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“There is growing evidence and professional wisdom to suggest that health disparities do not exist in isolation, but are part of a reciprocal and complex web of problems associated with inequality and inequity in education, housing, and employment (LaVeist and Isaac, 2013; Schultz and Mullings, 2006; Weber, 2010; Williams and Mohammed, 2013). These disparities affect the unborn child through social-emotional challenges such as maternal stress and diagnosed and undiagnosed medical problems, including higher prevalence of gestational and preexisting diabetes in some pregnant populations. In other cases, they are observable at birth, particularly pronounced when prenatal care is unavailable, when the importance of care is not understood fully, and when young children are not exposed to the cognitive and social-emotional stimulation needed to thrive. These and other problems are manifested in parental stress, for example, in mother-headed and two-parent, low-income, and immigrant households alike. Parent and family adversity may reduce the number and quality of resources available and life experiences for children and families in the early years and throughout the life course. Such adversity is exacerbated by structural barriers that limit employment opportunities, increase housing instability, and contribute to homelessness, and that constrain efforts by families to effect positive change.”
Source: Nancy López, PhD, and Vivian L. Gadsden, EdD. “Health Inequities, Social Determinants, and Intersectionality.” In Bogard, K., V. Murry, and C. Alexander, eds. 2017. Perspectives on health equity and social determinants of health. Washington, DC: National Academy of Medicine.
“While some of the reasons for unmet need are more personal (no time, fear of doctor, etc.), the most common factors are health system related. Although self-reported unmet need and other existing indicators, including catastrophic spending and impoverishing out-of-pocket spending, provide a general picture of the state of accessibility in EU Member States in relation to factors such as age, income or education, they do not necessarily reveal specific gaps in access or coverage that are linked to other characteristics.
“Access gaps relate to different and cumulative dimensions: person status (gender, age, ethnicity, sexual orientation, religious and cultural preferences); health status (disease, disability, mental and physical functional capacity); social status (personal or household income, education, affiliation to a socio-professional group); and legal status (administrative status, nationality, residence, state of legal dependency). All these overlapping elements can play a role in how a person is covered and, when a need arises, is able to access the health and social care system given the specific hurdles he or she may encounter.”
Source: Palm, W., Webb, E., Hernández-Quevedo, C., Scarpetti, G., Lessof, S., Siciliani, L., & van Ginneken, E. (2021). Gaps in coverage and access in the European Union. Health policy (Amsterdam, Netherlands), 125(3), 341–350. https://doi.org/10.1016/j.healthpol.2020.12.011
“The urgency to promote health, reduce health disparities, and address the social determinants of health is highlighted in countless reports (Hankivsky and Christoffersen, 2008; World Health Organization, 2006, 2015). In short, problems in health disrupt the human developmental process. They undermine the quality of life and opportunities for children, youth, and families, particularly those exposed to vulnerable circumstances. Despite incremental change within and across health-serving agencies and increased health education and scrutiny of patient care, we continue to see significant disparities in the quality of health and life options that children in racial and ethnic minority, low-income homes and neighborhoods experience (Bloche, 2001). Research has uncovered several interconnections between health and environmental and social factors (Chapman and Berggren, 2005; Thorpe and Kelley-Moore, 2013) but has not always shifted paradigms sufficiently to either disentangle intersecting inequalities or tease apart the ways social factors and structural barriers at once interlock to prevent meaningful and sustainable change.”
Source: Nancy López, PhD, and Vivian L. Gadsden, EdD. “Health Inequities, Social Determinants, and Intersectionality.” In Bogard, K., V. Murry, and C. Alexander, eds. 2017. Perspectives on health equity and social determinants of health. Washington, DC: National Academy of Medicine.
“The phrase “health disparity” refers to adverse health differences affecting marginalized groups, arising from systemic factors that lead to social disadvantage.23 Health disparities are an equity issue and reflect both gaps in the quality of care received and broader patterns of injustice within society.24 Work on health disparities has largely focused on racial and ethnic minorities, but people with disabilities are increasingly recognized as a health disparity population.25 For example, through the Healthy People 2030 initiative, the Department of Health and Human Services has designated people with disabilities as a health disparity population.26 A challenge in identifying health disparities affecting disabled people is that some disabling conditions do inevitably lead to poorer health, regardless of individual circumstances, whereas in other instances, poorer health may be attributable to economic and social inequities such as barriers to health care access, thereby being accurately described as health disparities.1 Disentangling cause and effect in attributing and addressing these differences is an ongoing challenge.27
“People with disabilities are more likely to report poor health and experience higher rates of chronic health conditions than nondisabled people. Data published in 2012 and 2015 indicate that disabled adults were more likely to experience chronic conditions such as cardiac disease, diabetes, higher weight, and asthma and to lack emotional support.28,29 They were also more likely to experience both injuries and intimate partner and interpersonal violence, according to studies published in 2015 and 2016.30,31
“Disabled women are more likely than their nondisabled peers to have chronic health conditions and to describe their general health as fair or poor.21 Women with disabilities have lower rates of breast and cervical cancer screening compared with nondisabled women, and disabled women with circulatory or respiratory conditions have higher rates of breast cancer mortality than women without disabilities.32
“Limited research identifies differences in health status and outcomes based on type of disability.33 One study published in 2013 found that people with multiple disabilities had worse health outcomes and that people with hearing disabilities fared better on most outcomes than people with vision, physical, or cognitive disabilities.34 Another study published in 2019 found that adults with intellectual disabilities or autism were more likely to report comorbidities, including poor mental health, than adults with other disabilities.35“
Source: Monika Mitra, Linda Long-Bellil, Ian Moura, Angel Miles, and H. Stephen Kaye, Advancing Health Equity And Reducing Health Disparities For People With Disabilities In The United States, Health Affairs 2022 41:10, 1379-1386.
“The association between health and education has been repeatedly tested because of the capacity of the latter to establish different levels of social stratification [20]. Population groups defined by a low educational level show a greater disadvantage in terms of health, although there are differences between countries according to their specificities regarding health behaviours and public policies [6, 20, 28]. Individuals with the lowest educational level have been consistently found to report the worse health [35]. Indeed, education has been shown to influence an individual’s health at different life-course stages (from adulthood to advanced age), as well as to mediate the long-term influence of early-life conditions on health [3].
“Educational differences in health across Europe are well documented, with a general pattern of large variations in the magnitude of the differentials across countries. In general, a high level of social transfer is expected to reduce exposure to deprivation, and this could be translated into reductions in the health disadvantage of poorly educated groups. For instance, for the Spanish population with a low educational level, Alcañiz et al. [2] found a higher prevalence of certain lifestyle indicators such as tobacco and alcohol consumption and a sedentary lifestyle, in addition to greater problems in performing daily activities. Additionally, the magnitude of the influence of education on health differs between women and men. According to the resource substitution theory, the absence of one or more socio-economic resources can be replaced by a greater influence from other resources [36]. As a consequence, lower female participation in the labour market, as well as the gender wage gap, has reinforced the importance of education for health among women [36, 37].”
Source: Gumà, J., Solé-Auró, A. & Arpino, B. Examining social determinants of health: the role of education, household arrangements and country groups by gender. BMC Public Health 19, 699 (2019). https://doi.org/10.1186/s12889-019-7054-0.
