Health equity

Health equity refers to the study of differences in the quality of and health care across different populations.^[1] It is a political concept which differs from health equality (which is any measurement of difference in health outcome). 'Equity' implies some kind of social injustice, whereas 'equality' does not. Thus if one population dies younger than another because of genetic differences, we tend do say that there is a health inequality, but if they die younger due to lack of access to medicines, we might say that there is a health inequity.^[2] These difference may include differences in the "presence of disease, health outcomes, or access to health care"^[3] across racial, ethnic, sexual orientation and socioeconomic groups.^[4] Similarly, the term 'disparities' may be used instead of 'differences' to indicate a moral valuation.^[5]

Health equity can be defined as follows:^[6]

- Horizontal equity: The equal treatment of individuals or groups in the same circumstances.

- Vertical equity: The principle that individuals who are unequal should be treated differently according to their level of need.

Differences between populations in the presence of disease and health outcomes are well-documented in many areas. In the United States, disparities are well documented in minority populations such as African Americans, Native Americans, Asian Americans, and Latinos, with these groups having higher incidence of chronic diseases, higher mortality, and poorer overall health outcomes.^[7] For example, the cancer incidence rate among African Americans is 10% higher than among whites,^[8] and adult African Americans and Latinos have approximately twice the risk as whites of developing diabetes.^[8] Similarly, differences in the overall level of health in individuals also exist between differing social classes, with lower-status socioeconomic groups generally having poorer health and higher rates of chronic illness including obesity, diabetes, and hypertension;^[9] whether these are considered disparities to be eliminated depends on the author.^[5]

Health equity by some definitions^[5] also includes differences in access to health care between populations. For example, those in lower-status socioeconomic groups receive less consistent primary care, which is positively correlated to overall level of health in the recipient.^[10] Similarly, in England, "people living in deprived areas were found to receive around 70% less provision relative to need compared with the most affluent areas for both knee and hip replacements."^[11] According to Thomas LaVeist, Director of the Hopkins Center for Health Disparities Solutions, there are six key factors that contribute to health disparities: socioeconomic conditions, social and physical environments, access to quality care, cultural competency, health literacy, and empowered healthcare consumers.^[12]

A lack of health equity is also evident in the developing world, where the importance of equitable access to healthcare has been cited as crucial to achieving many of the Millennium Development Goals.^[13] "As the populations of the developed countries are aging and coming to require ever more medical attention, they are sucking away local health talent from developing countries"^[14]

Ethnic and racial disparities

See Ethnicity and health and Race and health.

The United States historically had large disparities in health and access to adequate healthcare between races, and current evidence supports the notion that these racially-centered disparities continue to exist and are a significant social health issue.^[15] The disparities in access to adequate healthcare include differences in the quality of care based on race and overall insurance coverage based on race. The Journal of the American Medical Association identifies race as a significant determinant in the level of quality of care, with ethnic minority groups receiving less intensive and lower quality care. Ethnic minorities receive less preventative care, are seen less by specialists, and have fewer expensive and technical procedures than non-ethnic minorities.^[16]

There are also considerable racial disparities in access to insurance coverage, with ethnic minorities generally having less insurance coverage than non-ethnic minorities. For example, Hispanic Americans tend to have less insurance coverage than white Americans and receive less regular medical care. The level of insurance coverage is directly correlated with the level of access to healthcare including preventative and ambulatory care.^[15]

A 2010 study on racial and ethnic disparities in health done by the Institute of Medicine showed that these differences cannot be accounted for in terms of certain demographic characteristic like insurance status, household income, education, age, geographic location and severity of conditions is comparable. Even when the researchers corrected for these factors, the disparities persist.^[17]

It is pretty widely recognized that minority groups generally have higher death rates from cancer, heart disease and diabetes than whites. Gerard Boe’s article^[18] cites studies that show major disparities in health care as it relates to specific diseases:

• Heart Disease: African Americans are 13% less likely to be recommended for and undergo coronary angioplasty and 1/3 less likely to undergo bypass surgery than whites. Death rates from heart attack and stroke are 29% and 40% higher, respectively, among African Americans than whites^[19]
• Asthma: Of preschool aged children who were hospitalized for Asthma related conditions, only 7% of African American children, 2% of Hispanic children compared to over 20% of White children are prescribed medications to prevent future Asthma related hospitalizations.
• Breast Cancer: Studies have found that the length of time between and abnormal mammogram and further diagnostic testing to determine if a patient has cancer is more than twice as long in Asian-American, African American and Hispanic women than it is in White women. African American women are more than twice as likely as white women to die of cervical cancer and have the highest rate of breast cancer death of any racial or ethnic group^[19]
• Compared with rates in whites, the rates of diabetes are 1.9 times higher among Hispanics, two times higher among African Americans, and 2.6 times higher among Native Americans
• Some of these disparities are actually worsening. For example, the African American–to-white ratio of infant mortality has steadily increased during the past 2 decades and now is at 2.5:1

His article also discusses the increased incidence of receiving little or no routine and usual care and therefore, reduced chance of receiving preventative care and other health services.

• Hispanic children are almost three times as likely to receive no routine and usual source of health care as White children.
• Only 16% of White patients have a lack of routine and usual sources of health care compared to about 20% of African Americans and 30% of Hispanic patients.

