Racial and Ethnic Disparity in Diabetes Care

Race is a socially constructed concept, and its boundaries frequently shift. Though racial categories have changed over time, a major distinction remains between blacks and whites.¹ Race can be regarded as a proxy for class, and health care disparities are the products of social and economic inequality.² Upon the request of the U.S. Congress, the Institute of Medicine (IOM) formed a committee to evaluate these disparities and provide recommendations concerning how to combat them.³ They released a report showing the depth of racial and ethnic inequalities in American health care in 2002.⁴ 

The IOM committee defined health care disparities “as racial or ethnic differences in the quality of health care that are not due to access related factors, clinical needs, preferences, and appropriateness of intervention.”³ They concluded the following:

• Racial and ethnic disparities exist in the U.S. health care system.
• Disparities are rooted in historic as well as contemporary inequality in social and economic aspects of American lives.
• Ethnic discrimination is among historical factors leading to disparities.
• There are numerous sources contributing factors, including health systems, utilization managers and health care providers, stereotyping, prejudice, and bias.
• Clinical uncertainty amongst health care providers may affect equal health care as well.³

According to the Department of Health and Human Services, health care disparity can be linked with economic, social, and environmental disadvantages.⁵

Disparities in diabetes care

Many researchers have found racial and ethnic disparities in disease management, including diabetes.⁶ Other affected conditions include asthma, hepatitis, cancer, and HIV/AIDS.7 Associated with poor patient outcomes, disparities are deemed unacceptable.³ Findings in a majority of these studies show that regardless of cause, minorities’ experiences differ from whites in many disease categories. Most literary reports on diabetic disparities pertain to African Americans; data on Native Americans, Hispanics, and Asian Americans/Pacific Islanders were limited.³

According to Bal, projections estimate that by 2025, there will be about 300 million people with diabetes worldwide, with the biggest increase occurring in the developing countries.⁸ The effects of unmanaged diabetes can be life threatening. According to the Centers for Disease Control and Prevention (CDC), diabetes is the leading cause of many health problems, such as kidney failure, blindness, lower limb amputations, stroke, and heart disease; it is the seventh-leading cause of death in America.⁹ Reasons attributed to diabetes disparities include differences in income, barriers to health care (type and lack of insurance), and divergent medical needs. After accounting for these causative factors, racial and ethnic disparities in the delivery of health care still persist.10 The United States has made much progress in establishing fairness and justice in many aspects of its citizens’ lives. A barrier yet to be crossed is health care equity. One major economic effect of health inequality is overuse of urgent care centers or emergency rooms for routine care.¹¹

African Americans have the highest rates of diabetes diagnosis; Hispanics, Asian Americans, and American Indians are affected by diabetes disparities as well.⁹ Chin et al. evaluated the care received by 1,376 diabetic patients aged 65 years or older. Compared to whites, African Americans’ health perception and quality of care were low; they had fewer physician visits per year than whites, higher rates of emergency visits, and poor health perceptions.6 Although African Americans are less likely to receive certain treatments, they are more likely to receive non-leg-sparing treatment (amputation) than whites.¹² In 2005, diabetic blacks were over two times more likely to receive lower extremity amputation than diabetic whites.⁹ Amongst the elderly, diabetes was almost twice as prevalent in blacks as whites, and the frequency of amputations in blacks was almost four times the number with whites, with 62% of the principal diagnosis for amputation being diabetes.¹²

Chin et al. indicated that African Americans with diabetes might experience reduced use of the emergency department and improved perception of health if the access to preventive care is improved. They also recommend improving the quality of care for Medicare patients, many of whom are African Americans.⁶

Relevance to nursing

In many areas of practice, nurses provide the most direct patient care. In acute care, nurses assess patient glucose levels and treat as needed. They are also more likely to provide diabetic patients with disease education in collaboration with dieticians. Nurses must be aware of their own prejudices and biases that may interfere with the care they provide diabetic patients from different racial and/or ethnic backgrounds. In addition to nursing schools including cultural literacy in their curriculum, patient education must reflect cultural congruence with patient background to be effective. Brown et al. conducted a study to evaluate two different culturally sensitive interventions designed for Mexican Americans. Findings indicated the participants in both intervention groups had perceived improvements in sense of control over their diabetes.¹³

Piette et al. studied the effect of automated telephone disease management (ATDM), with nurses following up with patients via phone. After 12 months, researchers found the participants receiving the interventions had more frequent self blood sugar checks and foot inspections compared with patients receiving more standard care. In addition, the glycosylated hemoglobin level was lower in the intervention group, and overall, the glycemic control and the diabetic symptoms were improved. This result is significant for APNs who may be planning interventions for reducing diabetic care disparities in minorities. With proper monitoring, minority diabetic patients may have more successful diabetes management.¹⁴

In another study, Piette et al. reviewed automated telephone calls with a nurse’s follow-up of 280 Spanish-and English-speaking adults diabetics. Findings indicated that glycemic controls were better in patients receiving the interventions than those receiving the usual care; the treatment group also had better glucose, weight, and foot monitoring than the control group.¹⁵ The automated calling system was available in both Spanish and English language, providing culturally sensitive care to people who might not speak or understand English well.

Yeboah-Korang, Kleppinger, and Fortinsky studied variations in the use of home health services amongst participants from different racial and ethnic groups with type 2 diabetes. They found African Americans received fewer nurse visits and other clinical disciplines than whites. In addition, Hispanics were less likely to receive physical therapy or home health aide than whites as well.¹⁶

Jenkins et al. researched the efforts to decrease the number of amputations caused by diabetes in African Americans. The Racial and Ethnic Approaches to Community Health (REACH) program in South Carolina propelled the efforts toward reducing the number of amputations in African Americans. Data for South Carolina indicated foot amputation was a problem for African Americans, and Jenkins et al. evaluated how the Community Chronic Care Conceptual Model for REACH Charleston and Georgetown Diabetes Coalition addressed the issue. The coalition efforts involved racial and ethnic approaches, and they included education of health professionals, two days of nurse training on foot care, inclusion of podiatrist in staff membership, a foot examination by the nurses with a physician follow-up, a media campaign, volunteers and community health advocates, and diverse educational materials for patients. These REACH efforts have reduced the number of diabetes hospitalizations in both Charleston and Georgetown counties from about 38.7 per 1,000 diabetes patients in 1999 to about 21.7 per 1,000 in 2008. The numbers of amputations in both counties have also decreased significantly since 1999.¹⁷

Another study by Two Feathers et al. attempted to determine the effect of a community REACH program culturally tailored to address the diabetes care needs of African Americans and Latinos in Detroit, Michigan. Results showed significant improvement in dietary knowledge and glycosylated hemoglobin among participants.¹⁸ With these two reports, one can conclude that the REACH program has the potential to reduce disparities in diabetes care; hence, the need to adopt this program nationwide.

Chin, Walters, Cook, and Huang described many strategies to reduce health care disparities, such as interventions addressing multiple levels of change, culturally tailored quality improvement, and nurse-led interventions. Culturally tailored intervention has the potential to “enhance effectiveness of general quality improvement interventions among ethnic minority groups.” Additionally, nurse-led interventions can yield positive results because nurses are both cost effective, and may be able to spend more time with patients and provide culturally appropriate care.¹⁹ Using their training and experience, nurses can effectively collaborate with other health care workers to develop programs that reduce disparities in diabetic care. Peek et al. concluded there may be benefits to culturally tailored programs addressing disparities, and interventions should focus on not just patients but also providers and health systems, including nurse clinicians and case managers. They “found good evidence that nurses acting as clinicians (via treatment algorithms and physician support) can produce significant improvement in both process and outcome measures.”¹¹

Prejudice and bias

Although a majority of health care practitioners may abhor prejudice, prejudicial approaches to health care exist among health care providers; in fact, they may not be able to recognize they are displaying such behaviors.³ In a study of 720 physicians, Schulman et al. found a patient’s race and sex influenced how physicians provided care. Physicians were less likely to recommend cardiac catheterization to black females when compared with a white male, white female, or a black male.20 In a study of 60 therapists primed with African American stereotypes or neutral words, African American stereotypes may lead to either positive or negative impressions in health care providers. Indeed, negative impressions may influence the way health care providers rate patients’ attributes.²¹

Forces behind health care disparities can be multifaceted. Balsa and McGuire identified three mechanisms, including bias against minorities, significant uncertainty when practitioners interact with minority patients, and health care providers’ beliefs or stereotypes regarding minority patients’ behaviors and health. Some practitioners have difficulty understanding the symptoms minority patients report; with the greater clinical uncertainty along with stereotypes identified at the base of patient data gathering, there is the need for a policy that can prevent further propagation of disparities. Balsa and McGuire, in addressing unfairness and discrimination in health care, “treated prejudice as a ‘psychological cost’ born by the doctor when treating a patient of a different race or ethnic group.” A white practitioner may experience a distaste or psychological cost when dealing with patients of a different race, which then influences the practitioner’s decision making.²²

Pettigrew and Meertens presented two sides of prejudice in social research, including subtle and blatant prejudice. They called blatant prejudice “hot, close, and direct,” while subtle prejudice is the opposite. Prejudicial behaviors tend to lead to the formation of beliefs promoting discrimination and subtle prejudice. It often involves the defense of traditional values, which may include blaming victims and exaggerating cultural differences through gross stereotypes—although the differences may be genuine—and denial of positive responses toward the out-group.²³

Demographic and fiscal data

In general, health care disparities are costly, and the magnitude of the cost burden should not be overlooked. Waidmann reports that in 2009, disparities among African Americans, non-Hispanic whites, and Hispanics cost an estimated $23.9 billion dollars, while the extra cost for Medicare and private insurers was an estimated $15.6 billion and $5.1 billion, respectively. Disparities in diabetes, hypertension, renal disease, and stroke in African Americans and Hispanics resulted in excess cost in 2009; disparity between blacks and whites alone cost an estimated $2+ billion. With Medicare and Medicaid combined, health disparities for both African Americans and Hispanics cost about $12 billion and $5 billion, respectively.24 According to Rastogi, Johnson, Hoeffel, and Drewery, 308,745,538 million people lived in the United States in 2010, and 42,020,743 (13.6%) were black.²⁵

Many reasons have been attributed to health care disparities, but one discussed most commonly is insurance. Forty-nine percent of African Americans in 2007 had employer-sponsored insurance compared to 66% of whites. The average African American family earned $33,916; the average white family, $54,920.⁵

Between 2008–2009, 19% of all Americans, 23% of the black population, 14% of whites, and 34% Hispanics considered non-elderly were without health insurance.²⁶ A different report by Cohen, Ward, and Schiller stated that in 2010, 48.6 million Americans (16%) did not have health insurance; whites were more likely to have health insurance than Hispanics, Asians, and African Americans.²⁷ Minorities were also more likely to live in rural areas where there are fewer health care centers and hospitals. Even among those in urban areas, minorities were more likely to require multiple buses to reach health care facilities or hospitals. And, because minorities are more likely to be poor, they are less likely to receive adequate, quality health services.¹⁰

In a 2007–2009 national survey, of the Americans over 20 years old, about 7% of whites, 8% of Asian Americans, 12% of Hispanics, and 13% of blacks were diagnosed with diabetes. In 2010, diabetes affected 25.8 million people in the United States, or about 8.3% of the population; of that number, seven million went undiagnosed. In addition, 1.9 million Americans aged 20 years or older were newly diagnosed with diabetes in 2010. Among people 65 or older living in the United States in 2010, 10.9 million people (26.9%) had diabetes. Lastly, in 2010, about 215,000 Americans younger than 20 years old had either type 1 or 2 diabetes.⁹

In 2010, among those aged 20 years or older, 4.9 million (18.7%) blacks, as opposed to 15.7 million (10.2%) whites, had diabetes. In 2006, the rate at which treatment was initiated for end-stage renal disease for diabetic blacks was about two and a half times the rate for diabetic whites. In 2006, diabetic African Americans were one and a half times more likely to be discharged from the hospital than diabetic whites.⁹ Lastly, in 2006, African Americans were over two times more likely to die from diabetes than whites.²⁸ According to the 2008 National Healthcare Quality Report, the direct cost of diabetic care in 2007 was $116 billion, while the total cost was $174 billion.⁷

