Social Determinants, Health Disparities and Linkages to Health and Health Care: Volume 31

This chapter provides both an introduction to the volume and a review of literature on health disparities and social determinants.

Literature Review.

The chapter argues for the importance of greater consideration of social determinants of health disparities. This includes a consideration of race/ethnicity and socioeconomic status factors, geographic and place factors, and disparities especially linked to particular diseases.

Reviews the topic of health disparities and social determinants and previews this book.

Recent national policy adoptions of the social determinants of health approach present enormous challenges to practitioners designing health promotion programs aimed at eliminating health disparities. This chapter provides a framework for understanding the social determinant rationale embedded in Healthy People 2020 and introduces the concept of place as an important consideration.

This chapter presents a conceptual explanation of social determinant thinking and describes the potential impact for traditional health promotion activities that target the at-risk populations.

Two major resources, the Health Impact Assessment Toolkit and the HHS Disparities Action Plan, have emerged as frameworks for developing a health in all policies approach that will enable health practitioners to enhance their social determinant interventions.

Current social determinant approaches and models need to be strategically tailored to interventions aiming to reduce health disparities. Additional research focusing on how these approaches are integrated within the existing health promotion program frameworks is required.

Very few health practitioners have had the opportunity to integrate a social determinant approach that emphasizes the concept of place and explores the consequences of using a health in all policies approach. This chapter serves as a practical introduction and outlines the major challenges.

The tipping point for the inclusion of social determinants of health in addressing health disparities occurred with the publication of Healthy People 2020. As this innovation begins to diffuse throughout the country, health practitioners will benefit by reviews and applications of the new rationale and model.

The purpose of this chapter is to advance the medical sociology literature on the relationship between social cohesion and SRHS on an individual level. There is little information about how neighborhood social characteristics affect seniors’ SRHS. Guided by tenets of the collective efficacy theory, this chapter hypothesized that older individuals who perceived that their neighborhood has high levels of social cohesion around elderly issues will have better SRHS. A secondary hypothesis investigates whether the relationship was attenuated once their neighbors’ actual, self-reported attitudes toward seniors were taken into account.

Data come from a telephone survey of Indianapolis, Indiana residents, court data, and census information.

Logistic regression analyses indicated that both social cohesion and low income are statistically significant predictors of poor self-rated health status. Although both are statistically significant, the protective association between cohesion and poor SRHS (−0.69 log odds) is of similar magnitude to the risky association between income and poor health (−0.64 log odds).

Consistent with the classic work of Durkheim who found that individuals who were more socially integrated with society had lower rates of suicide, our study found a significant association between social cohesion and SRHS.

Future research is needed to target other health status outcomes in other geographical locations. Even though the body of research exploring the predictors of SRHS among older individuals is quite robust, this chapter adds to a more recent growing body of research, which has articulated the importance of the social environment in which an individual lives, especially community-dwelling older adults, is associated with their health status.

To examine a local primary health care infrastructure and the reality of primary health care from the perspective of residents of a small, urban community in the southern United States.

Data were derived from 13 semistructured focus groups, plus three semistructured interviews, and were analyzed inductively consistent with a grounded theory approach.

Structural barriers to the local primary health care infrastructure include transportation, clinic and appointment wait time, and co-payments and health insurance. Hidden barriers consist of knowledge about local health care services, nonphysician gatekeepers, and fear of medical care. Community residents have used home remedies and the emergency department at the local academic medical center to manage these structural and hidden barriers.

Findings might not generalize to primary health care infrastructures in other communities, respondent perspectives can be biased, and the data are subject to various interpretations and conceptual and thematic frameworks. Nevertheless, the structural and hidden barriers to the local primary health care infrastructure have considerably diminished the autonomy community residents have been able to exercise over their decisions about primary health care, ultimately suggesting that efforts concerned with increasing the access of medically underserved groups to primary health care in local communities should recognize the centrality and significance of power.

This study addresses a gap in the sociological literature regarding the impact of specific barriers to primary health care among medically underserved groups.

This chapter assesses the effects of two rural community residential advantages – economic growth and availability of health services – upon residents’ health and emotional well-being.

