Journal of Community Health

, 33:318

Racial Disparities in Access to Care for Men in a Public Assistance Program for Prostate Cancer

  • David C. Miller
  • Lillian Gelberg
  • Lorna Kwan
  • Sevan Stepanian
  • Arlene Fink
  • Ronald M. Andersen
  • Mark S. Litwin
Original Paper

Abstract

California’s IMPACT program provides all its enrollees with health insurance and social service resources. We hypothesized that racial/ethnic disparities in access to care might be attenuated among men served by this program. Our objective was to evaluate racial/ethnic differences in health services utilization and patient-reported health care outcomes among disadvantaged men in a prostate cancer public-assistance program, and to identify modifiable factors that might explain persistent disparities in this health care setting. We performed a retrospective cohort study of 357 low-income men enrolled in IMPACT from 2001 through 2005. We evaluated realized access to care with two health services utilization measures: (1) use of emergency department care without hospitalization and, (2) frequency of prostate-specific antigen testing. We also measured two patient-experience outcomes: (1) satisfaction with care received from IMPACT, and (2) confidence in IMPACT care providers. We observed significant bivariate associations between race/ethnicity and patient-experience outcomes (< 0.05), but not utilization measures. In multivariable models, Hispanic men were more likely than white men to report complete satisfaction with health care received in IMPACT (adjusted OR = 5.15, 95% CI 1.17–22.6); however, the association between race/ethnicity and satisfaction was not statistically significant (P = 0.11). Language preference and self-efficacy in patient-physician interactions are potentially-modifiable predictors of patient-experience outcomes. We observed no racial/ethnic disparities in health services utilization among disadvantaged men served by a disease-specific public assistance program. The greater satisfaction and confidence among Hispanic men are explained by modifiable variables that suggest avenues for improvement.

Keywords

Prostate cancer Low-income Uninsured Race/ethnicity Disparities Public assistance Self-efficacy 

References

  1. 1.
    Mandelblatt, J. S., Yabroff K. R., & Kerner, J. F. (1999). Equitable access to cancer services: A review of barriers to quality care. Cancer, 86, 2378–2390.PubMedCrossRefGoogle Scholar
  2. 2.
    Institute of Medicine of the National Academies. (2003). Unequal treatment: Confronting racial and ethnic disparities in healthcare. Washington D.C.: National Academies Press.Google Scholar
  3. 3.
    Lurie, N., & Dubowitz, T. (2007). Health disparities and access to health. The Journal of the American Medical Association, 297, 1118–1121.CrossRefGoogle Scholar
  4. 4.
    Eisenberg, J. M., & Power, E. J. (2000). Transforming insurance coverage into quality health care: Voltage drops from potential to delivered quality. The Journal of the American Medical Association, 284, 2100–2107.CrossRefGoogle Scholar
  5. 5.
    Davidson, P. L., Andersen, R. M., & Wyn, R., et al. (2004). A framework for evaluating safety-net and other community-level factors on access for low-income populations. Inquiry, 41, 21–38.PubMedGoogle Scholar
  6. 6.
    Call, K. T., McAlpine, D. D., & Johnson, P. J., et al. (2006). Barriers to care among American Indians in public health care programs. Medical Care, 44, 595–600.PubMedCrossRefGoogle Scholar
  7. 7.
    Echeverria, S. E., & Carrasquillo, O. (2006). The roles of citizenship status, acculturation, and health insurance in breast and cervical cancer screening among immigrant women. Medical Care, 44, 788–792.PubMedCrossRefGoogle Scholar
  8. 8.
    Flores, G. (2006). Language barriers to health care in the United States. The New England Journal of Medicine, 355, 229–231.PubMedCrossRefGoogle Scholar
  9. 9.
    De Alba, I., Hubbell, F. A., & McMullin, J. M., et al. (2005). Impact of U.S. citizenship status on cancer screening among immigrant women. Journal of General Internal Medicine, 20, 290–296.PubMedCrossRefGoogle Scholar
  10. 10.
    Schroen, A. T., Brenin, D. R., & Kelly, M. D., et al. (2005). Impact of patient distance to radiation therapy on mastectomy use in early-stage breast cancer patients. Journal of Clinical Oncology, 23, 7074–7080.PubMedCrossRefGoogle Scholar
  11. 11.
    Sox, C. M., Swartz, K., & Burstin, H. R., et al. (1998). Insurance or a regular physician: Which is the most powerful predictor of health care? American Journal of Public Health, 88, 364–370.PubMedCrossRefGoogle Scholar
  12. 12.
    Talcott, J. A., Spain, P., & Clark, J. A., et al. (2007). Hidden barriers between knowledge and behavior: The North Carolina prostate cancer screening and treatment experience. Cancer, 109, 1599–1606.PubMedCrossRefGoogle Scholar
  13. 13.
    Underwood, W., De Monner, S., & Ubel, P., et al. (2004). Racial/ethnic disparities in the treatment of localized/regional prostate cancer. Journal of Urology, 171, 1504–1507.PubMedCrossRefGoogle Scholar
  14. 14.
    Hoffman, R. M., Gilliland, F. D., & Eley, J. W., et al. (2001). Racial and ethnic differences in advanced-stage prostate cancer: The prostate cancer outcomes study. Journal of the National Cancer Institute, 93, 388–395.PubMedCrossRefGoogle Scholar
  15. 15.
    McFall, S. L. (2007). Use and awareness of prostate specific antigen tests and race/ethnicity. Journal of Urology, 177, 1475–1480.PubMedCrossRefGoogle Scholar
  16. 16.
    Spencer, B. A., Babey, S. H., & Etzioni, D. A., et al. (2006). A population-based survey of prostate-specific antigen testing among California men at higher risk for prostate carcinoma. Cancer, 106, 765–774.PubMedCrossRefGoogle Scholar
  17. 17.
    Hoffman, R. M., Hunt, W. C., & Gilliland, F. D., et al. (2003). Patient satisfaction with treatment decisions for clinically localized prostate carcinoma. Results from the prostate cancer outcomes study. Cancer, 97, 1653–1662.PubMedCrossRefGoogle Scholar
  18. 18.
    Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36, 1–10.PubMedCrossRefGoogle Scholar
  19. 19.
    Gelberg, L., Andersen, R. M., & Leake, B. D. (2000). The Behavioral model for vulnerable populations: Application to medical care use and outcomes for homeless people. Health Services Research, 34, 1273–1302.PubMedGoogle Scholar
  20. 20.
    Shi, L., & Stevens, G. D. (2005). Vulnerability and unmet health care needs. The influence of multiple risk factors. Journal of General Internal Medicine, 20, 148–154.PubMedCrossRefGoogle Scholar
  21. 21.
    Iverson, D. C. (1993). Involving providers and patients in cancer control and prevention efforts. Barriers to overcome. Cancer, 72(3 Suppl), 1138–43.PubMedCrossRefGoogle Scholar
  22. 22.
    Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191–215.PubMedCrossRefGoogle Scholar
  23. 23.
    Maly, R. C., Frank, J. C., & Marshall, G. N., et al. (1998). Perceived efficacy in patient-physician interactions (PEPPI): Validation of an instrument in older persons. Journal of the American Geriatrics Society, 46, 889–894.PubMedGoogle Scholar
  24. 24.