“Given the results that low-SES [Socioeconomic Status] populations often visit specialist physicians less often, but primary-care physicians more frequently at concurrently equal probabilities compared to high SES populations, an intuitive explanation is that barriers in access to specialists are important in explaining healthcare inequalities. One possible reason for access barriers to specialists might be rurality of low-SES populations [71]. Thus, waiting time and distance might carry more weight in visiting specialists, because those are often distributed regionally more widely than primary-care physicians. Furthermore, the results suggest that different information, preferences, and patient choices are relevant reasons for socioeconomic inequalities in physician visits, because the relationship with primary-care physicians is more trusting and familiar than with specialist. As a consequence, the lower educated might feel less exposed to existing communication problems (language barriers, terminology, information gap) [72] with their longtime, well-known primary-care physicians, and they might prefer visits to them compared to specialist physicians [10]. The perceived role in healthcare varies between SES groups, as those with low SES tend to delegate responsibility to healthcare professionals [73]. Given the trustful and longtime relationship with primary care physicians compared to specialists, and given that primary-care physicians have the task of gatekeeping in some countries, might emphasize the importance of primary-care physicians from the perspective of the low-SES population when delegating responsibility for their healthcare, and might therefore explain the more frequent visits from the most deprived.
“This review found that income inequalities advantaging high-SES groups in primary-care physician visits are more pronounced than educational differences. This may be an indication that financial barriers are a relevant additional factor explaining socioeconomic inequalities in utilization of primary-care physicians [74]. The finding that detrimental inequalities were found less often in shorter time periods is consistent with the finding that detrimental inequalities were found less often when utilization was operationalized with frequency versus probability. Accordingly, a higher frequency of physician visits among the most deprived means that they are more likely to have visited a physician at least once in a short period. A possible explanation could be that frequencies are more likely to be influenced by preferences and patient choice, whereas probabilities are more likely to be influenced by access barriers.”
Source: Lueckmann, S.L., Hoebel, J., Roick, J. et al. Socioeconomic inequalities in primary-care and specialist physician visits: a systematic review. Int J Equity Health 20, 58 (2021). https://doi.org/10.1186/s12939-020-01375-1.
Social Determinants & Health Equity: Recommended Resources
US Health and Human Services Health People 2030
Centers for Disease Control Social Determinants of Health
World Health Organization Health Equity Monitor
Breaking News
- Practice Consolidation and Access to Quality Care May 14, 2023May 14, 2023 The New York Times reports on a growing trend among healthcare organizations in the US, the impact of which may be of concern for patients and taxpayers. The Times reported on May 8, 2023 (“Corporate Giants Buy Up Primary Care Practices at Rapid Pace”) that: “CVS Health, with its sprawling pharmacy business and ownership ...
- Oregon Becomes First US State To Guarantee Its Residents Access To Affordable Healthcare January 20, 2023January 20, 2023 In the November 2022 general election, Oregon voters narrowly approved Oregon Measure 111, the Right to Healthcare Amendment. The measure amended the state constitution, adding a guarantee of access to affordable healthcare for all Oregon residents. According to Ballotpedia, last accessed Jan. 20, 2023: “Ballot title “The ballot title was as follows:“Amends Constitution: State must ...
- Massive Savings Possible In US Health System October 21, 2021October 21, 2021 The management consulting firm McKinsey & Company has issued a new report estimating that administrative changes and efficiencies could save the US health system more than a quarter trillion dollars. As noted in a Viewpoint article published in JAMA on October 20: “The analysis dissected profit and loss statements of individual health care organizations, estimated ...
- Health Care in the US Compared to Other High-Income Countries August 6, 2021On August 4, the Commonwealth Fund issued a new report entitled Mirror, Mirror 2021: Reflecting Poorly / Health Care in the US Compared to Other High-Income Countries. The report compares health care systems in eleven nations: the United States, Canada, Switzerland, France, Sweden, New Zealand, Germany, the United Kingdom, Australia, the Netherlands, and Norway. The report’s key ...
- Medical Debt in Collections in the US August 6, 2021On July 20, JAMA published an article on medical debt in collections in the US entitled “Medical Debt in the US, 2009-2020.” The researchers found: “In this retrospective analysis of credit reports for a nationally representative 10% panel of individuals, an estimated 17.8% of individuals in the US had medical debt in collections in June 2020 ...
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Page last updated March 12, 2023 by Doug McVay, Editor.
