Benz JK, Espinosa O, Welsh V, Fontes A. Awareness of racial and ethnic health disparities has improved only modestly over a decade. Health Aff (Millwood). 2011;30(10).

Appendix: Creating an Awareness Index & Survey Questionnaire

The Awareness Index Although individual questions from the survey reliably measure specific aspects of the respondents’ awareness of health care and health status disparities, a single measure (index) that summarizes this awareness is useful both in identifying the determinants of such perceptions and in reporting study results to a broad audience. The goal of creating such an index is to reliably report a valid measure of awareness in a simple, easy-to-understand manner. One method, which has been used previously to report results of the 1999 KFF study, is to calculate the average number of respondents who report awareness of disparities on a select group of health related concepts (health insurance, infant mortality, and life expectancy). Once the mean awareness level of each of the individual concepts is calculated, those means are averaged to calculate a grand mean of the awareness of health disparities among sample respondents. Although this method produces a single number that reflects awareness, it does not create a measure that validly reflects the proportion of the sample population who is aware of health disparities; rather, it is a measure of the number of times awareness of each of the individual health related concepts was indicated. Exhibit A1 presents this calculation method in detail.

Exhibit A1: Calculation of the Grand Average Metric

Aware / Sample Item Mean Total Aware / Total Sample Grand Mean

African Americans Worse Off than Whites in Terms of Getting Health Insurance (yes/N)= 63%

African Americans Worse Off than Whites in Terms of Infant Mortality (yes/N)= 39%

African Americans Worse Off than Whites in Terms of Life Expectancy (yes/N)= 46%

Hispanics/Latinos Worse Off than Whites in Terms of Getting Health Insurance (yes/N)= 62%

(yes + yes + yes + yes) / (N + N + N + N) 52.5%

This grand mean reflects the total number of survey items for which awareness was indicated. It is a metric of items, not of people and therefore cannot be used to indicate the proportion of the sample population who is aware of health disparities. In order to report the percentage of the population who is (or is not) aware of health disparities using multiple items, a metric must be defined for each individual in the sample population. While there are many ways to define such a metric, the most straightforward, yet statistically valid, is to create an index using statistical factor analysis. This method evaluates the correlation between items and calculates a loading structure to reduce the items, in this case, to one, with a minimal loss of information. Such an index measuring awareness of health disparities from the survey questionnaire was developed for this study. First, the appropriate survey items were identified. Items needed to be comparative in nature (comparing one racial and ethnic group to another), and to show some level of statistical cohesion. Because calculating a general measure of perceptions and misperceptions was of interest, the measure included eight survey items related to African American and White comparisons, eight items related to Hispanic/Latino and White comparisons, and eight items related to Asian American/Pacific Islander and White comparisons for a total of 24 items. Although the 2010 survey collected data on the awareness of disparities between Asian Americans/Pacific Islanders and Whites, the 1999 survey did not. These items are therefore excluded in the calculation of the disparity measure when making comparisons between 1999 and 2010. Exhibit A2 presents the survey items used in the awareness measure.

Exhibit A2:

Survey Items Used in the Measure of Awareness Question Text

Each question was asked for African Americans, Hispanics/Latinos, and Asian Americans/Pacific Islanders. Do you think the average (racial and ethnic minority group) is better off, just as well off, or worse off than the average White person in terms of getting needed health care? Do you think the average (racial and ethnic minority group) is better off, just as well off, or worse off than the average White person in terms of infant mortality? Do you think the average (racial and ethnic minority group) is better off, just as well off, or worse off than the average White person in terms of life expectancy? When going to a doctor or health clinic for health care services, do you think most (racial and ethnic minority groups) receive a higher quality of care, the same quality of care, or a lower quality of health care than most Whites? Do you think the average (racial and ethnic minority group) is better off, just as well off, or worse off as the average White person in terms of how healthy they are? Do you think the average (racial and ethnic minority group) is better off, just as well off, or worse off as the average White person in terms of getting routine medical care when they need it? Do you think the average (racial and ethnic minority group) is better off, just as well off, or worse off as the average White person in terms of getting specialized care when they need it? Do you think the average (racial and ethnic minority group) is better off, just as well off, or worse off as the average White person in terms of having health insurance?

