Planning minority health programs to eliminate health status disparity

Evaluation and Program Planning, Vol. 14,

pp. 211-219,

1991

0149-7189/91 $3.00 + .oo Copyright 0 1991 Pergamon Press plc

Printed in the USA. All rights reserved.

PLANNING MINORITY HEALTH PROGRAMS ELIMINATE HEALTH STATUS DISPARITY

LAURA B. WILSON

TO

and SHARON P. SIMSON

University of Maryland, College Park

ABSTRACT The purpose of this research is to determine program characteristics that are essential to address the problem of health status disparity between minority and nonminority populations. The respondent group consisted of a sample of SO minority health organizations currently listed as participants in the Minority Health Resource Network in the United States Public Health Service Office of Minority Health. A three-round Delphi technique was used to reach consensus by collecting data and assessing agreement and disagreement on the issue of health status disparity from a widespread national group. Findings indicate that there is strong consensus among respondents that cultural awareness is the top priority area to address in order to eliminate health status disparities.

INTRODUCTION pectancy of white males, which was 62 years in 1940 and rose to nearly 73 years in 1985. The life expectancy for black females was 55 years in 1940 and nearly 73 years in 1985. White females, however, had a life expectancy of 67 years in 1940 and 79 years in 1985 (Jackson, 1988). Federal government health care indices have reported differences in health status between whites and minorities. Figures show:

overall health status of people in the United States had improved greatly since the turn of the century (Office of Minority Health Resource Center, 1988). As a result of advances in biomedical sciences and changes in health care, the life expectancy of the overall population is higher and the rate of infectious disease is lower. Since 1960, the United States has experienced a steady decline in the overall death rate from all causes. Diseases common in 1900, such as influenza, pneumonia, diphtheria, tuberculosis, and gastrointestinal infection have been brought under control through improved sanitation, better nutrition, and immunizations (USDHHS, 1985). Despite these advances, disparity in health status between minorities and nonminorities is a key problem confronting minority health programs in the United States. Disparity exists between the nonminority population and ethnic minority populations in terms of life expectancy, health status, and excess deaths. Longevity is less for blacks, Hispanics, and Native Americans when compared with whites (Anderson, 1989). Blacks show the greatest disparity in terms of mortality and morbidity. The life expectancy for black males, for example, was just over 50 years in 1940, and increased to 65 years in 1985. These figures contrast with the life ex-

The

l

l

l

l

l

Whites outlive blacks by an average of nearly six years, 75.1 years to 69.3 years (Jones & Rice, 1987). No prenatal care was received by 40% of black mothers and 45% of Native American mothers (USDHHS, 1980). Black infant mortality rate in 1978 was nearly twice as high as that for whites, 23.1 deaths per 1,000 births to 12.0 deaths per 1,000 births. Native Americans had a 13.7 mortality rate; the rate for Hispanics was not available (USDHHS, 1980). Black maternal mortality rate is over three times higher than the white rate, 26.0 per 100,000 live births to 7.7 per 100,000 births (Jones & Rice, 1987). Blacks have higher age-adjusted death rates for 13 of the 15 leading cause of death. The greatest differences between blacks and whites were found for diseases of

Requests for reprints should be sent to Laura B. Wilson, College of Health and Human Performance, PERH 211

Bldg.,CollegePark, MD20742.