A de facto experimental design divided communities into four analytical types based on their economic growth and health services. Household survey data were gathered via a drop-off/pickup procedure and 400 randomly selected households were surveyed in each location. Physical health was measured with a subset of items from the Medical Outcomes Study’s 36-item short form. A 10-item emotional well-being index was used. Beyond sociodemographic items, questions concerned household assets, medical problems, social supports, and community ties. Nested regression analyses were used to assess the effects of residential advantage upon health, net of potentially confounding factors.

Contrary to expectations, both residential advantages were necessary for improved health. The most important negative net effect on health was aging. Beyond household assets and community economic expansion, miles commuted to work was the next most important factor enhancing physical health. In all types of communities, residents’ emotional well-being scores were independent of age, but positively related to household income and religious involvement.

Obviously the study is limited by geography and by the small number of communities in each residential type. While we could measure the effects of household members not being able to address all health needs, we could not assess the effects of such problems on anyone else in the households beyond the respondents. Our survey approach is also unable to address the effects of rural residents being unable to meet their health needs over time.

Ours is the first study that we know of applying a de facto natural experimental design to assess community residential effects. The interrelated effects of residential community resources for residents’ health suggests that more studies like this one should be done.

To investigate ethnic group differences in the utilization of preventive medical care services among U.S. Asian and Latino immigrant adults.

Using data from the 2002–2003 National Latino and Asian American Study, we examined whether differences exist in the reporting of any preventive physical care or dental/optician visit during the last year across Asian and Latino immigrant groups. Following, we applied Andersen’s (1995) Behavioral Model of Health Services Use to assess how ethnic disparities in preventive care use are a function of predisposing, enabling/impeding, and need-based factors.

Descriptive results showed that among Latinos, a much lower proportion of Mexican immigrants reported a preventive medical care visit during the last year than either Cuban or Puerto Rican immigrants. Asian immigrants show less variation in use, but significant differences still exist with Filipino immigrants reporting the highest level of use, followed by Vietnamese and then Chinese immigrants. Logistic regression models also indicated that predisposing characteristics, especially aspects of acculturation status, contribute strongly to ethnic group differences in preventive care use, while enabling/disabling and need-based characteristics are less important.

While studies of medical care use often treat Asians and Latinos as homogeneous groups, our findings illustrate the need for a more detailed view of the foreign-born population. Findings also highlight the role of acculturation status in shaping group differences in preventive medical care use – and as such, the importance of considering these differences when promoting the use of timely preventive care services among immigrant populations.

This chapter examines birth outcomes of patients enrolled in Familias Sanas (Healthy Families), an educational intervention designed to reduce health disadvantages of low-income, immigrant Latina mothers by providing social support during and after pregnancy.

Using a randomized control-group design, the project recruited 440 pregnant Latina women, 88% of whom were first generation. Birth outcomes were collected through medical charts and analyzed using regression analysis to evaluate if there were any differences between patients enrolled in Familias Sanas compared to those patients who followed a typical prenatal course.

Control and intervention groups were found to be similar with regard to demographic characteristics. In addition, we did not observe a decrease in rate of a number of common pregnancy-related complications. Likewise, rates of operative delivery were similar between the two groups as were fetal weight at delivery and use of regional anesthesia at delivery.

The lack of improvements in birth outcomes for this study was perhaps because this social support intervention was not significant enough to override long-standing stressors such as socioeconomic status, poor nutrition, genetics, and other environmental stressors.

This study was set in an inner-city, urban hospital with a large percentage of patients being of Hispanic descent. The study itself is a randomized controlled clinical trial, and data were collected directly from electronic medical records by physicians.

This chapter examines social variations in parent dissatisfaction with children’s medical care and tests whether greater dissatisfaction is associated with less preventive care and unmet medical need.

The 2007 National Survey of Children’s Health (NSCH) is a nationally representative cross-sectional sample of parents of U.S. children age 0–17 years (N=78,523). We use a combination of ordinary least squares (OLS) and binary logistic regression to analyze parent dissatisfaction, preventive care, and unmet medical need.

Our results indicate that parents’ dissatisfaction scores are significantly higher for racial/ethnic minorities, non-English speakers, lower socioeconomic status (SES) respondents, and the uninsured. Furthermore, parent dissatisfaction has a significant and robust association with lack of preventive care and reports of unmet medical need.

