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Health and Healthcare Disparities
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Defining healthcare disparities
Healthcare disparities refer to the differences in health experienced by people who belong to traditionally underserved social groups. Although the experience of disparities in care is intersectional, persons are most likely prone to disparity due to their race/ethnicity, religion, socioeconomic status, age, location, gender, able-bodiedness, and sexual orientation. (Kaiser Family Foundation, 2018)
In order for practitioners and scholars to best serve healthcare needs, it's important to recognize healthcare disparities, how and why they happen, why they matter, and how they can be addressed.
Recognizing disparities
From the Kaiser Family Foundation:
A complex and interrelated set of individual, provider, health system, societal, and environmental factors contribute to disparities in health and health care. Factors include (but are not limited to):
- cultural/linguistic barriers
- education
- following medical advice & seeking care
- food insecurity & access
- immigration status
- maintaining a health weight
- organization, funding, and delivery of services, including insurance
- poverty
- provider bias
- proximity to healthcare spaces
- neighborhood safety
- race & ethnicity
- sexual orientation & gender identity
Federal efforts to reduce disparities include a focus on designated priority populations who are particularly vulnerable to health and health care disparities. These priority populations include people of color, low-income groups, women, children, older adults, individuals with special health care needs, and individuals living in rural and inner-city areas. Again, these disparities do not occur in isolation; rather, they are intersectional, and prone to overlap.
Resources for health disparities
- 2017 National Healthcare Quality and Disparities Report (AHRQ)This massive report from the AHRQ covers healthcare disparities experienced by the general U.S. population; however, it also makes clear how social determinants (such as race and geographic location) can affect health and healthcare disparities.
- 2014 Digital Inclusion Survey (IMLS)The Digital Inclusion Survey provides a breakdown of information access resources and services by state, with breakdowns by age, gender, language, immigration, and race/ethnicity, economics, education, health, and libraries.
- Arizona Community Health Needs Assessments (Banner Health)In 2016, Banner Health conducted a state wide survey of health needs by population area. This list covers areas across the state.
- Arizona State Health Assessment (2014)An essential report that covers public health needs in Arizona. This report describes the major health disparities faced by Arizonans, and breaks those disparities down by race, sex, gender, age, class, and other social identities. (NOTE: does not cover LGBTQ+ health disparities)
- Healthy People 2020Healthy People 2020 is a project funded by the NIH to identify health disparities, social determinants of health, and directives to increasing health equity for communities in the U.S.
- The impact of stigma and discrimination against LGBT people in ArizonaThis 2018 report from The Williams Institute covers LGBTQ+ health disparities and social determinants of health in Arizona. It is the first report of its kind to focus specifically on LGBTQ+ Arizonans.
Social determinants of health
Social determinants of health are the conditions of a place where a person lives, which affect health outcomes, risks, and proximity to various disparities. Everybody inhabits a select social space, but statistically, there are social spaces which have longer lasting, negative effects on health outcomes. For instance, a person who lives and grows up in 85121, the lowest income zip code in Arizona, does not have access to:
- well-funded schools
- clean drinking water
- healthcare systems
- stable sources of income
- reliable mobile phone or Internet access
- walkable neighborhoods and parks
- fresh, whole foods
- support systems for LGBTQ+ persons
- public services such as libraries and museums
Additionally, someone who was born and raised in 85121, is more likely to have experienced adverse childhood experiences resulting from:
- proximity to underground labor
- proximity to illegal, opioid usage, overdoses, and deaths
- lack of childcare options
- likelihood of being in a low-income household
This is not to say that these experiences happen to all persons who live in 85121, or any other geographic location with a similar social structure. However, the likelihood of their occurring grows, along with the health and healthcare disparities that happen alongside them.
The following list details the range of social determinants that we all encounter:
How social determinants happen
Social determinants initiate and reproduce a cyclical relationship with health and healthcare disparities, one that is deeply entwined with systems of oppression and violence occurring at local, regional, national, and global levels. While there are many particulars of life which affect the social determinants that affect a person or community, many are perpetuated through the healthcare system itself. This is especially true in the United States, where healthcare and biomedicine are deeply entwined with the material history and cultural apparatuses that make up the US. In social terms, this series of networks can be called the Healthcare Industrial Complex. According to transformative justice and disability activist, Mia Mingus (2015), that complex is enormous, multi-pronged, and can be visualized as such:
Resources for social determinants of health
- Vulnerable Populations Footprint (requires free account)This interactive map from Community Commons shows vulnerable populations across the US, distributed by zip code. Vulnerability is defined by income level and proximity to healthcare.
- CDC - Social Determinants of Health"This website provides CDC resources for SDOH data, tools for action, programs, and policy. They may be used by people in public health, community organizations, and health care systems to assess SDOH and improve community well-being."
- NLM - Tox Town (Environmental health, toxicity, and water)"Tox Town provides consumer-level information on everyday locations and situations where you might be exposed to toxic chemicals. This site will help you better understand risks of exposure, potential health effects, and how to protect yourself."
- The Social Vulnerability Index"Social vulnerability refers to the resilience of communities when confronted by external stresses on human health, stresses such as natural or human-caused disasters, or disease outbreaks. Reducing social vulnerability can decrease both human suffering and economic loss. ATSDR's Social Vulnerability Index uses U.S. census variables at tract level to help local officials identify communities that may need support in preparing for hazards, or recovering from disaster."
- NAM - Social Determinants of Health 101 for Health Care: Five Plus FiveProvides a brief description of social determinants, how they are influenced, and how they can be integrated for better health outcomes.
