Health disparities in the U.S.

Question 1

Shi & Stevens. (2010). Chapter 1: A general framework to study vulnerable populations.

Answer 1

Gist: Vulnerability has been defined in a number of ways in the U.S. (e.g., disadvantaged, underserved) & researchers usually focus on distinct subpopulations. Vulnerable populations needs to be studied because they have greater health needs, they're increasing, it's a social issue (rather than individual), it's intertwined with the nation's health & resources, & vulnerability implies inequity in health. Models for studying vulnerability include: 
Individual Determinants Model (Rogers, 1997): Focuses on individual-level characteristics only to characterize specific groups as vulnerable. 3 stages inherently vulnerable: childhood, adolescence, & old age. Minority race/ethnicity is a vulnerable characteristic. Major life changes can create vulnerable periods. 
Individual Social Resources Model (Aday, 1994): Individual risks stem from intrinsic social & personal resources (social & human capital). The characteristics are not the determinants of poor health but reflect larger issues related to resources that contribute to vulnerability. 
Individual Health Behaviors Model (multiple researchers): Vulnerable populations engage in fewer health-promoting & more risky health behaviors. Factors include poorer social support, reduced sense of live control & self-esteem, racism, classism, & other stressors related to less social power & resources.
Individual Socioeconomic Status Model: Poor health status is influenced by individual SES via 2 mechanisms: (1) low-SES individuals have fewer financial resources to maintain & promote personal health adequately; (2) low-SES groups have less financial access to health care resources.  
Community Social Resources Model: Here is where models begin to explore community-level determinants of vulnerability & highlights responsibility of society to address consequences of vulnerability. Examines both community- & individual-level social resources. Flaskerud & Winslow take into account both socioeconomic & environmental circumstances in the definition of resource availability. Environmental circumstances include poor access to health care & poor quality care, & other environmental circumstances (e.g., community violence) are discussed only in terms of hindering access to health care & social services. Poor health status of a pop. may contribute to poor resources in a population, creating a cycle of vulnerability. 
Community Environmental Exposures Model: Potential role of health-impairing environmental exposures (e.g., substandard housing, air pollution) or accumulation of exposures. 
Community Medically Underserved Model: The absence of health services directly impacts the population's health (albeit contributing to only a small portion of pop. health). Guidelines for assessing medical underservice are (1) limited physical availability of health care resources, (2) financial barriers to obtaining health services, & (3) non-financial barriers (e.g., transportation, language difficulties). Medically underserved area is based on measurement of physician-to-population ratio, infant mortality rates, poverty rates, & proportion of population that's elderly. 
Individual and Community Interaction Model (Aday, 1993): Incorporates both individual- & community-level risk factors to determine vulnerability & identifies 9 specific subpopulations based on physical, psychological, & social vulnerability. Physical: high-risk mothers & infants, chronically ill & disabled, living with HIV/AIDS. Psychological: mentally ill & disabled, alcohol/substance abusers, at risk for suicide or homicide. Social: abusing families, homeless, immigrants & refugees. 
Sinner and Victims Social Policy Model: Based on a history of Puritanism (negative effect of social & religious sinners on community) vs. social gospel beliefs (influence of social trends, economics, & politics on members of the community). Basically, policies can be influenced by whether health problems are viewed as behaviors of a sinner compared to the result of societal influences outside of the individual's control. 
Vulnerability Model (current authors' new framework): Vulnerability refers to susceptibility to poor health/illness. Vulnerability defined as a convergence of predisposing, enabling, & need characteristics at both individual & ecological levels. 
Predisposing characteristics: propensity of individuals to use services (e.g., demographics, social structure variables, health beliefs)
Enabling characteristics: resources available for use of services (e.g., income, insurance coverage, availability of health care services in community)
Need characteristics: specific illness or health needs that are principal driving forces for seeking care
Vulnerability defined by individual characteristics, environment, & interaction of two. Emphasis is on convergence of risk factors that may lead to cumulative vulnerability, & vulnerability is a multidimensional construct. Presumption is that interaction between multiple factors contributes to higher level of vulnerability & greater risk of poor health. The book/framework focuses on race/ethnicity, SES, & insurance coverage.

Question 2

Shi & Stevens. (2010). Chapter 2: Community determinants and mechanisms of vulnerability.