Factor analysis indicated that the 24 items were highly correlated and relatively equal in their contribution to an overall awareness metric. These qualities allow for further simplification of the calculation of the awareness measure by creating an additive index in which respondents are given a 1 for each item where they indicate awareness of a disparity. The item scores (1/0) are then summed to create an awareness score of between 0 (indicating no awareness of disparities in any of the health-related items) and 24 (indicating awareness of disparities in all of the healthrelated items). The distribution of the public sample on this variable is shown in Exhibit A3. Respondents were categorized as “aware” if they indicated awareness of at least 25 percent (6 of the 24 items) included in the index. Although 25% was chosen for this analysis (based on evaluation of the index distribution and face validity), analysts interested in evaluating total awareness (24 of 24 items) or total unawareness (0 of 24 items) may utilize different breakpoints. This allows reporting, in a simple yet statistically valid manner, of the proportion of the

population that is or is not generally aware of disparities in health care and health status based on racial and ethnic identity. Furthermore, this index can be separated into three separate indicators of awareness of disparities for a specific race or ethnicity. For example, the eight items related to African American and White disparities can be isolated and the proportion of the population that is aware of disparities for this specific population can be reported.

Exhibit A3:

Distribution of Public Sample on Awareness Index

The Survey Questionnaire This research will help the federal government’s Office of Minority Health better understand peoples’ opinions about the differences in minority health care. I’d like to begin by asking you some questions about your health care and health information. 1. At what type of facility do you usually receive your medical care? Is it a doctor’s office, a clinic or health center, an HMO, a hospital emergency room, a hospital outpatient department or some other place? (SELECT ALL THAT APPLY) 1. DOCTOR’S OFFICE 2. CLINIC OR HEALTH CENTER 3. HMO 4. HOSPITAL EMERGENCY ROOM 5. HOSPITAL OUTPATIENT DEPARTMENT 6. OTHER (SPECIFY: ___________) (77) DON’T KNOW (99) REFUSED ______________________________________________________________________ 2.

How do you typically learn of general medical information? (SELECT ALL THAT APPLY) a. b. c. d. e. f. g. h. i. j.

The Internet Newspaper Medical Journals By talking with my doctor Television (news/documentary) Radio Friends/family Other (please explain)_______________________________________________ (Don’t’ know) (Refused)

1. YES 2. NO (77) DON’T KNOW (99) REFUSED ______________________________________________________________________

3.

In the last year, have you heard or read anything about racial and ethnic disparities in health and health care in America? 1. YES (Specify: ) 2. NO (77) DON’T KNOW (99) REFUSED

GO TO Q3_SPECIFY GO TO Q4 GO TO Q4 GO TO Q4

Q3_SPECIFY Please briefly describe what you have heard or provide examples. _______________________________________________ 4A. Have you ever heard of any of the following public health campaigns or read any of the following publications? The US Department of Health and Human Services’ Healthy People 2010 1. YES 2. NO (77) DON’T KNOW (99) REFUSED 4B (Have you ever heard of any of the following public health campaigns or read any of the following publications?) The Agency for Healthcare Research and Quality’s National Healthcare Disparities Report 1. YES 2. NO (77) DON’T KNOW (99) REFUSED 4C (Have you ever heard of any of the following public health campaigns or read any of the following publications? ) The Institute of Medicine’s 2003 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care 1. YES 2. NO (77) DON’T KNOW (99) REFUSED

4D (Have you ever heard of any of the following public health campaigns or read any of the following publications?) The Office of Minority Health’s National Partnership for Action 1. YES 2. NO (77) DON’T KNOW (99) REFUSED 4E (Have you ever heard of any of the following public health campaigns or read any of the following publications?) The PBS Documentary: Unnatural Causes: Is Inequality Making Us Sick? 1. YES 2. NO (77) DON’T KNOW (99) REFUSED ______________________________________________________________________ 5.

Thinking about people like yourself, is: a. being able to afford the cost of health insurance and necessary medical care; b. having enough doctors and other health providers near where they live; c. having difficulty getting care because of your race or ethnic background a major problem, a minor problem or not a problem? 1. MAJOR PROBLEM 2. MINOR PROBLEM 3. NOT A PROBLEM AT ALL (77) DON’T KNOW (99) REFUSED ______________________________________________________________________

For  the  next  few  questions,  I  would  like  you  to  think  about   African  Americans  in  our  country  today.   Q6A-C. Do you think the average African American is better off, just as well off, or worse off than the average white person in terms of: a. getting needed health care; b. infant mortality—that is, a baby’s chance of surviving after birth; c. life expectancy—that is, how long someone can expect to live? 1. BETTER OFF 2. JUST AS WELL OFF 3. WORSE OFF (77) DON’T KNOW (99) REFUSED ______________________________________________________________________ 7.

