HomeLarge Type Edition
HOME ARCHIVE SEARCH TABLE OF CONTENTS
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Services
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
PubMed
Right arrow PubMed Citation
The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 59:1318-1322 (2004)
© 2004 The Gerontological Society of America

Inner City African-American Elderly Patients' Perceptions and Preferences for the Care of Chronic Knee and Hip Pain: Findings From Focus Groups

Said A. Ibrahim1,, Amy Zhang2, Mary Beth Mercer2, Marcy Baughman1 and C. Kent Kwoh1

1 The Center for Health Equity Research and Promotion, VA Pittsburgh HealthCare System, Pennsylvania.
2 The Case Western Reserve University School of Medicine, Cleveland, Ohio.

Address correspondence to Said A. Ibrahim, MD, MPH, Center for Health Equity Research and Promotion, VA Pittsburgh HealthCare System, University Drive C, 11-East (130 A-U), Pittsburgh, PA 15240. E-mail said.ibrahim2{at}med.va.gov


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. African Americans undergo joint replacement less often than do white persons. The authors studied African-American perceptions and preferences for the care of knee and hip pain.

Methods. 10 focus groups were conducted in an inner city community. Participants, older persons with chronic knee or hip pain, were asked to discuss their perceptions and preferences for the care of knee and hip pain. Transcripts were coded for thematic structure using NUD*ST software.

Results. Cultural preferences and perceptions for care emerged as a major theme. Important subcategories of this theme included respect for the patient's faith and religiosity and perceptions of physician ethnicity, race, and sex.

Conclusions. This sample of older inner city African Americans expressed unique cultural perceptions and preferences for the care of their knee and hip pain. Respect for patients' faith was important, whereas physicians' race, ethnicity, and religious background were not.

A national consensus is emerging among health care providers, policy makers, and community advocacy groups that cultural factors are important in the delivery of health care (1–5). Calls for cultural competence in health care have evolved from recent research and policy initiatives showing the impact of culturally competent care on health care access and outcomes (6,7). Although a vast body of evidence supports the link between culture, health, and health behavior, less is known about the role that belief systems play in health care (8–11). Patients' health beliefs and perceptions (12–16), as well as their preferences for medical treatment (17–19), are affected by culture. With this understanding, a growing number of health care investigators have recognized that the effectiveness of health initiatives such as the Department of Health and Human Services national effort to eliminate ethnic and racial disparities in health care by 2010 could be optimized by reflecting the community's cultural perceptions and expectations for care.

Arthritis, particularly osteoarthritis, which is usually present in the elderly as chronic knee and hip pain, provides an ideal paradigm to study cultural factors in the process of care. Arthritis tends to be chronic in nature, is prevalent in all demographic and cultural groups including the African-American community, and is a leading cause of functional disability among elderly people (20–22). With the aging of the United States population, its prevalence is expected to increase. In addition, a racial and ethnic disparity is well documented in the use of knee and hip joint replacement therapy (23–26), which is an effective option widely used to treat osteoarthritis (27).

Osteoarthritis represents a disease model in which, despite similar biological disease, cultural and psychosocial factors may lead to varying symptoms, perceptions, and expectations for care and care-seeking behavior (28,29). For instance, Gerson and Skipper (30) assessed the influence of social factors in expectations of pain associated with osteoarthritis. They found that African Americans and patients from communities with low socioeconomic status expect a greater amount of pain from arthritis compared with white counterparts. In another study by Coulton and colleagues (31), ethnicity was associated with variation in self-care practices and medical care—seeking behavior for joint symptoms. In a study of Veterans Affairs patients, Ibrahim and colleagues (32) found that self-care attitudes and practices for knee or hip osteoarthritis among African-American patients differ from those of white patients. These examples suggest that the patient's cultural and psychosocial environments influence both their perceptions of disease and expectations for care.

In the current study, focus group interviews were conducted in an inner city African-American community to specifically solicit a more in-depth understanding of patients' cultural perceptions and expectations of care for knee and hip pain.


