racial & ethnic inequalities in american healthcare: information & implications john r....

Racial & Ethnic Inequalities Racial & Ethnic Inequalities in American Healthcare: in American Healthcare:

Information & Implications Information & Implications

John R. Stone, MD, PhDJohn R. Stone, MD, PhDSeptember 2011September 2011

Center for Health Policy and EthicsCenter for Health Policy and EthicsCreighton University School of MedicineCreighton University School of Medicine

402.280.2207; [email protected] 402.280.2207; [email protected]

Learning ObjectivesLearning Objectives

Summarize health & healthcare Summarize health & healthcare inequalitiesinequalities

Explain professional & institutional Explain professional & institutional factors in unequal healthcarefactors in unequal healthcare

Explain strategies for addressing Explain strategies for addressing health disparitieshealth disparities

Center for Health Policy and Ethics Center for Health Policy and Ethics

Major Disparities CategoriesMajor Disparities Categories

Race/ethnicityRace/ethnicity

Socio-economic statusSocio-economic status

GenderGender

Mental health statusMental health status

AgeAge

LanguageLanguage


““Health Disparities” LiteratureHealth Disparities” LiteratureArticles/Year*Articles/Year*

Center for Health Policy and Ethics Center for Health Policy and Ethics *April 1-April 1

Unequal Health & HealthcareUnequal Health & Healthcare““Unnatural CausesUnnatural Causes””**

Racial/Ethnic minorities, Native AmericansRacial/Ethnic minorities, Native Americans

DiseasesDiseases– DiabetesDiabetes– Infant mortality Infant mortality maternal health maternal health– Cardiovascular (HPT, MI, CHF)Cardiovascular (HPT, MI, CHF)– Cerebrovascular (Stroke)Cerebrovascular (Stroke)– ObesityObesity– CancerCancer

* http://www.unnaturalcauses.org/about_the_series.php (Accessed 11Oct2009)


Ethics and Health/Healthcare Ethics and Health/Healthcare InequalitiesInequalities

66

RESPECT

JUSTICE

CARE

Sufficient Level of Health for All*

HumanFlourishing/Well-being

*Powers M, Faden R. Social Justice: The Moral Foundations of Public Health and Health Policy. New York: Oxford Univ. Press, 2006.

SOLIDARITY


PhysiciansPhysicians’’ Social Responsibilities Social Responsibilities

PhysiciansPhysicians’’ are individually and collectively are individually and collectively obligated to work toward elimination of obligated to work toward elimination of unjust root social inequalities that unjust root social inequalities that adversely affect health.adversely affect health.

Moral foundations: respect, justice, social Moral foundations: respect, justice, social contract, reciprocitycontract, reciprocity

See the argument.See the argument.

Stone, Cambridge Quarterly of Healthcare Ethics, 2010Center for Health Policy and Ethics Center for Health Policy and Ethics

DeLancey JO, Thun MJ, Jemal A, Ward EM. Recent trends in black-white disparities in cancer mortality. Cancer Epidemiol Biomarkers Prev. 2008; 17(11):2908-2912.


Breast Ca Incidence/100k: B/WBreast Ca Incidence/100k: B/W


Baquet, C. R., Mishra, S. I., Commiskey, P., Ellison, G. L., & DeShields, M. (2008). Breast cancer epidemiology in blacks and whites: Disparities in incidence, mortality, survival rates and histology. Journal of the National Medical Association, 100(5), 480-488.

Breast Cancer B/WBreast Cancer B/W

Spread Spread Benefits from advances Benefits from advances (Dx, Rx) (Dx, Rx)

Mortality Mortality


65, Breast Ca, AA Woman65, Breast Ca, AA Woman

Excisional biopsyExcisional biopsy

Breast conserving surgeryBreast conserving surgery

RadiotherapyRadiotherapy– Are AA as likely to receive as Whites?Are AA as likely to receive as Whites?– NoNo (significant difference) (significant difference)

