Public Health Health Disparities
by
Leandris Liburd
  • LAST MODIFIED: 31 August 2015
  • DOI: 10.1093/obo/9780199756797-0185

Introduction

Despite improvements in the overall health status of the US population, health disparities remain widespread among selected population groups (CDC, MMWR CDC Health Disparities and Inequalities Report, 2013). Health disparities are differences in health outcomes that are closely linked with social, economic, and environmental disadvantages and are often driven by the social conditions in which individuals live, learn, work, and play (US Department of Health and Human Services, HHS Action Plan to Reduce Racial and Ethnic Health Disparities, 2011). Health inequalities and health inequities are related concepts used globally in the scientific literature to capture population- and individual-level differences influenced by social determinants of health and factors considered modifiable (unnecessary and avoidable) and ethically unfair (M. Whitehead, “The Concepts and Principles of Equity and Health,” International Journal of Health Services 22 [1992]: 429–445; O. Carter-Pokras and C. Baquet, “What Is a ‘Health Disparity’?” Public Health Reports 117 [2002]: 426–434; P. Braveman, “Health Disparities and Health Equity: Concepts and Measurements,” Annual Review of Public Health 27 [2006]: 167–194). Health disparities in the United States “adversely affect groups of people who have systematically experienced greater obstacles to health, based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion” (see HealthyPeople.gov). Why racial and ethnic health disparities exist and how to close the gap in health outcomes between population groups have been the sources of considerable debate and contemplation for decades. This article takes a socioecological approach to understanding and responding to racial and ethnic health disparities that incorporates attention to the social determinants of health (M. Marmot and Jessica J. Allen, “Social Determinants of Health Equity,” American Journal of Public Health 104 Suppl. 4 [2014]: S517–S519). A social ecology orientation to health and disease (a) assumes a population perspective on health determinants, (b) recognizes the complex interactions among multiple levels of influence, (c) examines the social context that shapes behavior, (d) adopts a life course and developmental perspective, and (e) identifies biological mechanisms (L. F. Berkman and A. Lochner, “Social Determinants of Health: Meeting at the Crossroads,” Health Affairs 21.2 [2002]: 291–293). A collection of resources (peer-reviewed journal articles, federal documents, textbooks, websites, etc.) are provided in this article that explore how health disparities are defined in the United States and the conceptual and measurement challenges associated with these definitions; theoretical perspectives on “why” health disparities disproportionately impact communities of color; and the role of “place” and the built environment on health as well as the impact of socioeconomic position, access to health care, and social and community contexts. This article highlights key conceptual, measurement, and practice models for understanding and reducing racial and ethnic health disparities in the United States. (Acknowledgement: I would like to acknowledge the contributions of Lia Scott and Domenica Nino who played a key role in reviewing the literature, and Benita Harris McBride for her role in supervising the students. Disclaimer: The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.)

General Overviews

Health disparities are well documented, but not well understood. A close examination of the literature reveals various ways racial and ethnic health disparities are defined and measured—some of which are related to the difficulty in defining “race” beyond what is prescribed by the US Office of Management and Budget (OMB). In this article, authors wrestle with concretizing “race” as a social construct and lived experience through conceptual and statistical models. These frameworks ground our understanding of the problem and point the reader in particular theoretical and practice directions to identify solutions. Health disparities are caused by a complex interaction of multiple factors including individual behaviors, access to high quality health care, environmental risk factors, and poor social conditions, to name a few, which contribute to a health disadvantage for all Americans as well as socially disadvantaged communities (Woolf and Aron 2013). Pervasive structural inequities and social determinants of health are believed to be the primary drivers of health disparities. The works provided in this article demonstrate strong associations between the neighborhood and built environment, socioeconomic position, access to health care, and social and psychosocial stresses such as racism and discrimination in the development of health disparities among racial and ethnic and other socially disadvantaged groups. How then do we move forward to reverse these persistent racial and ethnic health disparities? There is a growing and compelling literature of evidence-based and culturally tailored interventions implemented for particular population groups and in specific community and health-care contexts. A full listing of effective interventions implemented across population groups and in response to specific diseases and other public health conditions is beyond the scope of this article. Instead, methods that can be used at the local level to address diverse health problems are presented, for example, community-based participatory research and utilization of community health workers. Both of these strategies have been implemented and evaluated, and have demonstrated positive outcomes in reducing selected health disparities. More work is needed to expand the evidence base of effective interventions, particularly policy, systems, and environmental change strategies to improve the social ecology from which health disparities emerge.

  • Commission on Social Determinants of Health. 2008. Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva, Switzerland: World Health Organization.

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    This landmark report documents associations between health outcomes and social and environmental conditions. These conditions are unequally distributed and sustained through policies and other structural drivers of avoidable inequities. Using evidence and examples from around the globe, recommendations and concrete actions are provided. This report has inspired global attention to the social determinants of health.

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    • Woolf, S. H., and Laudan Aron, eds. 2013. US Health in International Perspective: Shorter Lives, Poorer Health. Washington, DC: National Academies Press.