Racial and Ethnic disparities in children:^[20] 31.4 million Children in the United States are of non-white race or ethnicity (March 2010), this compromises 43% of American children and shows an increase over 11% since 2000. Mortality rates are substantially higher in minority children for all-cause mortality. Overall mortality rates are consistently found to be significantly higher in African American and other minority children. Specifically, disparities are found in specific mortality rates for certain diseases, acute-lymphoblastic leukemia and congenital heart defect among others. Asthma has also been a topic of many studies.

Race is considered to be more strongly associated with higher rates of African American children with unmet health care needs and lower access to primary health care providers than income is.^[20]

One of the most important ways to help reduce health disparities is to work to reduce language barriers between patients and physicians. Language barriers are a major problem because of five main difficulties:^[19]

• First, arriving at an accurate diagnosis is difficult, because an adequate history cannot be obtained.
• Second, treatment options cannot be adequately explained and discussed.
• Third, it is impossible to obtain truly informed consent for diagnostic and therapeutic procedures.
• Fourth, any attempts to provide health education are severely compromised.
• Finally, it is very difficult for physicians to act as effective advocates for patients we do not really know.

If physicians and other clinicians are able to reduce language barriers the resulting improved communication can improve compliance, reduce the number of emergency room visits, and enhance patient understanding.^[19] Gunderman suggests that there are a few ways for physicians and the health care system in general to reduce language barriers like using nonverbal communication through gestures, the use of visual aids, and printed materials and videos in patients' native languages. They can also improve their fluency in the non-English equivalents of basic medical terms. The use of trained interpreters can also prove extremely valuable.

There is debate about what causes health disparities between ethnic and racial groups.^[21] However, it is generally accepted that disparities can result from three main areas:

The Institute of Medicine report, Race, Ethnicity, and Language Data identifies current models for collecting and coding race, ethnicity, and language data; ascertains the challenges involved in obtaining these data in health care settings; and makes recommendations for improvement.

A study of 20,000 cancer patients in the United States found that African Americans are less likely than European Americans to survive breast cancer, prostate cancer, and ovarian cancer even when given equal care, but that other forms of cancer had equal survival chances, which suggests that biological factors may be at work.^[22]

The National Partnership for Action to End Health Disparities (NPA) was established to mobilize a nationwide, comprehensive, community-driven, and sustained approach to combating health disparities and to move the nation toward achieving health equity. The mission of the NPA is to increase the effectiveness of programs that target the elimination of health disparities through the coordination of partners, leaders, and stakeholders committed to action. http://minorityhealth.hhs.gov/npa/

The National Stakeholder Strategy (NSS) for Achieving Health Equity is a product of the NPA. This document provides a common set of goals and objectives for public and private sector initiatives and partnerships to help racial and ethnic minorities—and other underserved groups—reach their full health potential. The strategy incorporates ideas, suggestions and comments from thousands of individuals and organizations across the country. Local groups can use the National Stakeholder Strategy to identify which goals are most important for their communities and adopt the most effective strategies and action steps to help reach them. http://minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286

LGBT minority group health disparities

See also LGBT issues in medicine.

Often under emphasized are the minority groups that are heavily affected by health disparities in America, UK and all the same worldwide. Health disparities are not just based on race, ethnic, and cultural differences. Such disparities are seen as affecting the sexuality minority groups and observations and surveys show that one’s sexual minority status may limit access to health care, with especially bad impact on lesbians,^[23] who are being discriminated both as females and as homosexual.^[24]

The homosexual, bisexual, and transgender population continuously experiences a wide range of health and mental health problems related to their sexuality and gender identity.^[25] The ongoing discrimination and reduced access to medical care, social and cultural experiences often worsens these problems.^[25] Medical professionals and all global citizens are strongly encouraged to treat each patient, consumer and individual equally while being aware of the ideal language, practices and comments to be employed, no matter the sexual orientation.^[25] Small changes in the lifestyles of heterosexuals and adjustments in what is considered to be a social norm can decrease the risks of mental health problems within homosexual, bisexual and transgender individuals and therefore develop social equality.^[25]

“Health inequalities exist for lesbian and bisexual women, largely related to experiences of discrimination, homophobia and heterosexism.”^[26] This known interference with health care access is a prime example of heterosexual privilege and homosexual prejudice prevalence in Western societies. Just as this lack of health care affects minority races, ethnic groups, and less represented cultural beliefs; lesbian and bisexual women are deteriorating their health by either not seeing (being feared of) or not be attended to by health care professionals.

It is important that health care professionals consider the nine cultural competency techniques suggested by the Agency for Healthcare Research and Quality and make an effort to break the barriers put into place through society’s homophobia and heterosexism.^[27]

"We don't have a good understanding of the developmental processes that affect LGBT persons. I would love to see something that pulls together what we have attempted to piece together: the LGBT life cycle," -Brian de Vries, gerontologist at San Francisco State University.

