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Barriers Contributing to Health Disparities among Latinos in the United States Cara Maffini, Indiana University, Indiana, USA Ahmed YoussefAgha, Indiana University, Indiana, USA Wasantha Jayawardene, Indiana University, Indiana, USA Elizabeth Perez-Medina, Indiana University, Indiana, USA Mohammad Torabi, Indiana University, Indiana, USA Abstract: Increasing ethnic diversity in the United States brings new challenges to many fields, including public health. Health care is a salient issue for many Americans, yet many ethnic minorities, immigrants, and people of low socio-economic status are unable to receive appropriate health care for many reasons. Latinos, for example, incur challenges related to health insurance, geographic location, language and communication, and immigration status. In fact, Latinos have the highest rates of uninsured people among all racial or ethnic groups in the U.S., a rate three times higher than that of the non-Hispanic White population. This review of literature examines research concerning these barriers to health care for Latinos living in the U.S. Policy makers should evaluate these barriers when addressing methods to remedy public health issues for this population. Keywords: Latinos, Hispanics, Health Disparities, Health Insurance, Geographic Location, Language, Immigration Status

Introduction HILE THE ETHNIC composition of the United States increasingly diversifies, greater awareness and discussions surround ethnic minorities. In 2006, the Census found that only 66.2% of the U.S. population identified themselves as non-Latino White. The remaining 33.8% percent identified themselves as African American, Latino, Asian American, Pacific Islander, “other,” or multiracial (U.S. Census Bureau, 2006). Increasing diversity has brought more awareness to the disparities in health and health care across ethnicities. Williams (1999) found that newer immigrants had better health outcomes; however, the longer amount of time immigrants spent in the U.S., the more their health deteriorated. Additionally, while the rates of cardiovascular disease for White Americans have fallen with increasing awareness of risk factors, ethnic minorities have not experienced that same reduction in rates (U.S. Department of Health and Human Services, 1996). The differences were not due to inherent qualities such as genetic composition; therefore, other research must be explored to provide possible reasons for this discrepancy. A 2007 study examined 4,013 Latinos and their experiences with U.S. health care. Twenty-three percent of that sample perceived the health care they received in the previous five years to be of poor quality. The most frequent self-reported reasons for receiving sub-standard care were inab-

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The International Journal of Health, Wellness and Society Volume 1, 2011, http://HealthandSocietyJournal.com/, ISSN 2156-8960 © Common Ground, Cara Maffini, Ahmed YoussefAgha, Wasantha Jayawardene, Elizabeth Perez-Medina, Mohammad Torabi, All Rights Reserved, Permissions: [email protected]

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ility to pay, racial background, and language barriers (Livingston, Minushkin, & Cohn, 2008; see Figure 1).

Figure 1: Perceived Reasons among Latino Adults for Receiving Poor Treatment: the Pew Latino Center/Robert Wood Johnson Foundation Latino Health Survey, 2007 Figure 1. Percentages denote the proportion of Latinos who perceive each reason to be the explanation as to why they received poor treatment. All responses were self-report. Source: “Hispanics and Health Care in the United States: Access, Information and Knowledge,” by G. Livingston, S. Minushkin, and D. Cohn, 2008, retrieved from the Pew Hispanic Center web site: http://pewhispanic.org/ files/reports/91.pdf.

Diversity and Disparity among Latinos Recent research has given greater attention to health disparities among the growing Latino population. The 2010 U.S. Census showed that Latinos (16.3% of the population) are the largest ethnic minority in the US, and that they are not a homogeneous group but a dynamic and diverse one. The Latino population in the US increased 43.0% during the first decade of the second millennium compared to a 5.7% increase in Whites and a 12.3% increase in African-Americans (U.S. Census Bureau, 2010). Therefore, the health problems of Latinos are becoming increasingly important. This population encompasses individuals of differing countries of origin, English-language proficiency, socioeconomic status, and U.S. geographic location. Roughly 67% of Latinos are of Mexican origin, and the remaining 33% emigrated from countries in Central and South America as well as the Caribbean. Latino descendents from the Caribbean are one of the fastest growing ethnic groups in the U.S., which includes concentrations of Puerto Ricans in New York and Cubans in Florida. While the populations of Latinos are most concentrated in California, Arizona, New Mexico, and Texas, Latinos are also found in greater proportions in Florida, New York, Nevada, and Colorado, with smaller percentages being found across the country (HHS, 1996). The geographic diversity both in countries of origin and U.S. suggests just two of the many factors that differentiate the Latino experience. Latino health reflects these differences in the ranges of access to care, insurance, communication abilities, as well as dietary and lifestyle risk factors that contribute to chronic illnesses such as cardiovascular disease.

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The U.S. Department of Health and Human Services disseminated a report in 1996 documenting the remarkably high numbers of Latinos without health insurance and the disproportionately high rates of Latinos with cardiovascular disease. In 1992, over one-third of this population did not have insurance. One contributing factor was that programs such as Medicaid offered limited coverage to the unemployed, but did not offer these options to low wage earners. Consequently, Latinos often had limited access to preventative and primary health care. Conditions that could potentially be prevented or effectively managed if caught early were not addressed, which could lead to costly hospitalizations and treatments. In addition to ineffective health insurance, many Latinos had higher risk factors that contributed to cardiovascular problems, including high levels of cholesterol and cigarette smoking (HHS, 1996). Another study found a disparity across the Latino population such that those of later generations had poorer health than newer immigrants. First generation Latinos had better health than second generation Latinos, and the second generation had better health outcomes than the third. This pattern continued in subsequent generations (Williams, 1999). Surprisingly, researchers found that Latinos were in better health than non-Latino Whites despite their poverty, lack of education, or reduced access to health care. This phenomenon is known as the “Latino Paradox,” a paradigm especially true for Mexican-born immigrants (Franzini & Fernandez-Esquer, 2004). The Latino immigrant population contradicts the expectation that if people are less educated, they will earn lower wages, be of a lower socio-economic status (SES), and have poorer health (Franzini, Ribble, & Keddie, 2001). Clearly, the predictors of health in this population are more complex than simple relationships between education, wealth, and health. Researchers did not have a firm grasp on what caused this anomaly though it was clear that SES, country of origin, and acculturation did play into the social and personal factors that impacted health (Franzini & Fernandez-Esquer, 2004). This paradox elicits the need for further research and exploration of the influences on public health in the Latino population beyond SES. This paper will explore a few of the barriers that prevent Latinos from receiving adequate health care, which can lead to negative health outcomes. Specifically, the roles of insurance, geographic location, language, and immigration status will be examined as four obstacles to sufficient health care.

Methods An online search of the PubMed database and a library search were performed to identify 20 articles published between 1987 and 2009 based on their descriptions and insight on Latino health. These articles discussed four potential barriers impeding Latinos from receiving proper health care: absence of health insurance or under-insurance, problems associated with geographic location, communication barriers, and illegal immigration status. Reports published by governmental and non-governmental organizations were also utilized. Articles that focused on more specific health-related issues of Latinos or sub-populations of Latinos were excluded. The selected articles and reports provided a context for current challenges faced by Latinos and proposed necessary changes in health care for this population. To maintain the consistency of statistical information, all the figures were adopted from one source - the 2007 Pew Hispanic Center/Robert Wood Johnson Foundation Latino Health Survey.