Smith, G. L., Shih, Y. C., Xu, Y., Giordano, S. H., Smith, B. D., Perkins, G. H., . . . Buchholz, T. A. (2010). Racial disparities in the use of radiotherapy after breast-conserving surgery: A national medicare study. Cancer, 116(3), 734-741. doi: 10.1002/cncr.24741

Breast Cancer-USA B/W 1980-2005Breast Cancer-USA B/W 1980-2005


Open diamonds represent Black data that includes Hispanics and closed circles represent White data that includes Hispanics (1980–1989). Closed Diamonds represents Non-Hispanic Blacks and open circles represents Non-Hispanic Whites (1990–2005)

Whitman, S., Ansell, D., Orsi, J., & Francois, T. (2011). The racial disparity in breast cancer mortality. Journal of Community Health, 36(4), 588-596. doi: 10.1007/s10900-010-9346-2

Black Non-Hispanic

White Non-Hispanic

White & Hispanic

Black & Hispanic

Breast Cancer Disparities B/WBreast Cancer Disparities B/WReasons 1Reasons 1

Access: screening, diagnosis, treatmentAccess: screening, diagnosis, treatment

Inferior institutionsInferior institutions

Environment Environment biology biology

Socio-economic disadvantagesSocio-economic disadvantages– TransportationTransportation– NavigationNavigation– Social supportSocial support– Education & understandingEducation & understanding


Breast Cancer Disparities B/WBreast Cancer Disparities B/WReasons 2Reasons 2

Access: screening, diagnosis, treatmentAccess: screening, diagnosis, treatment– MammogramsMammograms Quality of mammogramsQuality of mammograms Quality of treatmentQuality of treatment


Whitman, S., Ansell, D., Orsi, J., & Francois, T. (2011). The racial disparity in breast cancer mortality. Journal of Community Health, 36(4), 588-596. doi: 10.1007/s10900-010-9346-2

““Social PatterningSocial Patterning””Patient-DoctorPatient-Doctor

Lower social classLower social class– More directive, less participatoryMore directive, less participatory

Ethnic MinorityEthnic Minority– less expression of empathy or rapportless expression of empathy or rapport

Forde I, Raine R. Placing the individual within a social determinants approach to health inequity. Lancet. 2008; 372(9650):1694-1696.


Omaha ExperiencesOmaha ExperiencesAA Women with Breast CancerAA Women with Breast CancerBreast Cancer Treatment, Symptom Breast Cancer Treatment, Symptom Management and Invitation to Participate Management and Invitation to Participate in Clinical Trials: The Experience of in Clinical Trials: The Experience of African American WomenAfrican American Women– Amy Haddad, PhD and Jacqueline Hill, MSNAmy Haddad, PhD and Jacqueline Hill, MSN– Center for Health Policy and Ethics Center for Health Policy and Ethics


From: Amy Haddad, PhD and Jacqueline Hill, MSN. Breast Cancer Treatment, Symptom Management and Invitation to Participate in Clinical Trials: The Experience of African American Women. Center for Health Policy and Ethics. Poster.

Omaha ExperiencesOmaha ExperiencesAA Women with Breast CancerAA Women with Breast Cancer

PurposePurpose: Explore survivors’ experience: Explore survivors’ experience

ReRe: received information about: received information about– treatment options,treatment options,– symptom managementsymptom management– participation in clinical trials participation in clinical trials




4 focus groups, 21 participants, 31-684 focus groups, 21 participants, 31-68

Survivorship <1 - >5 yearsSurvivorship <1 - >5 years

90% health insurance90% health insurance

TreatmentTreatment– 90% surgery90% surgery– 76% chemotherapy76% chemotherapy– 66% radiotherapy66% radiotherapy




Themes groupingThemes grouping– Things Things patientspatients should know should know– Things health care Things health care providersproviders should know should know

Other needsOther needs– Ways to Ways to recordrecord relevant relevant infoinformation (patients)rmation (patients)– Culturally appropriate info Culturally appropriate info materialsmaterials– CommunityCommunity dissemination dissemination




Specific ideasSpecific ideas– Booklet: focus group key pointsBooklet: focus group key points– Diagnosis and treatment history cardDiagnosis and treatment history card– Key talking points to effectively utilize media Key talking points to effectively utilize media

opportunitiesopportunities



EcologyEcology


Annual ReviewsBraveman P, Egerter S, Williams DR. The social determinants of health: Coming of age. Annu Rev Public Health. 2011; 32:381-398.