    Peterman, A. H., Fitchett, G., & Brady, M. J., et al. (2002). Measuring spiritual well-being in people with cancer: The functional assessment of chronic illness therapy—spiritual well-being scale (FACIT-Sp). Annals of Behavioral Medicine, 24, 49–58.PubMedCrossRefGoogle Scholar
  25. 25.
    Deibert, C. M., Maliski, S., & Kwan, L., et al. (2007). Prostate cancer knowledge among low income minority men. Journal of Urology, 177, 1851–1855.PubMedCrossRefGoogle Scholar
  26. 26.
    Krupski, T. L., Bergman, J., & Kwan, L., et al. (2005). Quality of prostate carcinoma care in a statewide public assistance program. Cancer, 104, 985–992.PubMedCrossRefGoogle Scholar
  27. 27.
    Ware, J. Jr., Kosinski, M., & Keller, S. D. (1996). A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34, 220–233.PubMedCrossRefGoogle Scholar
  28. 28.
    McCorkle, R., & Young, K. (1978). Development of a symptom distress scale. Cancer Nursing, 1, 373–378.PubMedCrossRefGoogle Scholar
  29. 29.
    Charlson, M. E., Pompei, P., & Ales, K. L., et al. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. Journal of Chronic Diseases, 40, 373–383.PubMedCrossRefGoogle Scholar
  30. 30.
    Shapiro, M. F., Morton, S. C., & McCaffrey, D. F., et al. (1999). Variations in the care of HIV-infected adults in the United States: Results from the HIV Cost and services utilization study. The Journal of the American Medical Association, 281, 2305–2315.CrossRefGoogle Scholar
  31. 31.
    Scardino, P. (2005). Update: NCCN prostate cancer clinical practice guidelines. Journal of the National Comprehensive Cancer Network, 3(Suppl 1), S29–S33.PubMedGoogle Scholar
  32. 32.
    Kiefe, C. I., McKay, S. V., & Halevy, A., et al. (1994). Is cost a barrier to screening mammography for low-income women receiving Medicare benefits? A randomized trial. Archives of Internal Medicine, 154, 1217–1224.PubMedCrossRefGoogle Scholar
  33. 33.
    Blustein, J. (1995). Medicare coverage, supplemental insurance, and the use of mammography by older women. The New England Journal of Medicine, 332, 1138–1143.PubMedCrossRefGoogle Scholar
  34. 34.
    Leybas-Amedia, V., Nuno, T., & Garcia, F. (2005). Effect of acculturation and income on Hispanic women’s health. Journal of Health Care for the Poor and Underserved, 16, 128–41.PubMedCrossRefGoogle Scholar
  35. 35.
    Morales, L. S., Cunningham, W. E., & Galvan, F. H., et al. (2004). Sociodemographic differences in access to care among Hispanic patients who are HIV infected in the United States. American Journal of Public Health, 94, 1119–1121.PubMedGoogle Scholar
  36. 36.
    Baker, D. W., Hayes, R., & Fortier, J. P. (1998). Interpreter use and satisfaction with interpersonal aspects of care for Spanish-speaking patients. Medical Care, 36, 1461–1470.PubMedCrossRefGoogle Scholar
  37. 37.
    Katz, M. H., Cunningham, W. E., & Fleishman, J. A., et al. (2001). Effect of case management on unmet needs and utilization of medical care and medications among HIV-infected persons. Annals of Internal Medicine, 135, 557–565.PubMedGoogle Scholar
  38. 38.
    Bell, R. A., Kravitz, R. L., & Thom, D., et al. (2002). Unmet expectations for care and the patient-physician relationship. Journal of General Internal Medicine, 17, 817–824.PubMedCrossRefGoogle Scholar
  39. 39.
    Maliski, S. L., Kwan, L., & Krupski, T., et al. (2004). Confidence in the ability to communicate with physicians among low-income patients with prostate cancer. Urology, 64, 329–334.PubMedCrossRefGoogle Scholar
  40. 40.
    Senecal, C., Nouwen, A., & White, D. (2001). Motivation and dietary self-care in adults with diabetes: Are self-efficacy and autonomous self-regulation complementary or competing constructs? Health Psychology, 19, 452–457.CrossRefGoogle Scholar
  41. 41.
    Stutts, W. C. (2002). Physical activity determinants in adults. Perceived benefits, barriers, and self efficacy. AAOHN Journal, 50, 499–507.PubMedGoogle Scholar
  42. 42.
    Shiffman, S., Balabanis, M. H., & Paty, J. A., et al. (2000). Dynamic effects of self-efficacy on smoking lapse and relapse. Health Psychology, 19, 315–323.PubMedCrossRefGoogle Scholar
  43. 43.
    Boehm, S., Coleman-Burns, P., & Schlenk, E. A., et al. (1995). Prostate cancer in African American men: increasing knowledge and self-efficacy. Journal of Community Health Nursing, 12, 161–169.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • David C. Miller
    • 1
  • Lillian Gelberg
    • 2
  • Lorna Kwan
    • 3
  • Sevan Stepanian
    • 1
  • Arlene Fink
    • 1
  • Ronald M. Andersen
    • 4
  • Mark S. Litwin
    • 1
    • 3
    • 4
  1. 1.Department of UrologyDavid Geffen School of Medicine at UCLALos AngelesUSA
  2. 2.Department of Family MedicineDavid Geffen School of Medicine at UCLALos AngelesUSA
  3. 3.Jonsson Comprehensive Cancer CenterDavid Geffen School of Medicine at UCLALos AngelesUSA
  4. 4.Department of Health ServicesUCLA School of Public HealthLos AngelesUSA

Personalised recommendations