Moral and ethical issues

Concerns about moral and ethical issues surrounding these disparities call into question justice and fairness in the United States.¹⁰ Practitioners and policy makers alike must address disparities with a sense of urgency—projections show that by 2050, about 50% of the population will belong to a “minority” group.²⁹ For practitioners, disparities “pose moral and ethical dilemmas that will be among the most significant challenges of today’s rapidly changing health systems.”³

Health care practitioners must follow certain ethical principles, including beneficence, nonmaleficence, fidelity, justice, and veracity. Nonmaleficence requires that health care providers not do any harm to patients; justice pertains to the morality that is involved in fairness, equity, and rightness of care of all patients.³⁰ Many of the findings reviewed have shown disparities occur as a result of omission, commission, or inadequacy of action. According to Balsa and McGuire, information-based policies will “at least satisfy the medical creed, ‘first do no harm.’”²²

According to Smedley, health care providers must choose between what is ethically right and what limited health care resources can address. Providers may then allocate more resources to a particular group of people over the other. However, public trust may be harmed if people perceive health care providers engaging in social triaging.³ According to Bal, in the next 25 years the burden of diabetes may make the ethical issue of access to primary care shaper in order to avoid the need for intensive diabetes complication care. There is an urgent moral need to attack diabetes at the primary care and public health levels to implement prevention strategies.⁸

Health policy issues pertaining to disparities in diabetes care

One can assume and hope that when and if prejudice is at the base of disparities, having a policy that mandates practitioners provide equal care may “result in an improvement of health care conditions for minorities and in a fair outcome.”²² The U.S. Department of Health and Human Services (USDHHS) has begun reviewing factors affecting discrimination against the health care environment. One federal initiative by the Agency for Healthcare Research and Quality (AHRQ) focuses on the development of a national report on ethnic and racial health care disparities.³ Smith proposed the use of report cards to assess ethnic and racial disparities.³¹

The Department of Health and Human Services (HHS) has set some health care goals and action plans concerning these disparity issues. Their first goal is health care transformation, where insurance coverage expands to include people that do not have it, along with increased access to health care through an innovative health care delivery approach. The second goal is to strengthen the health and human services workshop, and to achieve this, there is a plan to recruit undergraduates from underserved communities for biomedical and public health fields, as well as supporting community health worker training. The third goal of the HHS is to advance the health, well-being, and safety of Americans. To achieve this, new CDC grants will be implemented to achieve improved health care in many of the diseases affected by disparities. The fourth goal is to advance scientific knowledge and innovation by implementing a new strategy for data collection and analysis as authorized by the Affordable Care Act. The fifth goal is to increase the efficiency, accountability, and transparency of the HHS programs by taking into consideration the assessment of health care disparities programs and policies.⁵

In a study focused on the preferences of patients for same race health care providers, Malat and Hamilton found when black patients believed discrimination existed in the health care provider-patient dyads, they were more likely to prefer the same-race provider.¹ Cooper and Roter in a study of 252 adults found patients may benefit from having race-concordant visits because the patients were more likely to rate their satisfaction with their physicians highly. Cooper and Roter recommended there be a policy concerning increased number of ethnic minority physicians; they also encouraged fostering trust between patients and providers.³² LaVeist and Nuru-Jeter examined the connection between the patient-doctor concordance and patient satisfaction using a sample that included African Americans, Caucasians, Hispanics, and Asian Americans. When patients had the choice of selecting their own physicians, the participants were more likely to select persons of their own race. There is then the need to increase the number of health care practitioners from diverse racial and ethnic backgrounds while at the same time increasing practitioners’ capacity to interact with patients in a culturally congruent way.³³

A major deterrent to equality in health care is finance; factors such as capitation and incentives to providers who practice frugally can negatively affect the quality of care people from racial and ethnic minorities receive, and lessen the negative effects on the care of whites. Provider incentives may not necessarily lead to disparities in care if more finely crafted; an example might include rewarding providers for time spent engaging with patients and their families, which may help overcome cultural communication barriers and improve provider empathy.³

Balsa and McGuire advocated for information-based policies that may break stereotypical patterns or reduce the degree of uncertainty in health care; these are more likely to be effective when lack of information is the underlying cause of disparities. Balsa and McGuire also suggest using rule-based policies, which require patients be treated the same way.²² Beal reports a gap in the training of health care providers in cultural competence. In addition, there is a need for improved interpersonal care, improved cross-cultural relationships, and proper provider training regarding engaging patients from all backgrounds. There are currently some programs in place to increase the number of practitioners from underrepresented populations; however, interested stakeholders have to apply for the funds. Additionally, many of the programs are underfunded.³⁴ 

Another policy issue is proximity of health care centers to where minorities live. Diabetic patients residing in remote areas should be able to reach their health care providers without undue stress. Nurse-managed clinics help reach people that otherwise would not have access to health services; however, there is a need for more nurse-managed facilities. Employing community health workers (CHW) can also reduce health disparities. Corkery et al. conducted a study to assess the effect of CHWs on diabetes education program completion among Hispanics. They found the assignment of a CHW had a robust effect on “program completion, controlling for financial status, and language spoken,” as well as “on knowledge, self-care behavior, or glycohemoglobin outcome variables was not statistically significant.” However, the researchers concluded that the ability of Hispanic patients to complete the diabetes education program led to improvement of patient knowledge, glycemic control, and the displayed self care behaviors.35 According to Smedley et al. in order for a CHW program to be successful, there is the need for a properly designed program that allows for adequate CHW training and supervision.3

After reviewing literature concerning disparities in diabetic care, White, Beech, and Miller concluded that in approaching diabetic disparities, the providers should consider patient and provider factors, including the use of nurse educators, case managers, algorithms, and diabetes self-management education. Other aspects of care, as recommended by White et al., include seeking patient colleague feedback, consideration of literacy and numeracy in designing educational materials, increasing the use of interpreters and language-specific reading materials, and use of patient-centered communication processes.³⁶

In a promising report, Peek et al. found many interventions to reduce disparities in diabetes care already implemented, but the design and method of evaluation of the current interventions “leave us with many unanswered questions regarding the benefits of cultural tailoring, the impact of interventions on health disparities, and the ideal target of interventions (patient, provider, organization).”¹¹

Summary, conclusions, and recommendations

There are three major issues surrounding disparity in diabetes care: the patient, the health care provider, and the system. The patient’s personal issues, including lack of trust in the system and/or health care providers, along with unhealthy habits, may serve as impediments to appropriate care. The provider issues may pertain to bias, stereotype, and care competency level, while the system concerns lack of access to health care services such as proximity of health care facility, insurance coverage, and education opportunity.

While the burden of diabetes is enormous, policies can be put in place to reduce the disparities in its care. Using trained volunteers and CHWs, such as the promotoras and curanderos (Latino/Hispanic community health care leaders), may help ease the burden of health care disparities in general. In order to improve the patient/health care provider interrelationship, there is the need for improved cultural literacy of health care. In addition, health care providers need to advocate for diabetic patients that are not getting adequate care so that the morbidity and mortality associated with diabetes can be minimized. All persons with diabetes deserve culturally appropriate care, tied to treatment and management success. Health policies are needed to address access and barriers to health care, and nurses have vital responsibilities in promoting system-wide positive change. Program initiatives like REACH need to be used in many more communities.

The work that needs to be done to reduce disparities in diabetes care may be challenging. There are scattered ongoing efforts to reduce diabetes disparities, but the efforts need to be present throughout the country. When such initiatives are widespread, there is the potential for greater improvement in diabetic care of minority patients. The multifaceted nature of the issues surrounding disparities in diabetic care requires careful assessment to employ appropriate strategies. Nurses are in a special position to make a difference in diabetes care and help reduce disparities.

There is the need for ongoing cultural competence training for health care providers, which should be standardized nationally, regionally, or by state. Just like health care practitioners are expected to have certain requirements for maintaining their license, cultural competence continuing education could be part of the requirements for license renewal. All health practitioner schools (medical, physical therapy, dental, etc.) should include cultural competence in the curriculum and not leave it to the individual student to find a way to attain the knowledge. Health care providers should work closely with local government on policies that improve health care equality. Nurses and other health providers should belong to professional organizations that enhance their capacity to lobby for policies and programs that reduce health care disparities.

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