   METHODS
Top
 Abstract
 Methods
Results
 Discussion
 References
 
Patients
This study was conducted during the 12-month period from February 2001 through February 2002. Participants, recruited from a single primary care health center serving an inner city African-American community in Cleveland, Ohio, were eligible for the study if they were African American and reported chronic symptomatic knee or hip pain lasting more than 6 months. To screen patients for the study and to assess the presence and duration of knee or hip osteoarthritis, we adopted a question from the arthritis supplement of the National Health and Nutrition Examination Survey I (33): "Have you ever had pain in and around your knee or hip on most days for at least 1 month?" Patients who answered yes to this question were further considered for the study. Primary care physicians at the center also referred the study patients who met this initial criterion. A research assistant described the study objectives to potential participants and confirmed eligibility. Those who expressed interest and consented to the study were invited to participate in focus group interviews. Follow-up postcards confirming the date, time, and location of the focus group sessions were sent to all participants. A reminder telephone call was then placed 1 or 2 days before the event.

Data Collection
Ten 90-minute focus group sessions with 5 to 11 participants were conducted at a community health center. Each focus group was led by a trained facilitator and was cofacilitated by an African American with experience participating in community-based health care focus group interviews. An interview guide, developed after a review of the pertinent literature and a series of investigator meetings, was used to stimulate and direct the focus group discussions. Consistent with standards of focus group methods, open-ended questions, initially broad and gradually more focused, were used to accommodate participants' views even if this meant a diversion from the interview guide. Table 1 summarizes the key discussion questions in the interview guide.


View this table:
[in this window]
[in a new window]
  		Table 1. Key Questions in the Focus Group Interview Guide.

 
Focus group discussions were audiotaped and then transcribed. Survey questionnaires were used at the end of each focus group discussion to gather information on participants' demographic and socioeconomic characteristics such as age, sex, race and ethnicity, religious background, education, marital status, and annual household income. The local Institutional Review Board of the University Hospital of Cleveland approved the study.

Data Analysis
Participant demographic data were analyzed using SPSS 10 for MacIntosh (SPSS, Chicago, IL). Two independent coders analyzed the focus group transcripts using NUD*ST software (34). NUD*ST software is used to organize and code qualitative data. It also allows the user to insert comments as they organize the data into nodes, which represent major themes and subcategories in the data. The first coder identified five major content themes from the transcripts. The second researcher independently read the transcripts and was in complete agreement with these themes found by the first coder. The second coder then further developed several subcategories for each main theme. This article focuses and reports findings of one of the major themes, cultural aspects of arthritis care, and its subcategories.


   RESULTS
Top
 Abstract
 Methods
 Results
Discussion
 References
 
Study Sample Characteristics
Seventy-five persons participated in 1 of 10 focus groups. The participants' mean age was 62 years (age range, 47–79 years) and mean years of education was 13.4 years (range, 8–22 years). The duration of knee and hip pain ranged from 5 to 20 years. The religious affiliation of the participants included Protestant (nearly all Baptist), 84%; Catholic, 3%; other Christian denominations, 8%; and other religions, 5%. Participants' marital status included single, 11%; married, 45%; divorced or separated, 23%; and widowed, 21%. A median annual house income of more than $20,000 was reported by 64% of participants. All were African American. Table 2 summarizes the demographic characteristics of the study sample.


View this table:
[in this window]
[in a new window]
  		Table 2. Sample Characteristics (N = 75).

 
Results Within the Theme "Cultural Aspects of Arthritis Care"
Effect of patients' religious belief on medical decisions.-- The most popular subcategory was use of prayer or faith for pain management, care, and prevention. More than one quarter of the sample indicated that they use prayer as a method of pain management. The same number of participants also indicated that they believed having faith could help them to alleviate disease. Nearly as popular was the concept that only God can heal. The patients seemed to believe that the physician was only a vessel through which God healed and that God could also instill wisdom into the physician so that he or she could treat them. Examples of statements used by patients to express this point include "Well, my faith is really important in most of the decisions, important decisions" and "I believe that healing comes more from the Lord than it does from any human being." Another patient remarked, "My faith, I know that my faith has allowed me to endure a lot of pain, emotional and physical pain, so it is really important because you do have to go back to God."