StressHPTDiabetesStrokeKidney Dis

Preterm birthLow birth wtHigher infant mortality

Adapted from: Gravlee CC. How race becomes biology: Embodiment of social inequality. Am J Phys Anthropol. 2009; 139(1):47-57


Ecology & PhysicianEcology & Physician


Physician

Healthcare Equity Reports: An Healthcare Equity Reports: An ““Action StepAction Step””

Aim: Aim: unequal care: race, ethnicity, unequal care: race, ethnicity, language, socio-economic statuslanguage, socio-economic status

MeasuresMeasures– Distribution: where seen, what conditionsDistribution: where seen, what conditions– Utilization & processUtilization & process

Do children receive advised # well-child visits?Do children receive advised # well-child visits?

How often & long are asthma patients in hospital?How often & long are asthma patients in hospital?

Do qualified patients preventive screening tests?Do qualified patients preventive screening tests?

Robin M.Weinick, Katherine Flaherty, and Steffanie J. Bristol. Creating Equity Reports:A Guide for Hospitals.The Disparities Solutions Center, Massachusetts General Hospital, 2008. http://www.massgeneral.org/disparitiessolutions/resources.html.


Healthcare EquityHealthcare EquityEliminating Inequalities: StructuresEliminating Inequalities: Structures

Measure outcomesMeasure outcomesRequire publishing outcomesRequire publishing outcomesAssess structuresAssess structuresInclude communities: all levels and rolesInclude communities: all levels and rolesChange structuresChange structuresImplement & evaluate strategiesImplement & evaluate strategies

Nicole Lurie. Nicole Lurie. Health Disparities — Less Talk, More Action. Health Disparities — Less Talk, More Action. NEJM 2005; 353:727-729NEJM 2005; 353:727-729


Evolution of Cultural CompetenceEvolution of Cultural Competence

““Cultural competence is Cultural competence is the ability of health care the ability of health care professionals to communicate with and professionals to communicate with and effectively provide high-quality care to patients effectively provide high-quality care to patients from diverse sociocultural backgrounds; aspects from diverse sociocultural backgrounds; aspects of diversity include—but go beyond—race, of diversity include—but go beyond—race, ethnicity, gender, sexual orientation, religion, ethnicity, gender, sexual orientation, religion, and country of origin.and country of origin.””

Previous Previous ““categorical approachcategorical approach””: : ““attitudes, attitudes, values, beliefs, and behaviors of specific cultural values, beliefs, and behaviors of specific cultural groupsgroups””

Betancourt 2010Center for Health Policy and Ethics Center for Health Policy and Ethics

Evolution of Cultural CompetenceEvolution of Cultural Competence

General community/cultural backgroundGeneral community/cultural background is is helpful.helpful.

Learning Learning sets sets of attributes of attributes stereotyping stereotyping and oversimplificationand oversimplification..

Current modelCurrent model: skills and framework for : skills and framework for individual assessment: individual assessment: ““what sociocultural what sociocultural factors might affect that patient's carefactors might affect that patient's care””

Betancourt 2010Center for Health Policy and Ethics Center for Health Policy and Ethics

Cross-cultural/Multi-culturalCross-cultural/Multi-culturalSystem LevelSystem Level

LeadershipLeadership

Cultural competency/proficiency/humilityCultural competency/proficiency/humility

Institutional journeyInstitutional journey

Trust through trustworthinessTrust through trustworthiness

Community partnering & collaborationCommunity partnering & collaboration


Teaching about R/E DisparitiesTeaching about R/E DisparitiesLearning ObjectivesLearning Objectives

““Understand your own racial and cultural Understand your own racial and cultural backgroundbackground””