In 2005, the University of California at San Francisco Lesbian, Gay, Bisexual, and Transgender Resource Center implemented processes to provide more equitable and culturally competent care to LGBT patients at its medical center. As of 2013, the medical center is the only institution in the United States to achieve perfect scores on the Healthcare Equality Index that rates hospitals on issues such as patient and employee non-discrimination policies, employee cultural competency training, and hospital visitation rights for LGBT patients' families.^[28]

Most of the current research that exists focuses on homosexual male adults in regards to HIV. There is very little research regarding the entire group of individuals who are categorized under the LGBT umbrella.^[29] A ground breaking report sponsored by the University of Minnesota’s Program in Human Sexuality looked into existing literature regarding findings on health issues for LGBT individuals. The report focused on HIV as well as other health issues, including lesbian, bisexual, and transgender individuals. The report listed many key findings:

• HIV is found disproportionately in young men, particularly young black men
• LGBT youth and adults have a higher risk for depression, suicidal thoughts or actions, mood and anxiety disorders; some small studies suggest the same elevated risk may be true in transgender youth
• Smoking, alcohol consumption and drug abuse may be have a higher incidence in LGBT youth
• Very little research has been done on this topic among transgender youth
• Lesbian and bisexual women may be at a greater risk of obesity and breast cancer than heterosexual women
• Some very limited research may suggest that older transgender individuals will experience some negative health problems as a result of long-term hormone use.^[30]

Gay, Lesbian, Bisexual, and Transgender Health Access Project:

The Gay, Lesbian, Bisexual, and Transgender Health Access Project was established in 1997 and first funded by Massachusetts Department of public health. The program developed standards of practice for quality health care services. It also developed a training curriculum for health care providers.

Mission: "To strengthen the Massachusetts Department of Public Health's ability to foster the development of comprehensive, culturally appropriate health promotion policies and health care services for GLBT people through a variety of venues including community awareness, policy development, advocacy, and prevention strategies."

Vision: "To create a partnership between the Massachusetts Department of Public Health, community-based health and human services agencies, and the GLBT communities and their straight allies to develop an awareness of health issues; reduce barriers to health care and prevention services; and promote, enhance, and sustain health norms for GLBT people throughout the Commonwealth of Massachusetts."

One of their major goals is the identify, quantify and close gaps in services as well as barriers to care for GLBT people. www.glbthealth.org/about.html

Healthcare equity and sex

The results in comparing inequities in access to adequate healthcare and gender show that women in the United States generally have higher levels of access to care. These disparities can be explained in part by looking at rates of overall insurance coverage (privatized and publicly assisted) between men and women, the effects of certain socioeconomic factors on levels of coverage between men and women, and overall gender-based differences in perceptions of health and health care.

In the United States, women have better access to healthcare, in part, because they have higher rates of health insurance. In one study of a population group in Harlem, 86% of women reported having health insurance (privatized or publicly assisted), while only 74% of men reported having any health insurance. This trend in women reporting higher rates of insurance coverage is not unique to this population and is representative of the general population of the US.^[10]

Gender-based perceptions of health and healthcare may help explain some of the lag of men behind women in levels of insurance coverage. Women report higher rates of illness than men, which barring the idea that women are sicker than men, indicates women are more likely to seek medical care out and are therefore more likely to possess medical insurance.^[10]

Gender-related disparities in access to healthcare are also related to socioeconomic factors including geographic job-market differences and differing levels of government assistance available to men and women. There are fewer job opportunities with insurance coverage available to men and women living in poorer communities, and of these opportunities, women tend to occupy more of the jobs with these benefits. Government assistance available to these individuals without job-related coverage varies between men and women, with women, especially women with children, receiving a higher percentage of available public assistance than men.^[10] Ultimately, for both men and women discrepancies in access to adequate healthcare is largely based on socioeconomic issues including income and full-time work status, with both groups of men and women with higher levels of income and full-time work receiving greater access to adequate healthcare.^[10]

Healthcare Inequality and Socioeconomic Status

While gender and race play significant factors in explaining healthcare inequality in the United States, socioeconomic status is the greatest determining factor in an individual's level of access to healthcare.

Socioeconomic differences vary between racial groups and its effects on health status. African Americans and Hispanics have a poverty rate of thirty three percent and twenty nine percent, which is significantly higher than the eleven percent in whites.^[31] Unfortunately, these socioeconomic disparities translate into three times higher death rates from heart disease in low-income blacks and whites when compared to their middle-income counterparts. In general, black women and men have higher rates of death from coronary heart disease among every income level when compared to whites, therefore, demonstrating that blacks tend to be in poorer health. In addition, cancer mortality is higher in blacks when compared to whites due inadequate preventative health screenings, or delays in diagnostics and treatment.^[32]

Actions such as smoking also affect health.^[33] Even when black individuals obtain the same educational attainment as their white counterparts, research has demonstrated that an inequality in health, income, and employment remains.^[34] In addition, when studying inequalities it is important to note that the association between health and education is minimize when compared to the large inequality associated with health and income.^[31]

Health Inequality and Environmental Influence

Minority populations have increase exposure to environmental hazards that include lack of neighborhood resources, structural and community factors as well as residential segregation that result in a cycle of disease and stress.^[35] The environment that surrounds us can influence individual behaviors and lead to poor health choices and therefore outcomes.^[36] Minority neighborhoods have been continuously noted to have more fast food chains and fewer grocery stores than predominantly white neighborhoods.^[36] These food deserts affect a family’s ability to have easy access to nutritious food for their children. This lack of nutritious food extends beyond the household into the schools that have a variety of vending machines and deliver over processed foods.^[36] These environmental condition have social ramifications and in the first time in US history is it projected that the current generation will live shorter lives than their predecessors will.^[36]

