The Health Implications of Discrimination:
Understanding Socioeconomic and Racial/Ethnic Health
Disparities in the City of Berkeley
San Francisco State University
HED 892 Community Needs Assessment – Berkeley Health Center for Women and Men
MPH Candidate 2005
Gwen Roe-Lee Sykes, DrPH, Executive Director Bay Area Consortium for Quality
Victoria Quijano, MPH, San Francisco State University
August 13, 2004
Table of Contents
Agency Introduction and Capability………………………………………………………4
Purpose of Internship……………………………………………………………………...7
Goals and Objectives……………………………………………………………………...8
Methods and Activities……………………………………………………………………9
Background and Significance……………………………………………………………12
Literature Search Results………..……….………………………………………………13
Appendix A: Bay Area Consortium for Quality Health Care Annual Report 2001..…....25
Appendix B: Bay Area Consortium for Quality Health Care Organizational Chart….…25
Appendix C: Map of MUA Designated Areas for Service Recipients………………..…25
Appendix D: Secondary Data Analysis - ICD9 Codes - January to June 2004...……….25
I would like to thank the following organizations and individuals who helped to
make this project a success. Most importantly, I wish to thank my site supervisor, and
course instructor for their valuable insight and support.
Bay Area Consortium for Quality Health Care-Gwen Roe-Lee Sykes, DrPH
Site Supervisor – Executive Director
San Francisco State University- Victoria Quijano, MPH
Berkeley Health Center for Women and Men-Helga Cooper
Administrative Clinic Manager
Berkeley Health Center for Women and Men-Carolyn Rowe-Carter
Clinical Nurse Manager
City of Berkeley Health and Human Services- Vicki Alexander, MD, MPH
Director Maternal, Child, Adolescent Health
Agency Introduction and Capability
The Bay Area Consortium for Quality Health Care was founded in 1975, and
incorporated as a California Nonprofit Public Benefit Corporation 501(C) (3) in 1979. A
Board of Directors, consisting of twenty -one social, health, and legal professionals,
governs it. They are an affiliate of the California Black Health Network, a broad based
federation of health professionals, community organizations and individuals, with six
chapters in California. The Network advocates and sponsors programs to improve the
health status of people of color. Their mission is to improve the quality of life in
multicultural communities in the five counties of the San Francisco Bay Area. They give
special attention to the physical, mental, social, and environmental health, of people of
color (Bay Area Consortium for Quality Health Care Annual Report, 2001).
The goals of the Bay Area Consortium for Health Care are as follows:
(1) Monitor the health and social indices of people of color and advocate for appropriate
public policies and actions to enhance research, public education, and delivery of services
to groups at high risk.
(2) Network with community based organizations and educational entities to coordinate
activities and capacity building, and form consortia to sponsor and promote community
health and environmental initiatives.
(3) Develop demonstration projects and new programs on pertinent health issues.
(4) Enhance access for low-income groups by providing them with health care and social
(5) Conduct ongoing community education and public information programs on timely
issues and concerns (Bay Area Consortium for Quality Health Care Annual Report,
The Berkeley Health Center (for Women and Men):
During 2001, the Berkeley Health Center (for Women and Men), previously an
independent corporation, became a full partner in the Consortium (Bay Area Consortium
for Quality Health Care, 2001). The BHC is a community-based primary care clinic,
which has provided comprehensive primary care health services for uninsured and
medically underserved community residents for the past thirty-one years. The BHC
provides a special focus on women’s health, however the current goal of the clinic is to
support the health of the entire family unit, and reduce the chronic conditions of diabetes,
hypertension and poor dental health. The name of the clinic was recently changed to
reflect the fact that services are now provided to both women and men. The BHC also
provides primary care services to immigrants and their family members of all ages
(EAPC Program Request, 2004).
The clinic’s recipients for care present with a variety of health conditions. The
most common issues include: gynecological problems, family planning services, breast
problems, STI’s/infections, urinary tract disorders, skin problems and ear, nose, throat
and eye infections. In addition, patients are seen for gastrointestinal, cardiovascular,
thyroid, musculoskeletal complaints, nervous systems disorders, and respiratory diseases.