Perceptions of physicians' religious beliefs.-- Another theme that emerged was the perception of the physicians' religious beliefs. This theme was expressed by 40% of the sample, although the comments seemed to vary widely. Those indicating that the physician did not need to be religious but that he or she must respect the patients' religious beliefs comprised 14% of the sample. For example, one participant said, "Well, my faith is really important ... I think it is important that my physician has a grounded faith also that if I tell them it is something I have got to pray about and think about, that is its not snubbed as, you know, ‘Well, okay,' you know ... Whether they believe or don't, just the idea that they have respect for what you think and what you believe is important."

Of the sample, 9% indicated that they believed that God heals through their physicians. One patient stated, "I believe that healing comes more from the Lord than it does from any human being, but I do believe that the Lord puts his hand in the doctors' hands and that is how I am healed." Approximately 5% of the sample believed that their physicians did not respect their beliefs or refused to discuss them.

Perceptions of the physician's race.-- Another main theme expressed by the participants was their feelings about their physician's race. More than one half of the participants indicated that they did not care about the physician's race, with most of these persons indicating that the only thing that mattered was the physician's medical competence. They needed to have faith in the physician's competence more than they needed to be treated by somebody of the same race. Some of the statements used to underline this point included "Both white and black doctors can be good or bad" and "African-American doctors do not necessarily treat African-American patients better."

Although 10% of the sample indicated that they preferred physicians of the same race, the main reason for that preference was the perception that their physicians could understand their problems better if they were of the same race. These persons seemed to feel that their race had something to do with having arthritis and thus a physician of the same race would be able to empathize or understand their problems better. Some of the statements used to underline this point included "An African-American doctor can be better for African-American patients because they understand certain aspects of their lifestyle that may not be the same for people of other races" and "Our diet has to do with our pain and what we grew up with. So, when you have an African-American (doctor) they understand how you got to where you are."

Perceptions of the physician's sex.-- The congruence of the physicians' and patients' sex was noted by 39% of the sample. Of those who commented on this topic, 18.2% preferred a physician of the same sex. The most common reason cited was that the participant did not feel comfortable discussing "private" topics with a physician of the opposite sex. They were worried that they would feel uncomfortable and therefore be less forthcoming with their physician. Some of the statements that support this notion were "I feel more comfortable talking with or receiving examinations from doctors of my gender" and "They could better relate to or share private issues." Among the participants who preferred a physician of the opposite sex, the most popular reason was tradition. They indicated that they were accustomed to seeing male physicians (the majority of this group were women), so they preferred to stay that way because it was what they were used to. Some women in the group commented "doctors were traditionally male" and that "they had bad experiences with female doctors in the past." Only 7.8% of the sample commented that they did not care about the physician's sex and were concerned only with medical competence. This percentage may have been higher if more participants had commented on this topic. It is possible that those persons who did not care about the sex of the physician chose not to say anything rather than to note that they did not care.


   DISCUSSION
Top
 Abstract
 Methods
 Results
 Discussion
References
 
This focus group study of 75 African-American men and women with chronic knee and hip pain had several important findings. First, faith affects how patients cope with pain, and they expect faith be considered in the process of care for their knee and hip pain. Second, although patients do not expect physicians to share religion or culture, they do expect physicians to respect their cultural and religious beliefs in the care process (14%). Some patients even hope, but do not expect, that physicians might pray with them. Third, for most patients in our study, the quality of care provided is more important than the race or ethnicity of the provider (52% of sample). Finally, some patients, especially female patients (about 18%), indicated that they preferred physicians of the same sex.

Our findings with respect to faith resonate with those of previous studies that show religiosity to be prevalent in urban African-American populations and that it is associated with health-related beliefs or practices (35). Many studies have shown that African-American patients rely on religious coping in times of crisis, including health crises (36,37). More specifically, in arthritis, prayer has been reported as one of the most common self-care treatment measures used by African-American patients (31,38,39). In one study, African-American patients were reported to use prayer as a pain control mechanism (38). Our study adds to the literature articulating the hope of some African-American patients that health providers overtly recognize the role of faith in the care process.

Our findings on African-American patients' preferences regarding the ethnicity or race of the physician are in contrast with what little is found in the literature. For instance, some evidence exists that nonwhite (i.e., ethnic minority) physicians are more likely than white physicians to provide care in communities of color or ethnic minorities (40,41), suggesting that there may be a higher preference in nonwhite communities for non-white health providers. Also in one study (42), African-American patients rated their white health care providers as less engaging than white patients rated white providers or African-American patients rated African-American providers. This difference was true even when adjusted for factors such as sex of the physician and socioeconomic status of the patient. Similarly, a study of more than 8000 patients and the 344 physicians who cared for them found that nonwhite patients rated their physicians as less interactive in decision making than did white patients (43).