In addition, minority neighborhoods have various health hazards that result from living close to highways and toxic waste factories or general dilapidated structures and streets.^[36] These environmental conditions create varying degrees of health risk from noise pollution, to carcinogenic toxic exposures from asbestos and radon that result in increase chronic disease, morbidity, and mortality.^[34] The quality of residential environment such as damaged housing has been shown to increase the risk of adverse birth outcomes, which is reflective of a communities health.^[37] Housing conditions can create varying degrees of health risk that lead to complications of birth and long-term consequences in the aging population.^[37] In addition, occupational hazards can add to the detrimental effects of poor housing conditions. It has been reported that a greater number of minorities work in jobs that have higher rates of exposure to toxic chemical, dust and fumes.^[31]

Racial segregation is another environmental factor that occurs through the discriminatory action of those organizations and working individuals within the real estate industry, whether in the housing markets or rentals. Even though residential segregation is noted in all minority groups, blacks tend to be segregated regardless of income level when compared to Latinos and Asians.^[38] Thus, segregation results in minorities clustering in poor neighborhoods that have limited employment, medical care, and educational resources, which is associated with high rates of criminal behavior.^[39][40] In addition, segregation affects the health of individual residents because the environment is not conducive to physical exercise due to unsafe neighborhoods that lack recreational facilities and have nonexistent park space.^[39] Racial and ethnic discrimination adds an additional element to the environment that individuals have to interact with daily. Individuals that reported discrimination have been shown to have an increase risk of hypertension in addition to other physiological stress related affects.^[41] The high magnitude of environmental, structural, socioeconomic stressors leads to further compromise on the psychological and physical being, which leads to poor health and disease.^[42]

Individuals living in rural areas, especially poor rural areas, have access to fewer health care resources. Although 20 percent of the U.S. population lives in rural areas, only 9 percent of physicians practice in rural settings. Individuals in rural areas typically must travel longer distances for care, experience long waiting times at clinics, or are unable to obtain the necessary health care they need in a timely manner. Rural areas characterized by a largely Hispanic population average 5.3 physicians per 10,000 residents compared with 8.7 physicians per 10,000 residents in nonrural areas. Financial barriers to access, including lack of health insurance, are also common among the urban poor.^[43]

Disparities in access to health care

Reasons for disparities in access to health care are many, but can include the following:

• Lack of insurance coverage. Without health insurance, patients are more likely to postpone medical care, more likely to go without needed medical care, and more likely to go without prescription medicines. Minority groups in the United States lack insurance coverage at higher rates than whites.^[44]
• Lack of a regular source of care. Without access to a regular source of care, patients have greater difficulty obtaining care, fewer doctor visits, and more difficulty obtaining prescription drugs. Compared to whites, minority groups in the United States are less likely to have a doctor they go to on a regular basis and are more likely to use emergency rooms and clinics as their regular source of care.^[45]
• Lack of financial resources. Although the lack of financial resources is a barrier to health care access for many Americans, the impact on access appears to be greater for minority populations.^[46]
• Legal barriers. Access to medical care by low-income immigrant minorities can be hindered by legal barriers to public insurance programs. For example, in the United States federal law bars states from providing Medicaid coverage to immigrants who have been in the country fewer than five years.^[47]
• Structural barriers. These barriers include poor transportation, an inability to schedule appointments quickly or during convenient hours, and excessive time spent in the waiting room, all of which affect a person's ability and willingness to obtain needed care.^[48]
• The health care financing system. The Institute of Medicine in the United States says fragmentation of the U.S. health care delivery and financing system is a barrier to accessing care. Racial and ethnic minorities are more likely to be enrolled in health insurance plans which place limits on covered services and offer a limited number of health care providers.^[47]
• Scarcity of providers. In inner cities, rural areas, and communities with high concentrations of minority populations, access to medical care can be limited due to the scarcity of primary care practitioners, specialists, and diagnostic facilities.^[49]
• Linguistic barriers. Language differences restrict access to medical care for minorities in the United States who are not English-proficient.^[50]
• Health literacy. This is where patients have problems obtaining, processing, and understanding basic health information. For example, patients with a poor understanding of good health may not know when it is necessary to seek care for certain symptoms. While problems with health literacy are not limited to minority groups, the problem can be more pronounced in these groups than in whites due to socioeconomic and educational factors.^[49]
• Lack of diversity in the health care workforce. A major reason for disparities in access to care are the cultural differences between predominantly white health care providers and minority patients. Only 4% of physicians in the United States are African American, and Hispanics represent just 5%, even though these percentages are much less than their groups' proportion of the United States population.^[51]
• Age. Age can also be a factor in health disparities for a number of reasons. As many older Americans exist on fixed incomes which may make paying for health care expenses difficult. Additionally, they may face other barriers such as impaired mobility or lack of transportation which make accessing health care services challenging for them physically. Also, they may not have the opportunity to access health information via the internet as less than 15% of Americans over the age of 65 have access to the internet.^[52] This could put older individuals at a disadvantage in terms of accessing valuable information about their health and how to protect it. On the other hand, older individuals in the US (65 or above) are provided with medical care via Medicare.

