Health equity

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Health gap in England and Wales, 2011 Census Health gap in England and Wales, 2011 Census.png
Health gap in England and Wales, 2011 Census

Health equity synonymous with health disparity refers to the study and causes of differences in the quality of health and healthcare across different populations. [1] Health equity is different from health equality, as it refers only to the absence of disparities in controllable or remediable aspects of health. It is not possible to work towards complete equality in health, as there are some factors of health that are beyond human influence. [2] Inequity implies some kinds of social injustice. Thus, if one population dies younger than another because of genetic differences, a non-remediable/controllable factor, we tend to say that there is a health inequality. On the other hand, if a population has a lower life expectancy due to lack of access to medications, the situation would be classified as a health inequity. [3] These inequities may include differences in the "presence of disease, health outcomes, or access to health care" [4] between populations with a different race, ethnicity, sexual orientation or socioeconomic status. [5]

Health is a state of physical, mental and social well-being in which disease and infirmity are absent.

Life expectancy Statistical measure of how long a person or organism may live, based on factors of their life

Life expectancy, often abbreviated to LEB, is a statistical measure of the average time an organism is expected to live, based on the year of its birth, its current age and other demographic factors including gender. The most commonly used measure of life expectancy is at birth, which can be defined in two ways. Cohort LEB is the mean length of life of an actual birth cohort and can be computed only for cohorts born many decades ago, so that all their members have died. Period LEB is the mean length of life of a hypothetical cohort assumed to be exposed, from birth through death, to the mortality rates observed at a given year.

Sexual orientation is an enduring pattern of romantic or sexual attraction to persons of the opposite sex or gender, the same sex or gender, or to both sexes or more than one gender. These attractions are generally subsumed under heterosexuality, homosexuality, and bisexuality, while asexuality is sometimes identified as the fourth category.

Contents

Health equity falls into two major categories: horizontal equity, the equal treatment of individuals or groups in the same circumstances; and vertical equity, the principle that individuals who are unequal should be treated differently according to their level of need. [6] Disparities in the quality of health across populations are well-documented globally in both developed and developing nations. The importance of equitable access to healthcare has been cited as crucial to achieving many of the Millennium Development Goals. [7]

Millennium Development Goals eight international development goals for the year 2015 by the United Nations

The Millennium Development Goals (MDGs) were eight international development goals for the year 2015 that had been established following the Millennium Summit of the United Nations in 2000, following the adoption of the United Nations Millennium Declaration. All 191 United Nations member states at that time, and at least 22 international organizations, committed to help achieve the following Millennium Development Goals by 2015:

  1. To eradicate extreme poverty and hunger
  2. To achieve universal primary education
  3. To promote gender equality and empower women
  4. To reduce child mortality
  5. To improve maternal health
  6. To combat HIV/AIDS, malaria, and other diseases
  7. To ensure environmental sustainability
  8. To develop a global partnership for development

Socioeconomic status

Socioeconomic status is both a strong predictor of health, and a key factor underlying health inequities across populations. Poor socioeconomic status has the capacity to profoundly limit the capabilities of an individual or population, manifesting itself through deficiencies in both financial and social capital. [8] It is clear how a lack of financial capital can compromise the capacity to maintain good health. In the UK, prior to the institution of the NHS reforms in the early 2000s, it was shown that income was an important determinant of access to healthcare resources. [9] Because one's job or career is a primary conduit for both financial and social capital, work is an important, yet under represented, factor in health inequities research and prevention efforts. [10] Maintenance of good health through the utilization of proper healthcare resources can be quite costly and therefore unaffordable to certain populations. [11] [12] [13]

Socioeconomic status Economic and social measure of a persons affluence and/or influence

Socioeconomic status (SES) is an economic and sociological combined total measure of a person's work experience and of an individual's or family's economic and social position in relation to others, based on household income, earners' education, and occupation are examined, as well as combined income, whereas for an individual's SES only their own attributes are assessed. However, SES is more commonly used to depict an economic difference in society as a whole.

Financial capital is any economic resource measured in terms of money used by entrepreneurs and businesses to buy what they need to make their products or to provide their services to the sector of the economy upon which their operation is based, i.e. retail, corporate, investment banking, etc.

Social capital Concept

Social capital broadly refers to those factors of effectively functioning social groups that include such things as interpersonal relationships, a shared sense of identity, a shared understanding, shared norms, shared values, trust, cooperation, and reciprocity. However, the many views of this complex subject make a single definition difficult.

In China, for instance, the collapse of the Cooperative Medical System left many of the rural poor uninsured and unable to access the resources necessary to maintain good health. [14] Increases in the cost of medical treatment made healthcare increasingly unaffordable for these populations. This issue was further perpetuated by the rising income inequality in the Chinese population. Poor Chinese were often unable to undergo necessary hospitalization and failed to complete treatment regimens, resulting in poorer health outcomes. [15]

The healthcare reform in China refers to the previous and ongoing healthcare system transition in modern China. China's government, specifically the National Health and Family Planning Commission, plays a leading role in these reforms. Reforms focus on establishing public medical insurance systems and enhancing public healthcare providers, the main component in China's healthcare system. In urban and rural areas, three government medical insurance system, Urban Residents Basic Medical Insurance, Urban Employee Basic Medical Insurance and New Rural Co-operative Medical Scheme cover almost everyone. Various public healthcare facilities, including county or city hospitals, community health centers, township health centers, were founded to serve diverse needs. Current and future reforms are outlined in Healthy China 2030.

Similarly, in Tanzania, it was demonstrated that wealthier families were far more likely to bring their children to a healthcare provider: a significant step towards stronger healthcare. [16] Some scholars have noted that unequal income distribution itself can be a cause of poorer health for a society as a result of "underinvestment in social goods, such as public education and health care; disruption of social cohesion and the erosion of social capital". [13]

The role of socioeconomic status in health equity extends beyond simple monetary restrictions on an individual's purchasing power. In fact, social capital plays a significant role in the health of individuals and their communities. It has been shown that those who are better connected to the resources provided by the individuals and communities around them (those with more social capital) live longer lives. [17] The segregation of communities on the basis of income occurs in nations worldwide and has a significant impact on quality of health as a result of a decrease in social capital for those trapped in poor neighborhoods. [11] [18] [19] [20] [21] Social interventions, which seek to improve healthcare by enhancing the social resources of a community, are therefore an effective component of campaigns to improve a community's health. A 1998 epidemiological studyshowed that community healthcare approaches fared far better than individual approaches in the prevention of heart disease mortality. [22]

Income segregation is the separation of various peoples by class based on income. For example, certain people cannot get into country clubs because of insufficient funds. Many residential areas are segregated as a practical matter by income due to exclusionary zoning, which may require limit dwellings to detached single family homes and require minimum lot sizes and minimum square footage for the house.

Unconditional cash transfers for reducing poverty used by some programs in the developing world appear to lead to a reduction in the likelihood of being sick. [23] Such evidence can guide resource allocations to effective interventions.

Education

Education is an important factor in healthcare utilization, though it is closely intertwined with economic status. An individual may not go to a medical professional or seek care if they don’t know the ills of their failure to do so, or the value of proper treatment. [24] In Tajikistan, since the nation gained its independence, the likelihood of giving birth at home has increased rapidly among women with lower educational status. Education also has a significant impact on the quality of prenatal and maternal healthcare. Mothers with primary education consulted a doctor during pregnancy at significantly lower rates (72%) when compared to those with a secondary education (77%), technical training (88%) or a higher education (100%). [25] There is also evidence for a correlation between socioeconomic status and health literacy; one study showed that wealthier Tanzanian families were more likely to recognize disease in their children than those that were coming from lower income backgrounds. [16]

Spatial disparities in health

For some populations, access to healthcare and health resources is physically limited, resulting in health inequities. For instance, an individual might be physically incapable of traveling the distances required to reach healthcare services, or long distances can make seeking regular care unappealing despite the potential benefits. [24]

Global concentrations of healthcare resources, as depicted by the number of physicians per 100,000 individuals, by country. Global physician density map - WHO 2010.png
Global concentrations of healthcare resources, as depicted by the number of physicians per 100,000 individuals, by country.

Costa Rica, for example, has demonstrable health spatial inequities with 12–14% of the population living in areas where healthcare is inaccessible. Inequity has decreased in some areas of the nation as a result of the work of healthcare reform programs, however those regions not served by the programs have experienced a slight increase in inequity. [26]

China experienced a serious decrease in spatial health equity following the Chinese economic revolution in the 1980s as a result of the degradation of the Cooperative Medical System (CMS). The CMS provided an infrastructure for the delivery of healthcare to rural locations, as well as a framework to provide funding based upon communal contributions and government subsidies. In its absence, there was a significant decrease in the quantity of healthcare professionals (35.9%), as well as functioning clinics (from 71% to 55% of villages over 14 years) in rural areas, resulting in inequitable healthcare for rural populations. [21] [27] The significant poverty experienced by rural workers (some earning less than 1 USD per day) further limits access to healthcare, and results in malnutrition and poor general hygiene, compounding the loss of healthcare resources. [15] The loss of the CMS has had noticeable impacts on life expectancy, with rural regions such as areas of Western China experiencing significantly lower life expectancies. [28] [29]

Similarly, populations in rural Tajikistan experience spatial health inequities. A study by Jane Falkingham noted that physical access to healthcare was one of the primary factors influencing quality of maternal healthcare. Further, many women in rural areas of the country did not have adequate access to healthcare resources, resulting in poor maternal and neonatal care. These rural women were, for instance, far more likely to give birth in their homes without medical oversight. [25]

Ethnic and racial disparities

Along with the socioeconomic factor of health disparities, race is another key factor. 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. [30] The disparities in access to adequate healthcare include differences in the quality of care based on race and overall insurance coverage based on race. A 2002 study in the Journal of the American Medical Association identifies race as a significant determinant in the level of quality of care, with blacks receiving lower quality care than their white counterparts. [31] This is in part because members of ethnic minorities such as African Americans are either earning low incomes, or living below the poverty line. In a 2007 Census Bureau, African American families made an average of $33,916, while their white counterparts made an average of $54,920. [32] Due to a lack of affordable health care, the African American death rate reveals that African Americans have a higher rate of dying from treatable or preventable causes. According to a study conducted in 2005 by the Office of Minority Health—a U.S. Department of Health—African American men were 30% more likely than white men to die from heart disease. [32] Also African American women were 34% more likely to die from breast cancer than their white counterparts. [32]

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 as a result receive less regular medical care. The level of insurance coverage is directly correlated with access to healthcare including preventative and ambulatory care. [30] A 2010 study on racial and ethnic disparities in health done by the Institute of Medicine has shown that the aforementioned disparities cannot solely be accounted for in terms of certain demographic characteristics like: insurance status, household income, education, age, geographic location and quality of living conditions. Even when the researchers corrected for these factors, the disparities persist. [33] Slavery has contributed to disparate health outcomes for generations of African Americans in the United States. [34]

Ethnic health inequities also appear in nations across the African continent. A survey of the child mortality of major ethnic groups across 11 African nations (Central African Republic, Côte d'Ivoire, Ghana, Kenya, Mali, Namibia, Niger, Rwanda, Senegal, Uganda, and Zambia) was published in 2000 by the WHO. The study described the presence of significant ethnic parities in the child mortality rates among children younger than 5 years old, as well as in education and vaccine use. [35] In South Africa, the legacy of apartheid still manifests itself as a differential access to social services, including healthcare based upon race and social class, and the resultant health inequities. [36] [37] Further, evidence suggests systematic disregard of indigenous populations in a number of countries. The Pygmys of Congo, for instance, are excluded from government health programs, discriminated against during public health campaigns, and receive poorer overall healthcare. [38]

In a survey of five European countries (Sweden, Switzerland, the UK, Italy, and France), a 1995 survey noted that only Sweden provided access to translators for 100% of those who needed it, while the other countries lacked this service potentially compromising healthcare to non-native populations. Given that non-natives composed a considerable section of these nations (6%, 17%, 3%, 1%, and 6% respectively), this could have significant detrimental effects on the health equity of the nation. In France, an older study noted significant differences in access to healthcare between native French populations, and non-French/migrant populations based upon health expenditure; however this was not fully independent of poorer economic and working conditions experienced by these populations. [39]

A 1996 study of race-based health inequity in Australia revealed that Aborigines experienced higher rates of mortality than non-Aborigine populations. Aborigine populations experienced 10 times greater mortality in the 30–40 age range; 2.5 times greater infant mortality rate, and 3 times greater age standardized mortality rate. Rates of diarrheal diseases and tuberculosis are also significantly greater in this population (16 and 15 times greater respectively), which is indicative of the poor healthcare of this ethnic group. At this point in time, the parities in life expectancy at birth between indigenous and non-indigenous peoples were highest in Australia, when compared to the US, Canada and New Zealand. [40] [41] In South America, indigenous populations faced similarly poor health outcomes with maternal and infant mortality rates that were significantly higher (up to 3 to 4 times greater) than the national average. [42] The same pattern of poor indigenous healthcare continues in India, where indigenous groups were shown to experience greater mortality at most stages of life, even when corrected for environmental effects. [43]

LGBT health disparities

Sexuality is a basis of health discrimination and inequity throughout the world. Homosexual, bisexual, transgender, and gender-variant populations around the world experience a range of health problems related to their sexuality and gender identity, [44] [45] [46] [47] some of which are complicated further by limited research.

In spite of recent advances, LGBT populations in China, India, and Chile continue to face significant discrimination and barriers to care. [47] [48] [49] The World Health Organization (WHO) recognizes that there is inadequate research data about the effects of LGBT discrimination on morbidity and mortality rates in the patient population. In addition, retrospective epidemiological studies on LGBT populations are difficult to conduct as a result of the practice that sexual orientation is not noted on death certificates. [50] WHO has proposed that more research about the LGBT patient population is needed  for improved understanding of its  unique health needs and barriers to accessing care. [51]

Recognizing the need for LGBT healthcare research, the Director of the National Institute on Minority Health and Health Disparities (NIMHD) at the U.S. Department of Health and Human Services designated sexual and gender minorities (SGMs) as a health disparity population for NIH research in October 2016. [52] For the purposes of this designation, the Director defines SGM as "encompass[ing] lesbian, gay, bisexual, and transgender populations, as well as those whose sexual orientation, gender identity and expressions, or reproductive development varies from traditional, societal, cultural, or physiological norms". [52] This designation has prioritized research into the extent, cause, and potential mitigation of health disparities among SGM populations within the larger LGBT community.

While many aspects of LGBT health disparities are heretofore uninvestigated, at this stage, it is known that one of the main forms of healthcare discrimination   LGBT individuals face is discrimination from healthcare workers or institutions themselves. [53] [54] A systematic literature review of publications in English and Portuguese from 2004–2014 demonstrate significant difficulties in accessing care secondary to discrimination and homophobia from healthcare professionals. [55] This discrimination can take the form of verbal abuse, disrespectful conduct, refusal of care, the withholding of health information,  inadequate treatment, and outright violence. [55] [56] In a study analyzing the quality of healthcare for South African men who have sex with men (MSM), researchers interviewed a cohort of individuals about their health experiences, finding that MSM who identified as homosexual felt their access to healthcare was limited due to an inability to find clinics employing healthcare workers who did not discriminate against their sexuality. [57] They also reportedly faced "homophobic verbal harassment from healthcare workers when presenting for STI treatment". [57] Further, MSM who did not feel comfortable disclosing their sexual activity to healthcare workers failed to identify as homosexuals, which limited the quality of the treatment they received. [57]

Additionally, members of the LGBT community contend with health care disparities due, in part, to lack of provider training and awareness of the population’s healthcare needs. [56] Transgender individuals believe that there is a higher importance of providing gender identity (GI) information more than sexual orientation (SO) to providers to help inform them of better care and safe treatment for these patients. [58] Studies regarding patient-provider communication in the LGBT patient community show that providers themselves report a significant lack of awareness regarding the health issues LGBT-identifying patients face. [56] As a component of this fact, medical schools do not focus much attention on LGBT health issues in their curriculum; the LGBT-related topics that are discussed tend to be limited to HIV/AIDS, sexual orientation, and gender identity. [56]

Among LGBT-identifying individuals, transgender individuals face especially significant barriers to treatment. Many countries still do not have legal recognition of transgender or non-binary gender individuals leading to placement in mis-gendered hospital wards and medical discrimination. [59] [60] Seventeen European states mandate sterilization of individuals who seek recognition of a gender identity that diverges from their birth gender. [60] In addition to many of the same barriers as the rest of the LGBT community, a WHO bulletin points out that globally, transgender individuals often also face a higher disease burden. [61] A 2010 survey of transgender and gender-variant people in the United States revealed that transgender individuals faced a significant level of discrimination. [62] The survey indicated that 19% of individuals experienced a healthcare worker refusing care because of their gender, 28% faced harassment from a healthcare worker, 2% encountered violence, and 50% saw a doctor who was not able or qualified to provide transgender-sensitive care. [62] In Kuwait, there have been reports of transgender individuals being reported to legal authorities by medical professionals, preventing safe access to care. [59] An updated version of the U.S. survey from 2015 showed little change in terms of healthcare experiences for transgender and gender variant individuals. The updated survey revealed that 23% of individuals reported not seeking necessary medical care out of fear of discrimination, and 33% of individuals who had been to a doctor within a year of taking the survey reported negative encounters with medical professionals related to their transgender status. [63]

The stigmatization represented particularly in the transgender population  creates a health disparity for LGBT individuals with regard to mental health. [53] The LGBT community is at increased risk for psychosocial distress, mental health complications, suicidality, homelessness, and substance abuse, often complicated by access-based under-utilization or fear of health services. [53] [54] [64] Transgender and gender-variant individuals have been found to experience higher rates of mental health disparity than LGB individuals. According to the 2015 U.S. Transgender Survey, for example, 39% of respondents reported serious psychological distress, compared to 5% of the general population. [63]

These mental health facts are informed by a history of anti-LGBT bias in health care. [65] The Diagnostic and Statistical Manual of Mental Disorders (DSM) listed homosexuality as a disorder until 1973; transgender status was listed as a disorder until 2012. [65] This was amended in 2013 with the DSM-5 when "gender identity disorder" was replaced with "gender dysphoria", reflecting that simply identifying as transgender is not itself pathological and that the diagnosis is instead for the distress a transgender person may experience as a result of the discordance between assigned gender and gender identity. [66]

LGBT health issues have received disproportionately low levels of medical research, leading to difficulties in assessing appropriate strategies for LGBT treatment. For instance, a review of medical literature regarding LGBT patients revealed that there are significant gaps in the medical understanding of cervical cancer in lesbian and bisexual individuals [50] it is unclear whether its prevalence in this community is a result of probability or some other preventable cause. For example, LGBT people report poorer cancer care experiences. [67] It is incorrectly assumed that LGBT women have a lower incidence of cervical cancer than their heterosexual counterparts, resulting in lower rates of screening. [50]  Such findings illustrate the need for continued research focused on the circumstances and needs of LGBT individuals and the inclusion in policy frameworks of sexual orientation and gender identity as social determinants of health. [68]

A June 2017 review sponsored by the European commission as part of a larger project to identify and diminish health inequities, found that LGB are at higher risk of some cancers and that LGBTI were at higher risk of mental illness, and that these risks were not adequately addressed. The causes of health inequities were, according to the review, "i) cultural and social norms that preference and prioritise heterosexuality; ii) minority stress associated with sexual orientation, gender identity and sex characteristics; iii) victimisation; iv) discrimination (individual and institutional), and; v) stigma." [69]

Sex and gender in healthcare equity

Sex and gender in medicine

Both gender and sex are significant factors that influence health. Sex is characterized by female and male biological differences in regards to gene expression, hormonal concentration, and anatomical characteristics. [70] Gender is an expression of behavior and lifestyle choices. Both sex and gender inform each other, and it is important to note that differences between the two genders influence disease manifestation and associated healthcare approaches. [70] Understanding how the interaction of sex and gender contributes to disparity in the context of health allows providers to ensure quality outcomes for patients. This interaction is complicated by the difficulty of distinguishing between sex and gender given their intertwined nature; sex modifies gender, and gender can modify sex, thereby impacting health. [70]  Sex and gender can both be considered sources of health disparity; both contribute to men and women’s susceptibility to various health conditions, including cardiovascular disease and autoimmune disorders. [70]

Health disparities in the male population

As sex and gender are inextricably linked in day-to-day life, their union is apparent in medicine. Gender and sex are both components of health disparity in the male population. In non-Western regions, males tend to have a health advantage over women due to gender discrimination, evidenced by infanticide, early marriage, and domestic abuse for females. [71] In most regions of the world, the mortality rate is higher for adult men than for adult women; for example, adult men suffer from fatal illnesses with more frequency than females. [72] The leading causes of the higher male death rate are accidents, injuries, violence, and cardiovascular diseases. In a number of countries, males also face a heightened risk of mortality as a result of behavior and greater propensity for violence. [72]

Physicians tend to offer invasive procedures to male patients more than female patients. [73] Furthermore, men are more likely to smoke than women and experience smoking-related health complications later in life as a result; this trend is also observed in regard to other substances, such as marijuana, in Jamaica, where the rate of use is 2–3 times more for men than women. [72] Lastly, men are more likely to have severe chronic conditions and a lower life expectancy than women in the United States. [74]

Health disparities in the female population

Gender and sex are also components of health disparity in the female population. The 2012 World Development Report (WDR) noted that women in developing nations experience greater mortality rates than men in developing nations. [75] Additionally, women in developing countries have a much higher risk of maternal death than those in developed countries. The highest risk of dying during childbirth is 1 in 6 in Afghanistan and Sierra Leone, compared to nearly 1 in 30,000 in Sweden—a disparity that is much greater than that for neonatal or child mortality. [76]

While women in the United States tend to live longer than men, they generally are of lower socioeconomic status (SES) and therefore have more barriers to accessing healthcare. [77] Being of lower SES also tends to increase societal pressures, which can lead to higher rates of depression and chronic stress and, in turn, negatively impact health. [77] Women are also more likely than men to suffer from sexual or intimate-partner violence both in the United States and worldwide. In Europe, women who grew up in poverty are more likely to have lower muscle strength and higher disability in old age. [78] [79]

Women have better access to healthcare in the United States than they do in many other places in the world. [80] In one population study conducted in Harlem, New York, 86% of women reported having privatized or publicly assisted health insurance, while only 74% of men reported having any health insurance. This trend is representative of the general population of the United States. [81]

In addition, women's pain tends to be treated less seriously and initially ignored by clinicians when compared to their treatment of men's pain complaints. [82] Historically, women have not been included in the design or practice of clinical trials, which has slowed the understanding of women's reactions to medications and created a research gap. This has led to post-approval adverse events among women, resulting in several drugs being pulled from the market. However, the clinical research industry is aware of the problem, and has made progress in correcting it. [83] [84]

Cultural factors

Health disparities are also due in part to cultural factors that involve practices based not only on sex, but also gender status. For example, in China, health disparities have distinguished medical treatment for men and women due to the cultural phenomenon of preference for male children. [85] Recently, gender-based disparities have decreased as females have begun to receive higher-quality care. [86] [87] Additionally, a girl’s chances of survival are impacted by the presence of a male sibling; while girls do have the same chance of survival as boys if they are the oldest girl, they have a higher probability of being aborted or dying young if they have an older sister. [88]

In India, gender-based health inequities are apparent in early childhood. Many families provide better nutrition for boys in the interest of maximizing future productivity given that boys are generally seen as breadwinners. [89] In addition, boys receive better care than girls and are hospitalized at a greater rate. The magnitude of these disparities increases with the severity of poverty in a given population. [90]

Additionally, the cultural practice of female genital mutilation (FGM) is known to impact women's health, though is difficult to know the worldwide extent of this practice. While generally thought of as a Sub-Saharan African practice, it may have roots in the Middle East as well. [91] The estimated 3 million girls who are subjected to FGM each year potentially suffer both immediate and lifelong negative effects. [92] Immediately following FGM, girls commonly experience excessive bleeding and urine retention. [93] Long-term consequences include urinary tract infections, bacterial vaginosis, pain during intercourse, and difficulties in childbirth that include prolonged labor, vaginal tears, and excessive bleeding. [94] [95] Women who have undergone FGM also have higher rates of post-traumatic stress disorder (PTSD) and herpes simplex virus 2 (HSV2) than women who have not. [96] [97]

Health inequality and environmental influence

Minority populations have increased 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. [98] The environment that surrounds us can influence individual behaviors and lead to poor health choices and therefore outcomes. [99] Minority neighborhoods have been continuously noted to have more fast food chains and fewer grocery stores than predominantly white neighborhoods. [99] 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. [99] 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. [99]

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. [99] 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. [100] 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. [101] Housing conditions can create varying degrees of health risk that lead to complications of birth and long-term consequences in the aging population. [101] 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. [102]

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. [103] 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. [104] [105] 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. [104] 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. [106] 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. [107]

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. [108]

Disparities in access to health care

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

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. [120] In contrast, the Hispanic population had the largest problem communicating with their provider, 33% of the time. [120] 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. [121] 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. [122] 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. [123] [124] 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. [125] 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. [126] 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. [127] 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. [128]

Provider discrimination

Provider discrimination occurs when 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. [129] 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. [130] 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. [130] Physicians are unaware of their implicit biases. [131] 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. [132]

Lack of preventive care

According to the 2009 National Healthcare Disparities Report, uninsured Americans are less likely to receive preventive services in health care. [133] 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. [134] Studies have shown that use of professional interpreters have significantly reduced disparities in the rates of fecal occult testing, flu immunizations and pap smears. [135] In the UK, Public Health England, a universal service free at the point of use, which forms part of the NHS, offers regular screening to any member of the population considered to be in an at-risk group (such as individuals over 45) for major disease (such as colon cancer, or diabetic-retinopathy). [136] [137]

Plans for achieving health equity

There are a multitude of strategies for achieving health equity and reducing disparities outlined in scholarly texts, some examples include:

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 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. [146]

In June 2018, the European Commission launched the Joint Action Health Equity in Europe. [147] Forty-nine participants from 25 European Union Member States will work together to address health inequalities and the underlying social determinants of health across Europe. Under the coordination of the Italian Institute of Public Health, the Joint Action aims to achieve greater equity in health in Europe across all social groups while reducing the inter-country heterogeneity in tackling health inequalities.

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, [148] mental health, [149] drug abuse, [150] obesity, [151] 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. [152] 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. [153]

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. [154] This is also true of the difference between mortality across all occupational classes in highly equal Sweden as compared to less-equal England. [155]

See also

Related Research Articles

Population health

Population health has been defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group". According to Akarowhe (2018), the working definition of population health is expressed thus; population health is an art, process, science and a product of enhancing the health condition of a specific number of people within a given geographical area - population health as an art, simply means that it is geared towards equal health care delivery to an anticipated group of people in a particular geographical location; as a science, it implies that it adopt scientific approach of preventive, therapeutic, and diagnostic service in proffering medical treatment to the health problem of people; as a product, it means that population health is directed toward overall health performance of people through health satisfaction within the said geographical area; and as a process it entails effective and efficient running of a health management/population health management system to cater for the health needs of the people. It is an approach to health that aims to improve the health of an entire human population. This concept does not refer to animal or plant populations. It has been described as consisting of three components. These are "health outcomes, patterns of health determinants, and policies and interventions". A priority considered important in achieving the aim of Population Health is to reduce health inequities or disparities among different population groups due to, among other factors, the social determinants of health, SDOH. The SDOH include all the factors that the different populations are born into, grow up and function with throughout their lifetimes which potentially have a measurable impact on the health of human populations. The Population Health concept represents a change in the focus from the individual-level, characteristic of most mainstream medicine. It also seeks to complement the classic efforts of public health agencies by addressing a broader range of factors shown to impact the health of different populations. The World Health Organization's Commission on Social Determinants of Health, reported in 2008, that the SDOH factors were responsible for the bulk of diseases and injuries and these were the major causes of health inequities in all countries. In the US, SDOH were estimated to account for 70% of avoidable mortality.

Covert racism is a form of racial discrimination that is disguised and subtle, rather than public or obvious. Concealed in the fabric of society, covert racism discriminates against individuals through often evasive or seemingly passive methods. Covert, racially biased decisions are often hidden or rationalized with an explanation that society is more willing to accept. These racial biases cause a variety of problems that work to empower the suppressors while diminishing the rights and powers of the oppressed. Covert racism often works subliminally, and often much of the discrimination is being done subconsciously.

A sexual minority is a group whose sexual identity, orientation or practices differ from the majority of the surrounding society. Primarily used to refer to LGB individuals, it can also refer to transgender, genderqueer or intersex individuals.

AIDS service organizations are community-based organizations that provide support for people affected by HIV/AIDS. This article focuses on HIV/AIDS service organizations in the United States only.

Race and health refers to how being identified with a specific race influences health. Race is a complex concept that changes across time and space and that depends on both self-identification and social recognition. In the study of race and health, scientists organize people in racial categories depending on different factors such as: phenotype, ancestry, social identity, genetic makeup and lived experience. “Race” and ethnicity often remain undifferentiated in health research.

Social inequality uneven distribution of resources in a society

Social inequality occurs when resources in a given society are distributed unevenly, typically through norms of allocation, that engender specific patterns along lines of socially defined categories of persons. It is the differentiation preference of access of social goods in the society brought about by power, religion, kinship, prestige, race, ethnicity, gender, age, sexual orientation, and class. The social rights include labor market, the source of income, health care, and freedom of speech, education, political representation, and participation. Social inequality linked to economic inequality, usually described on the basis of the unequal distribution of income or wealth, is a frequently studied type of social inequality. Although the disciplines of economics and sociology generally use different theoretical approaches to examine and explain economic inequality, both fields are actively involved in researching this inequality. However, social and natural resources other than purely economic resources are also unevenly distributed in most societies and may contribute to social status. Norms of allocation can also affect the distribution of rights and privileges, social power, access to public goods such as education or the judicial system, adequate housing, transportation, credit and financial services such as banking and other social goods and services.

The Hopkins Center for Health Disparities Solutions (HCHDS), a research center within the Johns Hopkins Bloomberg School of Public Health, strives to eradicate disparities in health and health care among racial and ethnic groups, socioeconomic groups, and geopolitical categories such as urban, rural, and suburban populations.

LGBT topics in medicine are those that relate to lesbian, gay, bisexual, and transgender people's health issues and access to health services. According to the US Gay and Lesbian Medical Association (GLMA), besides HIV/AIDS, issues related to LGBT health include breast and cervical cancer, hepatitis, mental health, substance abuse, tobacco use, depression, access to care for transgender persons, issues surrounding marriage and family recognition, conversion therapy, refusal clause legislation, and laws that are intended to "immunize health care professionals from liability for discriminating against persons of whom they disapprove."

Research on race and health in the United States shows many health disparities between the different racial/ethnic groups. Different outcomes in mental and physical health exist between all census-recognized racial groups, but these differences stem from different historical and current factors, including genetics, socioeconomic factors, and racism. Research has demonstrated that numerous health care professionals show "implicit bias" in the way that they treat patients. Certain diseases have a higher prevalence among specific racial groups, and life expectancy also varies across groups. This article is directed towards some of the historical and societal factors that impact the health of various minorities groups in the United States. Race and health in the United States is a topic that has been researched many times, but the causes of disparate outcomes remain something that can be further explored.

Structural inequality is defined as a condition where one category of people are attributed an unequal status in relation to other categories of people. This relationship is perpetuated and reinforced by a confluence of unequal relations in roles, functions, decisions, rights, and opportunities. As opposed to cultural inequality, which focuses on the individual decisions associated with these imbalances, structural inequality refers specifically to the inequalities that are systemically rooted in the normal operations of dominant social institutions, and can be divided into categories like residential segregation or healthcare, employment and educational discrimination.

The social determinants of health in poverty describe the factors that affect impoverished populations' health and health inequality. Inequalities in health stem from the conditions of people's lives, including living conditions, work environment, age, and other social factors, and how these affect people's ability to respond to illness. These conditions are also shaped by political, social, and economic structures. The majority of people around the globe do not meet their potential best health because of a "toxic combination of bad policies, economics, and politics". Daily living conditions work together with these structural drivers to result in the social determinants of health.

Gender disparities in health

WHO has defined health as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." Identified by the 2012 World Development Report as one of two key human capital endowments, health can influence an individual's ability to reach his or her full potential in society. Yet while gender equality has made the most progress in areas such as education and labor force participation, health inequality between men and women continues to plague many societies today. While both males and females face health disparities, girls and women experience a majority of health disparities. This comes from the fact that many cultural ideologies and practices have structured society in a way whereby women are more vulnerable to abuse and mistreatment, making them more prone to illnesses and early death. Women are also restricted from receiving many opportunities, such as education and paid labor, that can help improve their accessibility to better health care resources.

Healthcare in India three tier health care system

The Indian Constitution makes the provision of healthcare in India the responsibility of the state governments, rather than the central federal government. It makes every state responsible for "raising the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties".

Womens health in India

Women's health in India can be examined in terms of multiple indicators, which vary by geography, socioeconomic standing and culture. To adequately improve the health of women in India multiple dimensions of wellbeing must be analysed in relation to global health averages and also in comparison to men in India. Health is an important factor that contributes to human wellbeing and economic growth.

Societal racism is the formalization of a set of institutional, historical, cultural, and interpersonal practices within a society that more often than not puts one social or ethnic group in a better position to succeed and at the same time disadvantages other groups in a consistent and constant matter that disparities develop between the groups over a period of time. Societal racism has also been called structural racism, because, according to Carl E. James, society is structured in a way that excludes substantial numbers of people from minority backgrounds from taking part in social institutions.

Cultural competence in healthcare health care services that are respectful of and responsive to the health beliefs, practices and cultural and linguistic needs of diverse patients

Cultural competence in healthcare refers to the ability for healthcare professionals to demonstrate cultural competence toward patients with diverse values, beliefs, and feelings. This process includes consideration of the individual social, cultural, and feelings needs of patients for effective cross-cultural communication with their health care providers. The goal of cultural competence in health care is to reduce health disparities and to provide optimal care to patients regardless of their race, gender, ethnic background, native languages spoken, and religious or cultural beliefs. Cultural competency training is important in health care fields where human interaction is common, including medicine, nursing, allied health, mental health, social work, pharmacy, oral health, and public health fields.

The United States Veterans Health Administration (VHA) has a lesbian, gay, bisexual and transgender (LGBT) Program through the Office of Patient Care Services. However, VHA does not currently collect data on veteran’s sexual orientation or gender identity. There are estimated to be more than one million LGBT Americans who are military veterans. If LGBT veterans use VHA at the same rate as non-LGBT veterans, there could be more than 250,000 LGBT veterans served by VHA. Using diagnostic codes in medical record data, Blosnich and colleagues found that the prevalence of transgender veterans in VHA (22.9/100,000) is five times higher than reported prevalence of transgender-related diagnoses in the general population (4.3/100,000). Brown and Jones identified 5,135 transgender veterans receiving care in VHA using a broader set of diagnostic codes. Brown also notes that this methodology fails to identify transgender veterans who have not disclosed their gender identity to providers, those who don’t meet criteria for a diagnosis, or veterans who get their transition-related care outside of the VHA.

Transgender health care refers to how medical institutions, communities and individuals approach the care of transgender people. It includes the prevention, diagnosis and treatment of physical and mental health conditions, as well as sex reassignment therapies. In this article, you will find information about gender variance, sex reassignment therapy, health risks, access to healthcare for trans people in different countries around the world, and specific information about transgender youth and transgender older adults.

Mental health inequality refers to the differences in quality of mental health and mental health care for different identities and populations. Mental health can be defined as well-being and/or the absence of clinically defined mental illness. There are social economic factors that influence individuals or groups of people of a certain demographic. This can be a factor to mental health care access. Inequalities may include presence of mental health, access to mental health care, quality of mental health care, and mental health outcomes between populations with different race, ethnicity, sexual orientation, sex, gender, socioeconomic statuses, education level, and geographic location.

Healthcare disparity in Massachusetts refers to the issues in access to, and treatment of, the residents of the state of Massachusetts. Many factors contribute to healthcare disparity, including access, behavioral risk factors, family history, social determinants of health, social and cultural factors, and discrimination in the clinic. There is also a distinction between health disparity, otherwise known as health equity, and health inequality. If one population dies young as a result of genetic or a non-controllable factor, that is known as health inequality. If a population dies young as a result of lack of access to preventative treatment or care once they get sick, that is known as health inequity.

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Further notes