Discrimination in Healthcare Settings is Associated with Disability in Older Adults: Health and Retirement Study, 2008-2012.

BACKGROUND: As our society ages, improving medical care for an older population will be crucial. Discrimination in healthcare may contribute to substandard experiences with the healthcare system, increasing the burden of poor health in older adults. Few studies have focused on the presence of healthcare discrimination and its effects on older adults. OBJECTIVE: We aimed to examine the relationship between healthcare discrimination and new or worsened disability. DESIGN: This was a longitudinal analysis of data from the nationally representative Health and Retirement Study administered in 2008 with follow-up through 2012. PARTICIPANTS: Six thousand and seventeen adults over the age of 50 years (mean age 67 years, 56.3 % female, 83.1 % white) were included in this study. MAIN MEASURES: Healthcare discrimination assessed by a 2008 report of receiving poorer service or treatment than other people by doctors or hospitals (never, less than a year=infrequent; more than once a year=frequent). Outcome was self-report of new or worsened disability by 2012 (difficulty or dependence in any of six activities of daily living). We used a Cox proportional hazards model adjusting for age, race/ethnicity, gender, net worth, education, depression, high blood pressure, diabetes, cancer, lung disease, heart disease, stroke, and healthcare utilization in the past 2 years. KEY RESULTS: In all, 12.6 % experienced discrimination infrequently and 5.9 % frequently. Almost one-third of participants (29 %) reporting frequent healthcare discrimination developed new or worsened disability over 4 years, compared to 16.8 % of those who infrequently and 14.7 % of those who never experienced healthcare discrimination (p < 0.001). In multivariate analyses, compared to no discrimination, frequent healthcare discrimination was associated with new or worsened disability over 4 years (aHR = 1.63, 95 % CI 1.16-2.27). CONCLUSIONS: One out of five adults over the age of 50 years experiences discrimination in healthcare settings. One in 17 experience frequent healthcare discrimination, and this is associated with new or worsened disability by 4 years. Future research should focus on the mechanisms by which healthcare discrimination influences disability in older adults to promote better health outcomes for an aging population.

Black sexuality, social construction, and research targeting 'The Down Low' ('The DL').

PURPOSE: The purpose of this commentary is to explain how social constructions of black sexuality are relevant to research targeting black sexual behavior and the ostensibly new and race-specific phenomenon known as "the Down Low" (the DL). The term "the DL" is widely used to refer to black men publicly presenting as heterosexual while secretly having sex with other men and presumably spreading human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) to unsuspecting women. METHODS: We briefly review lay and public health literature from 1998 to 2004 about the DL, describe existing social constructions of black sexuality, discuss two implications for epidemiologic research, and offer recommendations to guide future research. RESULTS: The lifestyle referenced by the term the DL is neither new nor limited to blacks, and sufficient data linking it to HIV/AIDS disparities currently are lacking. Common perceptions about the DL reflect social constructions of black sexuality as generally excessive, deviant, diseased, and predatory. Research targeting black sexual behavior that ignores these constructions may unwittingly reinforce them. CONCLUSIONS: Unaddressed social constructions of black sexuality have implications for epidemiologic research targeting black sexual behavior. Explicit examination of these concerns is necessary to eliminate fundamental causes of health disparities.

Motivational interviewing to support antiretroviral therapy adherence: the role of quality counseling.

OBJECTIVE: Although research linking motivational interviewing (MI) to behavior change exists, few studies report on MI's quality or explore how it may influence effectiveness. We studied MI quality and adherence to antiretroviral therapy (ART) in the context of a randomized, controlled trial. METHODS: We used a structured instrument to code MI sessions and then correlated ART adherence (measured by electronic bottle cap monitor and pill count data at study exit) with specific counseling behaviors and the proportion of interactions that achieved quality benchmarks. RESULTS: The sample (n = 47) was predominantly male (79%), minority (90%), had a mean age of 40, and averaged 79% adherence at exit. On three of five benchmarks, most MI sessions achieved the targeted quality level: 100% achieved them for MI-consistent statements; 85% for complex reflections; 63% for reflections to questions ratio; 44% for global therapist rating; 19% for using open-ended questions. ART adherence was positively associated with the ratio of reflections to questions (r = .39, p = .02), affirming statements (r = .38, p = .02), and negatively associated with closed-ended questions (r = -.33, p = .04). DISCUSSION: Good quality MI can be conducted within the structure of a controlled trial but was generally not associated with ART adherence. CONCLUSION: Documenting treatment fidelity is critical to judging the efficacy of MI-based interventions. PRACTICE IMPLICATIONS: Regular feedback and close monitoring are needed to maintain MI quality.

Workplace Discrimination Is Associated With Alcohol Abuse Among Ethnically Diverse Hospital Staff.

Research suggests that workplace discrimination plays a role in absenteeism, productivity, and turnover. A link among workplace discrimination, mental health, and health disparities may also exist. The purpose of this study was to determine whether self-reported workplace discrimination is associated with alcohol abuse among hospital workers. Cross-sectional analysis of baseline data collected from a prospective cohort study of workers in two healthcare institutions (n = 664) was conducted. Workplace discrimination in the previous 12 months was reported by 14% (n = 91) of participants who were four times more likely to score higher on likely alcohol abuse than their peers. White participants who reported any discrimination were more likely to score higher on likely alcohol abuse than racial/ethnic minority participants who reported any discrimination. Given a diversifying workforce, further research is needed on how workplace discrimination contributes to stress and maladaptive coping, and ultimately health disparities.

Theory-guided selection of discrimination measures for racial/ ethnic health disparities research among older adults.

OBJECTIVE: Discrimination may contribute to health disparities among older adults. Existing measures of perceived discrimination have provided important insights but may have limitations when used in studies of older adults. This article illustrates the process of assessing the appropriateness of existing measures for theory-based research on perceived discrimination and health. METHOD: First, we describe three theoretical frameworks that are relevant to the study of perceived discrimination and health-stress-process models, life course models, and the Public Health Critical Race (PHCR) praxis. We then review four widely-used measures of discrimination, comparing their content and describing how well they address key aspects of each framework, and discussing potential areas of modification. DISCUSSION: Using theory to guide measure selection can help improve understanding of how perceived discrimination may contribute to racial/ethnic health disparities among older adults.

A framework for understanding modifications to measures for diverse populations.

OBJECTIVE: Research on health disparities and determinants of health disparities among ethnic minorities and vulnerable older populations necessitates use of self-report measures. Most established instruments were developed on mainstream populations and may need adaptation for research with diverse populations. Although information is increasingly available on various problems using these measures in diverse groups, there is little guidance on how to modify the measures. A framework of issues to consider when modifying measures for diverse populations is presented. METHODS: The authors describe reasons for considering modifications, the types of information that can be used as a basis for making modifications, and the types of modifications researchers have made. Recommendations are made to test modified measures to assure their appropriateness, and suggestions are provided on reporting modifications in publications using the measures. DISCUSSION: The issues open a dialogue about what appropriate guidelines would be for researchers adapting measures in studies of ethnically diverse populations.

Discrimination, distrust, and racial/ethnic disparities in antiretroviral therapy adherence among a national sample of HIV-infected patients.

OBJECTIVE: Although discriminatory health care experiences and health care provider distrust have been shown to be associated with health care disparities, little is known about their contribution to racial/ethnic disparities in antiretroviral therapy adherence. We therefore sought to assess the extent to which discriminatory health care experiences and health care provider distrust influence treatment-related attitudes, beliefs, and self-reported adherence in a national sample of HIV-infected patients. STUDY DESIGN: This secondary analysis used data from the HIV Cost and Services Utilization Study. We used structural equation modeling to identify pathways from minority status to adherence through discrimination, distrust, and treatment-related attitudes and beliefs. PARTICIPANTS: The sample was the 1886 participants who completed the baseline and 2 follow-up interviews and were prescribed antiretroviral therapy at the second follow-up interview (54% white, 28% black, 14% Hispanic, and 3% others). RESULTS: Minorities were less likely to report perfect adherence than whites (40% vs. 50%, P < or = 0.001). Over one third (40%) of all participants reporting ever having discriminatory health care experiences since having HIV, and 24% did not completely or almost completely trust their health care providers. The effect of minority status on adherence persisted in the full model. More discrimination predicted greater distrust, weaker treatment benefit beliefs, and, in turn, poorer adherence. Distrust affected adherence by increasing treatment-related psychological distress and weakening treatment benefit beliefs. CONCLUSIONS: The relationship between minority status and adherence was not fully explained by patient-level factors. Future studies should consider conceptualizing minority status as a contextual factor rather than predictor.