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      Although the United States is among the wealthiest nations in the world, Americans experience higher mortality and poorer health outcomes when compared to other high-income countries. Accounting for this “health disadvantage” is the focus of this special panel report. Beyond racial and ethnic health disparities, the panel posits causes of the health disadvantage across socioeconomic groups and across the life course, and makes recommendations for improving population health in the United States.

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      Textbooks

      Understanding racial and ethnic health disparities and their determinants between segments of the population is multi-faceted and can be examined in various contexts, across different historical periods, and from the standpoint of “place.” The textbooks in this section are essential resources that cover the landscape of what is known, as well as emerging scholarship in health disparities. LaVeist and Isaac 2012 in their public health reader cover a range of factors that contribute to persistent health disparities observed in the United States. Liburd 2010 argues for greater attention to structural and environmental influences on the growing burden of diabetes among racial and ethnic populations. Kawachi and Berkman 2003 help to clarify how and why neighborhood conditions contribute to health outcomes, and Satcher and Pamies 2006 explore health disparities across the life course among racial and ethnic populations, and posit remedies that embrace a multicultural approach to medicine.

      • LaVeist, T. A., and L. A. Isaac. 2012. Race, ethnicity, and health: A public health reader. San Francisco: Jossey-Bass.

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        This book is a compilation of selected readings from the peer-reviewed research literature covering multiple dimensions of racial and ethnic health disparities such as explanations for these disparities, the effects of culture and other social and environmental determinants, and solutions for eliminating health disparities. An important resource for faculty and students interested in addressing health disparities.

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        • Kawachi, I., and L. F. Berkman. 2003. Neighborhoods and health. New York: Oxford Univ. Press.

          DOI: 10.1093/acprof:oso/9780195138382.001.0001Save Citation »Export Citation »E-mail Citation »

          Social and physical characteristics of residential neighborhoods affect a person’s well-being over and above an individual’s actions to live a healthy lifestyle. This comprehensive text advances theory, methodology, and empirical evidence in support of the impact of place on health. Careful attention is given to methodological complexities associated with neighborhood research.

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          • Liburd, L. C. 2010. Diabetes and health disparities: Community-based approaches for racial and ethnic populations. New York: Springer.

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            This book investigates the epidemiology of diabetes in racial and ethnic communities, arguing that the determinants of diabetes include more than personal choices, but also social and contextual factors such as residential segregation and cultural patterns. Case studies of community interventions conducted in racial and ethnic communities impacted by diabetes are provided.

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            • Satcher, D., and R. Pamies. 2006. Multicultural medicine and health disparities. New York: McGraw-Hill.

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              The growing diversity of the United States and the disproportionate burden of disease experienced by people of color impact the provision of health care. Satcher and Pamies bring together clinical, policy, and public health experts and diverse points of view in this comprehensive volume describing the epidemiology of selected health disparities, policy initiatives, and clinical and community interventions.

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              Journals

              Education, income, and other indicators of social advantage and disadvantage are variables in the social construction of racial and ethnic health disparities. Defining these variables in ways that can be measured and understanding how they influence health outcomes are important first steps in being able to identify what factors to address when the goal is to reduce health disparities (Annals of the New York Academy of Sciences). In addition, national surveillance (Centers for Disease Control and Prevention, et al. 2013) and community-level surveillance of health issues, risk factors, and other determinants of health (Centers for Disease Control and Prevention 2011) are needed to stimulate targeted action, community engagement, and evaluation of public health strategies intending to improve health outcomes. Similarly, health and health-care disparities experienced by military veterans who represent the racial and ethnic makeup of the nation are gaining greater attention. Opportunities for achieving health equity among military veterans and their beneficiaries are addressed in a special supplement of the American Journal of Public Health.

              • Adler, Nancy E., and Judith Stewart, eds. 2010. Special issue: The biology of disadvantage; Socioeconomic status and health. Annals of the New York Academy of Sciences 1186:1–275.

                DOI: 10.1111/j.1749-6632.2009.05385.xSave Citation »Export Citation »E-mail Citation »

                This volume is a collection of articles exploring the complexities of how socioeconomic status “gets under the skin” to impact health (pp. 146, 223, 240). Authors grapple with definition and measurement issues associated with socioeconomic status, and how health disparities emerge from social disadvantage associated with larger structures of social stratification and exclusion of selected population groups.

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                • Centers for Disease Control and Prevention. 2011. Surveillance of health status in minority communities—Racial and Ethnic Approaches to Community Health Across the U.S. (REACH U.S.) Risk Factor Survey, United States, 2009. Morbidity & Mortality Weekly Report Surveillance Summaries 60.6 (20 May): 1–44.

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                  This report describes disparities in selected chronic conditions, risk factors, and demographic variables in twenty-eight communities located in seventeen states in the United States. These communities participated in the Centers for Disease Control and Prevention’s REACH program that is a community-based, coalition-driven approach to developing, implementing, and evaluating targeted interventions to reduce health disparities. Understanding how social factors such as socioeconomic status influence biological and health outcomes is critical to the process of identifying strategies at multiple levels and across sectors intending to reduce health disparities (see Annals of the New York Academy of Sciences).

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                  • Centers for Disease Control and Prevention. 2013. CDC Health disparities and inequalities report—United States, 2013. Morbidity & Mortality Weekly Report 62. US Government Printing office.

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                    This report contains consolidated assessments that highlight health disparities by sex, race, and ethnicity; income; education; disability status; and other social characteristics in the United States, and addresses disparities in health-care access, exposure to environmental hazards, mortality, morbidity, behavioral risk factors, disability status, and social determinants of health at the national level.

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                    • Uchendu, Uchenna S. 2014. Special issue: Health equity and the elimination of health disparities in U.S. veterans. American Journal of Public Health (Suppl.) 104.S4.

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                      This volume brings attention to the burden of health disparities experienced by veterans who comprise over eight million persons enrolled in Veterans Administration (VA) health-care facilities across the United States. Articles in this special supplement describe health problems, including mental health issues experienced by veterans, health-care disparities within the VA, and considerations for advancing health equity within this population.

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                      Federal Resources

                      The US federal government plays a key role in reducing health disparities by establishing national health disparities goals and objectives, coordinating action across the federal government, and implementing policies that reduce health disparities. These federal efforts are accomplished through initiatives such as the National Partnership for Action to End Health Disparities 2011, which includes goals and objectives designated for specific federal health agencies to achieve (see HHS Action Plan to Reduce Racial and Ethnic Health Disparities). As components of these national initiatives are adopted by state and local health agencies, tools and technical assistance to assist in implementing evidence-based strategies are also available from federal agencies like the Centers for Disease Control and Prevention (see Centers for Disease Control and Prevention 2013).

                      • Centers for Disease Control and Prevention—Division of Community Health. 2013. A practitioner’s guide for advancing health equity: Community strategies for preventing chronic disease. Atlanta: US Department of Health and Human Services.

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                        This Practitioner’s Guide for Advancing Health Equity is a tool to assist those working to reduce chronic diseases through policy, systems, and environmental improvements where people live, learn, work, and play. Strategies described in the Guide are intended to be adapted by local communities to fit their unique circumstances.

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                        • HHS action plan to reduce racial and ethnic health disparities. 2011. US Department of Health and Human Services.

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                          This departmental action plan details how federal agencies will pursue five goals: (1) transform health care; (2) strengthen health and human services infrastructure and workforce; (3) advance the health, safety, and well-being of the American people; (4) advance scientific knowledge and innovation; and (5) increase the efficiency, transparency, and accountability of the Department of Health and Human Services programs.

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                          • National Partnership for Action to End Health Disparities. 2011. National stakeholder strategy for achieving health equity. Rockville, MD: US Department of Health and Human Services, Office of Minority Health.

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                            The National Stakeholder Strategy is a comprehensive roadmap for eliminating health disparities through cooperative and collaborative actions that address social, behavioral, environmental, and biological and genetic determinants of health. Strategies are provided for implementation by regional and community stakeholders. Community engagement, partnerships, and cultural and linguistic competency are core features of this national strategy.

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                            Neighborhood and Built Environment

                            The disproportionate burden of the leading chronic diseases and associated risk factors and how they correlate with contextual factors such as residential segregation, lack of access to healthy foods and safe spaces for physical activity, and other dimensions of “place” are central findings of the resources highlighted in this section. Residential segregation persists in the United States between racial, ethnic, and low-income populations due to social, economic, and political forces that have historically concentrated poverty in cities, which impact the availability and quality of resources and services that promote and protect health (Acevedo-Garcia and Lochner 2003). Beyond race and ethnicity, the built environment also structures access to resources needed for physical and emotional health and well-being as well as opportunities to reduce risk factors for disease (Lovasi, et al. 2009). Documenting pathways from the built environment to physical and mental health disparities is not without its methodological and theoretical challenges (Diez-Roux and Mair 2010). LaVeist, et al. 2011, for example, describes research that demonstrates no statistically significant difference in the prevalence of selected chronic conditions and behavioral risk factors between whites and African Americans living in the same neighborhood in Baltimore, Maryland. The authors’ analytical orientation and findings suggest the social environment and “place” might be a better predictor of health disparities than race and ethnicity.

                            • Acevedo-Garcia, D., and K. A. Lochner. 2003. Residential segregation and health. In Neighborhoods and health. Edited by I. Kawachi and L. F. Berkman, 265–287. New York: Oxford Univ. Press.

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                              US urban areas have historically been and remain segregated by race and class, among other social variables. This is an important chapter by Acevedo-Garcia and Lochner because they describe how segregation works to isolate and cluster particularly whites from blacks, and they chronicle studies that provide empirical evidence of the impact of black/white residential segregation on negative health outcomes for blacks.

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                              • Diez-Roux, A. V., and C. Mair. 2010. Neighborhoods and health. Annals of the New York Academy of Sciences 1186.1: 125–145.

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                                Diez-Roux and Mair provide compelling evidence for the social patterning of residential environments and how they contribute to health disparities, particularly related to chronic disease outcomes and risk factors such as obesity, and mental health issues, namely depression and depressive symptoms. They describe key conceptual and methodological challenges in attributing a causal role to neighborhood features in creating disparities in selected chronic disease and mental health outcomes.