““Understand cultural diversity and the Understand cultural diversity and the relationship between racial and cultural attitudes relationship between racial and cultural attitudes and quality of careand quality of care””

““Understand U.S. racial and ethnic population Understand U.S. racial and ethnic population trends and the prevalence and severity of racial trends and the prevalence and severity of racial and ethnic health disparitiesand ethnic health disparities””

Smith WR et al. Recommendations for Teaching about Racial and Ethnic Disparities in Health and Health Care. Annals of Internal Medicine. 2007;147(9):654-665


Teaching about R/E DisparitiesTeaching about R/E DisparitiesLearning ObjectivesLearning Objectives

““Use a patient-centered approach to clinical Use a patient-centered approach to clinical encountersencounters””

““Negotiate conflict resulting from differences Negotiate conflict resulting from differences between patient explanatory models of illness between patient explanatory models of illness and treatment and physician modelsand treatment and physician models””

““Learn and apply skills to combat racial, ethnic, Learn and apply skills to combat racial, ethnic, and cultural barriers to effective careand cultural barriers to effective care”” [Add: [Add: language barriers]language barriers]

Smith WR et al. Recommendations for Teaching about Racial and Ethnic Disparities in Health and Health Care. Annals of Internal Medicine. 2007;147(9):654-665


Limited English Proficiency Limited English Proficiency (LEP)(LEP)

24 million people in the USA24 million people in the USA

[Anonymous]. Ending racial and ethnic health disparities in the USA. Lancet. 2011; 377(9775):1379.


EcologyEcology


CU Center for Promoting Health CU Center for Promoting Health and Health Equality (CPHHE)and Health Equality (CPHHE)

A community-academic partnershipA community-academic partnership

http://www.creighton.edu/health/cphhe/ http://www.creighton.edu/health/cphhe/


CBPRCBPR

CCommunity-ommunity-BBased ased PParticpatory articpatory RResearchesearch


Stone, JR. Ethics and Community-Based Participatory Research. Focus. Spring 2011. http://chpe.creighton.edu/publications/focus/spring-2011/CBPR.htm.

CBPR ModelCBPR Model

StudyStudy


CBPR Rationale-CBPR Rationale-11**

Knowledge & skills: local, investigatorsKnowledge & skills: local, investigators

No No ““value-freevalue-free”” science science

Builds capacitiesBuilds capacities

Builds cultural bridgesBuilds cultural bridges

*Israel et al. 1998


CBPR Rationale-CBPR Rationale-22**

Enhances community opportunitiesEnhances community opportunities

Community health primaryCommunity health primary

Vitally involves marginalizedVitally involves marginalized

*Israel et al. 1998


Insights Driving CBPRInsights Driving CBPR

UpstreamUpstream health influences health influences

InteractiveInteractive social determinants social determinants

Inadequate knowledge paradigmsInadequate knowledge paradigms

Respect for personsRespect for persons

JusticeJustice

Beneficence/harm minimizationBeneficence/harm minimization

HumilityHumility (cultural, epistemological, conflict) (cultural, epistemological, conflict)


Stone, JR. Ethics and Community-Based Participatory Research. Focus. Spring 2011. http://chpe.creighton.edu/publications/focus/spring-2011/CBPR.htm.

CBPR Challenges*CBPR Challenges*DistrustDistrust

Power/control inequalitiesPower/control inequalities

Conflicts: priorities, loyalties, Conflicts: priorities, loyalties, assumptions, values, beliefs, fundingassumptions, values, beliefs, funding

TimeTime

Community: defining, representationCommunity: defining, representation

Political/social in communityPolitical/social in community

Tenure/promotionTenure/promotion

*Israel et al. 1998 Center for Health Policy and Ethics Center for Health Policy and Ethics

Healthcare EquityHealthcare Equity

Robin M.Weinick, Katherine Flaherty, and Steffanie J. Bristol. Robin M.Weinick, Katherine Flaherty, and Steffanie J. Bristol. Creating Equity Reports: A Guide for Hospitals. The Creating Equity Reports: A Guide for Hospitals. The Disparities Solutions Center, Massachusetts General Disparities Solutions Center, Massachusetts General Hospital, 2008. The model and many related documents and Hospital, 2008. The model and many related documents and information is available at information is available at http://www2.massgeneral.org/disparitiessolutions/resources.hthttp://www2.massgeneral.org/disparitiessolutions/resources.htmlml. At that site see: . At that site see:

Resources Produced by the Disparities Solutions Center Resources Produced by the Disparities Solutions Center Improving Quality and Achieving Equity: A Guide for Hospital Improving Quality and Achieving Equity: A Guide for Hospital LeadersLeadersAssuring HealthCare Quality: A Healthcare Equity BlueprintAssuring HealthCare Quality: A Healthcare Equity BlueprintCreating Equity Reports: A Guide for Hospitals Creating Equity Reports: A Guide for Hospitals


Health/Healthcare InequalitiesHealth/Healthcare Inequalities& Culture& Culture

Adler NE, Stewart J. Health disparities across the lifespan: Meaning, methods, and Adler NE, Stewart J. Health disparities across the lifespan: Meaning, methods, and mechanisms. Ann N Y Acad Sci. 2010; 1186:5-23.mechanisms. Ann N Y Acad Sci. 2010; 1186:5-23.

Ashing-Giwa KT, Gonzalez P, Lim JW, et al. Diagnostic and therapeutic delays Ashing-Giwa KT, Gonzalez P, Lim JW, et al. Diagnostic and therapeutic delays among a multiethnic sample of breast and cervical cancer survivors. Cancer. 2010; among a multiethnic sample of breast and cervical cancer survivors. Cancer. 2010; 116(13):3195-3204.116(13):3195-3204.

Ayanian JZ. Racial disparities in outcomes of colorectal cancer screening: Biology or Ayanian JZ. Racial disparities in outcomes of colorectal cancer screening: Biology or barriers to optimal care? J Natl Cancer Inst. 2010; 102(8):511-513.barriers to optimal care? J Natl Cancer Inst. 2010; 102(8):511-513.

Betancourt JR, Green AR. Commentary: Linking cultural competence training to Betancourt JR, Green AR. Commentary: Linking cultural competence training to improved health outcomes: Perspectives from the field. Acad Med. 2010; 85(4):583-improved health outcomes: Perspectives from the field. Acad Med. 2010; 85(4):583-585.585.

Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: A critical Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multiculural education. J of distinction in defining physician training outcomes in multiculural education. J of Health Care for the Poor and Underserved. 1998; 9(2):117-125.Health Care for the Poor and Underserved. 1998; 9(2):117-125.


Health/Healthcare InequalitiesHealth/Healthcare Inequalities

Bleich, S. N., Jarlenski, M. P., Bell, C. N., & LaVeist, T. A. (2012). Health inequalities: Bleich, S. N., Jarlenski, M. P., Bell, C. N., & LaVeist, T. A. (2012). Health inequalities: Trends, progress, and policy.Trends, progress, and policy. Annual Review of Public Health, 33 Annual Review of Public Health, 33, 7-40. doi: , 7-40. doi: 10.1146/annurev-publhealth-031811-124658 10.1146/annurev-publhealth-031811-124658

Braveman, P. (2012). Health inequalities by class and race in the US: What can we Braveman, P. (2012). Health inequalities by class and race in the US: What can we learn from the patterns?learn from the patterns? Social Science & Medicine (1982), 74 Social Science & Medicine (1982), 74(5), 665-667. doi: (5), 665-667. doi: 10.1016/j.socscimed.2011.12.009 10.1016/j.socscimed.2011.12.009

Clark-Hitt, R., Malat, J., Burgess, D., & Friedemann-Sanchez, G. (2010). Doctors' and Clark-Hitt, R., Malat, J., Burgess, D., & Friedemann-Sanchez, G. (2010). Doctors' and nurses' explanations for racial disparities in medical treatment.nurses' explanations for racial disparities in medical treatment. Journal of Health Care Journal of Health Care for the Poor and Underserved, 21for the Poor and Underserved, 21(1), 386-400. doi: 10.1353/hpu.0.0275 (1), 386-400. doi: 10.1353/hpu.0.0275

