Nicole Dreisbach,  Research Associate, at 215-731-2168 or nicoled@phmc.org.

Notes:
Age-adjusted death rates are the number of deaths for any death or a cause-specific death, with age-adjustments. Age-adjusted rates are computed by the direct method, using the 2000 U.S. standard million population. Rates are per 100,000 population.
Adult overweight is defined as a score of 25 through 29 on the Body Mass Index (BMI) Level; obesity is defined as a score of 30 or greater on the BMI Level.
Extreme stress is defined as an 8 through 10 on a ten-point scale, rated by the respondent.