Racial healthcare disparities: A social psychological analysis

Around the world, members of racial/ethnic minority groups typically experience poorer health than members of racial/ethnic majority groups. The core premise of this chapter is that thoughts, feelings, and behaviours related to race and ethnicity play a critical role in healthcare disparities. Social psychological theories of the origins and consequences of these thoughts, feelings, and behaviours offer critical insights into the processes responsible for these disparities and suggest interventions to address them. We present a multilevel model that explains how societal, intrapersonal, and interpersonal factors can influence ethnic/racial health disparities. We focus our literature review, including our own research, and conceptual analysis at the intrapersonal (the race-related thoughts and feelings of minority patients and non-minority physicians) and interpersonal levels (intergroup processes that affect medical interactions between minority patients and non-minority physicians). At both levels of analysis, we use theories of social categorisation, social identity, contemporary forms of racial bias, stereotype activation, stigma, and other social psychological processes to identify and understand potential causes and processes of health and healthcare disparities. In the final section, we identify theory-based interventions that might reduce ethnic/racial disparities in health and healthcare.     

Enabling Action: Reflections upon Inclusive Participatory Research on Health with Women with Disabilities in the Philippines

People with disabilities experience health disparities arising from social, environmental, and system-level factors. Evidence from a range of settings suggests women with disabilities have reduced access to health information and experience barriers to screening, prevention, and care services. This results in greater unmet health needs, particularly in relation to sexual and reproductive health. Women with disabilities are also more likely to experience physical and sexual violence than women without disabilities, further undermining their health. Community-based participatory research (CBPR) can generate knowledge and underpin action to address such health disparities and promote health equity. However, the potential and challenges of disability inclusion in CBPR, particularly in contexts of poverty and structural inequality such as those found in low- and middle-income countries, are not well documented. In this paper, we reflect on our experience of implementing and evaluating W-DARE, a three-year program of disability-inclusive CBPR aiming to increase access to sexual and reproductive health and violence-response services for women with disabilities in the Philippines. We discuss strategies for increasing disability inclusion in research and use a framework of reflexive solidarity to consider the uneven distribution of the benefits, costs, and responsibilities for action arising from the W-DARE program.     

Considering J.Lo and Ugly Betty: a qualitative examination of risk factors and prevention targets for body dissatisfaction, eating disorders, and obesity in young Latina women

Latina women are vulnerable to poor body image, eating disorders, and obesity, particularly during the college years. This study sought to identify common cultural antecedents of these concerns in order to inform the development of prevention programs for this population. Six groups of university students who identified as Latina (N=27) discussed cultural aspects of body image, eating disorders, and obesity. Thematic analysis identified four main themes: (a) cultural disparities in body-ideal, including the influence of the media and acculturation issues; (b) messages about body shape and weight received by family, peers, and society; (c) difficulties making healthy eating and physical activity choices as a function of college life; and (d) the influence of peers and potential male partners on body satisfaction and body-ideals. These results have implications for the development of programs targeting body dissatisfaction and risk for eating disorders and obesity in Latina college women.     

Mental Health Disparities,Treatment Engagement,and Attrition Among Racial/Ethnic Minorities with Severe Mental Illness: A Review

Mounting evidence indicates that there are mental health disparities in the United States that disadvantage racial/ethnic minorities in medical and mental health settings. Less is known, however, about how these findings apply to a particularly vulnerable population, individuals with severe mental illness (SMI). The aim of this paper is to (1) provide a critical review of the literature on racial/ethnic disparities in mental health care among individuals with SMI; (2) identify factors which may contribute to the observed disparities; and (3) generate recommendations on how best to address these disparities. Specifically, this article provides an in-depth review of sociocultural factors that may contribute to differences in treatment engagement and rates of attrition from treatment among racial/ethnic minorities with SMI who present at medical and mental health facilities. This review is followed by a discussion of specific strategies that may promote engagement in mental health services and therefore reduce racial/ethnic disparities in SMI.     

Clinical Cancer Genetics Disparities among Latinos

The three major hereditary cancer syndromes in Latinos (Hereditary Breast and Ovarian Cancer, Familial Adenomatous Polyposis and Lynch Syndrome) have been shown to exhibit geographic disparities by country of origin suggesting admixture-based disparities. A solid infrastructure of clinical genetics geared towards diagnosis and prevention could aid in reducing the mortality of these cancer syndromes in Latinos. Currently, clinical cancer genetic services in Latin America are scarce. Moreover, limited studies have investigated the mutational spectrum of these cancer syndromes in Latinos resulting in gaps in personalized medicine affecting diagnosis, treatment and prevention. The following commentary discusses available genotype and clinical information on hereditary cancer in Latinos and highlights the limited access for cancer genetic services in Latin America including barriers to genetic testing and alternatives for providing better access to genetic services. In this review, we discuss the status of clinical genetic cancer services for both US Latinos and those Latinos living in Latin America.     