Disparities in quality of health care

Health disparities in the quality of care exist and are based on language and ethnicity/race which includes:

• Problems with patient-provider communication. Communication is critical for the delivery of appropriate and effective treatment and care, regardless of a patient’s race, and miscommunication can lead to incorrect diagnosis, improper use of medications, and failure to receive follow-up care. The patient provider relationship is dependent on the ability of both individuals to effectively communicate. Language and culture both play a significant role in communication during a medical visit. Among the patient population, minorities face greater difficulty in communicating with their physicians. Patients when surveyed responded that 19% of the time they have problems communicating with their providers which included understanding doctor, feeling doctor listened, and had questions but did not ask.^[53] In contrast, the Hispanic population had the largest problem communicating with their provider, 33% of the time.^[53] Communication has been linked to health outcomes, as communication improves so does patient satisfaction which leads to improved compliance and then to improved health outcomes.^[54] Quality of care is impacted as a result of an inability to communicate with health care providers. Language plays a pivotal role in communication and efforts need to be taken to ensure excellent communication between patient and provider. Among limited-English proficient patients in the United States, the linguistic barrier is even greater. Less than half of non-English speakers who say they need an interpreter during clinical visits report having one. The absence of interpreters during a clinical visit adds to the communication barrier. Furthermore, inability of providers to communicate with limited English proficient patients leads to more diagnostic procedures, more invasive procedures, and over prescribing of medications.^[55] Poor communication contributes to poor medical compliance and health outcomes. Many health-related settings provide interpreter services for their limited English proficient patients. This has been helpful when providers do not speak the same language as the patient. However, there is mounting evidence that patients need to communicate with a language concordant physician (not simply an interpreter) to receive the best medical care, bond with the physician, and be satisfied with the care experience.^[56][57] Having patient-physician language discordant pairs (i.e. Spanish-speaking patient with an English-speaking physician) may also lead to greater medical expenditures and thus higher costs to the organization.^[58] Additional communication problems result from a decrease or lack of cultural competence by providers. It is important for providers to be cognizant of patients’ health beliefs and practices without being judgmental or reacting. Understanding a patients’ view of health and disease is important for diagnosis and treatment. So providers need to assess patients’ health beliefs and practices to improve quality of care.^[59] Patient health decisions can be influenced by religious beliefs, mistrust of Western medicine, and familial and hierarchical roles, all of which a white provider may not be familiar with.^[60] Other type of communication problems are seen in LGBT health care with the spoken heterosexist (conscious or unconscious) attitude on LGBT patients, lack of understanding on issues like having no sex with men (lesbians, gynecologic examinations) and other issues.^[61]

• Provider discrimination. This is where health care providers either unconsciously or consciously treat certain racial and ethnic patients differently from other patients. This may be due to stereotypes that providers may have towards ethnic/racial groups. Doctors are more likely to ascribe negative racial stereotypes to their minority patients.^[62] This may occur regardless of consideration for education, income, and personality characteristics. Two types of stereotypes may be involved, automatic stereotypes or goal modified stereotypes. Automated stereotyping is when stereotypes are automatically activated and influence judgments/behaviors outside of consciousness.^[63] Goal modified stereotype is a more conscious process, done when specific needs of clinician arise (time constraints, filling in gaps in information needed) to make a complex decisions.^[63] Physicians are unaware of their implicit biases.^[64] Some research suggests that ethnic minorities are less likely than whites to receive a kidney transplant once on dialysis or to receive pain medication for bone fractures. Critics question this research and say further studies are needed to determine how doctors and patients make their treatment decisions. Others argue that certain diseases cluster by ethnicity and that clinical decision making does not always reflect these differences.^[65]

• Lack of preventive care. According to the 2009 National Healthcare Disparities Report, uninsured Americans are less likely to receive preventive services in health care.^[66] For example, minorities are not regularly screened for colon cancer and the death rate for colon cancer has increased among African Americans and Hispanic populations. Furthermore, limited English proficient patients are also less likely to receive preventive health services such as mammograms.^[67] Studies have shown that use of professional interpreters have significantly reduced disparities in the rates of fecal occult testing, flu immunizations and pap smears.^[68]

Plans for achieving health equity

The National Stakeholder Strategy for Achieving Health Equity (NSS) provides a common set of goals and objectives for public and private sector initiatives and partnerships to help racial and ethnic minorities—and other underserved groups—reach their full health potential.

Additionally, the Office of Minority Health has released the NPA Toolkit for Community Action. Community members can use the toolkit to engage fellow citizens and local media as they spread the word about health disparities and educate others about the impact disparities have in the lives of individuals and the greater impact on society.

The Bay Area Regional Health Inequities Initiative (BARHII) provides a Health Planning Guide intended to help public health and planning departments collaborate on strategies to promote healthier communities. Each page links health risks to aspects of the built environment, outlining ways to ensure that neighborhoods are designed to support health equity and community well-being.

