Approach Health Disparities From All Angles

Research shows that individuals with low socioeconomic status, as well as members of racial/ethnic minority populations, often face disparities in cancer care. Considering that about one-quarter of the Latino population lives in poverty, and that this is the largest ethnic minority group in the United States,¹ improving oncology care for this demographic should be a priority.

Cancer-related disparities for Latino populations include diagnosis at more advanced disease stages, delays in treatment initiation, and psychosocial morbidities such as poorer quality of life compared with non-Latino White individuals.^2-4 In addition, poverty-exposed children with cancer suffer from poorer cancer-related outcomes, including lower survival rates and earlier relapse.⁵ Cancer health disparities extend to caregivers as well, including increased stress and negative health among Latino caregivers of family members with cancer.⁶ Moreover, health care providers tend to underestimate the needs of Latino parents of children with cancer, assuming that Latino families want less information about a child’s cancer diagnosis and prognosis than is actually wanted.⁷ Therefore, understanding and ameliorating factors contributing to disparities in health outcomes in Latino children and adults with cancer as well as their caregivers is vital to minimizing disparities in morbidity and mortality.

It has been proposed that access to health care is a critical avenue to eliminating racial and ethnic health disparities because it reflects a societal, rather than individual, effort to address broader systemic issues that contribute to such disparities with a focus on provision and cost support of health care. Enacting change in health care access is a task for nurses engaged in clinical care, research, and policy.

A potentially valuable framework for this work divides the approach into 3 phases: detection, understanding, and reduction of health-related disparities. Much of the work in this field has focused on detection; that is, identifying certain groups as receiving poorer quality of care, lacking access to care, and having poorer health outcomes. The second phase, understanding, relates to identifying potential determinants of health disparities that will ideally inform interventions or efforts to eliminate disparities. Understanding is often limited by a narrow scope that fails to consider the interplay of the broad range of individual, family, community, societal, and systemic factors that contribute to health-related disparities. The final phase, reduction, involves developing and implementing interventions aimed at reducing and eliminating disparities that unfortunately are least representative of the literature on health disparities.

Clinically, application of this framework may be accomplished by broadening assessment of potential determinants of health to under- stand the complex range of factors that may contribute to potential disparities among the patients we serve. For example, more detailed assessment of social determinants of health (eg, food, housing, energy, and transportation insecurity) may reveal opportunities to address barriers to care. Cross-sector collaborations, such as partnering with digital transportation companies like Uber or Lyft, can help address barriers. Nurse scientists can also take the lead in developing research programs that address and reduce health disparities.

Engaging with the target community allows for development of sustainable and culturally relevant interventions. Such approaches, including community-based participatory research, establish a collaborative partnership that engages community experts in decision-making and changes in the practice of health care. Academic-community research collaborations can successfully reduce health disparities and, more specifically, have been shown to address systemic inequities, such as those related to education, financial insecurity, health literacy, and access to technology.

Advances in detection and treatment of cancer have led to increases in survival rates in recent decades. Unfortunately, for some populations, these advances have not affected cancer-related morbidity and mortality. Thus, it is crucial that nurse clinicians and scientists adopt a wide lens of assessment and intervention using a population health approach to incorporate myriad factors that contribute to these health inequities. Reduction and elimination of health disparities stems from detection and understanding, and nurses have a key role in clinical settings, research partnerships with communities impacted by disparities, and in policy decisions and implementation. Community and cross-sector partnerships can allow for innovative approaches that address social determinants of health not just at the individual but at the larger community and population levels and can lead to improvements in cancer- related outcomes for all patients and families.

References

1. Stepler R, Brown A. 2014, Hispanics in the United States statistical portrait. Pew Research Center. April 19, 2016. https://www.pewresearch.org/hispanic/2016/04/19/2014-statistical-information-on-hispanics-in-united-states/

2. Cancer Facts & Figures for Hispanics/Latinos 2018-2020. American Cancer Society. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-figures-for-hispanics-and-latinos/cancer-facts-and-figures-for-hispanics-and-latinos-2018-2020.pdf

3. Luckett T, Goldstein D, Butow PN, et al. Psychological morbidity and quality of life of ethnic minority patients with cancer: a systematic review and meta-analysis. Lancet Oncol. 2011;12(13):1240-1248. doi:10.1016/S1470-2045(11)70212-1

4. Wahi A, Phelan M, Sherman-Bien S, Sender LS, Fortier MA. The impact of ethnicity, language, and anxiety on quality of life in children with cancer. Appl Res Qual Life. 2016;11(3):817-836. doi:10.1007/s11482-015-9399-6

5. Bona K, Blonquist TM, Neuberg DS, Silverman LB, Wolfe J. Impact of socioeconomic status on timing of relapse and overall survival for children treated on Dana-Farber Cancer Institute ALL Consortium Protocols (2000-2010). Pediatr Blood Cancer. 2016;63(6):1012-1018. doi:10.1002/pbc.25928

6. Crist JD, García-Smith D, Phillips LR. Accommodating the stranger en casa: how Mexican American elders and caregivers decide to use formal care. Res Theory Nurs Pract. 2006;20(2):109-126. doi:10.1891/rtnp.20.2.109

7. Israel B, Eng E, Schulz A, Parker EA. Introduction to methods in CBPR for health. In: Israel BA, Eng E, Schulz AJ, Parker EA, eds. Methods for Community-Based Participatory Research for Health. Jossey-Bass; 2012:3-37.