Race and Healthcare Disparities: Overcoming Vulnerability

The paper summarizes recently published dataand recommendations about healthcaredisparities experienced by African Americanswho have Medicare or other healthcare coverage.Against this background the paper addresses theethics of such disparities and howdisadvantages of vulnerable populations likeAfrican Americans are typically maintained indecision making about how to respond to suchdisparities. Considering how to respond todisparities reveals much that vulnerablepopulations would bring to the policy-makingtable, if they can also be heard when they getthere. The paper argues that vulnerablepopulations like African Americans need fairrepresentation in bodies deciding what to doabout such disparities and that fairnessrequires proportional representation at alllevels of decisions that affect healthcare – aradical change. In this decision setting, howto provide adequate protection of minoritiesneeds much further attention. The mostattractive decision-making model isdeliberative democracy. The paper shows thatin deliberation, fair representation requiresnot only having a voice in decisions, but afair hearing of those voices. Achieving a fairhearing requires changes in norms ofcommunication and training of all to giveimportance to greetings and other measures ofcivility and trust building, and to be open todiverse forms of expression. Decisions abouthow to respond to healthcare disparities wouldinclude what programs to initiate for whom, howto evaluate the programs, and what to do inresponse to such evaluations. Conclusions arethat achieving such goals will take a seachange in how healthcare institutions andproviders do their business, and that socialactivism at every level will be needed toeffect these changes. The discussionhighlights many ethical issues that need muchgreater attention.     

Health,Luck and Moral Fallacies of the Second Best

Individuals who become ill as a result of personal lifestyle choices often shift the monetary costs of their healthcare needs to the taxpaying public or to fellow members of a private insurance pool. Some argue that policies permitting such cost shifting are unfair. Arguments for this view may seem to draw support from luck egalitarian accounts of distributive justice. This essay argues that the luck egalitarian framework provides no such support. To allocate healthcare costs on the basis of personal responsibility would arbitrarily and publicly burden socially detectable risk-takers while undetectable risk-takers continue to get a free ride. That problem is unavoidable even on the assumption that distributive institutions outside the healthcare sector are fully just. In actual, farfrom-just societies, imposing personal liability for the costs of voluntary risk taking would be wrong for an additional reason. Doing so would tend to magnify existing distributive injustices. These conclusions draw attention to two common ‘moral fallacies of the second best’ that can arise when applying ideal normative theory to matters of institutional design and in real-world policy contexts.     

Healthcare access as a right, not a privilege: a construct of Western thought

Over 45 million Americans are uninsured or underinsured. Those living in poverty exhibit the worst health status. Employment, education, income, and race are important factors in a person's ability to acquire healthcare access. Having established that there are people lacking healthcare access due to multi-factorial etiologies, the question arises as to whether the intervention necessary to assist them in obtaining such access should be considered a privilege, or a right. The right to healthcare access is examined from the perspective of Western thought. Specifically through the works of Aristotle, Immanuel Kant, Thomas Hobbes, Thomas Paine, Hannah Arendt, James Rawls, and Norman Daniels, which are accompanied by a contemporary example of intervention on behalf of the medically needy by the The Johns Hopkins Urban Health Institute.     

Experiences of Women Who Underwent Predictive BRCA 1/2 Mutation Testing Before the Age of 30

This qualitative interview study focuses on the experiences of a sample of British female BRCA 1/2 carriers who had predictive testing before the age of 30, which is the minimum age for breast screening in the UK. Following appropriate informed consent procedures participants were recruited through the Cancer Genetics Service for Wales. Semi-structured interviews were conducted face-to-face with seven participants, transcribed in full and analyzed using thematic analysis. The motives for testing and perceived advantages described by participants were similar to those identified in previous studies with older participants, such as increased awareness and knowledge and feeling more in control. However some of the perceived disadvantages were specific to younger women, including feeling pressured to make important life decisions earlier than they would have liked, such as about family planning and risk reducing surgery. Participants also reported feeling abandoned or forgotten because of lack of ongoing clinical contact, or feeling “stuck waiting” for screening to begin. However, none felt that these disadvantages were a reason to regret having testing. Findings in this small study suggest that having BRCA 1/2 predictive testing can have positive outcomes for young women even though they may be unable to access interventions such as breast screening. However it may be helpful to encourage young women during pre-test counseling to explore the decisions and choices they may face. These young women could benefit from ongoing support and follow up and increased interaction with healthcare professionals.     

