An Issue Paper Prepared by the National Rural Health Association— April 2001


Approximately 61.7 million (24.8 percent) of U.S. residents live in rural settings (1990 Census). Rural ethnic minorities, including African American, Asian American, Native American, Hispanic and others, comprise about 11.2 percent of Americans or 6.9 million people. Rural populations frequently have difficulty accessing adequate health care (Rabinowitz et al., 1999). The lack of adequate numbers of practitioners and in particular, ethnic minority practitioners in rural areas, is an obvious problem. Kamoromy et al (1996) found that communities with high proportions of African-American and Hispanic residents were four times as likely as others to have a shortage of physicians, regardless of community income. Conventional wisdom says factors (in addition to lack of practitioners) playing a role in making access more difficult for minorities include linguistic and cultural barriers, such as distrust of health care providers, chilly reception by health care providers, comfort with home remedies, and traditional care methods and discomfort with conventional Western care. The 1990 census shows linguistic isolation among 25.1 percent of Asian Americans, 23.8 percent of Hispanics, 4.5 percent of Pacific Islanders, 4 percent of Native American/Alaska Natives and 0.9 percent of African Americans. Practitioners who understand the language and tradition of their patients and communities may offer a more complete and effective kind of health care (Thomson and Denk, 1999).
Health care providers from underserved communities are more likely than other practitioners to provide care to underserved patient populations (Pew 1998). Ethnic minorities (with the exception of some Asian ethnicities) are woefully underrepresented in the ranks of health care professionals. In 1990 census data, African Americans comprise 12.1 percent of the population and only 3.7 percent of the physicians; Native Americans comprise 0.8 percent of the total population and 0.2
percent of the physicians and Hispanics comprise 9 percent of the population, yet only 4.9 percent of physicians. Pharmacy reflects similar under-representation; in 1990 census data, African Americans comprise only 3.7 percent of the pharmacists, Native Americans comprise 0.2 percent of pharmacists and Hispanics comprise 3.1 percent of pharmacists. African Americans are slightly better represented among physician assistants and registered nurses, though they are underrepresented in these vocations as well. Of 1.9 million registered nurses in the United States in 1990, about 8.9 percent were African American, while 8.7 percent of all physician assistants were African American.
When looking at the Asian-American and Pacific Islander populations in terms of health care provision and cultural and linguistic match, little data exists. The ethnic diversity of these populations is vast and often not understood. The often-used aggregate category of "Asian American and Pacific Islanders" reflects more than 60 distinct ethnicities with more than 100 distinct languages and dialects. In addition, the diversity includes indigenous populations such as Native Hawaiians and other Pacific Islanders, populations with multiple generations in the United States such as Chinese and Japanese Americans and populations who were essentially unknown in the United States until the 1970s such as Hmong and Mien. Complicating matters even more, many of the these populations have a history of being antagonistic towards one another. Finally, cultural traditions and language often are lost between the first generation immigrant and the second generation American-born; therefore, ethnic identity is not a proxy to cultural and linguistic competency.
Therefore, to say that "Asian Americans and Pacific Islanders are over represented" is an over simplification that does not recognize the great diversity within this federally recognized category. (Beginning in 2000, the Office of Management and Budget separated "Asian Americans" from "Native Hawaiians and other Pacific Islanders.") Demographically, especially related to health status, Native Hawaiians and other Pacific Islanders are more similar to Native Americans than to Asian Americans. Numerically, over 98 percent of the Asian American/Pacific Islanders category is Asian and less than two percent is Pacific Islander. The implications of this are tremendous. Asian Americans have, on average, greater health status indicators than even those of Caucasians in America; however, the overwhelming proportion of Asians mask the poor health status of Pacific Islanders.
While there may be an overrepresentation of Asian-American graduates in the health professions, one must look at those who are providing direct primary care as opposed to specialist or academic medicine, or if they are specifically serving their ethnic community or the community at large. It is not enough to simply match ethnic backgrounds. Studies have shown that the people most likely to locate and provide health care among minority populations are those who originate from these areas and those that are trained in these areas (Rosenblatt et al., 1992). A recent study of U.S. medical graduates shows racial and ethnic minority physicians are, in general, more willing to provide care to poor patients who find themselves with no insurance or public insurance such as Medicaid (Thermond and Cregler, 1993). However, the issues surrounding the lack of representation of these populations in health careers are often similar, and the barriers preventing successful underrepresented students from pursuing health careers are many.