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Insurance Lack of health insurance can obstruct access to proper care for many people, particularly Latinos in the U.S. In 1992, more than 30% of the Latino population was uninsured (HHS, 1996). In 2007, the U.S. Census Bureau found that 32.8% of Latinos were uninsured compared to only 10.4% of the non-Hispanic White population. In fact, Latinos have higher rates of uninsured people than all other racial and ethnic groups in the U.S. In order to further realize the influence of insurance, it is important to understand the context in which Latinos live. This can be done through an ecological model encapsulating the multidimensional factors contributing to the U.S. Latino experience. A closer examination of poverty and racial factors will contextualize the difficulties Latinos incur when trying to receive appropriate health care. Meyers (2007) presents a five-level ecological model conveying the social and environmental climate that contextualizes individuals’ experiences and illustrates that they do not exist independently of the community and greater society. On the individual level, people are influenced by their race, age, gender, and genetics. A study surveying Latinos found that males and younger people have a greater likelihood of lacking a primary healthcare provider than females or older adults (Livingston et al., 2008; see Figure 2). Socioeconomic factors such as education, social class, and income also impact health. Those factors are often interrelated with the availability of resources as well as preventative and appropriate care. Health is influenced by behaviors, resources, and beliefs, and can vary drastically between individuals.

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Figure 2: Latino Adults’ Likelihood of Lacking a Primary Healthcare Provider by Nativity, Gender, Age, Educational Status, and Health Insurance Status Figure 2. Percentages denote the proportion of Latino adults who are lacking a usual healthcare provider in each subcategory. Source: “Hispanics and Health Care in the United States: Access, Information and Knowledge,” by G. Livingston, S. Minushkin, and D. Cohn, 2008, retrieved from the Pew Hispanic Center web site: http://pewhispanic.org/files/reports/91.pdf. The second level is the interpersonal level and includes family, peers, and neighbors. The organizational level, or the third level, combines the previous two micro-levels and incorporates community groups, faith institutions, work, school, police, and transportation as well as health care institutions, including providers. The fourth level of the ecological model comprises the community environment, consisting of both physical and cultural factors. Physical factors include access to healthy foods, exercise and play areas, public safety, and exposure to pollution and toxins. Cultural factors consist of community assets, community relationships, and health-related norms. An important factor in this level is residential segregation either by race or income. Racial enclaves or poorer communities often called “ghettos” may not be privy to the same health service access as more affluent communities. The cultural component can be very influential as cultures perceive health differently and have different expectations regarding help-seeking behaviors. Many cultures have differing views of health-related norms that may support or discourage healthy behaviors and lifestyles (Meyers, 2007). Cultural norms affect how different symptoms are recognized and interpreted as well as how people approach seeking medical attention (Kavanaugh & Kennedy, 1992; Mullins, Blatt, Gbarayor, Yang, & Baquet, 2005).

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These four stages exist within the context of the greater society, which is intricately interwoven with public policy. The fifth level of the model includes factors such as segregation, racism, discrimination, economic conditions, media, marketing, and other issues like education, urban planning, housing, and criminal justice, all in concert with health policy. The ecological model encapsulates individual factors embedded in environmental, cultural, and societal level influence. This model illustrates the need for policy makers to consider the multidimensional components that influence an individual’s health and the public’s health. Examining the inherently valuable characteristics of the community and catering policies to address the multilevel ecological model could be more effective in managing health issues related to Latinos when compared to current strategies (Meyers, 2007). The ecological model also expresses that each individual does not act independently of others, but rather each person is embedded in many larger systems and is influenced by a variety of factors (Meyers, 2007). A well-designed intervention needs to address both the patient’s individual factors and the community factors while also acknowledging systemic contributors. As the ecological model illustrates, the issues related to proper health care and health insurance are imbedded in a larger social and institutional construct. Two salient issues that impact many ethnic minorities in the U.S. and influence health care are socio-economic status (SES) and racial factors. Studies have illustrated how these factors impact resources and incite discrimination when people are denied access to proper care based on their SES and race. Due to a lack of insurance, people of low SES are less likely to receive preventative care (Mullins et al., 2005). The lack of preventative care can cause a greater need for emergency procedures and higher medical costs. Several studies have examined racial differences in access to health care and services provided. A meta-analysis of 61 studies examined the prevalence of particular cardiac procedures. The results showed disproportionate rates of procedures performed on White patients as compared to ethnic minority patients. The greatest disparity was between African American and White patients. Many studies came to the same conclusion that African Americans received fewer cardiac procedures for treatment than White patients. Latinos and Asians were also less likely than Whites to receive these procedures, though these results were less consistent across studies (Kressin & Petersen, 2001). A recent study confirmed these previous findings of disparate health care across ethnic groups. This study compared the consumer cost for various procedures along with the number of procedures performed for Whites, African Americans, and Latinos. The results reaffirmed what other studies have found: African Americans and Latinos do not receive the same quality of care when expensive treatments are involved. In essence, When SES and health status characteristics are controlled for, more money is spent on White patients than ethnic minority patients. The results show that a need exists for greater access to necessary treatments, even if costly, for ethnic minority patients, particularly those with critical health conditions (Cook & Manning, 2009). Carlisle, Leake, and Shapiro (1997) conducted a large study (N = 104, 952) and assessed the prevalence of cardiovascular procedures in Los Angeles, California. Examining discharge records, they found that White patients were more likely to have Medicare or private insurance whereas African Americans, Asians, and Latinos had a greater likelihood of being uninsured or receiving Medicaid. African Americans and Latinos were more likely to be admitted because of chest pain, and within those particular groups, the likelihood that the patients were