Chronic diseases like hypertension and diabetes are prevalent among the clinic’s patient
population. These health conditions are addressed by primary care physicians that include
consultants in HIV/AIDS, gynecological, and psychiatric care. In the year 2003, the clinic
provided care to an average of 2046 patients, 4625 clinic visits. The clinic is open eight
hours per day, 5 days per week including some evenings (EAPC Program Request, 2004).
The clinic serves primarily the Berkeley – Oakland area of Alameda County, but
also sees patients from the San Francisco Bay Area. (See appendix C- Map of Medically
Underserved Designated Areas for Service Recipients) At least 75% of the clients who
utilize the BHC services are from the MUA. This is the designation or certification that at
least 50% of the patients served have incomes at or below 200 percent of the federal
poverty level. The designated area includes the community of South Berkeley, which has
historically been a medically underserved area (EAPC Program Request, 2004).
The racial/ethnic composition of the clinic’s population in 2003 is as follows:
Asian/Pacific Islander – 9%, African American – 33%, Latino – 15%, Native American –
0.5%, White – 41% other – 1.5%. The clinics population falls into the following age
categories: 13-19 years – 2.5%, 20 –34 years – 60%, 35-44 years – 27%, 45-64 years –
27%, 45-64 years – 10%, and 65 and over – 0.5% (EAPC Program Request, 2004).
Many of the patients are low-income, uninsured, homeless and have very limited
access to medical care. Day to day survival becomes an immediate concern resulting in
delays in seeking health care. This can result in complications for current existing health
conditions, combined with the negative impact of alcohol and drug abuse, and the
associated stress for the clinic’s service recipients who have no other access to health care
other than Highland Hospital (local county hospital) located several miles away. Barriers
to accessing Highland Hospital include the cost of public transportation, travel time by
public transportation, and the lack of same day appointments (EAPC Program Request,
Purpose of Internship
The Berkeley Health Center currently has no formal health education program to
meet the needs of its clients. The purpose of this community assessment was to identify
the medical and health education needs for the low-income women and men who are
served by the Berkeley Health Center. A profile of the population of low-income women
and men who attend the BHC and the surrounding community served by the clinic was
examined in terms of age, income, ethnicity, and heath insurance status. The literature
review examines the data sources on the health outcomes for the patients in the City of
Berkeley and compares that data to the five most common health care visits for the
patients who attend the BHC. The BHC clinic data was predicted to be reflective of the
leading causes of morbidity and mortality for the City of Berkeley. Socioeconomic and
racial/ethnic health disparities are examined from the National Healthcare Disparities
Report – U.S. Department of Health and Human Services, Select Indicators for Cities In
Alameda County, and the City of Berkeley Health Status Report, 2001 Mortality and
Hospitalizations. This comparison will help to demonstrate what types of health
education are needed for the BHC.
Methodology in the form of a secondary data analysis includes an analysis of
“ICD9”` codes from the clinic’s billing database to learn the most common reasons for
the clinic visits and to determine the consistency of the data on health disparities for the
City of Berkeley. Racial/ethnic health disparities for the women and men that attend the
clinic versus the general population of women and men who are not served by the clinic
Goals and Objectives
The overall goal of this community assessment was to assess the individual and
community health education needs for the low-income residents of the Berkeley Health
Center (for Women and Men). This was accomplished by applying appropriate research
principles and methods in community health education, while examining socioeconomic,
and racial/ethnic health disparities in the City of Berkeley. The secondary goal as a
Culminating Experience will be to design a program plan for health education services to
meet the three most common needs of the clients of the Berkeley Health Center (for
Women and Men), based upon the results of this community assessment and guided by
the theory of behavioral health motivation for change. The objectives for this project
were as follows:
Examine the demographics of the women and men who are served by the
Berkeley Health Center (for Women and Men) in terms of age, income, and
As a research tool, conduct a secondary data analysis that will include analysis of
the ICD9 codes from the clinic‟s database to learn the five most common reasons
for the clinic visits from January to June of 2004.
Conduct a literature review of the National Health Disparities Report, Select
Health Indicators For Cities in Alameda County, and the City of Berkeley Health
Status Report 2001, Mortality and Hospitalizations.
Examine the specific racial/ethnic health disparities for the women and men who
are served by the clinic, compared to the general population for the City of
Demonstrate the types of health education needed for the low-income residents of
the BHC within the context of a primary health care model.
Methods and Activities
The following methods and activities have been conducted:
Patient demographics for the Berkeley Health Center have been examined and
A secondary data analysis of the ICD9 codes for patient encounters from January
to June of 2004 have been examined using Microsoft Excel to determine the five
most common reasons for the clinic visits. This data will be cross-tabulated using
SPSS for HED 895.
A literature review of the socioeconomic and racial/ethnic health disparities in
health outcomes nationally, for Alameda County, and the City of Berkeley Data
Health Outcomes Report has been conducted. A comparison of the City of
Berkeley Data Outcomes and an examination of the health disparities for the
clients served by the BHC versus the population of the City of Berkeley have
been cited in the literature search results section.
A determination of the types of health education services needed for the BHC
based upon the five most common patient encounters has been assessed. They are
Hypertension, Hepatitis, and Allergic Rhinitis (See figure #1).
I have attended miscellaneous clinic meetings, as necessary.
Methodology in the form of a secondary data analysis was conducted by an
examination of the ICD9 codes from the clinic’s billing data base from January to June of
2004 to learn the five most common patient encounters and to determine the consistency
of the data in comparison to the health concerns for the broader population of the City of
Berkeley. All quantitative and qualitative information was coded using a codebook and
then entered into a Microsoft Excel spreadsheet (See Appendix D). Patient encounters
were extracted by recording the frequency that each patient diagnosis occurred. These
identified encounters were then used to determine the five most prevalent patient
encounters. Analyzing this secondary data source has determined the five most common
patient diagnosis (see figure 1 below).
Five Most Prevalent Patient Encounters
Berkeley Health Center for Women and Men from January – June 2004
Hypertension 193 Patients
Abdominal Pain related to Hypertension 123 Patients
Low Back Pain related to Hypertension
Hepatitis 364 Patients
Allergic Rhinitis 125 Patients
Total Patient Encounters from January - June 2004 = 2,784
This comparison has demonstrated the types of health education that are needed
for the BHC. The three most common patient encounters at the BHC are hypertension,
hepatitis, and allergic rhinitis. HTN is the most common and is reflective of the
socioeconomic, racial/ethnic health disparities data for the nation, Alameda County, and
the City of Berkeley as a whole.
TASK: DATE: HOURS:
Examine the patient June 25 – July 12 as Approximately:
demographics for the necessary. 20
Berkeley Health Center
Conduct a secondary data June 30 - July 15
analysis that will include an 40
analysis of ICD9 codes
from the BHC database.
Demonstrate the types of July 30 – August 5
health education needed for 10
the low- income residents of
Conduct a literature review June 26 – July 19 as
of the City of Berkeley Data needed. 40
Outcomes and examine
health disparities for the
clients served by the BHC
versus the population of the
City of Berkeley.
Complete mid-term report Approximately
on status of summer Friday, July 30 16
Compile data and highlights 895 Proposal Completion
into a fact sheet and/or 80
Power Point presentation
for the staff of the BHC
using the SPSS format after
meeting with Dr. June
Miscellaneous weekly and June 24 – August 5
unscheduled meetings, as 18
Complete final report on Approximately 16
Summer internship. Friday August 13
Background and Significance
Higher disease rates for African Americans compared to Whites are pervasive and
persistent over time, with the racial gap in mortality widening in recent years for multiple
causes of death. Other racial/ethnic minority populations also have elevated disease risk
for some health conditions. Race and socioeconomic status combine to affect health.
Socioeconomic status accounts for much of the observed racial disparities in health, yet
racism is an added burden for non-dominant populations. Individual and institutional
discrimination, along with the stigma of inferiority, can adversely affect health by
restricting socioeconomic opportunities and mobility. Racism can also affect health in
multiple ways. Residence in poor neighborhoods, racial bias in medical care, the stress of
experiences of discrimination and the acceptance of the societal stigma of inferiority can
have deleterious consequences for health (Williams, 1999).