Do you think the average African American is more likely, just as likely, or less likely to be diagnosed with: a. Acquired Immune Deficiency Syndrome (AIDS) or the HIV virus b. Cancer (including cancer of the stomach, prostate, or bladder) c. Hypertension—that is, high blood pressure d. Diabetes as the average white person? 1. MORE LIKELY 2. JUST AS LIKELY 3. LESS LIKELY (77) DON’T KNOW (99) REFUSED ______________________________________________________________________

8. When going to a doctor or health clinic for health care services, do you think most African Americans receive a higher quality of health care, the same quality of health care, or a lower quality of health care as most whites? 1. HIGHER QUALITY 2. SAME QUALITY 3. LOWER QUALITY (77) DON’T KNOW (99) REFUSED ______________________________________________________________________

9.

How big of a problem do you think: a. being able to afford the cost of health insurance and necessary medical care; b. having enough doctors and other health providers near where they live; c. having difficulty getting care because of their race or ethnic background; is for the average African American? Is this a major problem, a minor problem or not a problem at all for the average African American? 1. MAJOR PROBLEM 2. MINOR PROBLEM 3. NOT A PROBLEM AT ALL (77) DON’T KNOW (99) REFUSED ______________________________________________________________________

10.

Do you think the average African American is better off, just as well off, or worse off as the average white person in terms of:

a. b. c. d.

how healthy they are; getting routine medical care when they need it; getting specialized treatments or surgery when they need it; having health insurance?

1. BETTER OFF 2. JUST AS WELL OFF 3. WORSE OFF (77) DON’T KNOW (99) REFUSED ______________________________________________________________________

Now,  thinking  about  Hispanics  or  Latinos  in  our  country  today.   11.

Do you think the average Hispanic/Latino is better off, just as well off, or worse off as the average white person in terms of:

a. getting needed health care; b. infant mortality—that is, a baby’s chance of surviving after birth; c. life expectancy—that is, how long someone can expect to live? 1. BETTER OFF 2. JUST AS WELL OFF 3. WORSE OFF (77) DON’T KNOW (99) REFUSED ______________________________________________________________________ 12.

Do you think the average Hispanic/Latino is more likely, just as likely, or less likely to be diagnosed with:

a. Acquired Immune Deficiency Syndrome (AIDS) or the HIV virus b. Cancer (including cancer of the stomach and liver) c. Hypertension—that is, high blood pressure d. Diabetes as the average white person? 1. MORE LIKELY 2. JUST AS LIKELY 3. LESS LIKELY (77) DON’T KNOW (99) REFUSED ______________________________________________________________________ 13.

When going to the doctor or health clinic for health care services, do you think most Hispanics/Latinos receive a higher quality of health care, the same quality of health care as whites, or a lower quality of health care as most whites? 1. HIGHER QUALITY 2. SAME QUALITY 3. LOWER QUALITY (77) DON’T KNOW (99) REFUSED ______________________________________________________________________

Q14A How big a problem do you think being able to afford the cost of health insurance and necessary medical care is for the average Hispanic/Latino? Is this a major problem, a minor problem or not a problem at all for the average Hispanic/Latino?

1. MAJOR PROBLEM 2. MINOR PROBLEM 3. NOT A PROBLEM AT ALL (77) DON’T KNOW (99) REFUSED Q14B (How big a problem do you think) having enough doctors and other health providers near where they live is for the average Hispanic/Latino? (Is this a major problem, a minor problem or not a problem at all for the average Hispanic/Latino?)

1. MAJOR PROBLEM 2. MINOR PROBLEM 3. NOT A PROBLEM AT ALL (77) DON’T KNOW (99) REFUSED Q14C (How big a problem do you think) having difficulty getting care because of their race or ethnic background is for the average Hispanic/Latino? (Is this a major problem, a minor problem or not a problem at all for the average Hispanic/Latino?)

1. MAJOR PROBLEM 2. MINOR PROBLEM 3. NOT A PROBLEM AT ALL (77) DON’T KNOW (99) REFUSED ______________________________________________________________________

15.

Do you think the average Hispanic/Latino is better off, just as well off, or worse off as the average white person in terms of: a. how healthy they are; b. getting routine medical care when they need it; c. getting specialized treatments or surgery when they need it; d. having health insurance? 1. BETTER OFF 2. JUST AS WELL OFF 3. WORSE OFF (77) DON’T KNOW (99) REFUSED ______________________________________________________________________

Now,  thinking  about  Asian  Americans/  Pacific  Islanders  in  our   country  today,   16.