Cohen, M. G., Fonarow, G. C., Peterson, E. D., Moscucci, M., Dai, D., Hernandez, A. Cohen, M. G., Fonarow, G. C., Peterson, E. D., Moscucci, M., Dai, D., Hernandez, A. F., . . . Smith, S. C.,Jr. (2010). Racial and ethnic differences in the treatment of acute F., . . . Smith, S. C.,Jr. (2010). Racial and ethnic differences in the treatment of acute myocardial infarction: Findings from the get with the guidelines-coronary artery myocardial infarction: Findings from the get with the guidelines-coronary artery disease program.disease program. Circulation, 121 Circulation, 121(21), 2294-2301. doi: (21), 2294-2301. doi: 10.1161/CIRCULATIONAHA.109.922286 10.1161/CIRCULATIONAHA.109.922286

Krieger, N. (2012). Methods for the scientific study of discrimination and health: An Krieger, N. (2012). Methods for the scientific study of discrimination and health: An ecosocial approach.ecosocial approach. American Journal of Public Health, 102 American Journal of Public Health, 102(5), 936-944. doi: (5), 936-944. doi: 10.2105/AJPH.2011.300544 10.2105/AJPH.2011.300544


Health/Healthcare InequalitiesHealth/Healthcare Inequalities

Leeper, B., & Centeno, M. (2012). Disparities in cardiac care for patients with Leeper, B., & Centeno, M. (2012). Disparities in cardiac care for patients with complex cardiovascular care needs.complex cardiovascular care needs. The Journal of Cardiovascular Nursing, 27 The Journal of Cardiovascular Nursing, 27(2), (2), 114-119. doi: 10.1097/JCN.0b013e318239f4c1 114-119. doi: 10.1097/JCN.0b013e318239f4c1

Lunn, M. R., & Sanchez, J. P. (2011). Prioritizing health disparities in medical Lunn, M. R., & Sanchez, J. P. (2011). Prioritizing health disparities in medical education to improve care.education to improve care. Academic Medicine : Journal of the Association of Academic Medicine : Journal of the Association of American Medical Colleges, 86American Medical Colleges, 86(11), 1343. doi: 10.1097/ACM.0b013e3182308e26 (11), 1343. doi: 10.1097/ACM.0b013e3182308e26

Peterson, E., & Yancy, C. W. (2009). Eliminating racial and ethnic disparities in Peterson, E., & Yancy, C. W. (2009). Eliminating racial and ethnic disparities in cardiac care.cardiac care. The New England Journal of Medicine, 360 The New England Journal of Medicine, 360(12), 1172-1174. doi: (12), 1172-1174. doi: 10.1056/NEJMp0810121 10.1056/NEJMp0810121

Smedley, B. D. (2012). The lived experience of race and its health consequences.Smedley, B. D. (2012). The lived experience of race and its health consequences. American Journal of Public Health, 102American Journal of Public Health, 102(5), 933-935. doi: 10.2105/AJPH.2011.300643 (5), 933-935. doi: 10.2105/AJPH.2011.300643

Weinick, R. M., & Hasnain-Wynia, R. (2011). Quality improvement efforts under Weinick, R. M., & Hasnain-Wynia, R. (2011). Quality improvement efforts under health reform: How to ensure that they help reduce disparities--not increase them.health reform: How to ensure that they help reduce disparities--not increase them. Health Affairs (Project Hope), 30Health Affairs (Project Hope), 30(10), 1837-1843. doi: 10.1377/hlthaff.2011.0617 (10), 1837-1843. doi: 10.1377/hlthaff.2011.0617


Ethics & Health/Healthcare Ethics & Health/Healthcare InequalitiesInequalities

Stone JR. Elderly & Older Racial/Ethnic Minority Healthcare Inequalities: Care, Stone JR. Elderly & Older Racial/Ethnic Minority Healthcare Inequalities: Care, Solidarity, and Action. Solidarity, and Action. Cambridge Quarterly of Healthcare Ethics.Cambridge Quarterly of Healthcare Ethics. 2012; 21(3): 342- 2012; 21(3): 342-352. 352.

Stone JR. Saving and Ignoring Lives: PhysiciansStone JR. Saving and Ignoring Lives: Physicians’’ Obligations to Address Root Social Obligations to Address Root Social Influences on Health—Moral Justifications and Educational Implications. Influences on Health—Moral Justifications and Educational Implications. Cambridge Cambridge Quarterly of Healthcare EthicsQuarterly of Healthcare Ethics. 2010;19:497–509.. 2010;19:497–509.

Stone JR and Dula A. Stone JR and Dula A. ““Race/Ethnicity, Trust, and Health Disparities: Trustworthiness, Race/Ethnicity, Trust, and Health Disparities: Trustworthiness, Ethics, and Action.Ethics, and Action.”” Book chapter, Book chapter, Cultural Proficiency in Addressing Health Cultural Proficiency in Addressing Health DisparitiesDisparities. Editors: Kosoko-Lasaki S, Cook CT, O'Brien RL. Sudbury, MA: Jones & . Editors: Kosoko-Lasaki S, Cook CT, O'Brien RL. Sudbury, MA: Jones & Bartlett, 2008, pp. 37-56. Bartlett, 2008, pp. 37-56.

Stone JR. Healthcare inequality, cross-cultural training, and bioethics: Principles and Stone JR. Healthcare inequality, cross-cultural training, and bioethics: Principles and applications. Camb Q Healthc Ethics. 2008; 17(2):216-226.applications. Camb Q Healthc Ethics. 2008; 17(2):216-226.

Dula A, Stone JR. Wakeup call: Healthcare and racism. Dula A, Stone JR. Wakeup call: Healthcare and racism. Hastings Center ReportHastings Center Report, ;. , ;. 2002; 32(4):482002; 32(4):48

Stone J. Race and healthcare disparities: Overcoming vulnerability. Stone J. Race and healthcare disparities: Overcoming vulnerability. Theor Med BioethTheor Med Bioeth. . 2002; 23(6):499-518.2002; 23(6):499-518.

CenterCenter for Health Policy and Ethics for Health Policy and Ethics

Community-Based ResearchCommunity-Based ResearchBaldwin JA, Johnson JL, Benally CC. Building partnerships between Baldwin JA, Johnson JL, Benally CC. Building partnerships between indigenous communities and universities: Lessons learned in HIV/AIDS indigenous communities and universities: Lessons learned in HIV/AIDS and substance abuse prevention research. and substance abuse prevention research. American Journal of Public American Journal of Public HealthHealth. 2009; 99(S1): S77-S82. . 2009; 99(S1): S77-S82.

Flicker S, Travers R, Guta A, McDonald S, Meagher A. Ethical Flicker S, Travers R, Guta A, McDonald S, Meagher A. Ethical dilemmas in community-based participatory research: dilemmas in community-based participatory research: Recommendations for institutional review boards. Recommendations for institutional review boards. J Urban HealthJ Urban Health. 2007; . 2007; 84(4):478-493, (p. 490).84(4):478-493, (p. 490).

Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: Assessing partnership approaches to improve public based research: Assessing partnership approaches to improve public health. health. Annu Rev Public HealthAnnu Rev Public Health. 1998; 19:173-202.. 1998; 19:173-202.

Stone, JR. Ethics and Community-Based Participatory Research. Stone, JR. Ethics and Community-Based Participatory Research. FocusFocus. Spring 2011. . Spring 2011. http://chpe.creighton.edu/publications/focus/spring-http://chpe.creighton.edu/publications/focus/spring-2011/CBPR.htm2011/CBPR.htm. .

Wallwork E. Ethical analysis of research partnerships with communities. Wallwork E. Ethical analysis of research partnerships with communities. Kennedy Institute of Ethics JournalKennedy Institute of Ethics Journal. 2008; 18(1):57-85.. 2008; 18(1):57-85.


racial & ethnic inequalities in american healthcare: information & implications john r....

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