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young females was greater. African Americans and Latino patients were less likely to be admitted to hospitals that frequently performed invasive cardiac procedures. The greatest disparities in the lack of procedures provided were found among uninsured African Americans and Latinos. The results of this study are alarming and convey the lack of cardiac care given to African American and Latino patients. The issue of health insurance is a significant topic with no easy solution. It is imbedded in a larger complex social context. Individual health is affected by many factors, which can also impact access to health care. SES and racial factors play an alarming role in the access to and quality of health care. The lack of health insurance means many Latinos are not receiving appropriate preventative care or are not receiving treatment early on in their disease. They may not seek treatment until they are gravely ill and need costly treatment procedures. It is important that policy makers be conscious of the social context and issues related to health insurance for Latinos.

Geographic Location Access to health care is interrelated to where people live. As the ecological model of health illustrated earlier, demographic and environmental factors including SES, pollution, and community are influential to people’s health and access to appropriate health services. While it may be thought that people who live further away from metropolitan areas have reduced access to services resulting in poorer health, disparities actually span across people who live in both rural and urban communities. Similar to those residing in rural areas, Latinos living in low-income urban communities may not receive adequate care either. One study found that in New York City, those who live in impoverished communities were less likely to receive revascularization following a myocardial infarction than those in affluent areas. However, when facilities performing the procedures increased their availability, the revascularization rates rose. The results show that the capability is there, but the decreased resources available to lower income populations hindered proper health care and treatment (Mullins et al., 2005). Limited access to health care services and disparities were confirmed in other research examining metropolitan communities. Within urban areas, segregated communities or enclaves often characterized by poverty feel disempowered to influence change and have limited access to resources, including health care (Jackson, Anderson, & Johnson, 2000). These inequalities promote further segregation and greater deficits in health care (Miller & Collins, 2001; Williams & Collins, 2001). Geographical location drastically impacts people’s access to proper care. Those living in rural areas incur long travel to receive health care, which often limits access to preventative care and timely treatments when urgent care is needed. As a result, this population reports fewer annual visits to the doctor than those living in an urban area. They also have a decreased likelihood of receiving appropriate care for intensive treatments (Mullins et al., 2005). Conversely, Latinos living in urban communities may experience reduced access to health care because of inadequate resources to perform essential procedures at local clinics. Adding another layer is poverty, which is closely intertwined with the power to influence change, and contributes to the reduced accessibility of appropriate resources and proper care. Latinos are often at a disadvantage in receiving health care regardless of whether they live in urban or rural communities.