The Commonwealth Fund, in a report on how to eliminate health disparities, says that the following steps should be considered in developing policies to eliminate racial and ethnic disparities:^[69]

• Consistent racial and ethnic data collection by health care providers.
• Effective evaluation of disparities-reduction programs.
• Minimum standards for culturally and linguistically competent health services.
• Greater minority representation within the health care workforce.
• Establishment or enhancement of government offices of minority health.
• Expanded access to services for all ethnic and racial groups.
• Involvement of all health system representatives in minority health improvement efforts.

Other methods for ending health disparities or reducing health disparities have been suggested based on research that observes cultural differences within health care systems. According to the Agency for Healthcare Research and Quality and the assisting authors Cindy Brach^[70] and Irene Fraserirector, in an effort to reduce disparities between racial and ethnic groups, the health care system should consider the following nine cultural competency techniques:

• Interpreter services. If agencies take an active approach in hiring professional interpreters, for both foreign languages and for the speaking and hearing impaired, communication barriers will begin to decrease.
• Recruitment and Retention. Healthcare systems need to become more conscious of the staff within their facilities. It is essential to the reduction of disparities that most minority groups be represented within the various health care offices and clinics.
• Training. The Agency for Healthcare Research and Quality and its assisting authors emphasized the importance of health care professionals being trained to work with interpreters and minority groups.
• Coordinating with traditional healers. Health care workers should be supportive and able to adjust health care plans according to the patient’s cultural beliefs and traditional health practices.
• Use of Community Health Workers. These individuals could be responsible for bringing in the population of people who rarely seek out health care.
• Culturally competent health promotion. This information can be available through community health workshops, or simply by health care workers taking the necessary measures to promote early detection and treatment and outlining the good and risky health behaviors to all patients.
• Including family and/or community members. The Agency for Healthcare Research and Quality states that this particular cultural competency may be vital to obtaining consent and adherence to treatments.
• Immersion into another culture. Allowing yourself to step outside of your comfort zone will increase your tolerance for another culture as well as raise your awareness to new ideals and beliefs.
• Administrative and Organizational accommodations. These are some aspects of the health care offices that should be considered; they include the location of the healthcare offices, public transportation availability, clinic hours, the physical environment of the clinic, and the rapport built with the patients.^[27]

Programs Designed to Reduce Disparities

In 2011, HealthPartners Institute for Education and Research implemented the EBAN Experience™ program to reduce health disparities among minority populations, most notably East African immigrants.^[71]

Affordable Care Act (ACA) role in ending health disparities

The United States in the past has spent less on public health activities when compared to the administrative overhead of medical care and insurance, however, through the Affordable Care Act, a projected $15 billion will be provided for expansion of public health services.^[72] An increase in public health spending by 10 percent has been associated with reductions in infant mortality by 6.85 percent, cardiovascular deaths by 3.22 percent, diabetes death by 1.44 percent and cancer deaths by 1.13 percent.^[72] Many minority communities lack sufficient funds and resources, therefore, these neighborhoods could benefit significantly from this added financial resource that can help narrow that gap of inequality.^[73] These additional measures will add to the benefits from expanded insurance coverage through the exchange programs, Medicare, and Medicaid. The ACA is providing the opportunity for millions of uninsured to have access to quality care. The previously uninsured will have multiple programs to help facilitate healthier living such as community promotoras,^[74] and racial and ethnic approaches to community health (REACH).^[75] Furthermore, the ACA is creating cultural and linguistic standards for healthcare professionals working in federally funded centers to maintain and meet the needs of the diverse population that is vulnerable to unequal access.^[75]

Health inequalities

Health inequality is the term used in a number of countries to refer to those instances whereby the health of two demographic groups (not necessarily ethnic or racial groups) differs despite comparative access to health care services. Such examples include higher rates of morbidity and mortality for those in lower occupational classes than those in higher occupational classes, and the increased likelihood of those from ethnic minorities being diagnosed with a mental health disorder. In Canada, the issue was brought to public attention by the LaLonde report.

In UK, the Black Report report was produced in 1980 to highlight inequalities. On 11 February 2010, Sir Michael Marmot, an epidemiologist at University College London, published the Fair Society, Healthy Lives report on the relationship between health and poverty. Marmot described his findings as illustrating a "social gradient in health": the life expectancy for the poorest is seven years shorter than for the most wealthy, and the poor are more likely to have a disability. In its report on this study, The Economist argued that the material causes of this contextual health inequality include unhealthful lifestyles - smoking remains more common, and obesity is increasing fastest, amongst the poor in Britain.^[76]

Poor Health and Economic Inequality

Poor health outcomes appear to be an effect of economic inequality across a population. Nations and regions with greater economic inequality show poorer outcomes in life expectancy,^[77] mental health,^[78] drug abuse,^[79] obesity,^[80] educational performance, teenage birthrates, and ill health due to violence. On an international level, there is a positive correlation between developed countries with high economic equality and longevity. This is unrelated to average income per capita in wealthy nations.^[81] Economic gain only impacts life expectancy to a great degree in countries in which the mean per capita annual income is less than approximately $25,000. The United States shows exceptionally low health outcomes for a developed country, despite having the highest national healthcare expenditure in the world. The US ranks 31st in life expectancy. Americans have a lower life expectancy than their European counterparts, even when factors such as race, income, diet, smoking, and education are controlled for.^[82]