Due to the cross-sectional research design, we were unable to determine whether dissatisfaction caused parents to delay children’s medical care, thus resulting in a lack of annual preventive care and greater unmet needs.

Although there is extensive research on adult perceptions of their own medical care, few sociological studies have examined parents’ perceptions about their children’s care. Yet, there is substantial evidence that parents transmit health-related attitudes, beliefs, and behaviors to their children. As with adult patients, parent satisfaction with their child’s medical care is stratified by social characteristics; however, we also find a strong association between dissatisfaction and use of other important health services. It may be the case that when parents feel that they did not receive satisfactory care, they are more likely to delay, or to forgo, preventive and other health services.

The race concordance hypothesis suggests that matching patients and health providers on the basis of race improves communication and patients’ perceptions of health care, and by extension, encourages patients to seek and utilize health care, which may reduce health disparities. However, relatively few studies have examined the impact of race concordance on the utilization of health services. This chapter is grounded on Andersen’s Emerging Model of Health Services Utilization (Phase 4) and extends that model to include race concordance.

The data were collected from a stratified random sample of adult beneficiaries enrolled in North Carolina Medicaid’s primary care case management delivery system in 2006–2007. Propensity score matching techniques were used to sort respondents on their propensity for race concordance and indices were constructed to generate key control variables. Poisson regression was used to examine the impact of race concordance on the utilization of primary care and emergency room care, under the assumption that race concordance would increase the use of primary care and decrease the use of emergency care for minority patients.

While blacks (compared to whites) used less primary care and had more emergency care visits, race concordance was not a statistically significant predictor of either primary care or emergency room use. However, patients’ satisfaction with their primary care providers was associated with significantly fewer primary care and emergency care visits while trust in one’s provider was associated with more primary care visits.

The study findings suggest that the central premises of the race concordance hypothesis require further study to confirm the assumption that better patient – primary care provider relationships result in less utilization of more costly and resource-intensive forms of health care.

The study makes a valuable contribution by expanding the relatively small body of literature dedicated to exploring the impact of race concordance on health services utilization. Additionally, by virtue of researching the experience of Medicaid enrollees, the study controls for health insurance status.

Older adults’ sexual health is becoming an increasingly important component of healthy aging in the wake of the HIV/AIDS epidemic and rising infection rates among this age cohort. The increase in HIV/AIDS diagnoses in the older adult population ignites the need to understand the reasons why older adults are omitted from HIV/AIDS prevention education policy.

This chapter examines the social forces that influence HIV/AIDS policy at the state and community levels. Through qualitative methodology and analysis, including interviews with state policymakers and managers of AIDS service organizations in four Midwestern states (n=31), I look for trends and patterns as to whether or not older adults are considered as an “at-risk” group for HIV infection.

Findings reveal that HIV/AIDS policy may be impacted by enduring sexual scripts about older adults. To some extent both state policymakers and AIDS service organization personnel adhere to stereotypes about older adults’ sexuality and sexual activity, which is then implemented in their health promotion activities. The result is that gaps exist in HIV/AIDS prevention education for older adults, despite the fact that current trends show an increase in new HIV infections and AIDS diagnoses among people over the age of 50.

While this is an exploratory study of the available HIV/AIDS prevention education and health promotion activities for older adults, as well as the viewpoints of state policymakers and AIDS service organization personnel, the findings do indicate the need for additional research on the potentially dangerous sexual behaviors – lack of HIV testing, low condom usage, multiple partners – exhibited by older adults. Future research involving interviews with older adults, physicians, and medical personnel may add new perspectives to the current research.

As the baby boomers continue to age and challenge cultural stereotypes of sexual behaviors among older adults, research in the area of sexual health and HIV/AIDS prevention education will remain an important component of healthy aging. This research begins what will ultimately be a necessary conversation.

The purpose of this chapter is to use sociological theory and research to develop an explanation for how chronic illnesses are managed at home and to thereby suggest some ways in which a sociological perspective can be applied to improve health care for persons with chronic illnesses. Self-care illness management is crucial to the prevention of and reduction of morbidity and mortality from chronic illness.

Review and synthesis of research literature.

