While studying for an American Nurse Association Commission on Nurse Certification examination, I was surprised to read a question regarding an African American male diagnosed with lung cancer. The question inquired how a master’s-prepared nurse would respond when the patient said he would have a better prognosis if his doctor listened to his symptom complaints. Interestingly, the “correct response” did not strike me as a response at all; it was an acknowledgement of his statement, given that statistically, despite his education or economic level, he would likely still receive substandard health care treatment as an ethnic minority.
I shared this scenario with my colleague Maria Krol, a fellow Bridgeport Hospital School of Nursing faculty member. Ms. Krol, Peruvian by familial origin, and myself, a Jamaican American, began to discuss the unfortunate state of health care if this has to be a question on a certification exam. Ms. Krol shared her own personal experience of witnessing Latino patients, who spoke minimal or no English, unable to have their health care needs explained to them despite the availability of translator phones, an electronic translator, and trained health care translators. She noted the problem was often the infrequency of translator device usage and the lack of availability, specifically during the evening and nighttime hours, of trained health care translators. Ms. Krol also noted that in outpatient settings like clinics and physician offices, translator devices and health care translators are often unavailable. How do we begin to bridge the gap imposed upon segments of our society in America—the land founded upon opportunity for all?
Examining the case for the existence of vulnerable populations
As the American Heart Association noted in Health Day News, “wide differences in the care of people who’ve had a stroke still exist between whites and ethnic minorities in the United States.”1 Dr. Salvador Cruz-Flores, the study’s author and Director of the Souers Stroke Institute at Saint Louis University, says, “We see disparities in every aspect of stroke care, from lack of awareness to stroke risk factors and symptoms to delayed arrival to the emergency room and increased waiting time.” Even after the stroke has occurred, disparities continue throughout the treatment and rehabilitation stages of care, he says.
The American Heart Association suggested that the varied medical risk factors of diabetes, obesity, and high blood pressure contribute to the disparities among ethnic minority groups in stroke care. It was noted that amongst African Americans and Hispanic Americans, the risk of metabolic syndrome and diabetes is significant, placing both ethnic minority groups at increased risk for stroke.
In her article “Vulnerability in Research and Health Care: Describing the Elephant in the Room,” Dr. Samia A. Hurst discusses how although the medical and science communities recognize vulnerable populations, historically, figuring out ways to protect them has proven difficult. Hurst provides a comprehensive list consisting of cited examples of vulnerability in human subjects research, including the following:
- International Conference on Harmonisation (ICH) of Tripartite Guidelines: Those incapable of giving consent, minors, refugees, nomads, homeless persons, ethnic minority groups, patients in emergency situations, unemployed or impoverished persons, persons in nursing homes, patients with incurable diseases, and more
- Council for International Organizations of Medical Sciences (CIOMS): The unemployed, members of communities unfamiliar with modern medical concepts, individuals who are politically powerless, patients with incurable disease, prisoners, refugees or displaced persons, nomads, homeless persons, some ethnic and racial minority groups, patients in emergency rooms, people receiving welfare benefits or social assistance and other poor people, residents of nursing homes, elderly persons, and more
- Declaration of Helsinki: Persons susceptible to coercion, persons who will not derive direct benefits from participation, persons for whom research is mixed with clinical care, and incompetent persons
- Belmont Report. The very sick, the institutionalized, economically disadvantaged, and racial minorities
- 45 Code of Federal Regulations (CFR): Pregnant women and fetuses, children and prisoners2
The variation among organizations regarding what populations are considered vulnerable is significant in itself, it contributes to a narrowed view of who should be protected and why. Persons can become vulnerable through injustices, their own fault, and misfortune; nevertheless, the goal of all health care organizations, as well as organizations conducting research with vulnerable populations, is to ensure equality of services rendered.
Disparities in ethnic populations across the socioeconomic spectrum
D’Anna, Ponce, and Siegel, in their article “Racial and ethnic health disparities: evidence of discrimination’s effects across the SEP spectrum,” discuss how discrimination, from a psychosocial perspective, can be a stressor for affected populations. Ultimately, the discrimination ethnic/racial groups experience could contribute to having physical and mental health problems. The purpose of their research was to investigate the association between perceived discrimination in receiving health care and racial/ethnic disparities in self-rated health status, physical, and emotional functional limitations among a diverse sample of California adults; to assess whether discrimination effects vary by racial/ethnic group and gender; and to evaluate how the effects of discrimination on health are manifest across the socioeconomic position (SEP) spectrum.”3
The diverse racial/ethnic group data was collected from a 55,428-participant California Health Interview Survey in 2001. The researchers noted two types in their study that qualitatively identified discrimination: “discrimination due to race/ethnicity, language, or accent and other discrimination.”3 The California Health Interview Survey included such topics as alcohol and cigarette use, diet, exercise, dental health, mental health, medical care/advice, physical health conditions, the utilization of health care services, compliance with recommended tests and treatment, prescriptions, perception of discrimination in health care settings, immigrant status, gun access, sexual orientation, education, employment, income, age, sex, race/ethnicity, and self-reported physical and mental health status. The survey frame included only Californian households that had listed landline telephone numbers. Interviews were conducted in Korean, Vietnamese, Spanish, Chinese (Cantonese and Mandarin dialects), Khmer, and English.
D’Anna, Ponce, and Siegel found discrimination due to race/ethnicity and language/accent, as well as other discrimination, had a negative effect on how ethnic minorities self-rated their emotional and physical health. And, while researchers observed variations between racial/ethnic groups and even gender, the effect of discrimination on physical health was noted as attenuated among participants of higher socioeconomic position. For example, Latinos reported discrimination when it came to emotional health; however, for physical health, minimal discrimination was noted.3 The Latino population encompasses a broad mix of persons from different countries that from a linguistic, migratory, and cultural perspective vary greatly. This alone may prompt the need for further studies in health care discrimination for similar yet distinct racial/ethnic groups.
Historically, discrimination and racial harassment have been linked to poor health and health outcomes as self-reported by ethnic minority patients.4 Researchers noted that prolonged exposure to inferior health care treatment invalidated patients’ self-worth, blocked aspirations, and damaged their self-esteem. The ethnic minority patients’ initial psychological response may eventually develop into the physiological problems that lead to deterioration in health manifesting in the form of such conditions as cardiovascular disease, mental illness, and hypertension.4,5
Exploring the direct socioeconomic effects of physical illness in an ethnic minority group with education and income being factors, Jackson researched the inverse association existing between hypertension and income for African American men and women.6 Roux et al. noted that in New York City’s Harlem, African American women had a decreased risk of hypertension that correlated with the achievement of a higher level of education and income, whereas African American men had a higher risk for hypertension with the achievement of a college education.7 Researchers recommend further exploration on how education and income in other ethnic minority groups affect psychological and physiological health outcomes.
How do we repair a system that doesn’t seem to empower the education of underrepresented ethnic minority groups on their risk factors for poor health outcomes? And when do we actually use current research to not only acknowledge that disparities exist, but hold health care facilities and professionals accountable for the delivery of quality health care to all of their patients regardless of their ethnic origin?
As nurses, we are patient advocates who assist in navigating the health care system. Our goal is to ensure our patients obtain optimum wellness by educating them on such topics as safe medication administration, exercise, self-injections of prescribed medications, daily weights, and various signs and symptoms of bodily and emotional illnesses. Therefore, when we see patients that are not given thorough or accurate medical, surgical, rehabilitation, or psychiatric treatment, are we not obligated as health care professionals to ensure equitable treatment is provided?
The Department of Health and Human Services released a plan in 2011 to reduce racial and ethnic disparities in the United States. The plan has five major goals: “transform the health care system by expanding the health care coverage of persons and thereby increase access to health care; strengthen the health care workforce by recruiting more minorities for medical and public medical careers, supporting of the training of community health workers such as promotoras (Spanish-speaking community health workers), and improving health care interpreting services; improving the health of minority communities through community transformation grants to target health disease, tobacco-related illnesses, flu, asthma, maternal child health, and childhood obesity; the improvement of research and data collection involving racial and ethnic minorities; and, lastly, an increase accountability and transparency of the Department of Health and Human Services’ programs that are working toward the goal of the reduction of minority health disparities.”8,9
As nurse educators responsible for preparing the minds of future nurses for direct patient care in a variety of clinical settings, we feel obligated to train our students understand and respect the rights of all people, as they deserve the opportunity—through the conveying of nursing and medical knowledge—to make informed decisions about their health care and to receive quality care. Skin color and language differences should never be a consideration that clouds our judgment.
- Health Day News, retrieved on May 26, 2011, American Heart Association, (2011): 1-2.
- Samia A. Hurst, “Vulnerability in Research and Health Care: Describing the Elephant in the Room,” Bioethics 22 (2008): 193.
- Laura Hoyt D’Anna, Ninez A. Ponce, and Judith M. Siegel, “Racial and ethnic health disparities: evidence of discrimination’s effects across the SEP spectrum,” Ethnicity and Health 5 (2010):
- S. Karlsen and J.Y. Nazroo, “Relation between racial discrimination, social class, and health among ethnic minority groups,” American Journal of Public Health 92 (2002): 624-631.
- B.K. Finch, et al., “The Role of Discrimination and Acculturative Stress and the Physical Health of Mexican Origin Adults,” Hispanic Journal of Behavioral Sciences 23 (2001): 399-429.
- P. Jackson, “Health and inequalities among minority populations,” The Journals of Gerontology: Series B 60 (2005): S63-S67
- A. Diez-Roux, et al., “Prevalence and social correlates of cardiovascular disease, risk factors in Harlem,” American Journal of Public Health 89 (1999): 302-307.
- Sherry A. Gilead, Garth Graham, and Howard K. Koh, “Reducing racial and ethnic disparities: the action plan from the Department of Health and Human Services,” Health Affairs 30 (2011): 1822-1829. doi: 10.1377/hlthaff.2011.0673.
- J. Warner, “New United States plan to improve health care for minorities,” WebMD Health News, April 12, 2011: 1-2, http://www.medscape.com/viewarticle/740906_print
- Alexander, G. Caleb, Gadon, Margaret, Vanderbilt, Susanne K. and Wynia, Matthew K.(2007). A qualitative study of physicians’ engagement in reducing healthcare disparities. Journal of the National Medical Association, December 99 (2007): 1315-1322.
- Espinosa, M. Cristina. (2009). Ethnic spirituality, gender and health care in the Peruvian Amazon. Ethnicity and Health, October 14(5): 423-437.
- Tirado, Miguel. (2011). Role of mobile health in the care of culturally and linguistically diverse United States populations. Perspectives in Health Information Management, Winter 2011: 1-7.