overall contribution to less appropriate care for minorities, or to explaining racial and ethnic differences in health in later life, remains uncertain.

PATIENT BEHAVIOR

Differences in patient self-care—a behavior about which stereotypes may exist—are themselves unconfirmed. Patient self-care covers behavior ranging from seeking health care to compliance with prescribed therapies. Compliance with complicated new therapies, such as those to control insulin-dependent diabetes and for HIV, has been shown to be better among those, including older adults, with more education. However, with education controlled, neither blacks nor Hispanics differ significantly from whites in these self-maintenance behaviors (Goldman and Smith, 2002). But other studies have documented differences by race. For instance, persistence with statin therapy among older patients—which tends to decline over time and is also related to socioeconomic status—declines more, regardless of status, among blacks and other nonwhite patients than in white patients. In fact, black subjects had 2.7 times the odds of suboptimal persistence with statin therapy compared with whites, the racial difference being greater than that on any other predictor analyzed (Benner et al., 2002).

Somewhat inconsistent results also have been shown for the use of screening tests. Winkleby and Cubbin (2004) show that, at ages 45-64, black and Hispanic women do not differ from whites with regard to having had a Pap test or a mammogram in the preceding 2 years. However, when the proportions of women having had such tests are adjusted for education and income, blacks and Hispanics are significantly more likely to be screened than whites. This result also holds for Hispanics aged 65-74; for blacks the differences were not significant at that age. However, Medicare reimbursement records tell the opposite story. Black and Hispanic women aged 52-69 less often receive a mammogram paid for under Medicare fee-for-service than the average beneficiary of this program (Figure 10-1; Hebb et al., 2003). In addition, Strzelczyk and Dignan (2002) show that nonwhite women in the Colorado Mammography Project are less likely than whites to adhere to a recommended follow-up screening. Such apparent inconsistencies may have explanations, but they suggest that the role of patient self-care in racial and ethnic differences has not been clearly established.

One needs to attend, to begin with, to differences across specific diseases or conditions. Psychosis and substance abuse, for instance, are related to contrasting differences. Blacks with psychotic disorders visit psychiatrists less often than whites. But blacks with substance abuse disorders have more psychiatric visits than whites (Kales et al., 2000). Other factors, from socioeconomic status to differences in cultural beliefs relating to fatalism



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