Racial Disparities in Access to Care Under Conditions of Universal Coverage.

BACKGROUND: Racial disparities in access to regular health care have been reported in the U.S., but little is known about the extent of disparities in societies with universal coverage. PURPOSE: To investigate the extent of racial disparities in access to care under conditions of universal coverage by observing the association between race and regular access to a doctor in Canada. METHODS: Racial disparities in access to a regular doctor were calculated using the largest available source of nationally representative data in Canada--the Canadian Community Health Survey. Surveys from 2000-2010 were analyzed in 2014. Multinomial regression analyses predicted odds of having a regular doctor for each racial group compared to whites. Analyses were stratified by immigrant status--Canadian-born versus shorter-term immigrant versus longer-term immigrants--and controlled for sociodemographics and self-rated health. RESULTS: Racial disparities in Canada, a country with universal coverage, were far more muted than those previously reported in the U.S. Only among longer-term Latin American immigrants (OR=1.90, 95% CI=1.45, 2.08) and Canadian-born Aboriginals (OR=1.34, 95% CI=1.22, 1.47) were significant disparities noted. Among shorter-term immigrants, all Asians were more likely than whites, and among longer-term immigrants, South Asians were more like than whites, to have a regular doctor. CONCLUSIONS: Universal coverage may have a major impact on reducing racial disparities in access to health care, although among some subgroups, other factors may also play a role above and beyond health insurance.

Societal context and the production of immigrant status-based health inequalities: a comparative study of the United States and Canada.

BACKGROUND: We compare disparities in health status between first-generation immigrants and others in the United States (US) and Canada. METHODS: We used data from the Joint Canada-US Survey of Health. The regression models adjusted for demographics, socioeconomic status, and health insurance (the US). RESULTS: In both countries, the health advantage belonged to immigrants. Fewer disparities between immigrants and those native-born were seen in Canada versus the US. Canadians of every immigrant/race group fared better than US native-born Whites. DISCUSSION: Fewer disparities in Canada and better overall health of all Canadians suggest that societal context may create differences in access to the resources, environments, and experiences that shape health and health behaviors.

Stress and the city: housing stressors are associated with respiratory health among low socioeconomic status Chicago children.

Asthma disproportionately affects non-whites in urban areas and those of low socioeconomic status, yet asthma's social patterning is not well-explained by known risk factors. We hypothesized that disadvantaged urban populations experience acute and chronic housing stressors which produce psychological stress and impact health through biological and behavioral pathways. We examined eight outcomes: six child respiratory outcomes as well as parent and child general health, using data from 682 low-income, Chicago parents of diagnosed and undiagnosed asthmatic children. We created a continuous exposure, representing material, social and emotional dimensions of housing stressors, weighted by their parent-reported difficulty. We compared the 75th to the 25th quartile of exposure in adjusted binomial and negative binomial regression models. Higher risks and rates of poor health were associated with higher housing stressors for six of eight outcomes. The risk difference (RD) for poor/fair general health was larger for children [RD = 6.28 (95% CI 1.22, 11.35)] than for parents [RD = 3.88 (95% CI -1.87, 9.63)]. The incidence rate difference (IRD) for exercise intolerance was nearly one extra day per 2 weeks for the higher exposure group [IRD = 0.88 (95% CI 0.41, 1.35)]; nearly one-third extra day per 2 weeks for waking at night [IRD = 0.32 (95% CI 0.01, 0.63)]; and nearly one-third extra day per 6 months for unplanned medical visits [IRD = 0.30 (95% CI 0.059, 0.54)]. Results contribute to the conceptualization of urban stress as a "social pollutant" and to the hypothesized role of stress in health disparities. Interventions to improve asthma outcomes must address individuals' reactions to stress while we seek structural solutions to residential stressors and health inequities.

Parent perceptions of neighborhood stressors are associated with general health and child respiratory health among low-income, urban families.

BACKGROUND: This cross-sectional study examines parents' perceptions of their neighborhoods and general and respiratory health among low-income Chicago families. Asthma disproportionately affects nonwhite, urban, and low socioeconomic status (SES) populations, but Chicago's burden, and the national epidemic, are not well explained by known risk factors. Urban dwellers experience acute and chronic stressors that produce psychological distress and are hypothesized to impact health through biological and behavioral pathways. Identifying factors that covary with lower SES and minority-group status-e.g., stress-is important for understanding asthma's social patterning. METHODS: We used survey data from 319 parents of children 5-13 years with asthma/respiratory problems and principal components analysis to create exposure variables representing parents' perceptions of two aspects of neighborhoods: collective efficacy ("CE") and physical/social order ("order"). Adjusted binomial regression models estimated risk differences (RDs) and 95% confidence intervals (CIs) for eight binary outcomes. RESULTS: Magnitude was generally as expected, i.e., RD for low- versus high- (most favorable) exposure groups (RD(low v. high)) was larger than for the middle versus high contrast (RD(mid v. high)). "Parent general health" was strongly associated with "CE" (RD(low v. high) = 20.8 [95% CI: 7.8, 33.9]) and "order" (RD(mid v. high) = 11.4 [95% CI: 2.1, 20.7]), unlike "child general health," which had nearly null associations. Among respiratory outcomes, only "waking at night" was strongly associated with "CE" (RD(low v. high) = 16.7 [95% CI: 2.8, 30.6]) and "order" (RD(low v. high) = 22.2 [95% CI: 8.6, 35.8]). "Exercise intolerance" (RD(low v. high) = 15.8 [95% CI: 2.1, 29.5]) and "controllability" (RD(mid v. high) = 12.0 [95% CI: 1.8, 22.3]) were moderately associated with "order" but not with "CE," whereas "school absences," "rescue medication use," and "unplanned visits" had nearly null associations with both exposures. CONCLUSIONS: More negative perceptions tended to be associated with higher risk of undesirable outcomes, adding to evidence that the social environment contributes to health and supporting research on stress' health impact among disadvantaged populations. Interventions must address not only traditional "environmental" factors, but also individuals' reactions to stress and attempt to mitigate effects of stressors while structural solutions to health inequities are sought.

Racial and ethnic disparities in diagnosed and possible undiagnosed asthma among public-school children in Chicago.

OBJECTIVES: We examined racial and ethnic disparities in the total potential burden of asthma in low-income, racially/ethnically heterogeneous Chicago schools. METHODS: We used the Brief Pediatric Asthma Screen Plus (BPAS+) and the Spanish BPAS+, validated, caregiver-completed respiratory questionnaires, to identify asthma and possible asthma among students in 14 racially/ethnically diverse public elementary schools. RESULTS: Among 11490 children, we demonstrated a high lifetime prevalence (12.2%) as well as racial and ethnic disparities in diagnosed asthma, but no disparities in prevalences of possible undiagnosed asthma. Possible asthma cases boost the total potential burden of asthma to more than 1 in 3 non-Hispanic Black and Puerto Rican children. CONCLUSIONS: There are significant racial and ethnic disparities in diagnosed asthma among inner-city schoolchildren in Chicago. However, possible undiagnosed asthma appears to have similar prevalences across racial/ethnic groups and contributes to a high total potential asthma burden in each group studied. A better understanding of underdiagnosis is needed to address gaps in asthma care and intervention for low-income communities.