tion. The literature has more to say about ethnicity and disparities in health than about ethnicity and disparities in health care; this is reflected in the balance of articles reviewed in this chapter. To complement the research studies, data are also presented for selected population characteristics that can place people at risk of disparities (e.g., low education levels, poverty, lack of facility with English among those speaking a non-English language at home, and place of origin).
This focus on literature with respect to more granular detail on subgroups is not to negate the important differences found among the OMB racial groups and for Hispanics compared with non-Hispanics, but to learn more about where to focus interventions when categorical differences are masked by the OMB categories. Being able to focus interventions at the more granular level has been posited as a way to use resources most efficiently to reduce disparities.
Awareness of health and health care disparities has been heightened through the release of multiple documents besides Unequal Treatment, including—Healthy People 2010 and the National Healthcare Disparities Reports (AHRQ, 2008a; HHS, 2000), and successful initiatives have addressed some disparities using a variety of approaches. For example, some successful initiatives have applied general quality improvement concepts and techniques, while others have developed and used culturally sensitive outreach and education materials for health plan members, and still others have involved training of staff in culturally competent communications. Common to virtually all successful projects are some fundamental steps, including the acquisition of data on race and ethnicity, the stratification of quality-of-care data by race and ethnicity, the use of race and ethnicity to identify members of a target population to whom elements of an intervention would apply, and reanalysis of stratified quality data to evaluate the impact of the activities. Data on race and ethnicity are a fundamental requirement for disparity reduction initiatives. Without these data, it is impossible to identify disparities and track the impact of initiatives over time, and it is difficult to target those aspects of interventions that involve direct contact with individuals. The presence of data on race and ethnicity does not, in and of itself, guarantee any subsequent actions in terms of analysis of quality-of-care data to identify disparities or any actions to reduce or eliminate disparities that are found. The absence of data, however, essentially guarantees that none of those actions will occur.
The United States is a diverse country whose composition is changing. Table 2-1 shows the results of Census 2000 on the size and percentage distribution of the total U.S. population primarily by the broad OMB racial and Hispanic ethnic groupings. The Black and Hispanic groups are of equivalent size; the Census has multiple check-off boxes for specific Hispanic groups (i.e., Mexican, Puerto Rican, Cuban, and a write-in option for other groups) that it routinely reports, but there are no such more specific check-off boxes under the Black or White races. Asians and Pacific Islanders have many specific groups listed on the Census form from which to choose as well. There are efforts to legislatively mandate expansions to the current Census categories (e.g., add Caribbeans in general and Dominicans specifically).1 The groups included in the OMB race and Hispanic ethnicity categories are defined in Chapter 1 (see Table 1-1).
Ethnicity is a concept that the subcommittee, for standardization purposes, distinguishes from race. The term ethnicity represents a common ancestral heritage that gives social groups a shared sense of identity that exists even though a particular ethnic group may contain persons who self-identify with different race categories. The OMB categories use the term ethnicity only in conjunction with Hispanic ethnicity. The U.S. Census captures data on a few discrete ethnic groups both under the Hispanic ethnicity question, by having check-off boxes for some Hispanic groups (e.g., Puerto Ricans, Dominicans), and under the race question, by listing some groups of