Answer 2

Gist: This chapter looks at multiple characteristics of vulnerability & discusses trends in occurrences, determinants, & potential mechanisms in relationship with adverse health care experiences & health outcomes.
Race/ethnicity: (a) proxy measure for other explanatory factors; (b) challenging in future to discuss “minority”; (c) minority race/ethnicity predicts poorer health status, access to care, & quality of care; (d) mechanisms include SES, cultural factors, discrimination, health needs, provider factors, & health system factors.
SES: (a) multidimensional construct; (b) summary of trends - blacks & Hispanics have highest rates of poverty; single-parent households headed by women; # of children in poverty rising (higher among minorities than whites); income inequality seems greater in US compared to other developed nations; disparities in education; (c) mechanisms include material deprivation (threshold) & lack of social participation (gradient); (d) material deprivation - lack of material resources that enable protection or promotion of health; (d) social participation - 3 mechanisms correlated with health include effects of stress & coping, health-related behaviors, & life control; (e) social cohesion - community-level equivalent of social participation; (f) health care system - certain types of medical care more beneficial than others in reducing country’s overall burden of disease.
Health insurance: (a) two barriers to universal coverage - majority of public & politicans have not demed health care as a funcamental right & inherent in American culture is belief that government-run programs are invasive & inefficient; (b) trends - major problem among wokring poor (less likely to have coverage through work but make too much for public coverage); coverage rates differ by state (worse in southern, than middle compared to northern); Medicaid, Medicare, CHIP; (c) mechanisms - health plan policies may affect care-seeking & cost-sharing behaviors of beneficiaries; providers’ incentives & reimbursement strategies may influence provider behaviors; patient perceptions of health insurance programs may create feelings of stigma & affect use of services & reports of quality; health plan policies - FFS vs. prepaid plans, gatekeeping, seek care only within network of providers, sigma of Medicaid & welfare programs.
Multiple risk factors: (a) potential interactions & pathways of all risk factors to potentially create vicious cycle where vulnerable adults & children have greater difficulty.
Summary: Pathways begin with family characteristics that then lead through the health care delivery system that contribute to disparities in care. The three pathways of SES characterize an individual’s relative position along the socioeconomic gradient & related to health care in 2 ways: material deprivation & social participation.

Question 3

Shi & Stevens. (2010). Chapter 3: The influence of individual risk factors.

Answer 3

Gist: This chapter presents findings regarding disparities according to the 3 main vulnerability characteristics & presented for access to health care, quality of care, & health.
Racial/ethnic disparities: (a) health care access - minorities less likely to have a regular source of care (esp. for Hispanic and black children) & factors that increase this lack include being a permanent resident or undocumented; Hispanics & Asians report little/no choice of where to seek care and Hispanics & blacks face more barriers to timely access; (b) health care quality - minorities less likely to receive preventive services, receipt of prenatal care in 1st trimester, mammography, & smoking cessation counseling; Hispanics & Asians least likely to receive preventive services (except higher immunization for Asians & prenatal care for Asian women); black & Hispanic children less likely to obtain all recommended well-child care; minorities more likely to report lack of trust in physician, feel looked down upon, & believe treated unfairly due to race or language; (c) health status - SRH lowest in AI/AN followed by blacks & Hispanics (adults & children); minorities have higher rates of infant mortality, LBW, overall & cause-specific mortality rates; blacks have higher mortality rates from homicide, breast cancer, & HIV; Hispanics have 2nd highest mortality rates from most of these causes & Asians have lowest rates (followed by whites).
Socioeconomic status disparities: (a) health care access - greater differences associated with individual SES than for race/ethnicity; poor adults less likely to have regular source of care & feel more barriers; (b) health care quality - receipt of preventive services in creases as SES increases; higher ambulatory care sensitive conditions (e.g., asthma, diabetes) among low-income urban areas; physicians perceive patients of lower SES to be less independent, responible, rational, & intelligent; lower satisfaction of low-SES patients; (c) health status - individuals in poverty report worse health status than other income groups; still a large dose-response relationship; all 3 SES measures associated with higher mortality, fewer years of healthy life, & lower overall life expectancy.
Health insurance disparities: (a) health care access - people without insurance less likely to have regular source of care & seek routine care through EDs or delay/forego necessary health services; uninsured & Medicaid more likely to be hospitalized for ambulatory sensitive conditions; (b) health care quality - insured women more likely to receive mammogram & worse for women if uninsured longer; most primary care quality measures higher for insured than uninsured; (c) health status - most studies rely on cross-sectional data (limited conclusions); uninsured lower SRH, higher mortality; children on Medicaid also had slightly higher odds of mortality compared to privately insured.
Summary: Evidence that minorities, lower-SES, & uninsured experience worse access to care, lower-quality care, & poorer health status & health outcomes than whites, higher-SES, & insured.

Question 4

Shi & Stevens. (2010). Chapter 4: The influence of multiple risk factors.

Answer 4

Gist: Overlap of risk factors can create a cumulative impact on access to care, quality of care, & health status. The most common risk factor is minority race/ethnicity. About 29% of adult population has at least 2 risk factors but 42% of child population has 2+ risk factors. Children are more likely to be minority & low-income than adults & adults more likely to be minority & uninsured.
Health care access: (poverty compounds problems minorities have in getting regular source of care. Whites and blacks (compared to Asians & Hispanics) are more likely to be affected by a combination of risk factors for outcomes that include delayed/missing medical care, prescriptions, mental health care, & dental care.
Quality of health care: Blacks & whites had similar rates of not receiving necessary care but this widened as income decreased. Effect of education is different: blacks & whites lacking HS degree had smaller gap than groups at higher levels of education. Racial/ethnic disparities in preventive services not fully explained by SES & access to care.
Health status: Combinations of risk factors were associated with increases in poor physical & mental health status (although minority adults do slightly better than whites at most levels of income & education for SRH). For children, each risk factor was independently associated with poor health status & there was an association between the # of risk factors & SRH. Lower social class & minority status place greater risk for premature stroke mortality. Developmental delays in children also associated with multiple risk factors.

Question 5

Shi & Stevens. (2010). Chapter 5: Current strategies to serve vulnerable populations.

Answer 5

Gist:

Question 6

Shi & Stevens. (2010). Chapter 6: Resolving disparities in the United States.

Answer 6

Gist: