Health Disparities

by

Leandris Liburd

• LAST REVIEWED: 05 May 2017
• 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.

  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.

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

  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.