The preferences for same-sex physicians expressed by our study sample is consistent with results reported in other studies. For example, in a study to determine why cancer-screening rates are higher for patients of female physicians compared with patients of male physicians, Lurie and colleagues (44) found that patients prefer a female physician examiner. In contrast, a health maintenance organization study found no significant sex congruency effect on receipt of flu shots or cholesterol checks (45). The reasons for sex preference may have something to do with the nature of the health condition in question but may also be related to differences in communication styles. Male patient encounters with male physicians have been reported to be less interactive (43,46). In addition, it has been reported that female physicians talk more than male physicians do during visits. They elicit more talk from the patients, engage in more interactive discussion with patients, and cover more health information, including psychosocial issues, than do male physicians (42,47–50). Female patients of female physicians are more likely to report receiving screening and counseling than are patients of male physicians (51). Our findings on this issue corroborate previous findings by other studies that female patients prefer female physicians (43,46).

Our study has important limitations. First, we studied only African-American patients, one cultural group, in one community and primary health care center in an inner city. Therefore, our findings may not have a general application to other African-American patients in different community settings or to other cultural or ethnic groups. Second, we directed the focus of our inquiry to persons with knee and hip pain. It is possible that patients with other health conditions such as heart disease or diabetes have different perceptions and expectations for care and that our findings may be unique to the care of knee or hip pain. Finally, we addressed primarily religion and faith, one dimension of the complex concept called culture. Other dimensions of culture such as diet and other rituals were not adequately assessed.

Conclusion
This study of African-American men and women with chronic knee or hip pain from an inner city community found that faith and religion play important roles in patients' perceptions and expectations of care. Patients value quality of care and care that respects their beliefs more than the physician's race or ethnicity. Finally, most participants in this study expressed preferences for same-sex physicians. The significance of these cultural perceptions and expectations in understanding and eliminating ethnic and racial disparities in arthritis care and outcomes needs further investigation.


View this table:
[in this window]
[in a new window]
  		Table 3. Summary of Major Subcategories That Emerged From the Theme "Cultural Aspect" of Arthritis Care.

 

   Acknowledgments
 
Dr. Ibrahim is the recipient of a VA Advanced Career Development Award in Health Services Research and the Robert Wood Johnson Minority Medical Faculty Development Program Award.

Supported by a grant from the Northeastern Ohio Multi-Purpose Arthritis Center of the National Institutes of Health.

