July/August 2003 Tip Sheet

Media Contact:
Angela Lower
Annals of Family Medicine
(800) 274-2237 ext. 5224 or (913) 906-6253
alower@aafp.org

New Annals of Family Medicine Issue Focuses on Health Care Disparities

The July/August 2003 issue of Annals takes an up-close look at solutions for eliminating health care inequalities in the United States, a central goal of the Department of Health and Human Services' Healthy People 2010 initiative. A cluster of articles examines health care disparities on many levels - from the conceptual framework to that of the individual patient experience. Collectively, the authors challenge policy makers to stop looking for simple, single-level solutions to the unfairness in the delivery of health care, calling for a long-term approach that bridges policies, systems, practices, individuals and communities.

The July/August 2003 issue also features the U.S. Preventive Services Task Force recommendation and rationale for measures primary care physicians can take to increase breastfeeding rates in the United States, also a goal of the Healthy People 2010 initiative.

In This Issue:

U.S. Preventive Services Task Force Issues New Breastfeeding Recommendation

The U.S. Preventive Services Task Force releases new recommendations for measures primary care providers can take to support and encourage breastfeeding among new mothers. In its statement, the USPSTF recommends the use of structured educational breastfeeding classes and behavioral counseling programs to promote breastfeeding.

The USPSTF found evidence that programs combining breastfeeding education with behaviorally oriented counseling are associated with increased rates of breastfeeding initiation and its continuation for up to three months. The USPSTF also found evidence that providing ongoing support for patients, through in-person visits or telephone contacts with providers or counselors, increased the proportion of women continuing breastfeeding for up to six months.

The USPSTF found insufficient evidence to recommend for or against the following interventions to promote breastfeeding: brief education and prevention counseling by primary care providers during routine office visits, peer counseling when used alone, and written materials.
Behavioral Interventions to Promote Breastfeeding: Recommendations and Rationale
U.S. Preventive Services Task Force

Education and Support Programs Shown to Improve Breastfeeding Rates

To assist the U.S. Preventive Services Task Force in developing new recommendations for primary care-based interventions to improve breastfeeding rates, Guise and colleagues conducted a systematic review of related studies conducted between 1966 and 2001 to determine the effectiveness of counseling, behavioral, and environmental interventions.

The researchers found that education sessions that review the benefits of breastfeeding, principles of lactation, myths, common problems, solutions and skills training appear to have the greatest single effect on breastfeeding rates. The researchers also found that the common practice of providing patients with written materials and discharge packets were not effective in prompting breastfeeding. In fact, discharge packets, especially those containing promotional materials with or without formula samples, were found to have a detrimental effect.
The Effectiveness of Primary Care-Based Interventions to Promote Breastfeeding: Systematic Evidence Review and Meta-Analysis for the U.S. Preventive Services Task Force
Jeanne-Marie Guise, M.D., M.P.H., et al

Americans with Health Insurance and a 'Medical Home' Receive Higher Rates of Health Care

Americans with a usual source of care and health insurance are more likely to receive health care services than people who have neither, according to this study by Fryer and colleagues. The analysis expands the well-known ecology of medical care model to quantify how the location of medical care delivery differs depending on a number of sociodemographic characteristics, including age, sex, race, ethnicity, income, education, insurance, location of residence, and having a usual source of care.

The study found that lack of insurance is associated with less care in all settings except the emergency department and that not having a "medical home" (a particular doctor's office, clinic or other place a person routinely goes to for medical care) is related to lower rates of care in all health care settings. Additionally, the study found that the frequency and location of health care delivery varies substantially with sociodemographic characteristics. The results provide policy makers with a framework for considering future health care policy options and might be helpful in conceptualizing system redesign solutions to health care disparities.
Variation in the Ecology of Medical Care
George E. Fryer, Jr., Ph.D., et al

Study Finds that People with Less Education Benefit from HMO Participation

HMO participation may help reduce the large disparities in health care for people of lower economic status, according to this study by Fiscella and colleagues. Through a cross-sectional analysis, the researchers found that respondents with less education were significantly less likely to have had a physician visit, mental health visit, mammogram or influenza vaccination in the past year. Interestingly, however, they also found that membership in an HMO significantly reduced these preventive care disparities.

In particular, the analysis showed that HMO members with less than 12 years of education received services at levels comparable to non-HMO respondents with more education. In their discussion, the authors suggest that future policies to eliminate inequalities in health care should consider the salutary effect of HMOs, which by virtue of their population focus and reporting, are well-positioned to address disparities in care.
Do HMOs Affect Educational Disparities In Health Care?
Kevin Fiscella, M.D., M.P.H., et al

Nonphysician Primary Care Clinicians and Family Physicians Most Likely to Care for the Underserved

In the first study to compare the geographic distribution and patient populations of clinicians across the different primary care disciplines, Grumbach and colleagues found that a higher percentage of physician assistants, nurse practitioners, and family physicians care for underserved populations than do internists, pediatricians, and obstetricians-gynecologists.

Based on the survey results from California and Washington, the authors suggest that the continued maldistribution of primary care clinicians should be addressed through federal policies that continue to support successful training grant programs, such as Title VII and VIII, and through policies that provide incentives to training programs that prepare clinicians to practice in underserved communities.
Who is Caring for the Underserved? A Comparison of Primary Care Physicians and Nonphysician Clinicians in California and Washington
Kevin Grumbach, M.D., et al

Racial Concordance Not Shown to Influence Children's Primary Care Experiences

In contrast to studies among adults, patient-provider race/ethnicity concordance was not found to be associated with parent-reported primary care experiences of children, according to this study by Stevens and colleagues.

The community-based survey of parents of elementary school children, aged 5 to 12 years, indicated that racial/ethnic concordance was not important for the parent's assessment of the accessibility, utilization, interpersonal relationship, and comprehensiveness of care. Additionally, the researchers found that having a concordant relationship did not reduce disparities in primary care experiences between minorities and whites. The researchers point out that these preliminary findings call into question simplistic solutions to disparities, such as matching the race/ethnicity of the clinician to that of the patient.
Patient-Provider Racial and Ethnic Concordance and Parent Reports of the Primary Care Experiences of Children
Gregory D. Stevens, Ph.D., et al

Filipino Americans Heightened Bodily Awareness May Help Guide Effective Treatment

Through a rigorous qualitative study of 85 Filipino Americans, Becker found that the unique ways in which Filipino Americans combine attention to the body, values of balance and harmony, and emphasis on social well-being result in a heightened attention to bodily processes.

This emphasis on bodily awareness among Filipino Americans offers clinicians a unique opportunity utilize this strength to enhance chronic illness management plans. Becker suggests that awareness of culture-specific traditions can provide clinicians with insights into how best to help patients understand their illnesses and incorporate illness management plans into their lives.
Cultural Expressions of Bodily Awareness Among Chronically Ill Filipino Americans
Gay Becker, Ph.D.

Editor's Note: To arrange an interview with one of the authors or for full-text copies of any of the articles included in the July/August 2003 issue of Annals of Family Medicine, contact Angela Lower at (800) 274-2237 ext. 5224 or (913) 906-6253 or via e-mail at alower@aafp.org.