212

LAURA

B. WILSON

the heart, malignant neoplasms, and homicide and legal intervention (USDHHS, no date). Asian Americans, however, have a lower rate of diseases compared to whites (Anderson, 1989). Disparity in deaths is also reported. Excess deaths are those “deaths that would not have occurred if minorities had the same age- and sex-specific death rate as the nonminority population” (OMH-RC, 1988). These deaths occur in six illness categories: heart disease and stroke (18,181 excess deaths), homicide and accidents (10,909), cancer (8,118), infant deaths (6,178), chemical dependency (2,154), and diabetes (1,850). This disparity occurs between whites and all key minorities including blacks, Hispanics, Native Americans and Asian/Pacific Islanders. Influence of Ethnicity, Health Beliefs, and Health Behavior Ethnicity, racial, and cultural background, have been shown to be key factors that influence health beliefs and health behavior. Studies of blacks, Native Americans, and Hispanics have produced these findings: (a) Comparative studies have shown that ethnic groups have different conceptions of their own well-being and methods for disease prevention, health maintenance, and self care. (b) Different people perceive, evaluate, and act upon symptoms of illness in different ways in different social settings. (c) Although class factors and the organization of delivery systems affect utilization patterns, ethnic considerations such as residential segregation are particularly important. (d) Concepts of disease and illness vary; for example, causes may be linked to religious beliefs and symptoms may be classified into different illness categories. (e) Interaction with mainstream health professionals and organizations may be influenced and even avoided due to styles of interaction, attitudes toward authority figures, sex-role allocations, and ways of expressing emotion and asking for help (Harwood, 1981). Efforts of Public Health Services Although a vast array of problems related to disparity in health has been confronted by the public health movement, efforts have been limited by funds and resources. As a result, public health has tended to focus on areas that are popular with middle and upper income groups, such as sanitation, immunization, and epidemiology. This social class bias was reflected in efforts to control two infectious diseases, polyeomyelitis and tuberculosis. Although there was strong public and government support for research and therapy related to polyeomyelitis, a disease of great concern to the middle class, there was less support for research and therapy related to tuberculosis, a disease that disproportionately affected less affluent and minority groups. The different consequences of these diseases has been demon-

and SHARON P. SIMSON strated dramatically; in 1950 poliomyelitis killed 1,686 people, whereas tuberculosis killed 33,633, most of whom were from less affluent and minority groups. Despite this record, the public health movement has developed and delivered health programs aimed specifically at minorities and/or the poor. These programs have tended to be noncontroversial in nature, such as programs for the care of infants and pregnant mothers. Historically, programs have entered into areas where public institutions already exist, such as school health programs. One result of this approach to provision of health care has been unevenness and gaps in medical care for minorities and/or the poor (Bullough & Bullough, 1982). Problems and Solutions from the Past In the past, many health problems have been encountered and various solutions have been proposed to the health disparity problem: Drug and alcohol abuse is the number one health and social problem among blacks. Although medical and social epidemiological data indicate the increased risk of premature mortality and morbidity, the development and implementation of prevention and treatment strategies designed to accommodate the sociocultural needs of blacks have not proliferated. In order to reduce substance abuse, as well as other health problems in the black community, racist and discriminatory practices in the larger society must be reduced (Clifford, 1987; Jones & Rice, 1987). The black-white gap in low-birth-weight rates is another problem. Policy alternatives to reduce this gap by providing prenatal care include: do nothing; expand Medicaid coverage; target selected groups for special services; provide access to comprehensive prenatal care for all pregnant women; and provide adequate income maintenance support (Howze, 1987). Mental health problems significantly affect minorities. Prevention strategies for minorities include: definition of goals that are operational and relevant for the target population; definition of boundaries of intervention activities into micro level (individual responsibility) or macro level (focus on normative changes in society); ideological biases that center on political and social factors; political impediments, including legislation, lack of resources, and lack of coordination of programs; and implementation barriers. (Jones & Rice, 1987). Current Federal Initiative Concerned with the continuing disparity between whites and minority Americans in terms of the burdens of death and illness, Margaret M. Heckler, former Secretary of U.S. Department of Health and Human Services, established a Secretary’s Task Force on Black and Minority Health. This Task Force was charged with conducting a comprehensive investigation of the health problems of blacks, Native Americans, Hispanics and

Eliminating

Disparity in Minority Health Programs

Asian/Pacific Islanders. The report of this task force sought to account for the health status disparity by examining the social characteristics of minority populations, mortality and morbidity indicators, the top six health problems, and health services and resources for minorities. The report also includes recommendations of the task force on health information and education, health services, health professions development, cooperative efforts, data development, and research agenda. This report was intended to “serve not only as a standard resource for department wide strategy, but as the generating force for an accelerated national assault on the persistent health disparities” (USDHHS, 1985). According to the Task Force Report, differences in health status between minority and nonminority groups are related in part to the health care resources and services available to individuals. General factors include

RESEARCH The primary purpose of this research was to make projections about characteristics that health programs serving minorities need in order to address the question of health status disparity. Such projections can be used to shape public policy regarding minority health programs and to bring about necessary organizational change. The development of projections about the future can be made by using an array of forecasting methods, such as time series analysis, leading indicators that predict, brainstorming speculations, scenario construction, and the Delphi technique. This research was conducted using the Delphi technique because it provides pooled judgment about questions while eliminating the negative personal factors, other than knowledge, from group problem solving. The Delphi technique is defined as “a method for structuring a group communication process so that the process is effective in allowing a group of individuals as a whole to deal with a complex problem” (Linstone &

RESEARCH

213

health services’ utilization, health care financing, availability of health care facilities and personnel, health knowledge and behavior, and the influence of health education on health knowledge and behavior. Examination of these general factors by the Secretary’s Task Force led to the identification of these specific concerns: l l l l l l l

access, use of sources ability health health health

utilization, and financing; health professionals; of care; to pay for services; insurance; professionals; education and information.

These concerns were seen as contributing to the disparity in health status between minority and nonminority groups (USDHHS, 1985).

METHODS Turoff, 1975, p. 3). The Delphi technique was originally developed in 1950 by the Rand Corporation to be used in forecasting and making predictive statements through use of written response, in order to obtain opinions from a group of people. The advantage of the technique was described as the ability to minimize the pressure for compromise or irrelevancy in small group interaction by eliminating the opportunity to interact directly with other study participants (Dalkey, 1972). The characteristics of the Delphi technique are that of anonymity, controlled feedback, and statistical analysis of group response (Dalkey, 1972). The Delphi is viewed as appropriate in a variety of specific situations, including inadequate communication methods among those examining the issues, need to interact with large numbers of individuals, cost projections about the future need to be made using an effectiveness of written versus face-to-face meetings, heterogeneity of participants is necessary to assure validity, or anonymity is essential.

DESIGN AND METHODS

The purpose of this research was to gain consensus among providers currently working in health programs serving minorities about essential program characteristics necessary to address health status disparity among minority populations. The respondent group consisted of a sample of 50 minority health organizations currently listed as participants in the Minority Health Resource Network of the United States Public Health Service Office of Minority Health. The Delphi technique was chosen in order to obtain responses from minority programs across the United States. This method allowed for a nationwide sample of a geographically widely dispersed group, provided a method for analyzing subjective judgments, provided a

means of group interaction for a non-affiliated, non-interactive group of respondents, and assured anonymity. A three-round decision Delphi technique was used to solicit the opinions of the service providers in organizations serving minority populations. Each organization on the list of organizations provided by the Office of Minority Resource Center was sent a Round One questionnaire in August, 1989. The questionnaire asked the open-ended question. “What are the barriers to reducing health status disparity in health programs serving minority populations?” Respondents were asked to list as many barriers as they perceived. All responses obtained from the first questionnaire were content analyzed and included verbatim on the Round Two