Relative inequality negatively affects health on an international, national, and institutional levels. The patterns seen internationally hold true between more and less economically equal states in the United States.The patterns seen internationally hold true between more and less economically equal states in the United States, that is, more equal states show more desirable health outcomes. Importantly, inequality can have a negative health impact on members of lower echelons of institutions. The Whitehall I and II studies looked at the rates of cardiovascular disease and other health risks in British civil servants and found that, even when lifestyle factors were controlled for, members of lower status in the institution showed increased mortality and morbidity on a sliding downward scale from their higher status counterparts. The negative aspects of inequality are spread across the population. For example, when comparing the United States (a more unequal nation) to England (a less unequal nation), the US shows higher rates of diabetes, hypertension, cancer, lung disease, and heart disease across all income levels.^[83] This is also true of the difference between mortality across all occupational classes in highly equal Sweden as compared to less-equal England ^[84]

Inequalities among Canadians

Despite dramatic improvements in health in general, significant inequalities in health among Canadians persist.^{[85][86][87][88]} Access to essential medical procedures is guaranteed by Medicare in Canada. Nevertheless, access to care issues are common^[89] and this is particularly the case in regards to required prescription medicines where income is a strong determinant of such access.^[90] It is believed however that health care issues account for a relatively small proportion of health status differences that exist among Canadians.^[91] As for differences in health behaviours (e.g., tobacco and alcohol use, diet, and physical activity, etc.), studies from as early as the mid 1970s—reinforced by many more studies since then—find their impact upon health to be less important than social determinants of health such as income and other social determinants of health.^[92][93][94]

Instead, evidence indicates that health differences among Canadians result primarily from experiences of qualitatively different living conditions associated with the social determinants of health. As just one example, consider the magnitude of differences in health that are related to the social determinant of health of income. Income is especially important as it serves as a marker of different experiences with many social determinants of health.^[95] Income is a determinant of health in itself, but it is also a determinant of the quality of early life, education, employment and working conditions, and food security. Income also is a determinant of the quality of housing, need for a social safety net, the experience of social exclusion, and the experience of unemployment and employment insecurity across the life span. Also, a key aspect of Aboriginal life and the experience of women in Canada is their greater likelihood of living under conditions of low income.^[96]

Income is a prime determinant of Canadians’ premature years of life lost and premature mortality from a range of diseases.^[95][97] Numerous studies indicate that income levels during early childhood, adolescence, and adulthood are all independent predictors of who develops and eventually succumbs to disease.^{[98][99][100][101]}

In Canada almost a quarter of excess premature years of life lost (mortality prior to age 75) can be attributed to income differences among Canadians.^[88] These calculations are obtained by using the mortality in the wealthiest quintile of urban neighbourhoods as a baseline and considering all deaths above that level to be “excess” related to income differences. These analyses indicate that 23% of premature years of life lost to Canadians can be accounted for by differences existing between wealthy and other Canadians.^[88]

What are the diseases that differentially kill people of varying income levels? Income-related premature years of life lost can be correlated with death certificate cause of death.^[88] Among the not-wealthy, mortality by heart disease and stroke are especially related to income differences. Importantly, premature death by injuries, cancers, infectious disease, and diabetes are also all strongly related to not being wealthy in Canada. These rates are especially high among the least well-off Canadians.

In 2002, Statistics Canada examined the predictors of life expectancy, disability-free life expectancy, and the presence of fair or poor health among residents of 136 regions across Canada.^[102] The predictors included socio-demographic factors (proportion of Aboriginal population, proportion of visible minority population, unemployment rate, population size, percentage of population aged 65 or over, average income, and average number of years of schooling). Also placed into the analysis were daily smoking rate, obesity rate, infrequent exercise rate, heavy drinking rate, high stress rate, and depression rate.

Consistent with most other research, behavioural risk factors were rather weak predictors of health status as compared to socio-economic and demographic measures of which income is a major component.^{[98][103][104]} For life expectancy, the socio-demographic measures predicted 56% of variation (total variation is 100%) among Canadian communities. Daily smoking rate added only 8% more predictive power, obesity rate only another 1%, and exercise rate nothing at all! For disability-free life expectancy, socio-demographics predicted 32% of variation among communities, and daily smoking rated added only another 6% predictive power, obesity rate another 5%, and exercise rate another 3%. Differences among Canadians communities in numbers of residents reporting poor or fair health were related to socio-demographics (25% predictive power) with smoking rate adding 6%, obesity rate adding 10%, and exercise rate adding 3% predictive power.