IMPULSIVITY IN STUDENTS WITH SERIOUS EMOTIONAL DISTURBANCE: THE INTERACTIVE EFFECTS OF REINFORCER RATE,DELAY, AND QUALITY

We conducted two studies extending basic matching research on self-control and impulsivity to the investigation of choices of students diagnosed as seriously emotionally disturbed. In Study 1 we examined the interaction between unequal rates of reinforcement and equal versus unequal delays to reinforcer access on performance of concurrently available sets of math problems. The results of a reversal design showed that when delays to reinforcer access were the same for both response alternatives, the time allocated to each was approximately proportional to obtained reinforcement. When the delays to reinforcer access differed between the response alternatives, there was a bias toward the response alternative and schedule with the lower delays, suggesting impulsivity (i.e., immediate reinforcer access overrode the effects of rate of reinforcement). In Study 2 we examined the interactive effects of reinforcer rate, quality, and delay. Conditions involving delayed access to the high-quality reinforcers on the rich schedule (with immediate access to low-quality reinforcers earned on the lean schedule) were alternated with immediate access to low-quality reinforcers on the rich schedule (with delayed access to high-quality reinforcers on the lean schedule) using a reversal design. With 1 student, reinforcer quality overrode the effects of both reinforcer rate and delay to reinforcer access. The other student tended to respond exclusively to the alternative associated with immediate access to reinforcers. The studies demonstrate a methodology based on matching theory for determining influential dimensions of reinforcers governing individuals' choices.     

Dismantling institutional racism: theory and action

Despite a strong commitment to promoting social change and liberation, there are few community psychology models for creating systems change to address oppression. Given how embedded racism is in institutions such as healthcare, a significant shift in the system's policies, practices, and procedures is required to address institutional racism and create organizational and institutional change. This paper describes a systemic intervention to address racial inequities in healthcare quality called dismantling racism. The dismantling racism approach assumes healthcare disparities are the result of the intersection of a complex system (healthcare) and a complex problem (racism). Thus, dismantling racism is a systemic and systematic intervention designed to illuminate where and how to intervene in a given healthcare system to address proximal and distal factors associated with healthcare disparities. This paper describes the theory behind dismantling racism, the elements of the intervention strategy, and the strengths and limitations of this systems change approach.     

Minority stress,substance use,and intimate partner violence among sexual minority women

Compared to the research literature on intimate partner violence (IPV) in heterosexual relationships, our understanding of IPV among sexual minority women (SMW) lags far behind. This paper reviews the literature regarding the prevalence of IPV among SMW and discusses disparities between SMW and heterosexual women. Methodological issues in this area are also discussed. Moreover, we review associations among substance use, sexual minority stress, and IPV in this population. Finally, potential protective factors, such as social and community support, identity, mastery, and coping, are examined. As researchers and clinicians work to improve the health of SMW it is important to consider the associations among relationship violence, substance use, and minority stress. Moreover, it is essential to understand what factors may promote adjustment among SMW.     

‘Use what God has given me’: Difference and disparity in breast reconstruction

African-American women are significantly less likely to undergo postmastectomy breast reconstruction compared to white women in the USA. These observed differences have been interpreted as evidence of a healthcare disparity. The current study examines breast reconstruction decision-making among African-American women, locating reconstruction decisions in a context of culture, racial inequality and biomedicalisation. Semi-structured interviews were conducted with 27 African-American women who underwent mastectomy for breast cancer to add patient-centred perspectives to existing conceptualisations of racial/ethnic differences in reconstruction. Participants were socio-demographically diverse, and resided in the New York metropolitan area. Data analysis was informed by grounded theory. Spiritually and culturally informed body ethics often guided surgery decisions. Participants expressed reservations about breast implants, preferring autologous procedures that use ‘what God has given’. For some, breast reconstruction restored a sense of normalcy after cancer; others challenged an imperative to reconstruct. Several participants redirected our focus on access to reconstruction toward access to alternatives, noting the low reimbursement for prostheses, or their unavailability in patients’ skin tones. We suggest that a framework of ‘stratified biomedicalization’ better addresses the complexities of race, class and gender that inform preference, access and recommendations for breast reconstruction, and focuses attention on access to high and low-tech interventions.     

"If I had it to do over again...": midlife review, midcourse corrections, and women's well-being in midlife

Regrets about early adult life choices, expressed in midlife, are examined as a source of motivation for life changes in later midlife in 2 samples of women. Replicated findings with longitudinal data indicate that regret motivates goal setting but is not associated with actually making desired life changes. In both samples, women who had regrets about early adult life choices but did not make relevant life changes were lower in later well-being than both women with regrets who did make such changes and women without regrets. Compared with women who transformed regrets into life changes, women who did not were lower in effective instrumentality and higher in rumination, though they did not appear to face more barriers to change. Analyses with longitudinal data indicated that both rumination and effective instrumentality mediated the relationship between regret and well-being for women who did not translate regret into life changes.     