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Communication with Doctors Language is the third area that poses a great challenge to Latinos receiving proper health care. Language is integral to the doctor-patient relationship and improves patient well-being and adherence to doctor’s recommendations (Ashton et al., 2003). Several studies have found that positive outcomes and improved health are connected to effective communication (Henbest & Stewart, 1990; Orth, Stiles, Scherwitz, Hennrikus, & Vallbona, 1987). Communication is important to ensure that the doctor and patient have the same conceptual model of the illness. This model includes demographic factors, values, cultural perceptions, and the individual’s perception. When the doctor and patient are able to come to a similar understanding of internal and external biological and social factors influencing the individual and the illness, an effective treatment can be developed. Cultural differences in communication styles also need to be considered. A doctor and patient of differing cultures may misperceive what each other is saying. Some cultures are very direct, whereas others use mitigated speech as a sign of respect and may be less straightforward in conveying their symptoms (Ashton et al., 2003). There are many factors that influence communication between doctors and patients that are integral to the patient receiving effective treatment. Though the necessity for effective communication in the doctor-patient relationship is vital to treatment, many Latino patients lack the English proficiency to effectively communicate with their doctors. One study found that Latinos with low English proficiency were less likely to seek services than non-Latinos who spoke English as their native language. It was speculated that these discrepancies in seeking help led to poorer health outcomes (Derose & Baker, 2000). Spanish-dominant speakers were more prone to lack a primary healthcare provider (Livingston et al., 2008). Additionally, Latino children were less likely than White children to utilize public health care services. These differences were also attributed to a lack of English proficiency in their parents (Weinick & Krauss, 2000). Language can be a powerful tool, but can also pose a challenge to non-English speakers seeking health care in the U.S. Cultural and linguistic differences in the perception and communication of symptoms and illnesses can cause misunderstandings in the doctor-patient relationship and treatment. Many Latinos with low English proficiency feel discouraged and are less inclined to seek medical aid at all.

Illegal Immigration While Latinos have many challenges hindering them from receiving proper health care, illegal immigrants have additional barriers. They often come to the U.S. with pre-existing conditions, such as tuberculosis, and lack proper immunizations and preventative care. Many endure treacherous journeys to the U.S., and then find refuge in substandard living conditions upon arrival. The majority (66%) of Latino immigrants are from Mexico (HHS, 2009). Once in the U.S., Latino immigrants still do not receive proper care. Foreign-born Latinos, particularly those who immigrated during the past five years, lacked a primary healthcare provider more often than native-born Latinos (see Figure 3). The absence of a permanent legal residence is another major reason why Latinos lack a primary healthcare provider (see Figure 3). All of these issues can exacerbate illnesses. Other deterrents include lack of insurance, money, knowledge of the U.S. health care system, and language barriers (Kullgren, 2003).

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Finally, the overwhelming fear for many illegal immigrants is that they will be detected, reported, and deported (Berk & Schur, 2001; Kullgren, 2003).

Figure 3: Latino Adults’ Likelihood of Lacking a Usual Healthcare Provider by Spoken Language, Immigration Status, and Period of Living in the U.S. Figure 3. Percentages denote the proportion of Latino adults who are lacking a usual healthcare provider in a particular subcategory. Source: “Hispanics and Health Care in the United States: Access, Information and Knowledge,” by G. Livingston, S. Minushkin, and D. Cohn, 2008, retrieved from the Pew Hispanic Center web site: http://pewhispanic.org/files/reports/ 91.pdf.