Sociological research and theory suggest two important insights that should inform health care services aimed at improving self-care; chronic illness care occurs in the context of the household, neighborhood, and community and, therefore, the “patient” (i.e., the object of health services) is really the caregiving social network around the patient, and because the risk of chronic illness and the resources available to deal with it are socially (and unequally) distributed, “health care” interventions need to take account of disparities in risks and resources that will affect the patient’s ability to successfully comply with self-care regimens.

The review does not include an examination of the clinical research literature. It does, however, suggest that sociologists need to explicitly study chronic illness and health care related to it.

The chapter links the long history of research on family caregiving to the concern with the success of self-management of chronic illness. It also links concerns about that success to social disparities in the distribution of social resources and hence to morbidity and mortality disparities.

Disparities in transplant rates across social categories provide limited information about gatekeeping processes in access to kidney transplantation. We hypothesized that early opportunities for discussion of kidney transplantation potentially generate social capital that serves as a resource for patients as they navigate the transplantation pathway.

A national sample of first-year dialysis patients was surveyed and asked if kidney transplantation had been discussed with them before and after starting dialysis treatment. Associations between reported discussion and patient-specific clinical and nonclinical (sociodemographic) indicators of attributed utility for transplantation were investigated, and the association of reported transplant discussion with subsequent transplant waitlisting was analyzed.

Time to placement on the kidney transplant waiting list was significantly shorter for patients who reported that transplantation had been discussed with them before, as well as after, starting dialysis. Likelihood of reported discussion varied by patient age, employment and insurance status, cardiovascular comorbidity burden, and perceived health status; in addition, women were less likely to report early discussion.

It would be valuable to know more about the nature of the transplant discussions recalled by patients to better understand how social capital may be fostered through these discussions.

Indicators of attributed utility for successful transplantation were associated with transplant discussion both before and after starting dialysis, potentially contributing to observed disparities in access to kidney transplantation.

Predialysis nephrology care and patient participation in discussion of kidney transplantation may foster social capital that facilitates navigating the transplantation pathway.

Research on health care disparities is making important descriptive and analytical strides, and the issue of disparities has gained the attention of policymakers in the United States, other nation-states, and international organizations. Still, disparities research scholarship remains US-centric and too rarely takes a cross-national comparative approach to answering its questions. The US-centricity of disparities research has fostered a fixation on race and ethnicity that, although essential to understanding health disparities in the United States, has truncated the range of questions that researchers investigate. In this chapter, we make a case for comparative research that highlights its ability to identify the institutional factors that may affect disparities.

We discuss the central methodological challenges to comparative research. After describing current solutions to such problems, we use data from the World Values Survey to show the impact of key social fault lines on self-assessed health in Europe and the United States.

The negative impact of socioeconomic status (SES) on health is more generalizable across context, than the impact of race/ethnicity or gender.

Our analysis includes a limited number of countries and relies on one measure of health.

The chapter represents a first step in a research agenda to understand health inequalities within and across societies.

This chapter explores public perceptions of health disparities by taking political ideology and political party identification into account and applies theories of cognitive dissonance, cognitive prejudice, and moral prejudice to understand the impact of political ideology on perceptions of health disparities.

A statewide telephone survey asked 1,036 people about health disparities. Eight independent variables – political ideology, political party identification, gender, race, age, community type, income, and education achieved – were entered in an additive stepwise regression containing one of four dependent variables – unfair treatment based on health insurance, unfair treatment based on ability to speak English, minorities unable to get care when needed, and quality of care for minorities.

Political ideology entered all four equations while political party identity entered only two. Liberals were most likely to believe that minorities were unable to get routine care when needed and democrats that ability to speak English meant differential treatment. Respondents with low education were most likely to believe people were treated unfairly based on insurance, while those with lower incomes were more likely to believe that minorities received higher quality of care than whites.

A public opinion survey in one state cannot be generalized for the whole country. The survey was conducted in the spring of 2009 just as the debate over the proposed health care reform legislation was reaching a crescendo, which may explain the importance of political ideology on perceptions of health disparities.

This chapter explicitly examines the effect of political ideology and party identification on perceptions of health disparities by utilizing theories of cognitive and moral prejudice. Political ideology reflecting cognitive and moral prejudice may combine with support for a social movement or political faction that supports or opposes reducing health disparities.