Received May 19, 2003

Accepted July 18, 2003


   References
Top
 Abstract
 Methods
 Results
 Discussion
 References
 

  1. Lavizzo-Moury R, MacKenzie ER. Cultural competence: essential measurements of quality for managed care organizations. Ann Intern Med. 1996;124:919-921.[Free Full Text]
  2. Department of Health and Human Services. The Initiative to Eliminate Racial and Ethnic Disparities in Health: Policy Statement. Washington, DC: U.S. Government Printing Office; 1998.
  3. Department of Health and Human Services. Cultural Competence Services. Washington, DC: U.S. Government Printing Office; 1992.
  4. Thomas SB, Fine MJ, Ibrahim SA. Health disparities: the importance of culture and health communication. Am J Publ Health. 2004;94:2050.[Free Full Text]
  5. Pachter LM. Culture and clinical care: folk illness beliefs and behaviors and their implications for health care delivery. JAMA. 1994;271:690-694.[Abstract/Free Full Text]
  6. Lau A, Zane N. Examining the effects of ethnic-specific services: an analysis of cost-utilization and treatment outcomes for Asian-American clients. J Comm Psych. 2000;28:63-77.
  7. Takeuchi DT, Sue S, Yeh M. Return rates and outcomes from ethnicity-specific mental health programs in Los Angeles. Am J Publ Health. 1995;85:638-643.[Abstract/Free Full Text]
  8. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from athropologic and cross-cultural research. Ann Intern Med. 1978;88:251-258.
  9. Berger JT. Culture and ethnicity in clinical care [Commentary]. Arch Intern Med. 1998;158:2085-2090.[Free Full Text]
  10. Murphy ST, Palmer JM, Azen S, Frank G, Michel V, Blackhall LJ. Ethnicity and advance directives. J Law Ethics. 1996;24:108-117.
  11. Eleazer GP, Hornung CA, Egbert CB, et al. The relationship between ethnicity and advance directives in a frail older population. J Am Geriatr Soc. 1996;44:938-943.[Medline]
  12. Hughes C, Lerman C, Lustbader E. Ethnic differences in risk perceptions among women at increased risk for breast cancer. Breast Cancer Res Treat. 1996;40:25-35.[Medline]
  13. Glanz K, Resch N, Lerman C, Rimer BK. Black-white differences in factors influencing mammography use among employed female health maintenance organization members. Ethn Health. 1996;1:207-220.[Medline]
  14. Ren XS, Amick BC. Racial and ethnic disparities in self-assessed health status: evidence from the National Survey of Families and Households. Ethn Health. 1996;1:293-303.[Medline]
  15. Morgan M. The significance of ethnicity for health promotion: patients' use of antihypertensive drugs in inner London. Int J Epidemiol. 1995;24:579-584.
  16. Brown CM, Segal R. Ethnic differences in temporal orientation and its implications for hypertension management. J Health Soc Behav. 1996;37:350-361.[Medline]
  17. McKinley ED, Garrett JM, Evans AT, Danis M. Differences in end-of-life decision-making among black and white ambulatory cancer patients. J Gen Intern Med. 1996;11:651-656.[Medline]
  18. Garrett JM, Harris RP, Norburn JK, Patrick DL, Danis M. Life-sustaining treatment during terminal illness: who wants what? J Gen Intern Med. 1993;8:361-368.[Medline]
  19. Gramelspacher GP, Zhou XH, Hanna MP, Tierney WM. Preferences of physicians and their patients for end-of-life care. J Gen Intern Med. 1997;12:346-351.[Medline]
  20. Felson DT. Osteoarthritis. Rheum Dis Clin North Am. 1990;16:499-512.[Medline]
  21. Guccione AA, Felson OT, Anderson JJ, et al. The effects of specific medical conditions on the functional limitations of elders in the Framington Study. Am J Publ Health. 1994;84:351-358.[Abstract/Free Full Text]
  22. Prevalence and impact of arthritis by race and ethnicity. US 1989–1991. MMWR Morb Mortal Wkly Rep. 1996;45:373-378.[Medline]
  23. Wilson MG, May DS, Kelly JJ. Racial differences in the use of total knee arthroplasty for osteoarthritis among older Americans. Ethn Dis. 1994;4:57-67.[Medline]
  24. Hoagland FT, Oishi CS, Gialamas GG. Extreme variations in racial rates of total hip arthroplasty for primary coxarthrosis: a population-based study in San Francisco. Ann Rheum Dis. 1995;54:107-110.[Abstract/Free Full Text]
  25. Katz BP, Freund DA, Heck DA, et al. Demographic variation in the rate of knee replacement: a multi-year analysis. Health Serv Res. 1996;31:125-140.[Medline]
  26. Baron BJ, Barrett J, Katz JN, Liang MH. Total hip arthroplasty: use and select complications in the U.S. Medicare population. Am J Publ Health. 1996;86:70-72.[Abstract/Free Full Text]
  27. Chang RW, Pellissier JM, Hazen GB. A cost effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip. JAMA. 1996;275:858-865.[Abstract/Free Full Text]