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Figure 4: Latino Adults’ Likelihood of Lacking a Usual Healthcare Provider by the Country of Origin Figure 4. Individual regions are mutually exclusive; however, countries and regions are not mutually exclusive. Source: “Hispanics and Health Care in the United States: Access, Information and Knowledge,” by G. Livingston, S. Minushkin, and D. Cohn, 2008, retrieved from the Pew Hispanic Center web site: http://pewhispanic.org/files/reports/91.pdf. In a closer examination of the fear that illegal immigrants experience, one study found that almost half of the sample of illegal immigrants would not seek help when in need of medical attention. As a result, they received less medical and surgical care, prescription medications, dental work, and eye care (Berk & Schur, 2001). Illegal immigrants are often too fearful of detection to seek necessary medical services. Illegal immigrants experience all of the barriers to health care. They may lack health insurance and may not have easy access to appropriate services. Any difficulties communicating are compounded by issues related to immigration to the U.S. Pre-existing conditions, long journeys, unsafe and unsanitary living conditions, and fear of detection may aggravate medical conditions while also impeding the possibility of receiving appropriate care. It should be emphasized that disparities in education among Latinos are closely related to their health disparities, which perpetuates a vicious cycle of poverty. Latino children are less likely to participate in early childhood education. Latino girls are less likely to participate in after-school activities including sports, arts, scouts, and religious activities. Moreover, 25% of Latinos have less than a 9th-grade education, with Mexicans having the lowest attainment. In addition, Latinos are also underrepresented among healthcare workers in the U.S. compared with their proportion of the general population, the main reason being the relatively low enrollment of Latino students in medical, dental, and nursing schools (de Leon Siantz, 2006).

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Conclusion This literature review illustrates that the disparities in Latino health can be linked to many factors including insurance, geographic location, communication barriers, and immigration status. The high rate of uninsured Latinos results in many individuals lacking preventative care. Health problems often escalate until people finally seek help, at which point they need costly procedures. Racial disparities in health insurance reveal that ethnic minorities, including Latinos, receive fewer cardiac procedures than White patients. Geographic location can also thwart access to health care. Latinos living in rural communities may incur longer travel times over greater distances to seek medical attention. The journey may delay proper treatment or may deter people from receiving care at all. Latinos in urban settings are not exempt from disparities in health services either. Studies have shown that fewer resources may be available to Latinos residing in ethnic enclaves or lower income communities in urban areas. Even if Latinos are able to overcome the challenges of health insurance and the possible distance to see a health care provider, language barriers can be yet another obstacle to medical treatment. Individuals with lower English language proficiency are often deterred from seeing a doctor. Language may interfere with treatment if the patient is unable to adequately convey his/her symptoms, if the doctor is unable to understand the patient’s concerns, or if there is miscommunication or differing conceptualizations of the illness and treatment due to cultural differences. Finally, while Latinos experience many barriers to receiving proper health care, illegal immigrants have some added challenges. Many come to the U.S. with pre-existing medical conditions, which may be exacerbated by their often treacherous journey to the U.S. Many illegal immigrants reside in unhealthy or unsafe environments and live in fear of being detected and deported, which deters them from seeking needed medical treatment. Latinos and other immigrants face innumerable challenges when attempting to receive proper health care in the U.S. The inability to receive appropriate care impacts Latino health and has a greater impact on American society. The lack of preventative care can lead to more costly procedures later. Having people with untreated contagious illnesses in the population leads to further expenditures in health care as more people become infected with these diseases. Addressing some of the hurdles that many Latinos experience in seeking medical aid would be beneficial to U.S. society both in terms of overall health as well as finances. As this review demonstrates, there is an urgent need for plausible solutions to this crisis in public health.

Implications and Future Research Policy makers need to consider the factors outlined in this article when addressing and improving public health for Latinos and other ethnic minority and immigrant groups. Meyers (2007) illustrated how the individual is imbedded in the larger context of the society and that many factors including demographic variables along with cultural, environmental, and political factors influence health. The ecological model should be taken into account when addressing improvements in health policy for Latinos in the U.S. Health insurance, geographic location, use of language in the doctor-patient relationship, and the experiences and fears of

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illegal immigrants need to be considered within that ecological model. It is also recommended that health-care systems increase accessibility to underserved communities. The culture in medical schools and other health profession schools must be changed to address increased diversity. Institutions must develop new and non-traditional paths to health profession education with the highest level of commitment for partnerships between academics, practitioners, and stakeholders. There are many values that are imbedded in Latino culture that could be utilized in the creation of public policy. Latino cultures are generally collectivist in nature, meaning they value the group and define their roles in terms of how they contribute to the family and community. Closely intertwined with this notion is the familismo, which gives a strong value and priority to family, including both immediate and extended relatives. Simpatía refers to the notion of maintaining positive interpersonal relations. This is similar to respeto, which values treating others with respect, particularly those in professional roles like doctors and teachers. Finally, there are many community leaders within Latino enclaves that have a greater knowledge of the language, beliefs, and health practices of their enclave and may be more aware of the local resources available (HHS, 1996). These individuals would be effective consultants in the creation of new public policies that take Latino culture and values into account. Future studies should examine the impact of national health care reform on Latinos. A similar literature review would be beneficial to understanding barriers in health care for Arab Americans, Middle Eastern Americans, and other immigrant groups.

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Williams, D. R. (1999). Race, socioeconomic status, and health: The added effects of racism and discrimination. Annals New York Academy of Sciences, 896, 173-188. Williams, D., & Collins C. (2001). Racial residential segregation: A fundamental cause of racial disparities in health. Public Health Reports, 116, 404–416.

About the Authors Cara Maffini I am a PhD candidate in Counseling Psychology at Indiana University. I study multicultural issues and am interested in historical, legal, social, and systemic factors that lead to disparities in health and mental health among ethnic minorities in the U.S. Another segment of my research explores protective and risk factors that influence participation in violence among atrisk youth. Prof. Ahmed YoussefAgha I have worked as a Biostatistician for the Oncology Department of Novartis Pharmaceutical, a Biostatistician for Health Outcome Innovations in Humana Health Insurance, an Adjunct Faculty in Computer Sciences Department of Spalding University, KY, a Research Assistant in School of Public Health, University of Louisville, KY, an instructor in computer studies in the American University in Cairo, Egypt, and a Management Information System Specialist of US-Aid Programs for Development in Egypt. I’m interested in the integration of Biostatistics, Decision Analysis Techniques, and Computer Sciences for researches in Public Health. My research works include: Abuse of Prescription and Non-Prescription Drugs among Indiana Adolescents; an Extension of Stochastic Tree Model Utilizing WAFT Model; Multiobjective Simulation-Based Methodologies for Disease/Injury Treatment; Adjuvant Chemotherapy for Breast Cancer: How Presentation of Recurrence Risk Influences Decision-Making; Redesigning UofL Occupational Health Surveillance Program Databases; The Egyptian Industries’ Needs for Entering the International Markets; Old Cairo Tanneries Relocation Project; and The Implications of Business Regulations on Small Enterprises in Egypt. Dr. Wasantha Jayawardene I obtained my medical degree in Moscow and completed medical internship in Sri Lanka followed by working as a Regional Epidemiologist in Sri Lanka for three years. During this period, I had also been conducting rehabilitation following South-Asia Tsunami, post-war rehabilitation, and attended three WHO workshops on management of epidemics in SouthEast Asia. I have conducted research on “Psychological Distress Among Nurses Caring for War-Victims in Sri Lanka”, which was accepted by Journal of Disaster Medicine and Public Health Preparedness for publication. One of my other researches is “Prevention of Dengue fever: an exploratory school-community intervention involving students empowered as change agents”, which was accepted by Journal of School Health for publication. Few researches/reviews are also completed: Dimensions of HIV/AIDS in Africa; Characteristics of Diabetes Epidemic across Global Regions; Abuse of Prescription and Non-Prescription Drugs among Indiana Adolescents; Socio-Economic Factors Affecting Violence and Bullying among Adolescents across Global Regions.

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