The most important predictor of quality of health care across all racial and ethnic
groups is access, especially insurance status and the ability to pay for health care. If we
consider populations with equal access to health care, two groups emerge with differing
qualities of health care: non-minority and minority populations. When studies control for
the stage of disease at presentation, co morbidities, severity of illness, and other
variables, substantial differences in health care based on race and ethnicity can still be
found. Raising the consciousness of this issue is an important step toward recognizing
and eliminating health care disparities (Cohen J., 2003).
Literature Search Results
Secondary Data Analysis:
Socioeconomic and racial/ethnic health disparities data have been examined from
the National Healthcare Disparities Report – U.S. Department of Health and Human
Services, Select Indicators for Cities In Alameda County, and the City of Berkeley Health
Status Report, 2001 Mortality and Hospitalizations. The results are as follows:
National Health Disparities Report – U.S. Department of Health and Human
The data sources used for the National Health Disparities Report were as follows:
Administration for Children and Families
Administration on Aging
Assistant Secretary for Health
Assistant Secretary for Legislation
Assistant Secretary for Planning and Evaluation
Assistant Secretary for Planning and Evaluation
Assistant Secretary for Public Affairs
Centers for Disease Control and Prevention (CDC)
CDC-National Center for Health Statistics
Center for Medicare and Medicaid Services
Food and Drug Administration
Health Resources and Services Administration
Indian Health Service
National Institute of Health
Office of Civil Rights
Office of Minority Health
Substance Abuse and Mental Health Services Administration
2001 Data – Commonwealth Fund Health Care
Note: There are surveys collected from samples of civilian,
noninstitutionalized populations, data collected from samples of health care
facilities, and data extracted from administrative data systems of health care
organizations. Please see report for a brief listing of databases.
Findings and Discussion:
„”Communities of color suffer disproportionately from diabetes, heart disease,
HIV/AIDS, cancer, stroke, and infant mortality. Eliminating these and other health
disparities is a priority of HHS…”
-DHHS Secretary Tommy Thompson
“The evidence of the damaging health consequences of racial and ethnic disparities in
health care continues to be overwhelming…”
-John W. Rowe, M.D. Chairman and CEO of Aetna
The NHDR presented many key findings to clinicians and community members from
their report to improve health care services for all populations. In summary:
1. Inequalities in quality of care exist.
2. Disparities come at a personal and societal price.
3. Differential access may lead to disparities in quality of care.
4. Opportunities to provide preventative care are frequently missed.
5. Knowledge of why disparities exist is limited.
6. Improvement is possible.
7. Data limitations hinder targeted improvement efforts.
8. Patients of lower socioeconomic position are less likely to receive recommended
diabetic services and more likely to be hospitalized for diabetes and its
complications. Blacks and poorer patients have higher rates of avoidable
9. While most of the population has health insurance, racial and ethnic minorities are
less likely to report health insurance compared with whites. Lower income
persons are also less likely to report insurance compared with higher income
10. Higher rates of avoidable admissions by Blacks and persons of lower
socioeconomic position may be explained, in part, by lower receipt of routine care
by these populations.
11. Many racial and ethnic minorities and persons of lower socioeconomic position
are less likely to receive screening and treatment for cardiac risk factors.
12. High blood pressure, high cholesterol, and smoking are three of the most
important risk factors for heart disease that can be potentially modified by
screening and treatment.
13. Many racial minorities and persons of lower socioeconomic position are less
likely to receive screening and treatment for cardiac risk factors such as smoking
among the uninsured, lend themselves to quality improvement initiates that can
potentially reduce heart disease disparities among populations at risk.
In summary, access to care is a prerequisite to obtaining quality care. This report
presented a broad array of differences related to access, use and patient experience of
care by racial, ethic, socioeconomic and geographic groups. Many of the differences
constitute evidence of disparity. Patient race, ethnicity, and socioecomic status are
important indicators of the effectiveness of health care (NHDR, 2003).
Select Indicators for Cities In Alameda County
The data sources used to elicit health indicators for Alameda County were as
California State Department of Health Services, Immunization Branch
Alameda County Public Health Department Communicable Disease System.