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                                • laVeist, T., K. Pollack, R. Thorpe Jr., R. Fesahazion, and D. Gaskin. 2011. Place, not race: Disparities dissipate in southwest Baltimore when blacks and whites live under similar conditions. Health Affairs 30.10: 1880–1887.

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                                  LaVeist and his colleagues explore the impact of residential segregation by considering a racially integrated, low-income neighborhood in Baltimore, Maryland. In this context, they found that disparities between African Americans and whites in hypertension, diabetes, obesity among women, and use of health services either vanished or substantially narrowed. They did find a higher smoking prevalence among whites, as compared to African Americans. Might equalizing social factors minimize health disparities?

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                                  • Lovasi, G. S., M. A. Hutson, M. Guerra, and K. M. Neckerman. 2009. Built environments and obesity in disadvantaged populations. Epidemiologic Reviews 31.1: 7–20.

                                    DOI: 10.1093/epirev/mxp005Save Citation »Export Citation »E-mail Citation »

                                    Can the disproportionate burden of obesity in disadvantaged populations be explained by living in an “obesogenic” environment? Tipping the lens away from the individual, Lovasi and colleagues document strong correlations between the built environment (having places to exercise, access to food stores, aesthetic perceptions, and traffic or crime-related safety) and obesity and behavioral correlates.

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                                    Socioeconomic Position

                                    Socioeconomic status, social class, the social environment, and social conditions are all terms used to describe factors that characterize an individual’s or community’s contextual experience. Their theoretical orientations and definitions differ by discipline and epistemology. Explanations for how and why individuals and population groups are assigned to a particular position in the larger social hierarchy or structure and the impact of this positioning on psychosocial stress and health disparities also differ by the lens through which related research questions are pursued and interpreted (Diez-Roux 2012). The works cited in this section examine the cumulative impact of chronic stress and other negative life events related to socioeconomic status on health (Lantz, et al. 2005). Williams, et al. 2010 describes research demonstrating that “racial differences in health persist at every level of SES” (p. 69), thus complicating traditional analyses and interpretations of race, socioeconomic status (SES), and other factors in the social environment that when combined with biological factors over the life course impact health outcomes. Phelan, et al. 2004 and Phelan, et al. 2010 argue for a causal relationship between socioeconomic status and mortality disparities by elaborating on measures such as prestige, power, and social connections that constitute dimensions of socioeconomic status not typically studied. DiPrete and Eirich 2006 theorizes how cumulative advantage is reproduced over generations and structures the kind of opportunities that protect health.

                                    • Diez-Roux, A. V. 2012. Conceptual approaches to the study of health disparities. Annual Reviews in Public Health 33:41–58.

                                      DOI: 10.1146/annurev-publhealth-031811-124534Save Citation »Export Citation »E-mail Citation »

                                      Diez-Roux critiques conceptual models intending to explain why health disparities exist (e.g., genetic, fundamental cause, pathways, and interaction models). She describes strengths and shortcomings of selected models as well as points of convergence between conceptual models. She argues for a systems approach to understanding health disparities to move the field forward with new questions, analytic methods, and interpretations that better inform health policy.

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                                      • diPrete, T. A., and G. M. Eirich. 2006. Cumulative advantage as a mechanism for inequality: A review of theoretical and empirical developments. Annual Review of Sociology 32.1: 271–297.

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                                        The construct of cumulative advantage seeks to describe the mechanism that structures opportunities for advancement or alternatively socioeconomic inequality over family generations and across the life course. The sociological literature delineates multiple meanings for cumulative advantage and mechanisms that produce advantage that may inform strategies for reversing preventable health disparities.

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                                        • Lantz, P. M., J. S. House, R. P. Mero, and D. R. Williams. 2005. Stress, life events, and socioeconomic disparities in health: Results from the Americans’ Changing Lives Study. Journal of Health and Social Behavior 46.3: 274–288.

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                                          Lantz and colleagues find evidence that supports the hypothesis that differential exposure to stress and negative life events over time experienced by selected population groups contribute to socioeconomic inequalities in health. These life events and other types of stressors are related to socioeconomic position, which is related to education, income, and the social gradient or one’s standing within the established social hierarchy.

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                                          • Phelan, J. C., B. G. Link, A. Diez-Roux, I. Kawachi, and B. Levin. 2004. “Fundamental causes” of social inequalities in mortality: A test of the theory. Journal of Health and Social Behavior 45.3: 265–285.

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                                            The effect of socioeconomic status on mortality has been documented over decades despite changes in the health conditions presumed to explain this disparity in mortality. High socioeconomic status is not always protective against health threats. In instances where the cause of death is more preventable, socioeconomic status is more strongly associated with mortality.

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                                            • Phelan, J. C., B. G. Link, and P. Tehranifar. 2010. Social conditions as fundamental causes of health inequalities: Theory, evidence, and policy implications. Journal of Health and Social Behavior 51.1 (Suppl.): S28–S40.