These barriers include:


Preparing Underrepresented Students for College

Evidence shows that efforts to overcome barriers toward higher education and health career majors can be effective in the practices of elementary and high school preparatory programming for underrepresented students. The Health Resources and Services Administration has provided funds to numerous institutions of higher education for over 25 years to provide pre-college educational enrichment and social support for disadvantaged students interested in health careers. Through these and other means, colleges and universities have shown some success. For example, the University of Louisville has increased its number of underrepresented minority students enrolled at the school to almost 10 percent, up 2 to 3 percent from before 1993, through many years of developing and implementing a continuum of preparation and retention programs at the elementary and secondary education levels (Crump et al, 1999). The Louisiana State University School of Medicine has a summer science program for Louisiana high school students from underrepresented minorities. An estimated 432 of 665 students have chosen education paths in medicine, another health profession or science since 1985 (Heml et al, 1999). In the Health Sciences and Technology Academy at West Virginia University, 98 students from West Virginia were given social support and academic enrichment for four years prior to college. Forty-nine percent of the students were African American or biracial, while 51 percent were rural, disadvantaged Appalachian whites. Ninety-six percent of these students are currently in college, while only 51 percent of their peers went to college. Seventy-seven percent are majoring in pre-health career majors with average grades fully one half a point higher than their peers majoring in the same fields who were not in the program (McKendall, 2000). Similar results are shown for Hawaiian Natives (Little et al, 1999), Hispanics, and Asians/Pacific Islanders (Palacio-Cayetano et al, 1999). These results show that just a little special attention from kindergarten through 12th grade has a tremendous impact.

Preparing Underrepresented Students for Professional School

Efforts to prepare ethnic minority students for professional school are effective in the practices of the historically black colleges and universities. Xavier University alone produces seven percent of the African-American applicants to medical schools. Undergraduate programs and post-baccalaureate programs in majority institutions scattered across the nation provide minorities and other underrepresented youth academic enrichment and social support towards health careers beginning the summer before coming to college and following them through professional school.
The University of Virginia Medical Academic Advancement Program for minority and disadvantaged students has been successful in increasing the number of underrepresented minority students matriculating into and continuing in medical education (Fang et al, 1999). This program and others illustrate successful approaches at the pre-matriculation level (Willliams, 1999).
Southern Illinois MEDPREP is a successful post-baccalaureate program. This program establishes high expectations for student progress, designs individual curricula, offers extensive academic and personal counseling, has its own teaching faculty and operates in a specially equipped designated facility. Since 1972, MEDPREP has served about 900 minority and disadvantaged students. By 1998 over 500 MEDPREP students had been accepted into medical or other health professions schools, and 86 percent of them had graduated or were scheduled to graduate. These students make two to nearly six times greater improvement in MCAT retakes than non MEDPREP students (McGlinn et al, 1999).
The pipeline for students graduating from high school through undergraduate training and through professional school education is long and demanding. Consequently, a number of reinforcements and supports are needed through this multi-year pipeline. Even maintaining a database from high school through graduate school or medical residency is an enormous challenge, but necessary to accurately reflect results of programs.

Preparing Practitioners to Serve the Underserved

A concerted effort needs to be made to understand the underserved populations to best prepare practitioners to serve them. Cultural and linguistic appropriateness of the traditional training needs to be assessed and adapted to promote more appropriate interactions with underserved people. The usage and potential conflicts in usage of alternative medicine by these populations needs to be assessed and addressed in training practitioners to promote more appropriate interfacing of traditional and alternative medical practice. Training of practitioners needs to incorporate culturally sensitive mental health promotion, general health promotion and disease prevention. The nation needs to evaluate the current rural and minority health initiatives to identify gaps and determine needs.


The authors make the following recommendations:


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Ann Chester, Ph.D. Assistant Vice President for Health Sciences, West Virginia University, PO Box 9026, Morgantown, WV 26506, [email protected] (304) 293-1651.
Mary Bowers, MSW, Public Health Advisor HIV AIDS, USDHHS Office of Population Affairs, 4350 East West Highway, East West Towers Suite 200 West, Bethesda MD 20814. [email protected]
Angeline Bushy, PhD, RN, CNS, Bert Fish Endowed Chair, University of Central Florida, 1200 W. International Speedway BLVD. Daytona Beach, FL 32114, [email protected]
Michael Huppert, Statewide Director, Massachusetts Statewide Area Health Education Center, 55 Lake Avenue, North, Worcester, MA 01605. [email protected]
Stephen P. Jiang, Planner, State Office of Rural Health, Hawai`i State Department of Health, 1250 Punchbowl Street, Room 340. Honolulu, HI 96813. [email protected]

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