Alameda County Public Health Department Vital Statistics Files from the
Automated Vital Statistics System
California Office of Statewide Health Planning and Development
Northern California Cancer Center
California Cancer Registry
Department of Finance
U.S. Census Bureau
Findings and Discussion:
1. The three leading causes of death in each city in Alameda County were the same
as in the county as a whole. These were diseases of the heart, cancer and stroke.
Diseases of the heart accounted for 26% to 30% of all deaths in each city.
2. Leading causes of death differed by race/ethnicity. Among African Americans in
all cities, the two leading causes of death varied by city and included stroke,
unintentional injuries, influenza/pneumonia, diabetes and homicide.
3. Coronary heart disease is one of the major diseases of the heart. It is the leading
cause of death for both men and women in the United States. Each year, about
500,000 Americans die of heart attacks caused by coronary heart disease. Many of
these deaths can be prevented through lifestyle changes in diet, physical activity
and smoking habits. Oakland had the highest age-adjusted mortality rate for
coronary heart disease (101 per 100,00 population), followed by Hayward and
San Leandro. Among African Americans, the rates of death from coronary heart
disease ranged from 108 per 100,000 in San Leandro to 293 in Berkeley. (Select
Indicators for Cities in Alameda County)
4. Stroke is the third leading cause of death in the United States and a leading cause
of serious, long-term disability. The risk of stroke generally increases with age.
Many stroke deaths can be prevented by lifestyle changes in diet, physical activity
and smoking habits. Oakland had the highest age-adjusted mortality rate for
stroke (34 per 100,000 populations). (Select Indicators for Cities in Alameda
City of Berkeley Health Status Report, 2001 Mortality and Hospitalizations
The data sources for the City of Berkeley Health Status Report are as follows:
Berkeley Public Health Division Epidemiology and health Statistics
Automated Vital Statistics System
California Department of Finance, Demographic Research Unit
U.S. Census Bureau
California office of statewide Health Planning and development (ICD-9-CM
Findings and Discussion:
1. Berkeley‟s population is ethnically and racially diverse: 55.2% of residents are
White, 16.4% Asian/Pacific Islander, 13.3% African American, 9.7%
Hispanic/Latino, and). 3% American Indian. (City of Berkeley Health Status
2. African Americans comprise 13.3% of the population of Berkeley compared to
14.6 % of the total population of Alameda County and 6.4% of the State of
California. Among the four cites in Alameda County with greater than 100,000
residents, Berkeley has the second largest proportion of African Americans,
second only to Oakland (37.7%) (City of Berkeley Health Status Repor,2001t)
3. The three leading causes of death for Berkeley residents in 1998 were heart
disease, cancer, and stroke. Cancer is the leading cause of death for Whites in
Berkeley and heart disease is the leading cause of death for African Americans.
(City of Berkeley Health Status Report,2001)
4. African Americans die at significantly younger ages than do Whites in Berkeley.
For African Americans, 50% of deaths occur before the age of 75, whereas for
Whites, 36% of deaths occur before the age of 75. Mortality is also significantly
higher for African Americans between the ages for two and 34 and under the age
of five. (City of Berkeley Health Status Repor,2001)
5. Census tracts in South and West Berkeley have the highest number of premature
deaths each year. This data is consistent with previous analysis and reports
showing a high concentration of population at risk for premature mortality in this
geographical area. (This is the same geographical area for recipients of care for
the Berkeley Health Center for Women and Men). (City of Berkeley Health Status
6. The overall adjusted death rate for all causes of death in Berkeley is three times
greater for African Americans than for the White population. By comparison, the
overall age adjusted rate for African Americans in the United States, as a whole is
1.5 times greater than the age adjusted death rates for Whites in the U.S. (City of
Berkeley Health Status Report,2001)
7. Heart disease, cancer, and stroke are the top three causes of death in Berkeley and
account for 59% of all deaths. Cancer is the leading cause of death for Whites and
heart disease is the leading cause of death for African Americans in Berkeley.
Heart disease was the leading cause of death for all Berkeley residents in 1998.
Many of these deaths could be prevented through lifestyle changes in diet,
exercise and smoking. The age-adjusted mortality rate for coronary heart disease
for African Americans is more than three times that of Whites in Berkeley.
