Unfair access

A shorter life expectancy. Higher rates of chronic health conditions and disabilities. And striking differences in disease prevention services and treatment. Those are just some of the health disparities APA is emphasizing to President Obama and key members of Congress as they tackle health-care reform.

Psychologists have several suggestions for eliminating those disparities in the nation's health-care system. They include increasing funding for research on population groups affected by disparities in health and health care, integrating behavioral and primary health care, diversifying the psychology work force and improving health literacy.

Recognizing that psychology can't tackle the problem on its own, APA is spearheading an ad hoc working group of more than 130 coalitions and organizations representing more than 30 million Americans. The ad hoc working group is collaborating to ensure that legislators take advantage of this historic opportunity.

"Health-care reform cannot focus exclusively on health insurance coverage," emphasizes Daniel E. Dawes, JD, senior legislative and federal affairs officer in APA's Public Interest Directorate. "Of course, health insurance for the 46 million people who are uninsured or underinsured—most of them racial and ethnic minorities—is critical. But coverage doesn't equate to access. And access doesn't equate to high-quality treatment and better outcomes."

Addressing disparities

To help educate legislators, APA's Office of Ethnic Minority Affairs (OEMA) and Public Interest Directorate recently published a special issue of Communiqué (March 2009) offering psychological and behavioral perspectives on health disparities. "We wanted to make the point boldly that psychological science, practice and training significantly promote public health goals across a range of populations and health conditions," says OEMA's senior director Bertha G. Holliday, PhD.

The publication, which is available online, offers several recommendations:

• Supporting research on disparities. One of the first steps toward addressing disparities is to uncover just how bad the situation is, says Teresa L. Chapa, PhD, MPA, senior policy adviser for mental health in the Office of Minority Health at the U.S. Department of Health and Human Services.

Epidemiological research on the prevalence of mental health conditions in different racial and ethnic groups is lacking, she says. So is evidence that specific interventions are effective with particular groups. That's because large studies often don't include breakdowns by race and ethnicity, Chapa explains. And studies that focus on particular racial and ethnic groups—when they're done at all—are often too small to be included in meta-analyses.

"It may turn out that the evidence-based interventions we currently have work for all of us, but we don't know right now because we're not part of studies," says Chapa.

• Integrating psychological and primary care. There is one approach Chapa believes could help eliminate disparities—and improve care for everyone: integrating behavioral and primary health care. "The primary care site appears to be a more hospitable point of entry for many people," says Chapa, explaining that racial and ethnic minorities often head to primary care settings even when their concerns are purely psychological. "Stigma could be one reason, but it also could be that they feel it could be a one-stop shop."

To make that happen, Chapa calls for more interdisciplinary training for psychologists and medical professionals and closer partnerships between the two. "In places where this already exists, it seems to be an ideal model of care," she says.

• Ensuring cultural competence. But it's not enough just to improve psychologists' understanding of physical health and medical professionals' understanding of psychological health, says Gayle Y. Iwamasa, PhD, psychology director at Logansport State Hospital in Logansport, Ind.

Linguistic and cultural competence is also key. "Our society is getting more and more diverse every second," Iwamasa says. Yet the number of racial and ethnic-minority psychologists hasn't kept up with the nation's changing demographics, she says, and psychologists overall often lack training in cultural competence. Further contributing to disparities is the fact that racial and ethnic-minority patients often see the most inexperienced therapists, she adds.

Without cultural competence, Iwamasa says, patients and psychologists may have completely different ideas about what's causing distress and what to do about it. Take Asian-American and Pacific Islander populations, for example. For these patients, says Iwamasa, psychological problems may be the result of disruptions in the balance of yin and yang. They may seek help from indigenous healers or believe that a cure can come via willpower alone.

Even the way they describe their symptoms may be different. Although Iwamasa rejects the old idea that Asians express psychological distress through physical symptoms as too simplistic, she believes that that may be true of less acculturated Asian-Americans.

• Diversifying psychology's work force. In addition to ensuring cultural competence among all psychologists, what's needed are more bilingual psychologists, says Chapa.

Adding more psychologists of color is also key, says Scyatta A. Wallace, PhD, an associate psychology professor at St. Johns University in Queens, N.Y.

"We know that ethnic-minority providers are more likely to want to serve in ethnic-minority communities, so if we increase the number of ethnic-minority providers, hopefully there will be more services available," says Wallace.

Providers of color are also more attuned to cultural issues, says Wallace. Because of stigma, she says, many minority patients resist seeking care for both physical and psychological issues. "For many, it's a last resort type of situation," she says, explaining that ethnic-minority psychologists may be more sensitive to how disempowered such patients feel. They may also have a better understanding of the use of alternative medicine and the important role that family members and spiritual leaders play in health-care decision-making.

Yet ethnic-minority high school students—even those participating in programs designed to get them into science careers—don't know enough about psychology. A study Wallace conducted in a New York City "pipeline" program found that students were interested in behavioral health careers, but teachers didn't know enough about the field to help them pursue those interests. Wallace is hoping to develop a curriculum to expose ethnic-minority high schoolers to careers in behavioral research.

• Promoting health literacy. Psychologists aren't just focusing on disparities in mental health, however. Lydia P. Buki, PhD, an associate professor of kinesiology and community health at the University of Illinois at Urbana-Champaign, hopes that health-care reform will also address health literacy.

Ethnic-minority communities' own cultural beliefs can contribute to disparities, she points out. In some communities, for instance, cultural norms can keep women away from cancer screening. "Women learning about their bodies is taboo in certain cultures," she explains. Misinformation also plays a role. Many Latinas, for instance, believe that Pap smears are necessary only after you've become sexually active, or that cancer is inevitably fatal.

Ethnic-minority women may also have expectations about doctor visits that are unmet. "When the doctor comes in and out because they have a large number of patients still to see that day, women feel they don't have a connection," explains Buki. "If their health literacy is low, they haven't even been able to formulate a question before the doctor's out the door."

What's needed are more and better trained interpreters, training for medical professionals and interventions for women themselves, says Buki, who has developed a measure of immigrant women's health literacy along with a colleague. But, she adds, it's not enough to just translate English materials into other languages. Materials must dispel myths common in the target audience, use culturally appropriate images and offer communication tips designed especially for ethnic-minority patients who may feel uncomfortable asking doctors questions.

Working together

Psychologists are working alongside groups from the faith, racial and ethnic, LGBT, disability, HIV/AIDS, rural, consumer, insurance and business communities to help make sure health-care reform addresses disparities. "If we're going to be successful, we've got to get everyone together and speak with one voice," says APA's Dawes.

So far, the working group has met with legislators and their staffs and distributed copies of the special Communiqué issue on Capitol Hill. The group has also called for a hearing on health disparities. The working group will soon launch a grassroots campaign.

Want to get involved? Contact Dawes via e-mail.

Rebecca A. Clay is a writer in Washington, D.C.