Definitions & frameworks Flashcards
Adler & Rehkoph. (2008). U.S. disparities in health: Descriptions, causes, and mechanisms.
Gist: Health disparities is a fundamental albeit not always an explicit goal of public health research. Although there is a lot of research in this area, there are a number of unresolved issues. These include: (1) definition of health disparities; (2) relationship of different bases of disadvantage; (3) ability to attribute cause from association; (4) establishment of mechanisms by which social disadvantage affects biological processes that get into the body. Definitions are varied but usually start with bases of social disadvantage which result in differences that are unjust and avoidable. Methodological issues include the possibility for alternative explanations: (1) possibility that associations result from random chance; (2) associations may be due to a selection bias or inappropriate control variables; (3) potential for reverse causation or health selection bias; (4) whether associations result from the joint association of SES and health with a common underlying cause (e.g., genetic factors, time preferences/delayed gratification, cognitive ability). Five analytic methods that may be useful for this area include: propensity score matching, instrumental variables, time-series analysis, causal structural equation modeling, & marginal structural models. Most of the research in health disparities finds that health is consistently worse for individuals with few resources and for blacks compared to whites, but disparities vary by outcome, time, and geographic location in the U.S. One important pathway between social disadvantage and health is exposure to chronic stress and the resulting psychosocial & physiological responses to stress.
Braveman & Griskin. (2003). Defining equity in health.
Gist: The key points include:
(1) A definition of equity in health is needed that can guide measurement & hence accountability for the effects of actions.
(2) Health equity is the absence of systematic disparities in health (or its social determinants) between more & less advantaged social groups. Health represents both physical & mental wellbeing, not just the absence of disease. Systematic means that the associations must be significant & frequent or persistent.
(3) Social advantage means wealth, power, and/or prestige - the attributes defining how people are grouped in social hierarchies.
(4) Health inequities put disadvantaged groups at further disadvantage with respect to health, diminishing opportunities to be healthy.
(5) Health equity, an ethnic concept based on the principle of distributive justice, is also linked to human rights.
Carter-Pokras & Baquet. (2002). What is a “health disparity”?
Gist: This article discusses current definitions and related disagreements regarding the terms “disparity”, “inequality”, and “inequity”. The authors identified 11 different definitions. Disagreements center on which term to use, whether a judgment of what is avoidable & unfair is included, & how these judgments are made. The term “health disparity” is almost exclusively used in the U.S. while the terms “health inequity” or “health inequality” are commonly used outside of the U.S. A health disparity should be viewed as a chain of events signified by a difference in: (1) environment, (2) access to, utilization of, & quality of care, (3) health status, or (4) a particular health outcome that deserves scrutiny. Such a difference should be evaluated in terms of both inequality and inequity since what is unequal isn’t necessarily inequitable. Whitehead & WHO adopted the definition as “differences in health which are not only unnecessary and avoidable, but, in addition, are considered unfair and unjust”. However, there is argument regarding what is considered avoidable & who should make that determination. The Rockefeller Foundation suggests taking 5 steps to select measures to assess health inequalities: (1) define which aspect(s) of health to measure; (2) identify the relevant population groups across which to compare health status; (3) choose a reference group against which to compare the health of different groups; (4) decide whether to measure inequality using the absolute or relative difference in health status between population groups; (5) select among alternative “social weights” for preferences that are built into health measures. Comparison groups can be the non-minority or majority population, the general population, or different segments of the population. Disadvantages of the “best” rate, average rate, and total population rate is that they can change over time. Overall, disparity should act as a signpost that indicates something is wrong.
Dehlendorf, Bryant, Huddleston, Jacoby, & Fujimoto. (2010). Health disparities: Definitions and measurements.
Gist: Although there are multiple definitions of “health disparities”, the central aspect of most definitions is that not all differences in health status between groups are considered disparities but rather only the differences which systematically and negatively impact less advantaged groups. In the U.S., discussion of disparities is primarily focused on race and ethnicity. In international literature and some in the U.S., disparities research has also focused on SES, gender disparities, disparities based on disability, and disparities by sexual orientation. From a social justice perspective, it is most important to focus on those differences which society has a role in creating & has the greatest potential to ameliorate. “Health care disparities” are a small piece of health disparities and IOM defined it as “differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, or appropriateness of intervention”. One of the challenges is identification & categorization into groups. Self-identification is generally the gold standard for non-genetic studies. The inclusion of mixed-race categories & the degree of granularity for ethnicity are both active topics. OMB includes 5 race categories & 1 ethnicity choice. A more recent IOM report calls for using OMB categories along with more precise ethnicity categories in accordance with the geographic area of data collection. For SES, it’s common to use one or two factors; this is inadequate since patterns can change depending on which SES measures are used. Race/ethnicity & SES may also interact in complex ways. Overall, there are 3 generations of research in health disparities: (1) descriptive; (2) understanding mechanisms & pathways; (3) designing interventions (the latter less common).
Institute of Medicine. (2003). Chapter 1: Introduction and literature review.