The role of explanatory context for racial disparities in predicting sociopolitical attitudes during COVID-19

The COVID-19 pandemic placed preexisting racial health disparities in stark relief. Recent studies have already established that, among prejudiced Whites, exposure to such racial disparities reduced concern about the pandemic and support for mitigation policies (Harrel & Lieberman, 2021; Stephens-Dougan, 2022). In response to such results, one cautionary line of reasoning argues that communicating the disparity figures without explanatory context can perpetuate (or at least not undermine) myths that African Americans are more likely to contract COVID-19 due to genetic predispositions or maladaptive behavioral tendencies (Chowkwanyun & Reed, 2020). In two studies, we test the claims that (a) explanatory context mitigates the tendency to attribute racial disparities to essential racial differences and (b) that perceptions of racial disparities are attuned to specific racial inequalities in the U.S., and not merely expressions of outgroup bias. In Study 1, we found that exposure to racial disparities with explanatory context (vs. without explanatory context) did not reduce racial essentialism or stereotyping, but did promote support for healthcare equity. In Study 2, we found that black disadvantage frames (vs. white vs. Hispanic) uniquely promoted support for equitable healthcare and multicultural inclusion. Importantly, and contrary to other recent findings, exposure to black disadvantage did not preclude support for equity.     

The Role of the Black Church in HIV Prevention: Exploring Barriers and Best Practices

Black people have the highest rate of HIV/AIDS infection in the USA, and they are less likely to access quality physical and mental healthcare. To address these disparities as outlined in the National HIV/AIDS Strategy, there is a need for culturally congruent, innovative approaches to HIV/AIDS prevention. The first multi‐denominational national study of Black faith leaders was conducted utilizing focus groups that were held in 11 US cities. The 265 participants were faith leaders who reported involvement in such prevention practices as sponsoring HIV/AIDS workshops, integrating HIV/AIDS messaging in the worship service, hosting HIV/AIDS screenings, distributing written materials about HIV/AIDS through the bulletin or flyers, pastoral counselling, advocating for policies that provide quality healthcare to the community and disseminating HIV/AIDS prevention messages through new media such as the Church website. These findings, including attention to barriers to engagement, provide insight into innovative practices that can be integrated into faith‐based HIV/AIDS prevention programming. Copyright © 2016 John Wiley & Sons, Ltd.     

The relation of congruence,differentiation, and consistency to interest and aptitude scores in women with stable and unstable vocational choices

This study examined by canonical variate analysis the relation between congruence, differentiation, and consistency, and academic aptitude and vocational interests for 280 women with stable vocational choices over 4 years and 327 women with unstable vocational choices over 4 years. Findings offered support for the importance of congruence in stable women; differentiation and consistency operated similarly for women with stable and unstable choices.     

Service Delivery Outcomes in ASD: Role of Parent Education,Empowerment, and Professional Partnerships

Children with Autism Spectrum Disorder (ASD) utilize a greater number of healthcare services compared to children with other developmental disabilities. Despite this, children with ASD remain at high risk for unmet service needs, which are compounded by differences in socioeconomic status (SES). Both empowerment and parent-professional partnership play a role in service outcomes and may be especially important in understanding these service disparities. Our goal was to better understand the contributions of these variables to service disparities in families of children with ASD. Two-hundred forty-nine parents of children with ASD between the ages of 3 and 20 participated in this online survey. Results support previous research highlighting high levels of unmet needs that are exacerbated by differences in parent education, a common indicator of SES. Empowerment and parent-professional partnership also predicted service delivery outcomes. While high quality partnership predicted greater service adequacy, empowerment was inversely related to services. Furthermore, an interaction found that highly empowered families experiencing poor quality partnerships reported worse service delivery outcomes, while empowerment was not a factor in services for families experiencing high quality partnerships. Parent-professional partnership partially mediated the relationship between parent education and service delivery outcomes. As such, increasing parent-professional partnerships through family-centered care and professional training may help to reduce education-related service disparities and improve satisfaction with care for families and children with ASD.     

A methodological review of sex-related access discrimination problems

This article provides a comprehensive review of the literature pertaining to sex-related access discrimination problems. The results indicate that positive and negative access discrimination occurs for both males and females. The major variables that appear to account for sex-related access discrimination are the sex role of the position, the amount of job-related information regarding the applicant, and the characteristics of the evaluator population. In general, it appears that the effects of access discrimination can be obfuscated if sufficient information is available regarding job-related variables other than sex. In selected instances, it also appears that populations which have been sensitized to female access discrimination problems may demonstrate reverse discrimination towards women applying for “out-of-role” positions. The article ends with a set of specific hypotheses designed to further investigate and clarify the process of sex-related discrimination in employment situations.