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Chapter 7 ■ Health Disparities and the Social Determinants of Health
at home as the primary language, particularly among the 40% of the students whose families came from Asia, Africa, South America, and Central America. The make up of the rest of the students is 40% black, 10% second-generation Hispanic, and 10% white. Emily reviewed the health statistics for the population at her school from the beginning of the school year. In this school, she found disparities in disease and illness rates compared with those in other schools in the district: • 32% of students were not completely immunized compared with 3% at other schools. • 51% of students had not received the required physical examination. • There was a higher-than-average rate of failure for the vision and hearing screening tests. • There was a higher absenteeism rate. • 67% of students had not seen a dentist compared with 31% at the other schools. • 24% of the students were overweight but not much more than the students in the other community schools. • Students between 5 and 8 years old had a higher rate of asthma than children of the same age in other schools in the same district. Emily wondered if one of the issues facing these families was access to care. To help determine what barriers to health care the families might be experi- encing, she examined the students’ school records in more detail, as well as resources available within the neighborhood. She found that: • Few students had a primary care physician listed in their school record. • The nearest pediatric and family practice clinics required that families using the bus system make a minimum of two transfers. Emily wished to gather more data from the parents but was challenged by the language barriers and by the fact that most of the parents worked during school hours. She sought interpreters in the community for the different languages spoken at home and then set up focus groups (see Chapter 4) with parents to help find out more about why the students had received less health care than students in the other schools in the district, especially preventive care. Although she was unable to conduct a focus group with all of the different groups within the community, she was able to include immigrant, Hispanic, black, and
white parents. For all of the parents, a central issue was the difficulty of getting to the primary care clinics located outside the neighborhood because it required taking two to three buses with time-consuming trans- fers, and the offices were only open during working hours. They said the clinics were very crowded, and when they finally got to see someone, they often had less than 10 minutes with the care provider. For the non-English-speaking parents, translators were rarely available. The parents, even those with English as their primary language, reported that going to the clinic had little value because often they did not understand what the health-care provider was telling them; the suggested steps for prevention weren’t always possible to carry out (“I can’t afford all that fancy fruit!”); and often min- imal explanation was provided related to any prescrip- tions, including where to get them filled. When their children were really sick, most of the parents used the urgent care clinic in the community, but this required up-front payment, so they often delayed going until their child was really sick, which often meant a trip to the ED. The parents mentioned that the department of public health provides free immunization clinics and school physicals for a nominal charge, but they pointed out they cannot afford to miss a day of work without pay to bring their children. They wished the clinics were open on Saturday or in the evenings. Based on the data from these focus groups, Emily identified several factors in the health-care system that contrib- uted to the health-care disparity at her school: • Limited access to care • Lack of primary care practitioners in the overburdened clinics • No primary health care in the immediate neighborhood • Health department clinic hours inaccessible to the working population in the community • Limited public transportation • Lack of translators at the clinics She invited parents, teachers, and staff to at- tend a series of early-evening meetings to strategize about how some of these factors could be mitigated to reduce the disparity. She promised to invite a Spanish-speaking interpreter for those parents who could not speak English. Several of the teachers and the school counselor saw this as an important component of school health and also agreed to at- tend. She encouraged the families to bring others from the community. She pointed out that it is really
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