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                                              Traditional constructs of socioeconomic status leave unexamined the resources and benefits that may accompany (higher) SES such as knowledge, prestige, power, and beneficial social connections that protect health. Phelan and colleagues elaborate additional indicators of SES in their explanatory framework for health disparities, and posit how this theoretical perspective can inform policies to weaken the link between access to health-promoting advances and socioeconomic resources.

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                                              • Williams, D. R., S. A. Mohammed, J. Leavell, and C. Colins. 2010. Race, socioeconomic status, and health: Complexities, ongoing challenges, and research opportunities. Annals of the New York Academy of Sciences 1186.1: 69–101.

                                                DOI: 10.1111/j.1749-6632.2009.05339.xSave Citation »Export Citation »E-mail Citation »

                                                Differences in socioeconomic status (SES) across racial groups are a major contributor to racial disparities in health. Race, understood as a social construct and lived experience, reflects multiple dimensions of social inequality. Research is needed that will comprehensively characterize the critical pathogenic features of social environments and identify how these features combine with each other to affect health over the life course.

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                                                Health Care

                                                To eliminate disparities in the provision of health care, these health services must be culturally and linguistically appropriate; eliminate unconscious bias in the provision of health care; be delivered by a diverse and culturally competent workforce; remove barriers to access, such as lack of health insurance; and build linkages between primary care, public health, and the community to increase access to prevention and wellness services. These articles describe research and interventions intending to eliminate health-care disparities experienced by racial and ethnic populations. Racial and ethnic health disparities are costly to the United States and undermine the economic viability of the nation (laVeist, et al. 2011). These costs may be reduced through the provision of culturally competent health care that is enhanced when providers reflect the patients they serve as described in laVeist, et al. 2003, a study of doctor-patient race concordance and the utilization of health services. Cultural competence has been part of the discourse for reducing health-care disparities for over a decade, but clarifying what it means and how to integrate cultural models into health-care interventions is still challenging as discussed in Fisher, et al. 2007 and Engebretson, et al. 2008.

                                                • Engebretson, J., J. Mahoney, and E. D. Carlson. 2008. Cultural competence in the era of evidence-based practice. Journal of Professional Nursing 24.3: 172–178.

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                                                  Cultural competence among providers, in the provision of health services, and in health policies is a goal of public health and clinical medicine. While broadly embraced as integral to the elimination of health and health-care disparities, cultural competence is difficult to concretize and measure. Engebretson and colleagues unpack cultural competence for greater utility in clinical practice.

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                                                  • Fisher, T. L., D. L. Burnt, E. S. Huang, M. H. Chin, and K. A. Cagney. 2007. Cultural leverage interventions using culture to narrow racial disparities in health care. Medical Care Research and Review 64.5 (Suppl.): 243S–282S.

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                                                    Culture is a well established, but not uniformly defined factor that influences health behavior, acts as a social determinant, and is an important consideration in eliminating racial and ethnic health disparities. Fisher and colleagues examine the literature on cultural competence to identify how to leverage culture in the development of multilevel interventions intending to reduce disparities in health care.

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                                                    • laVeist, T. A., D. Gaskin, and P. Richard. 2011. Estimating the economic burden of racial health inequalities in the United States. International Journal of Health Services 41.2: 231–238.

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                                                      Persistent racial and ethnic health disparities are costing the entire society in direct and indirect medical costs, including lost productivity and premature mortality. It is in the interest of the US economy to implement programs and policies that eliminate preventable health disparities.

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                                                      • laVeist, T. A., A. Nuru-Jeter, and K. E. Jones. 2003. The association of doctor-patient race concordance with health services utilization. Journal of Public Health Policy 24.3–4: 312–323.

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                                                        Ensuring a health-care workforce that is reflective of the racial and ethnic diversity of the United States is an effective strategy for reducing health and health-care disparities. This study finds that doctor-patient race concordance is particularly beneficial for African American patients.

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                                                        Social and Community Context

                                                        The social and community contexts that characterize communities of color impact their health. Social support, optimism, and community engagement in decisions that impact family and community life play an important role in shaping who is most vulnerable to illness and how easily and quickly illnesses are resolved. Racial, religious, and gender-based discrimination contribute to chronic stress and the onset of some chronic diseases, mental health disorders, and marginalization and disenfranchisement. These articles examine the relationship between the social environment and health disparities. There is a large literature associating racism and other stressors experienced by socially disadvantaged groups with negative health outcomes. The works cited in this section represent research on the impact of perceptions of racial discrimination on racial and ethnic health disparities; the relationship between structural racism and intersectionality on health disparities observed among immigrants; associations between maternal age, infant mortality, low birth weight and very low birth weight outcomes and chronic exposure to social inequality; and the health impact of long-term exposure to psychosocial stressors across the lifespan. Williams and Mohammed 2009 defines racism and perceptions of racial discrimination as psychosocial stressors contributing to racial and ethnic health disparities, and argues for refinements to how we capture the breadth of experiences of racism, and how we measure discrimination and perceived discrimination and its impact on health. Viruell-Fuentes, et al. 2012 expands conceptual thinking about health disparities among immigrants beyond culture to structural racism and intersectionality, that is, “how multiple dimensions of inequality intersect to impact health outcomes” (p. 2099). Cummings and Jackson 2008 further elaborates intersectionality theory and uses it to interpret differences in self-assessed health reported by race, gender, and socioeconomic status in the General Social Survey for the period 1974 to 2004. Examining associations between teen pregnancy and high risks for infant mortality, low birth weight, and very low birth weight births among African American mothers, Geronimus 1992 and Geronimus 1996 pioneer groundbreaking research that demonstrates early deterioration in health among these mothers as a physical response to social inequality. Pearlin, et al. 2005 adds theoretical perspectives to the literature on the impact of adverse life experiences and associated stressors over the life course and their influence in mortality and morbidity rates among socially disadvantaged population groups.

                                                        • Cummings, J. L., and P. B. Jackson. 2008. Race, gender, and SES disparities in self-assessed health, 1974–2004. Research on Aging 30.2: 137–167.

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                                                          Intersectionality theory posits that race, class, and gender are socially constructed and mutually constituted systems of oppression when associated with the experience of being black/African American and female in the United States. This theory is used to help explain why racial and gender disparities persist in self-assessed health after controlling for socioeconomic status.

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                                                          • Geronimus, A. T. 1992. The weathering hypothesis and the health of African-American women and infants: Evidence and speculations. Ethnicity & Disease 2.3: 207–221.

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                                                            Infant mortality rates are used worldwide to gauge the health and well-being of populations across the life course. The infant mortality rate for black infants is more than two times the rate for white infants. Geronimus hypothesizes that the disparity in infant mortality is a physical consequence of cumulative social disadvantage experienced by the mother.

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                                                            • Geronimus, A. T. 1996. Black/white differences in the relationship of maternal age to birthweight: A population-based test of the weathering hypothesis. Social Science & Medicine 42.4: 589–597.

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                                                              The black/white disparity in birth outcomes is attributed to “weathering” in this study conducted among young, adult African American women (fifteen to thirty-four years of age). Geronimus finds that among those African American women living in low-income areas, there is a markedly increased risk of having a baby that is Low Birth Weight (LBW) or Very Low Birth Weight (VLBW) with advancing maternal age.

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                                                              • Pearlin, L., S. Schieman, E. M. Fazio, and S. C. Meersman. 2005. Stress, health, and the life course: Some conceptual perspectives. Journal of Health and Social Behavior 46.2: 205–219.

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                                                                The material and experiential conditions that contribute to persistent disparities in morbidity and mortality among social groups and across the lifespan may be anchored in early childhood experiences, enduring economic strain, and other stressors including discrimination. The impact on health doesn’t become evident until the middle-age years and latter stages of the life course.

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                                                                • Viruell-Fuentes, E. A., P. Y. Miranda, and S. Abdulrahim. 2012. More than culture: Structural racism, intersectionality theory, and immigrant health. Social Science & Medicine 75.12: 2099–2106.

                                                                  DOI: 10.1016/j.socscimed.2011.12.037Save Citation »Export Citation »E-mail Citation »

                                                                  Many immigrants to the United States experience worse health over time. Is this downward shift in health status a reflection of culture or structural factors embedded in immigration policies and perceived discrimination? Viruell-Fuentes and colleagues describe limitations of cultural explanations for disparities in immigrant health and highlight perspectives that address how multiple dimensions of inequality intersect to impact health outcomes.

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                                                                  • Williams, D. R., and S. A. Mohammed. 2009. Discrimination and racial disparities in health: Evidence and needed research. Journal of Behavioral Medicine 32.1: 20–47.

                                                                    DOI: 10.1007/s10865-008-9185-0Save Citation »Export Citation »E-mail Citation »

                                                                    There is a consistent inverse association between discrimination and health despite inconsistencies in how “discrimination” as a variable is operationalized across health outcomes and population groups. Perceived discrimination is a subtext of racism, and additional research is needed to improve how racism and discrimination are measured and to identify the mechanisms that link discrimination to health.

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                                                                    Addressing Racial and Ethnic Health Disparities

                                                                    Racial and ethnic health disparities can be reduced. Cross-cutting strategies for reducing health disparities include community health workers, and community-based participatory research. Integral to the effectiveness of these methods is active community engagement, and the design, implementation and evaluation of targeted, community-oriented, and multi-sectoral interventions. Advancing the science and practice of reducing health disparities requires the measurement of health disparities and their determinants, and the identification of appropriate analytic methods. Given the complexities associated with socioecological approaches to reducing health disparities, innovative evaluation research is needed to identify appropriate evaluation methods.

                                                                    Community Health Workers

                                                                    For decades, public health practitioners and researchers have recognized the importance of engaging members of the community in the implementation of public health initiatives and research. Community health workers, lay health advisors, and peer educators have been effective in achieving selected health outcomes as documented in Gibbons and Tyus 2007, a systematic review of community health workers. Participation by members of the community can also increase the cultural appropriateness and sensitivity of research methods. Johnson, et al. 2013 describes how promotoras increased community participation in a nutrition study with a Mexican-origin community.