African Americans are 12 times more likely to be hospitalized for hypertensive
heart disease than Whites in Berkeley. Hypertension (or high blood pressure) is a
common precursor to heart disease and stroke. Berkeley residents. The risk of
dying from stroke is almost five times higher for African Americans than it is for
whites in Berkeley. Many stroke deaths can also be prevented by changes in diet,
exercise, and smoking. (City of Berkeley Health Status Report,2001)
In conclusion this data is reflective of the ICD-9 excel data results for the
most common patient encounters for the Berkeley Health Center for Women and
Men from January to June of 2004. (See figure 1.) African Americans in Berkeley
still die at a younger age overall than Whites in Berkeley. The evidence of health
disparities among racial/ethnic groups in Berkeley is consistent with those
originally presented in the 1999 Health Status Report. This data can help
community groups focus efforts aimed at the elimination of these disparities. This
report can be used to help identify gaps in services, and unmet health needs and,
in turn, guide the development of programs, the provision of health services, and
health education strategies. All of these are strong indicators of social equality.
Health administrators at all levels and community members have the
responsibility to respond and take action to eliminate health disparities in
Berkeley (City of Berkeley Health Status Report, 2001).
Themes and Recommendations
There are three major themes and recommendations that emerged from the
relevant literature in this field:
1. Health targeting efforts and behavioral change through expanded health
promotion activities and education,
2. Cultural competency of medical staff and provider behavior, and
3. Policy changes to address health disparities.
Our healthcare system continues to emphasize care that occurs after an illness occurs,
rather than preventative services that could potentially prevent the illness or reduce the
burden of disease (NHDR, 2003). There are four physician roles for improving
modifiable public health-risk behavior burdens. They are preventive services, health
promotion, educator, and health promotion advocate (Dibble R., 2003). Health education
efforts should target the health conditions that account for most of the socioeconomic and
racial disparities – smoking related diseases in the case of most mortality among persons
with fewer years of education, and hypertension, HIV, diabetes mellitus, and trauma in
the case of mortality among African Americans (Wong, Shapiro, Boscardin, 2002). The
persistence of racial and ethnic disparities in health care access, quality, and outcomes
has prompted considerable interest in increasing the cultural competence of health care
providers, both as an end in its own right and as a potential means to reduce disparities
(Brach , Fraser, 2002). New solutions are needed to address this issue. Focusing efforts to
eliminate unequal burdens can strengthen existing solutions and policy formation related
to health disparities. Reducing socioeconomic disparities in health will require policy
initiatives addressing the components of socioeconomic status (income, education, and
occupation) as well as the pathways by which these affect health (Alder, Newman, 2002).
Limitations of Research Data
Gaps in national data exist. Large gaps in the data required for a complete study
of disparities were noted. For analyses of disparities related to racial/ethnic groups, data
limitations were related to sample sizes. Data limitations for the study of socioeconomic
groups usually relate to the lack of relevant information included in many health care
provider databases. In addition, possible disparities in the care provided for many medical
conditions have yet to be addressed. More complete and reliable data would improve
understanding of disparities. Priority subpopulations i.e. racial and ethnic minorities,
often have different health care priorities and different needs for services. Measures that
capture the unique needs of specific priority populations are required for a fuller
understanding of disparities faced by each group. While we may have sufficient data
about racial disparities by race and ethnicity, it is difficult to tease out the individual
contributions of race, income, or education to these differences. While improved data
would help to measure disparities, the field would also benefit from more robust
measures that would improve our understanding of the underlying mechanisms and
causal paths that result in disparities (NHDR, 2003).
Agency for Healthcare Research and Quality (2003). National Health Disparities Report
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Van Ryn M.,et al. (2003). Paved with good intentions: do public health and human
service providers contribute to racial/ethnic disparities in health? Center for Chronic
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Wong, MD., (2002). Contribution of major diseases to disparities in mortality. New
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racism and discrimination. University of Michigan, Department of Sociology and Survey
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Bay Area Consortium for Quality Health Care Annual Report 2001
Bay Area Consortium for Quality Health Care Organizational Chart
Map of MUA Designated Areas for Service Recipients
Secondary Data Analysis - ICD9 Codes - January to June 2004