Do you think the average Asian American/Pacific Islander is better off, just as well off, or worse off as the average white person in terms of: a. getting needed health care; b. infant mortality—that is, a baby’s chance of surviving after birth; c. life expectancy—that is, how long someone can expect to live? 1. BETTER OFF 2. JUST AS WELL OFF 3. WORSE OFF (77) DON’T KNOW (99) REFUSED ______________________________________________________________________

17.

Do you think the average Asian American/Pacific Islander is more likely, just as likely, or less likely to be diagnosed with: a. Acquired Immune Deficiency Syndrome (AIDS) or the HIV virus; b. Cancer (including cancer of the stomach and liver); c. Hypertension—that is, high blood pressure; d. Diabetes? as the average white person? 1. MORE LIKELY 2. JUST AS LIKELY 3. LESS LIKELY (77) DON’T KNOW (99) REFUSED ______________________________________________________________________

18.

When going to the doctor or health clinic for health care services, do you think most Asian American/ Pacific Islanders receive a higher quality of health care, the same quality of health care, or a lower quality of health care as most whites? 1. HIGHER QUALITY 2. SAME QUALITY 3. LOWER QUALITY (77) DON’T KNOW (99) REFUSED _____________________________________________________________________

19.

How big a problem do you think: a. being able to afford the cost of health insurance and necessary medical care; b. having enough doctors and other health providers near where they live; c. having difficulty getting care because of their race or ethnic background is for the average Asian American/ Pacific Islander; is for the average Asian American/ Pacific Islander? Is this a major problem, a minor problem or not a problem at all for the average Asian American/ Pacific Islander? 1. MAJOR PROBLEM 2. MINOR PROBLEM 3. NOT A PROBLEM AT ALL (77) DON’T KNOW (99) REFUSED ______________________________________________________________________

20.

Do you think the average Asian American/ Pacific Islander is better off, just as well off, or worse off as the average white person in terms of: a. how healthy they are; b. getting routine medical care when they need it; c. getting specialized treatments or surgery when they need it; d. having health insurance? 1. BETTER OFF 2. JUST AS WELL OFF 3. WORSE OFF (77) DON’T KNOW (99) REFUSED ______________________________________________________________________

I  have  one  last  set  of  questions  to  help  us  better  understand  the   people  who  participate  in  our  survey.   21.

RESPONDENT’S GENDER 1. MALE 2. FEMALE (77) DON'T KNOW (99) REFUSED ______________________________________________________________________

22.

Are you currently married, living as married, widowed, divorced, separated, or have you never been married? 1. 2. 3. 4. 5. 6.

MARRIED LIVING AS MARRIED WIDOWED DIVORCED SEPARATED NEVER MARRIED (77) DON’T KNOW (99) REFUSED ______________________________________________________________________ 23.

What is your age? 18-98 RECORD NUMBER (77) DON’T KNOW (99) REFUSED ______________________________________________________________________

24.

What is the last year or grade of school you completed? 1. GRADE 8 OR LOWER 2. HIGH SCHOOL INCOMPLETE 3. HIGH SCHOOL DIPLOMA OR EQUIVALENT 4. BUSINESS, TECHNICAL OR VOCATIONAL SCHOOL AFTER HIGH SCHOOL 5. SOME COLLEGE, NO DEGREE 6. TWO-YEAR OR ASSOCIATE’S COLLEGE DEGREE 7. FOUR-YEAR COLLEGE DEGREE 8. GRADUATE OR PROFESSIONAL SCHOOL AFTER COLLEGE (77) DON’T KNOW (99) REFUSED

______________________________________________________________________ 25.

In general, how would you describe your own health? Would you say it is excellent, very good, good, fair or poor?

1. EXCELLENT 2. VERY GOOD 3. GOOD 4. FAIR 5. POOR (77) DON’T KNOW (99) REFUSED 26.

Are you yourself of Hispanic, Latino or Spanish origin?

1. YES 2. NO 8. (DON’T KNOW) 9. (REFUSED) ______________________________________________________________________ RACE What is your race? 1. White 2. Black or African American 3. Asian American/ Pacific Islander 4. Other (77) DON’T KNOW (99) REFUSED RACE_SPC (SPECIFY _________________________) HHADULTS Including yourself, how many adults 18 years of age or older live in this household? ENTER 77 FOR DON'T KNOW AND 99 FOR REFUSED NUMBER OF PEOPLE: