Vernellia R. Randall
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| VI. Cultural and Structural Roots of Inequities in
Healthcare for Latino Elders
excerpted Wrom: FVWRKJVZCMHVIBGDADRZFSQHYUCDDJBLVLMHAA Equitable Health Systems: Cultural and Structural Issues for Latino Elders, 29 American Journal of Law and Medicine 247-267 (2003) (159 Footnotes Omitted) Latino culture and the structure of U.S. social systems are the most likely root causes of inequities in healthcare system performance for Latino elders. In this Section, we discuss how culture affects the immediate behaviors of Latino elders influencing their health status and medical care use. The structures of the economy and medical care system, however, have more basic and underlying influences on inequities. The following Section discusses policy approaches to address these causes of healthcare inequities. "Culture" is a group's shared beliefs, norms and values that can affect how individuals perceive and communicate symptoms of disease. It may also influence whom one might turn to for information and help, as well as the shared meanings about the treatment and the disease itself. Culture is learned and constantly shaped by the demands of the environment on a group. Researchers offer Latino culture as a partial explanation for the advantages in mortality and life expectancy, as well as for Latino disadvantages in chronic disease and in patient satisfaction. The favorable mortality profile for Latinos has been attributed to protective aspects of culture and selective immigration. Strong family ties and cultural practices associated with traditional Latino culture, "familialism," arguably encourage good health practices which protect one's health status. Additionally, U.S. immigrants are healthier than individuals born in the United States, indicating that the recent wave of Latino immigrants may be contributing to some of the advantages experienced by the Latino population. This "healthy immigrant" effect may partly explain the lower mortality of the population along with more favorable health behaviors found among Latino immigrants and less acculturated Latinos. Research has found, for example, that elderly Latina females who were mostly foreign-born and less acculturated than their daughters had diets lower in fat and included higher levels of fruits and vegetables than their daughters. More generally, acculturated Latinos have worse diets and consume more alcohol than less acculturated Latinos. These ethnic specific behaviors include reliance on family and friends for support, low-fat nutritious eating habits and low use of alcohol, tobacco and illicit drugs. While culturally patterned health behaviors have been used to explain lower Latino mortality, other health practices increase the risk of developing certain chronic disease. In particular, the high prevalence of diabetes among all Latinos has been linked to the relatively high levels of obesity found among the population. Studies consistently show that Latinos with diabetes are more likely than non-Latino whites with diabetes to be obese and to have upper body obesity. Overall, Latinos have risk profiles for several chronic diseases that are equivalent to, or worse than, those found among non-Latino whites. Inequities in the responsiveness of care to Latinos have also attracted cultural explanations. For example, Latinos are less likely than non-Latino whites or African Americans to make yearly physician visits or use preventative health services, such as mammographies or flu shots. Between 1997 and 1999, African American and whites used more preventative services than Latinos. Some of the difference in the use of healthcare services is attributed to cultural beliefs and practices among older Latinos, such as a lower orientation to preventive care and traditional non-western medical practices that substitute for western medical care. In addition, differences in satisfaction with medical care between Latinos and non-Latino whites are perhaps the result of different cultural expectations and interpretations of the medical encounter. Latinos who speak primarily Spanish are less satisfied with their care than those who speak English, possibly resulting from communications barriers or different levels of acculturation. Factors that shape the health status and care use for Latino elders are grounded in our economic structure and the structure of our healthcare system. Socioeconomic status (SES) forms the foundation for understanding health disparities including outcomes, process and financing. SES may underlie all of the major determinants of health status including access to care, health behaviors and environmental exposure. Additionally, the chronic stress associated with low SES can increase morbidity. Several studies find that low SES--whether measured by poverty, education or income--is linked to a higher prevalence of cardiovascular disease, diabetes, hypertension, arthritis and cancer. Not only does the individual's SES affect his or her health status and services use, but the SES characteristics of the neighborhood has an independent effect as well. Persons living in neighborhoods with high levels of social disorder, poverty, crime and other socioeconomic problems are more likely to report poor health and disability than those with similar incomes living in more stable neighborhoods. The disproportionately high levels of Latino poverty, as well as their low educational levels, place Latino elders at increased risk for disease and disability. While poverty among the elderly population has declined markedly over the past thirty years, Latino elderly remain overrepresented among the ranks of the poor. While the overall poverty rate of the non-Latino white elderly population is 8.1%, the poverty rate for elderly Latinos is over twice as high at 21.8%. Levels of those near poverty are almost as compelling with 21.3% of non-Latino white elderly below 150% of the poverty line, compared to 42.1% for elderly Latinos. As with poverty, median income also varies greatly across the elderly population by ethnic minority status and gender. The median income for elderly non-Latino white males is $20,856 and $11,929 for non-Latino white females. Latino males age 65 and older have a median income of $12,338, and Latino women have a median income of $7,585. Disparities in the sources of income are a major factor in the earnings disparities noted above, and are the result of lifetime employment patterns. Minority elderly populations are more reliant on Social Security and less likely than non-Latino whites to have income from assets and private pensions. It is estimated that while 43% of non-Latino whites have pensions from previous employers and 67ave income from assets, only 20% of Latinos have a private pension and 27ave income from assets. Among the near-elderly (ages 51-61), non-Latino whites report a mean asset level of $310,765, compared to $88,821 among Latinos. These differences are linked to their overrepresentation in low-wage service industry jobs and labor-intensive occupations, which do not offer pensions or other retiree benefits such as supplemental retiree insurance. Additionally, Latino elders experience educational and employment segregation, institutional racism and glass ceilings that preclude their economic advancement. These differences between non-Latino whites and Latino elderly in the use of services are only partially explained by income. Even after controlling for the level of need and a variety of other variables including income and supplemental health insurance, substantial differences remain in the use of hospital, outpatient and nursing home services. While some of the differences may be driven by cultural preferences in care patterns, there are a number of unmeasured structural factors that contribute to the disparities in the use of services and satisfaction with the process of care, including the structural factors that underlie the acceptability issues discussed supra.
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