                                                                    • Gibbons, M. C., and N. Tyus. 2007. Systematic review of U.S.-based randomized controlled trials using community health workers. Progress in Community Health Partnerships: Research, Education, and Action 1.4: 371–381.

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                                                                      Community health workers (CHWs), also referenced in the literature as lay health educators, peer educators, and promotoras, are effective in reducing health disparities across a range of health conditions, including preventive screenings. Community health workers are used in different contexts and approaches, but this systematic review found positive benefits attributable to use of CHWs.

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                                                                      • Johnson, C. M., J. R. Sharkey, W. R. Dean, J. A. St John, and M. Castillo. 2013. Promotoras as research partners to engage health disparity communities. Journal of the Academy of Nutrition and Dietetics 113.5: 638–642.

                                                                        DOI: 10.1016/j.jand.2012.11.014Save Citation »Export Citation »E-mail Citation »

                                                                        Community engagement is a key component of public health research and practice. Achieving true engagement and participation in the research process is challenging. Interpersonal skills and awareness of cultural and community nuances are needed. Johnson and colleagues describe a community-academic partnership with a Mexican-origin community to improve nutrition practices using promotoras de salud.

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                                                                        Community-Based Participatory Research

                                                                        Since the 1980’s, researchers in academic centers and other community institutions have forged a more democratic and community-engaged model of research known as community-based participatory research. There are many benefits associated with this approach, such as building community capacity to champion needed change identified by the community and achieved in collaboration with the researchers. Israel, et al. 2010 describes the researchers’ work with communities to build this capacity. Similarly, identifying and achieving policy changes in support of community health are benefits of community-based participatory research as described in Minkler 2010. In Schulz, et al. 2011, researchers engaged community members in the process of conducting a community needs assessment, in identifying resources and interventions needed, and in implementing a range of strategies and interventions to improve cardiovascular health. Gaining community trust and sustaining community engagement in research is challenging as discussed in Wallerstein and Duran 2010. Wallerstein, et al. 2011 also acknowledges the need for multidisciplinary participation in the science of community-based participatory research to enhance its rigor, comprehensiveness, and effectiveness in improving population health and advancing health equity.

                                                                        • Israel, B. A., C. M. Coombe, R. R. Cheezum, et al. 2010. Community-based participatory research: A capacity-building approach for policy advocacy aimed at eliminating health disparities. American Journal of Public Health 100.11: 2094–2102.

                                                                          DOI: 10.2105/AJPH.2009.170506Save Citation »Export Citation »E-mail Citation »

                                                                          Implementing social and economic policies that promote health equity are frequently touted as the way to effect structural change in communities experiencing health disparities. There is also evidence that communities that are politically well organized are healthier. Israel and colleagues use community-based participatory research methods and partnership to build local capacity to advocate for policies that support health and reduce disparities.

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                                                                          • Minkler, M. 2010. Linking science and policy through community-based participatory research to study and address health disparities. American Journal of Public Health 100 (Suppl.) 1.S1: S81–S87.

                                                                            DOI: 10.2105/AJPH.2009.165720Save Citation »Export Citation »E-mail Citation »

                                                                            Minkler describes how an equitable research partnership with the community facilitates policy change in communities experiencing health disparities. She details case studies and lessons learned where community-based participatory research methods have been used to mobilize action for policy changes that address health disparities.

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                                                                            • Schulz, A. J., B. A. Israel, C. M. Coombe, et al. 2011. A community-based participatory planning process and multilevel intervention design: Toward eliminating cardiovascular health inequities. Health Promotion Practice 12.6: 900–911.

                                                                              DOI: 10.1177/1524839909359156Save Citation »Export Citation »E-mail Citation »

                                                                              Community-based participatory approaches provide an organizing framework for the development of multilevel interventions needed to address the root causes of health inequities. Health inequities are modifiable, associated with social disadvantage, and considered ethically unfair. Schulz and colleagues describe a community-based participatory approach that engaged community members in a community assessment, action planning, and implementation of multilevel interventions.

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                                                                              • Wallerstein, N., and B. Duran. 2010. Community-based participatory research contributions to intervention research: The intersection of science and practice to improve health equity. American Journal of Public Health 100 (Suppl.) 1.S1: S40–S46.

                                                                                DOI: 10.2105/AJPH.2009.184036Save Citation »Export Citation »E-mail Citation »

                                                                                Community-based participatory research (CBPR) is a useful tool in the battle to eliminate health disparities, but it is not without its challenges and barriers. Democratic research processes and beneficial outcomes derived from translational research are not easily achieved or sustained. Wallerstein and Duran discuss these dynamics at length in this article.

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                                                                                • Wallerstein, N., I. H. Yen, and S. L. Syme. 2011. Integration of social epidemiology and community-engaged interventions to improve health equity. American Journal of Public Health 101.5: 822–830.

                                                                                  DOI: 10.2105/ajph.2008.140988Save Citation »Export Citation »E-mail Citation »

                                                                                  No single academic discipline or sector can improve population health outcomes on its own. Transdisciplinary, multisector approaches and collaborations are needed. Working from the perspective of traditional silos will not eliminate longstanding health disparities. Wallerstein and colleagues call for reciprocal learning across disciplines in concert with community engagement.