Income-related effects are seen therefore in greater incidence and mortality from just about every affliction that Canadians experience. This is especially the case for chronic diseases. Incidence of, and mortality from, heart disease and stroke, and adult-onset or type 2 diabetes are especially good examples of the importance of the social determinants of health.^[105][106]

While governments, medical researchers, and public health workers emphasize the importance of traditional adult risk factors (e.g., cholesterol levels, diet, physical activity, and tobacco and alcohol use), it is well established that these are relatively poor predictors of heart disease, stroke, and type 2 diabetes rates among populations.^{[107][108][109]} The factors making a difference are living under conditions of material deprivation as children and adults, stress associated with such conditions, and the adoption of health threatening behaviours as means of coping with these difficult circumstances.^[110] In fact, difficult living circumstances during childhood are especially good predictors of these diseases.^{[100][111][112][113]}

In addition to predicting adult incidence and death from disease, income differences — and the other social determinants of health related to income — are also related to the health of Canadian children and youth. Canadian children living in low-income families are more likely to experience greater incidence of a variety of illnesses, hospital stays, accidental injuries, mental health problems, lower school achievement and early drop-out, family violence and child abuse, among others.^[114] In fact, low-income children show higher incidences of just about any health-, social-, or education-related problem, however defined. These differences in problem incidence occur across the income range but are most concentrated among low-income children.^{[115][116][117]}

See also

• Center for Minority Health
• Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries
• HealthEquity
• Hopkins Center for Health Disparities Solutions
• Population health
• Public health
• Unnatural Causes: Is Inequality Making Us Sick?
• Health Disparities Center
• The Cultural Competency Organizational Assessment-360 (COA360)
• Drift Hypothesis
• Healthcare and the LGBT community
• California Health Equity

References

Further Notes

• Bleich, S. N.; Jarlenski, M. P.; Bell, C. N.; Laveist, T. A. (2012). "Health Inequalities: Trends, Progress, and Policy". Annual Review of Public Health 33: 7–40. doi:10.1146/annurev-publhealth-031811-124658. PMID 22224876. 
• Diez Roux, A. V. (2012). "Conceptual Approaches to the Study of Health Disparities". Annual Review of Public Health 33: 41–58. doi:10.1146/annurev-publhealth-031811-124534. PMID 22224879. 
• Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004).
• McDonough, J., Gibbs, B., Scott-Harris, J., Kronebusch, K., Navarro, A., and Taylor, K. A. "State Policy Agenda to Eliminate Racial and Ethnic Health Disparities," Commonwealth Fund (June 2004).
• Smedley, B., Stith, A., and Nelson, A. "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care." Institute of Medicine (2002).

External links

• Progress in Community Health Partnerships: Research, Education, and Action (PCHP)
• Institute of Medicine Roundtable on Health Disparities was created to enable diaologue and discussion of issues related to the visibility of racial and ethnic disparities in health and health care as a national problem, the development of programs and strategies to reduce disparities and the emergence of new leadership.
• Center for Managing Chronic Disease
• Cultural Diversity in Health Care Speaker Series videos presentations from expert lecturers, University of Wisconsin School of Medicine and Public Health
• Cultural Diversity in Health Care Research Symposium video presentations from expert lecturers, University of Wisconsin School of Medicine and Public Health
• National Center on Minority Health and Health Disparities
• Journal of Health Care for the Poor and Underserved
• Understanding Health Disparities
• Initiative to Eliminate Racial and Ethnic Disparities in Health United States government minority health initiative
• Health Disparities Collaborative
• Massachusetts General Hospital seeks to bridge healthcare's racial gap
• Diversity Health Institute Clearinghouse
• Case Center for Reducing Health Disparities
• FIU Health Disparity Research Group
• "Kaiser Health Disparities Report: A Weekly Look at Race, Ethnicity and Health", News summary report from kaisernetwork.org
• Health inequality in New Zealand
• BBC News article regarding health inequalities
• EXPORT Project webpage atTuskegee University
• VIDEO: Health Status Disparities in the US, April 4, 2007, featuring Paula Braveman, Gregg Bloche, George Kaplan, Thomas Ricketts, Mary Lou deLeon Siantz, and David Williams
• UK National Health Service Specialist Library for Ethnicity & Health
• National Rural Health Association
• The National Partnership for Action to End Health Disparities
• The National Partnership for Action Toolkit for Community Action

v t e Public health General Auxology Biological hazard Chief Medical Officer Deviance (sociology) Environmental health Euthenics Genomics Globalization and disease Health economics Health literacy Health policy Health system Healthcare reform Public health law Maternal health Medical anthropology Medical sociology Mental health Pharmaceutical policy Public health laboratory Reproductive health Social psychology Sociology of health and illness Tropical disease Preventive healthcare Family planning Health promotion Human nutrition Hygiene Hand washing Food safety Infection control Oral hygiene Occupational safety and health Ergonomics Hygiene Injury prevention Medicine Nursing Patient safety organization Pharmacovigilance Safe sex Sanitation Community-led total sanitation Sanitary sewer Waterborne diseases Water management Smoking cessation Vaccination Vector control Population health Biostatistics Community health Epidemiology Global health Health impact assessment Health software Health system Public health informatics Social determinants of health Health equity Race and health Social medicine   Organizations, education and history Agencies and organizations World Health Organization Europe Centre for Disease Prevention and Control Committee on the Environment, Public Health and Food Safety India Ministry of Health and Family Welfare U.S. Public Health Service Centers for Disease Control and Prevention Council on Education for Public Health Public Health – Seattle & King County World Toilet Organization Globalization and Health Education Health education Bachelor of Science in Public Health Master of Public Health Doctor of Public Health European Programme for Intervention Epidemiology Training (EPIET) Professional Further Education in Clinical Pharmacy and Public Health History Sara Josephine Baker Samuel Jay Crumbine Carl Rogers Darnall Joseph Lister Margaret Sanger John Snow Typhoid Mary Germ theory of disease Social hygiene movement