  28. Wolff BB, Langley S. Cultural factors and the response to pain. In: Landy D, ed. Culture, Disease and Healing. New York: MacMillan; 1977:313–319.
  29. Davis MA, Ettinger WH, Nauhaus JM, Barclay JD, Segal MR. Correlates of knee pain among U.S. adults with and without radiographic knee osteoarthritis. J Rheumatol. 1992;19:1943-1949.[Medline]
  30. Gerson LW, Skipper JKJ. The influence of social factors in expectations of pain associated with osteoarthritis. Scand J Rheumatol. 1975;4:139-143.[Medline]
  31. Coulton CJ, Milligan S, Chow J, Hang M. Ethnicity, self-care, and use of medical care among the elderly with joint symptoms. Arthritis Care Res. 1990;3:19-28.[Medline]
  32. Ibrahim SA, Burant CJ, Siminoff LA, Kwoh CK. Variation in perceptions of treatment and self-care practices in elderly with osteoarthritis: a comparison between African-American and white patients. Arthritis Care Res. 2001;45:340-345.
  33. Tepper S, Hochberg MC. Factors associated with hip osteoarthritis: data from the first National Health and Nutrition Examination Survey (NHANES-I). Am J Epidemiol. 1993;137:1081-1088.[Abstract/Free Full Text]
  34. Richards L. NUD*ST-4: Introductory Handbook. Melbourne: Qualitative Solutions and Research Pty. Ltd.; 1998.
  35. Klessig J. The effect of values and culture on life-support decisions. West J Med. 1992;157:316-322.[Medline]
  36. Rosen C. Ethnic differences among impoverished rural elderly in use of religion as a coping mechanism. J Rural Community Psychology. 1982;3:27-34.
  37. Swanson WC, Harter CL. How do elderly blacks cope in New Orleans? Int J Aging Hum Dev. 1971;2:210-216.
  38. Bill-Harvey D, Rippey RM, Abeles M, Pfeiffer CA. Methods used by urban, low-income minorities to care for their arthritis. Arthritis Care Res. 1989;2:60-64.[Medline]
  39. Cronan T, Kaplan RM, Kozin F. Factors affecting unprescribed remedy use among people with self-reported arthritis. Arthritis Care Res. 1993;6:149-155.[Medline]
  40. Komaromy M, Grumbach K, Drake M, et al. The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med. 1996;334:1305-1310.[Abstract/Free Full Text]
  41. Keith SN, Bell RM, Swanson AG, Williams AP. Effects of affirmative action in medical schools. A study of the class of 1975. N Engl J Med. 1985;313:1519-1525.[Abstract]
  42. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282:583-589.[Abstract/Free Full Text]
  43. Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE. Patient and visit characteristics related to physicians' participatory decision-making style. Med Care. 1995;33:1176-1187.[Medline]
  44. Lurie N, Margolis KL, McGovern PG, Mink PJ, Slater JS. Why do patients of female physicians have higher rates of breast and cervical cancer screening? J Gen Intern Med. 1997;12:34-43.[Medline]
  45. Schmittdiel J, Grumbach K, Selby JV, Quesenberry CPJ. Effect of physician and patient gender concordance on patient satisfaction and preventative care practices. J Gen Intern Med. 2000;15:761-769.[Medline]
  46. Hall JA, Roter DL. Medical communication and gender: a summary of research. J Gend Specif Med. 1998;1:39-42.[Medline]
  47. Roter D, Lipkin MJ, Korsgaard A. Sex differences in patients' and physicians' communication during primary care medical visits. Med Care. 1991;29:1083-1093.[Medline]
  48. Roter D, Hall JA. Gender differences in patient-physician communication. In: American Psychological Association, ed. Health Care for Women: Psychological, Social and Behaviorial Influences. Washington, DC: American Psychological Association; 1997:57–71.
  49. Meeuwesen L, Schaap C, van der Staak C. Verbal analysis of doctor-patient communication. Soc Sci Med. 1991;32:1143-1150.
  50. Hall JA, Irish JT, Roter DL, Ehrlich CM, Miller LH. Gender in medical encounters: an analysis of physician and patient communication in a primary care setting. Health Psychol. 1994;13:384-392.[Medline]
  51. Henderson JT, Weisman CS. Physician gender effects on preventive screening and counseling: an analysis of male and female patients' health care experiences. Med Care. 2001;39:1281-1292.[Medline]



This article has been cited by other articles:


Home page
 Journals of Gerontology Series A: Biological Sciences and Medical SciencesHome page
N. Steel, A. Clark, I. A. Lang, R. B. Wallace, and D. Melzer
Racial Disparities in Receipt of Hip and Knee Joint Replacements Are Not Explained by Need: The Health and Retirement Study 1998-2004
J. Gerontol. A Biol. Sci. Med. Sci., June 1, 2008; 63(6): 629 - 634.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Services
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
PubMed
Right arrow PubMed Citation

HOME ARCHIVE SEARCH TABLE OF CONTENTS