214

LAURA B. WILSON and SHARON P. SIMSON

questionnaire. Some items identified by respondents were grouped into conceptual statements in order to reduce redundancy, although records of frequency of similar responses were maintained. A final listing of 100 barriers to successful minority health program development were randomly assigned placement on the Round Two questionnaire. The second questionnaire was mailed to all 50 Minority Health Resource Center participants, regardless of whether or not they had responded to the Round One questionnaire. This was done to assure the broadest base of opinion and to assure the anonymity of the Round One responses. Respondents were asked to rate each item on the lOO-item barriers list on a five-point scale. They were to mark each item either essential, very desirable, desirable, not desirable, or optional in terms of its relevance to health status disparity in minority populations. The Round Two questionnaire was mailed in October, 1989. A total of 36 respondents returned the Round Two questionnaire. The responses were analyzed and descriptive statistics and weighted frequencies on the statements were prepared. A group rating or mean was calculated for each statement. The Round Three questionnaire was distributed to all 50 members of the sample. The third questionnaire provided a complete listing of the 100 items defined as barriers in the second questionnaire, as well as the cal-

culated group rating or mean. Respondents were asked either to agree or disagree with the group rating. If they chose to disagree, the respondent was given the opportunity to provide a new rating on the five-point scale used in Round Two. This Likert-type scale ranged from 0 (disagree completely) to 4 (agree completely). Round Three was mailed in November, 1989. A total of 36 providers of health in organizations serving minorities responded to the final questionnaire. Descriptive statistics and rankings were analyzed in Round Three to determine priority rankings. A final list of rank order barriers was provided, based on the descriptive statistics. Because the Delphi technique was chosen as the most efficient means of collecting data, the process used to analyze findings was selected as a correiate of this efficiency. A monitoring team, rather than an individual, analyzed the results of the rounds and designed the format for the ensuing rounds. Each round was developed with approximately 45 days for completion, and all responses were reported in a verbatim or nearly verbatim manner. The anonymity of al1 respondents was maintained. Respondents were leaders in developing and implementing health-related programs for minority audiences, and were identified by the Office of Minority Health Resource Center of the Public Health Service, U.S. Department of Health and Human Services.

FINDINGS The findings from Rounds One, Two, and Three of the Delphi mail questionnaire were analyzed separately and comparatively. A list of the 100 response categories determined through the Delphi opinion process Round One are listed in Table 1, and a comparison of the findings for the group rating and weighted group rating are reported. On Round Two the respondents ranked 53 of the 100 items with high group ratings of 3.0 or greater. A total of 17 of the 100 items were ranked with a low mean rating of 2.5 or less. The highest ranked ten items of consensus for the high group ratings from Round Two, included in rank order from highest at a 3.74 group rating to lowest at 3.30, are the following: cultural sensitivity; cultural relativity; know the habits and customs of the groups for which the programs are intended; willingness to use ethnic sensitivity on behalf of the minority community; adequate funds; improve the quality of health care; equality of access to care; acceptance of Medicaid and Medicare and resources to allow follow-up; awareness of financial aspects of health care for low-income minorities; acceptance of consultation and help from the minority community; and cultural training for service providers. The ten items rated the lowest in Round Two from a low ranking of 1.90 to a high of 2.26 were: deductibles

discourage health care; providers should handle all billing of third parties; retirement only on demand and demonstrated incapacity; managed educational programs; providers should be minority group members; lack of government funded programs is a major impediment to health care for minorities; pay better attention to how sliding scale should be established; provide transportation; use of certified health care specialists; and declare a moratorium on the closing of public health institutions. In Round Three the final group mean was achieved by weighting the scores and incorporating into the final weight the changes that the respondents requested after assessing what their colleagues had provided as group mean ratings for the Round Two questionnaire. In Round Three, the top ten areas defined as relevant in relieving health status disparity for minorities were ranked from a high 3.73 to a low of 3.44. See Table 2. Of the 100 items in Round Three, 60 items were high consensus, with a ranking of 3.0 or greater. The low rankings for Round Three of 2.5 or less ranged from 2.07 to 2.59, and are depicted in Table 3. Respondents ranked 9 items as low consensus with a rating of less than 2.5. See Table 3. A comparison of the top rankings from Rounds Two and Three shows that eight items were in both lists, al-

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Disparity in Minority Health Programs TABLE 1 OF ROUND TWO AND THREE GROUP RATINGS

COMPARISON

Round 2 group rating (mean)

Round 3 weighted group rating

1. Cultural sensitivity.

3.74

3.73

2. Willingness to use ethnic sensitivity on behalf of minority community.

3.61

3.66

3. Commitment to prevention and health promotion.

3.52

3.52

4. Not threatened

2.97

3.09

3.18

3.29

3.62

3.53

Item regarding characteristics that health programs serving minorities need to eliminate health status disparity.

by nontraditional

5. Recognize complexities 6. Resist tendency

leaders; willing to support them.

in helping oppressed

persons move toward self-determination

in health matters.

to provide fewer health services to minorities.

7. Illuminate the value of pharmacist and other allied health care professionals disparities.

in addressing health status 2.58

2.87

8. Cultural relativity; know habits and customs of groups for which programs are intended.

3.66

3.67

9. Awareness of financial aspects of health care for low-income minorities.

3.19

3.52

10. Program should have common theory, but allow for flexibility to respond to differences geographical area implemented. 1 1. Awareness that minority is not synonymous

in each

with poor.

2.79

2.85

3.36

3.42

2.75

2.88

13. Sufficient staffing to allow counseling and education on health problems and prevention.

3.1 1

3.38

14. Availability of low-literacy

12. Sell program by face-to-face

contact between programs, persons, and population.

3.08

3.29

15. Availability of health materials suited to minorities.

3.40

3.52

16. Facility in neighborhood;

3.16

3.38

17. Resources to allow for follow-up.

3.44

3.49

18. Community board.

2.63

2.99

19. Accessibility

3.02

3.26

20. Sliding fee scale.

3.00

3.08

21. Accept Medicaid and Medicare.

3.44

3.67

22. Holistic approach.

2.71

2.98

3.13

3.30

24. Reduced rate medicine.

2.34

2.61

25. Cultural training for providers.

3.30

3.45

26. Information and referral.

3.00

3.19

27. Provider should handle all billing of third party.

1.94

2.15

28. Make appointment scheduling easy.

3.25

3.28

29. Walk-ins acceptable.

2.80

2.91

30. Health educational programs in waiting rooms.

2.88

2.91

31. Health care facilities should be subsidized,

2.74

2.87

health materials.

convenient

location.

to mass transit.

23. Use of interdisciplinary

health team.

but patients should pay according to their means.

32. Providers should be minority group members.

2.13

2.38

33. Provide transportation.

2.19

2.39

34. Pay better attention to how sliding scale should be established.

2.16

2.42

35. Mandate educational programs.

2.08

2.42

36. Don’t use white standards to determine health of nonwhites.

3.06

3.21

37. Awareness of family values of minority population.

3.17

3.41

38. Awareness of life/death/quality

3.26

3.44

of life within groups being served.

3.17

3.42

40. Hire bilingual and bicultural staff.

3.14

3.36

41. Adequate funds.

3.54

3.64

42. Participatory process that involves the target audiences in designing effective programs.

3.20

3.25

43. Use focus groups and field testing for material and program development.

3.02

3.01

44. Develop effective marketing and outreach.

2.91

3.00

39. Improve discrepancy

in black/white

mortality rates.

continued

LAURA

216

B. WILSON

and SHARON

P. SIMSON

TABLE 1 continued

Item regarding characteristics that health programs serving minorities need to eliminate health status disparity. 45. Invest in training health professionals,

people of color, to serve people better.

Round 2 group rating (mean)

Round 3 weighted group rating

3.26

3.38

3.17

3.39

47. Bilingual handouts.

2.94

3.18

48. Equality of access.

3.48

3.61

46. Target services specifically

to reach minority population.

49. Treatment compliance. 50. Improve fragmentation 51

of delivery system.

Break down distrust of minority populations in health care systems.

52. Do epidemiological

profile to be aware of needs.

2.60

2.85

3.02

3.29

3.02

3.12

3.17

3.22

2.82

3.12

54. Use certified health care specialists

2.23

2.55

55. Sensitivity to working class cultures.

3.08

3.25

56. National health insurance.

2.51

2.94

57. Need adequate nutrition, housing and education more than health care to reduce disparity.

2.82

2.99

58. Provide job opportunities.

2.50

2.77

59. Lack of government

2.14

2.77

60. Closing of public hospitals has impeded care of minorities

2.30

2.76

61. Poor ratio of provider to population in minority communities.

2.57

2.93

62. Reduced funding for education has reduced number of health care providers.

2.42

2.69

53. Assess predisposing

and enabling factors for access to health care.

funded programs are major impediment to health care for minorities.

63. Grants and scholarships for minority students in health care professions.

3.22

2.25

64. Declare moratorium on closing of public health institutions.

2.26

2.32

65. Upgrade existing facilities serving minorities.

3.05

3.25

66. Provide uniform health care financial incentives regardless of pay class to avoid institutional bras toward insured pouplation.

2.94

3.04

67. Commit funds to applied research and demonstration

2.88

3.01

68. Fund research to address program acceptance.

2.47

2.59

69. More exposure to different minority groups in health professional training.

3.02

3.29

70. More mrnonties should be in leadership positions in health care.

3.20

3.45

71

projects, especially for children and elderly.

2.85

3.17

72. Ability to Interact well with locals.

3.17

3.28

73. Accept consultation

and help from minority community.

3.34

3.43

74. Time to develop mutual trust with communities served.

3.20

3 21

75. Chemical dependency

2.97

3.35

76. Assure continuity of care.

3.05

3.25

77. Providers tn minority communities should advocate freedom of choice for consumer.

2.79

2.94

78. Health care cost containment

2.57

2.73

79. Improve quality of health care.

3.52

3.55

80. Decrease waiting times.

2.76

2 89

8 1 Courteous,

3.26

3.34

82. Don’t fragment patients according to ethnicity, age, or sex.

2.69

2.79

83. Retire only on demand or demonstrated

2.00

2.20

84. Differentrate health care from medical care.

2.75

2.89

85. Don’t fragment preventive

2.77

2.87

3 11

3.24

Fundamental changes in socioeconomic

respectful

issues to avoid bandaid policies in health care.

education.

has eliminated or limited accessibility.

staff.

incapacity.

medtcine on basis of states rights.

86. Health education programs which emphasize behavioral change and institutional change.

1.90

2.07

88. Address private sector barriers to health care.

2.88

2.98

89. Build on strengths of community;

3.22

3 33

87. Deductibles discourage

health care.

develop strong traditional norms.

90. Programs should emphasize family planning, prenatal care, work safety, environmental

pollution.

2.74

2 95 continued

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217

Disparity in Minority Health Programs TABLE 1 continued

Round 2 group rating (mean)

Item regarding characteristics that health programs serving minorities need to eliminate health status disparity. 91. Target populations: addicts, homeless.

Round 3 weighted group rating

aged, youth, unwed mothers, street people, trauma victims, cancer patients, drug

92. Reduce blaming the victim mentality.

3.00

3.16

2.88

3.06

93. Research attitudes and behaviors of health planners.

2.47

2.65

94. Take into account subgroups of minority populations.

3.00

3.11

95. Use media to reach populations

2.62

2.93

96. Remove unethical political motives, placation or tokenism in agency’s issues.

response to minority health 3.07

3.27

97. Remove stress induced by racial tensions, crowded conditions, physical danger, sense of hopelessness about financial future, poverty, sexuality in teen years causing STDs, infant mortality, substance abuse.

3.14

3.35

98. Guarantee ambulatory services in local neighborhoods

2.77

2.94

2.40

2.60

3.25

3.25

as promised by de-institutionalization

99. Provide ambulatory services at work and school sites. 100. Convenient

hours of facility.

though not necessarily ranked the same. Only two items, cultural sensitivity and improving the quality of care, had the same rankings for the two rounds. These items are identified in Table 4. Of the items ranked lowest in Rounds Two and Three, four items were the same for the two rounds in terms of ranking. These included the top three items of

TABLE 3 LOWEST RANKINGS OF ROUND THREE 1. Deductibles discourage health care 2. Provider should handle all billing of third party 3. Retire only on demand or demonstrated 4. Grants and scholarships professions

incapacity

for minority students

in health care

5. Declare moratorium on closing of public health institutions 6. Providers should be minority group members 7. Provide transportation TABLE 2 HIGHEST RANKINGS OF ROUND THREE (original question number in parentheses)

8. Pay better attention to how sliding scale established Mandate educational programs 9. Use certified health care specialists 10. Fund research to address program acceptance

1 Cultural sensitivity (1) 2. Willingness to use ethnic sensitivity on behalf of minority community (2) and Cultural relativity; know habits and customs of groups for which programs are intended (8) 3. Adequate funds (41) 4. Equality of access (48) 5. Improve quality of health care (79) 6. Resist tendency to provide fewer health services to minorities (6) 7. Awareness of financial aspects of health care for low income minorities (9) and Commitment to prevention and health promotion (3) 8. Resources to allow for follow-up (17) 9. Cultural training for providers (25) and More minorities should be in leadership positions in health care (70) 10. Awareness of life/death/quality of life within groups being served (38)

TABLE 4 RANKED IN TOP TEN IN ROUNDS TWO AND THREE 1 Cultural sensitivity 2. Improve quality of health care 3. Adequate funds 4. Equality of access 5. Awareness 6. Willingness community

of financial aspects to use ethnic

7. Cultural relativity 8. Cultural training for providers

for low income maintenance

sensitivity

on behalf

of minority

218

LAURA B. WILSON

providing transportation, paying better attention how sliding scales should be established, mandating

to ed-

and SHARON P. SIMSON ucational programs, specialists.

and

using

certified

health

care

DISCUSSION The health service providers responding to this threeround Delphi consensus study represented facilities from various sites across the United States. The choice of the Delphi technique permitted the collection of data and the assessment of agreement and disagreement on the issues of health status disparity for minority populations from a widespread national group of practicing professionals. Without the use of the Delphi, consensus would have been difficult to attain, given the dispersion of the respondents. As pointed out by several critics of the Delphi system (Sackman, 1974), the effects of the Delphi feedback may be viewed as uncertain. Sackman suggests that the Delphi technique encourages conformity. Item variantes tend to be lower and individual variation lower when group feedback was provided. However, in this study, many respondents changed responses from Round Two to Round Three, based on their review of the group mean. The final comparisons showed that only two rank orderings remained the same in the top

ten rankings and four remained the same in the bottom ten. The findings regarding priorities to reduce health status disparity among minority populations showed that the top ranking item for both rounds was cultural sensitivity. Of the other top items, an additional four items (awareness of low income problems, ethnic sensitivity, cultural relativity, and cultural training) had cultural issues included in their definitions. Thus, 50% of the top choices were related to issues of awareness, sensitivity, and acknowledgement of cultural issues. The remaining top items focused on financial, access, and quality of care issues. In the final weighted scores for low rankings, the low rankings of four items clustered around the topic of third-party reimbursement and financing of care. An additional four items were related to the education and background of health care professionals. Two items were related to sites for the delivery of care, and the remainder were in transportation and research.

IMPLICATIONS The literature associated with minority health has focused on health status and difficulties in access to health care. Several commissions and task forces have begun to examine these issues further and do long-range planning and make recommendations that would deal with these issues. However, no studies have been reported that seek to assess systematically the perceived barriers to achieving these goals and the priority needs for strong programming. Responses to this survey clearly indicate that the strongest issues are in the realm of cultural awareness. More powerful than even adequate funding, equality of access, or improved quality of health care, cultural issues dominated the top three places on the final ratings. Even items that included other issues related to health care delivery, such as financing, were likely to have a special caveat related to meeting the needs of minority and low-income minority populations. While financial issues were among the top ranked items, respondents were far less interested in the detailed aspects of the financing of care. Adequate funding was perceived as essential, as well as an understanding of the financial implications of care for low-income populations; but details such as deductibles, third-party billing, reduced rate Medicare, and sliding scales were rated as low priorities in dealing with the health status disparity issue. While the difference ranking between these two sets of financial issues seems somewhat con-

tradictory it may be that providers, in attempting to rank the issues before them, chose to provide a broadbased picture of the health status disparity issues and preferred, both for the research and for their organizations, not to get mired in the details of financing these needs. Similarly, the training and background of current and future providers of health care appeared on both the high and low ranking lists. Among the high rank items were cultural training for providers and more minorities in leadership positions in health care. Among the low rank items, the mandating of educational programs, use of certified health care specialists, retirement on demand, grants and scholarships for minority students, and providers being minority group members were not viewed as priorities. This finding appears to contradict the position of importance assigned to minorities in health care leadership positions included in the top-ranking list. One explanation is that to relieve health status disparity, having minority health providers and the availability of training for providers are not as important as simply having adequate providers of any type in those communities. In the realm of priorities, a few primary positions of leadership for minority providers in health care and many adequate positions for any racial or ethnic background providers is suggested. In reporting, providers appear to indicate that good medical care that is culturally aware is more im-

Eliminating

Disparity in Minority Health Programs

portant than the background and training of those providing that care. A final area of similar potential confusion is in the realm of access to care. Equality of access is listed as among the top five priority ranking in the final rating of the respondents. However, among the items on the low-ranking list, issues such as ambulatory services at work and school sites, transportation for health care, and sliding scales appear as low priority items. Perhaps the respondents did not feel that these low-ranking items represented their definition of equality of access and there were more important and less clearly delineated issues in this category. Or perhaps, as in the case of financing, respondents were attempting to emphasize the larger picture without overemphasizing specific details concerning barriers. At a future stage of program development when cultural issues may be less impor-

219

tant, detailed financial issues could emerge as holding a high priority for organizations to address. An overview of these findings and their implications clearly indicates strong consensus among providers as to the priority areas for eliminating health status disparity in the delivery of health care to minority populations, and that these priorities focus upon cultural awareness. In using these findings to shape programmatic and planning aspects of health care delivery, these respondents viewed the success of such programs as heavily dependent upon this cultural awareness. Adequate training, careful hiring policies, financing options that take into consideration the specialized needs of low-income minorities and improved quality of care focused specifically at these populations are possible methods for responding to the priorities established in this study.

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CLIFFORD, P.R. (1987). Substance abuse in the black community. In W. Jones, Jr., & M.F. Rice (Eds.), Health Care Issues in Black America. (pp. 143-158). Greenwood Press.

JONES, JR., W., & RICE, M.F. (1987b). Promoting mental health: The potential for reform. In W. Jones, Jr., & M.F. Rice (Eds.) (pp. 159-172.) Health care issues in black America. New York: Greenwood Press. LINSTONE, H.A., & TUROFF, M. (Eds.) (1975). The Delphi method: Techniques and applications. Reading, MA: Addison-Wesley. OFFICE

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Office of Minority DALKEY, N.C., ROURKE, D.L., LEWIS, R., & SNYDER, D. (1972). Studies in the quality of life: Delphi and decision-making. Lexington, MA: Lexington Books. HARWOOD, A. (1981). Ethnicity and medical care. Cambridge: vard University Press.

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JACKSON, J.S., (Ed.), NEWTON, P., OSTFIELD, A., SAVAGE, D., & SCHNEIDER, E. (Assoc. Eds.) (1988). The black American elderly. New York: Springer Publishing Co.

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