Gist: Despite overall improvements in population health in the U.S., racial & ethnic minorities experience higher rates of morbidty & mortality than non-minorities. This book focuses on racial/ethnic disparities in healthcare, defined as the continuum of services provided in traditional healthcare settings as well as home-based care. Healthcare services refers to the provision of preventive, diagnostic, rehabilitative, and/or therapeutic medical or health services to individuals or populations. Quality of care refers to the degree to which health services for individuals & populations increase the likelihood of desired health outcomes & are consistent with current professional knowledge. Disparities in healthcare as racial/ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, & appropriateness of intervention. Disparities can operate on two levels: (1) operation of healthcare systems & legal & regulatory climate in which health systems function and (2) discriminatino at the individual, patient-provider level. Although healthcare alone plays a minor role in overall health disparities, it is also necessary for health. Research in healthcare disparities have found the following:
(1) Cardiovascular care: Strongest & most consistent evidence for existence of racial/ethnic disparities. Both potential underuse & overuse of services & appropriateness of care.
(2) Other disparities: cerebrovascular disease; renal transplantation; HIV/AIDS; asthma; diabetes; analgesia; maternal & child health; childrens’ health services; mental health services (more than any other area of health & medicine); other
(3) Mixed results: rehabilitative services
Aday. (2001). Chapter 1: Who are the vulnerable?
Gist: Discusses concepts regarding the origins & remedies of vulnerability.
Health status: (a) WHO defines as state of complete physical, mental, & social well-being; (b) community & individual health.
Relative risk: (a) Ratio of the risk of poor health among groups that are exposed to the risk factors vs those that are not; (b) “differential vulnerability hypothesis” argues that negative or stressful life events hurt some people more than others (found true for high vs. low SES).
Resource availability: (a) macrolevel look at availability & distribution of community resources; (b) social status is associated with positions that individuals occupy in society as a function of age, sex, or race/ethnicity; individuals w/ a combination of statuses (poor, minority elderly women or young males) that put them at a high risk of having both poor health & few material & nonmaterial resources are in a highly vulnerable position; (c) social capital resides in the quantity & quality of interpersonal ties among people; social support is an important resource for individuals to cope with & minimize the impact of negative life events or adversity on their health; (d) human capital refers to investments in people’s skills & capabilities.
The chapter then discusses a framework & topics in studying vulnerability.
Williams & Collins. (2013). U.S. socioeconomic and racial differences in health: Patterns and explanations.
Gist: Class is a widely used concept in the social sciences it isn’t well-defined. SES is a widely used proxy for social class in studies of the distribution of disease. SES is typically assessed more in line with Weberian notions of stratification rather than the Marxist emphasis on the relationship to the system of production. The direction of causality between SES & health has been debated. The positive association could reflect selection or “drift” on one side or could reflect the health consequence of low socioeconomic circumstances. The former makes only a minor contribution to SES differences in health. Although absolute SES has improved, relative SES differences have widened over time. The widening income inequality reflects more rapid gains in health status for high SES than for low SES & for some health indicators, evidence suggests a worsening health status at the low end of the socioeconomic spectrum. The gradient has been believed to be a stepwise progression of risk with each higher level of SES associated with better health status (Whitehall study). There’s also evidence of a threshold in which there is an increasingly diminished effect among those with higher SES.
Bloche. (2013). Health care disparities - science, politics, and race.
Gist: Provides a little history regarding a DHHS report that was mandated to be “positive” and not discuss racial inequities in health care. It emphasizes while science is not value free, there needs to be peer review and balance.
Thomas. (2013). The color line: Race matters in the elimination of health disparities.
Gist: The meaning of race has changed over time & the burdens & privileges have matched. For example, the Irish were once considered a minority and were discriminated against. Although some researchers believe the concept of race should be abandoned and ethnicity should be used instead, this ignores or minimizes the health impact of racism on health (social justice perspective). Shifting to ethnicity would move towards a greater emphasis on people’s cultural and behavioral attitudes, beliefs, lifestyle patterns, etc. From this perspective, interventions to address health disparities would focus more on individual behavior change. From the perspective of racial discrimination as a root cause, however, interventions need to focus on addressing social inequality & power relationships in society via community policies and mobilization.
Issac. (2013). Defining health and health care disparities and examining disparities across the life span.
Gist: No clear definition for health disparities (similar information provided in other literature). The term health disparity is used mostly in the U.S. and the term health inequality is mainly used in Europe. Health inequity is the preferred term by some. A life-span perspective on social status & health is that social status can affect health at any point from birth (or even before) until death. There are racial/ethnic disparities in mortality (black), infant mortality (black), motor vehicle mortality (AIAN), suicide (whites & AIAN), coronary heart disease & stroke mortality (black), homicide (black), cancer mortality (black), obesity (black & Mexican American), preterm birth (black), access to care & hospitalizations (minorities), vaccination (blacks), asthma (multiracial, Puerto Ricans, blacks), HIV (black), diabetes (black, Hispanic, AIAN), hypertension (black), smoking (minorities esp. AIAN), cancer (black).