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                                                                                  Measurement and Evaluation

                                                                                  Definitions for racial/ethnic health-care disparities have not been consistent in the health services research literature or public health literature. How we define racial and ethnic groups and who gets included, methodological approaches, and contextual influences on the lived experiences of these racial and ethnic categories are important considerations when determining policy and environmental, clinical, and other interventions and strategies to reduce health disparities. Multiple definitions and methods for measuring disparities exist as described in Cook, et al. 2012. This lack of consistency impacts the ability to accurately target populations experiencing health disparities. Dorsey and Graham 2011 describes how data provisions within the Affordable Care Act will facilitate improved data collection and inclusion of population groups previously underrepresented in national datasets. Hebert, et al. 2008 and Diez-Roux 2000 further complicate the measurement of health disparities by addressing challenges associated with how to measure fairness and the need for multilevel analyses given the cumulative impact of multiple factors not easily isolated interacting within a population experiencing health disparities. A transdisciplinary approach to understanding why health disparities exist brings together different ways of conceptualizing and analyzing the problem as described in Holmes, et al. 2008. Transdisciplinary approaches are also helpful in identifying interventions to reduce health disparities as discussed in Dulin, et al. 2012, presenting the researchers’ work in increasing access to health care in a Hispanic community living in the southeastern region of the United States.

                                                                                  • Cook, B. L., T. G. McGuire, and A. M. Zaslavsky. 2012. Measuring racial/ethnic disparities in health care: Methods and practical issues. Health Services Research 47.3: 1232–1254.

                                                                                    DOI: 10.1111/j.1475-6773.2012.01387.xSave Citation »Export Citation »E-mail Citation »

                                                                                    Definitions of racial/ethnic disparities in health care lack consistency across studies (varying by theoretical perspectives), as do statistical methods used to document these disparities. Cook and colleagues review these and other measurement and statistical issues with a particular eye toward implementing the Institute of Medicine’s definition of health-care disparities.

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                                                                                    • Diez-Roux, A. V. 2000. Multilevel analysis in public health research. Annual Review of Public Health 21.1: 171–192.

                                                                                      DOI: 10.1146/annurev.publhealth.21.1.171Save Citation »Export Citation »E-mail Citation »

                                                                                      Determinants of racial and ethnic health disparities cannot be adequately analyzed at the individual level alone. Multilevel analytic methods may be helpful in considerations of how factors at multiple levels are impacting health outcomes. Diez-Roux explores how multilevel analysis can be applied to problems in public health.

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                                                                                      • Dorsey, R., and G. Graham. 2011. New HHS data standards for race, ethnicity, sex, primary language, and disability status. Journal of the American Medical Association 306.21: 2378–2379.

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                                                                                        The Patient Protection and Affordable Care Act (ACA) aims to improve the specificity, uniformity, and quality of data collected from racial and ethnic minorities, people with disabilities, and persons with limited English proficiency. Dorsey and Graham describe ACA Section 4302 data standards that position data collection to be more useful for reducing health disparities.

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                                                                                        • Dulin, M. F., H. Tapp, H. A. Smith, et al. 2012. A trans-disciplinary approach to the evaluation of social determinants of health in a Hispanic population. BMC Public Health 12:769.

                                                                                          DOI: 10.1186/1471-2458-12-769Save Citation »Export Citation »E-mail Citation »

                                                                                          Strengthening linkages between the community and the health-care system is associated with greater acceptance of health services and may reduce health disparities. Dulin and colleagues use community-based participatory research and geospatial models to assess the needs of a Hispanic community in Charlotte, North Carolina, and determine interventions to increase access to primary care.

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                                                                                          • Hebert, P. L., J. E. Sisk, and E. A. Howell. 2008. When does a difference become a disparity? Conceptualizing racial and ethnic disparities in health. Health Affairs 27.2: 374–382.

                                                                                            DOI: 10.1377/hlthaff.27.2.374Save Citation »Export Citation »E-mail Citation »

                                                                                            Race and ethnicity are widely regarded as social constructs. Clarifying and measuring unfairness associated with health disparities are challenging tasks, but necessary for consistency in documenting and measuring progress in eliminating health disparities. Hebert and colleagues describe how the conceptualization of race and ethnicity in statistical models of disparities impacts the interpretation of the disparity and actions to reduce them.

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                                                                                            • Holmes, J. H., A. Lehman, E. Hade, et al. 2008. Challenges for multilevel health disparities research in a transdisciplinary environment. American Journal of Preventive Medicine 35.2 (Suppl.): S182–S192.

                                                                                              DOI: 10.1016/j.amepre.2008.05.019Save Citation »Export Citation »E-mail Citation »

                                                                                              The complex causation of health disparities requires research methods that can rigorously accommodate this complexity, accounting for multiple levels of causal factors and incorporating multiple data sources. Overcoming challenges associated with this research has implications for the targeting of interventions to reduce disparities. Holmes and colleagues delineate challenges and opportunities associated with multilevel, transdisciplinary research.

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