- WHO - Social Determinants of HealthThe WHO's site on social determinants also includes fact sheets and information for public health professionals interested in sustainable development goals to combatting negative outcomes.
Patient + Research + Provider
Even though healthcare disparities are far-reaching, the American Medical Association insists that all providers should address disparities such that they ensure equitable, appropriate, effective, safe and high quality care for all, with no gaps in services based on any medically irrelevant factor (2007, p. 3). In short, providers should seek to end disparities rather than striving primarily to reduce them. The AMA has developed 10 guiding principles to assist providers in making evidence-based decisions to battle healthcare. Policies and actions should be:
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relationship centered | supportive of the delivery of patient-centered, family-focused, community-oriented care to individuals throughout the life span
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culturally and linguistically appropriate | strategies tailored to the unique needs of diverse patient populations
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targeted | with a focus on recognized and demonstrated gaps in access to health prevention, health care, safety, and quality
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data-driven | making use of both quantitative and qualitative information to inform
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transparent, participatory and collaborative | designed in open processes with the input of all key stakeholders and interested constituency groups
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both long and short-term | quick fixes are important, but solutions should also aim to resolve underlying causes of disparities and should create permanent structural and financial incentives to prevent the reemergence of disparities
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comprehensive | because health care disparities are intersectional, a set of policies to eliminate disparities must be broad-based
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judicious in the use of incentives and requirements | both incentives and mandates might have a role in ending disparities, but policy-makers should recognize a preference for incentives, since mandates often risk backlash and long-term failure
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fiscally responsible and bi-partisan | eliminating health care disparities is a non-partisan goal that can be accomplished in fiscally responsible ways
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monitor and revise | policies to end disparities should be tracked closely over time for both intended and unintended effects so that they can be revised in the future
Inherent in these guidelines are the core principles of evidence-based practice, in which providers should concern themselves with patient interactions by asking, aligning, acquiring, and appraising information while balancing their expertise with the level of knowledge conveyed in research, and the patients' values and circumstances. Arguably, providers should take particular care to their patients' values and circumstances, as these are both complexly associated with the disparities attributed to a patient's social grouping.
Finding the best available research
PubMed/MEDLINE
The NLM has dedicated resources to helping researchers and providers find information that can help them make informed decisions that best suit patients prone to inequity in treatment and health. The following search terms are recommended by NLM to assist in accessing information relevant to healthcare disparities research:
- "health disparities"
- "healthcare disparities"
- "health status disparities"
- "inequalit*"
- "inequit*"
- "socioeconomic factors"
- "minority groups"
- "social determinants of health"
- racism
- sexism
- ageism
- "ethnic groups"
Collapsed into a search string, they appear as such: "Health disparities" OR "healthcare Disparities" OR "health Status disparities" OR inequalit* OR inequit* OR "socioeconomic factors" OR "Minority groups" OR "Social Determinants of Health" OR racism OR sexism OR ageism OR "Ethnic groups"
The NLM has also created a much more cohesive search strategy that includes MeSH, filters for title and abstract([TIAB]), major topics with no explosions (ie: [MAJR:noEXP]), and a more diverse array of search terms. The complete search strategy can be accessed here. Search results can be accessed by clicking here.
The following online resources can help providers make evidence-based decisions that fall within the guidelines set by the AMA and NIH:
- Agency for Healthcare Research and Quality (AHRQ)The Agency for Healthcare Research and Quality's (AHRQ) mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used. AHRQ priorities are described.
- CDC - Data on Social Determinants of Health"Data can be a catalyst for improving community health and well-being. Understanding data on social determinants of health, such as income, educational level, and employment, can help focus efforts to improve community health. The following tools are supported by CDC resources; some tools include references to data sources outside of CDC."
- Community Approaches to Addressing Health DisparitiesA review that takes the position that the “action” in community approaches to addressing health disparities lies in better understanding, design, and implementation of “hybrid” approaches to community development and health disparities.
- The Community GuideThe Guide to Community Preventive Services (The Community Guide) is a collection of evidence-based findings of the Community Preventive Services Task Force (CPSTF). It is a resource to help you select interventions to improve health and prevent disease in your state, community, community organization, business, healthcare organization, or school.
- Healthcare CommunitiesThis website hosts various communities that are crowdsourcing information pertaining to their own health. Primarily, it is used by subcultures and communities that experience healthcare disparities.
- Healthcare Disparities - Kaiser Family FoundationOne of the most well-known policy groups advocating and lobbying for healthcare equality. Has a robust and informative well of resources, including infographics, multimedia, and updates concerning the American Healthcare Act.
- Health Disparities by State - NCSLA useful site for finding policy and legislation dating to 2016. Data is broken down by state and includes bills, descriptions, and enactment.
- The Health Inequality ProjectThe Health Inequality Project is a non-profit research organization that has collected massive amounts of non-identifiable healthcare information and made it available for academic and citizen researchers interested in community health and health disparities.
- Healthy People 2020provides science-based, 10-year national objectives for improving the health of all Americans. For 3 decades, Healthy People has established benchmarks and monitored progress over time in order to: 1) Encourage collaborations across communities and sectors. 2) Empower individuals toward making informed health decisions. 3) Measure the impact of prevention activities.
- Institute for Diversity and Health Equity"The Institute for Diversity and Health Equity, a 501(c)(3) nonprofit organization, works closely with health services organizations to advance health equity for all and to expand leadership opportunities for ethnic minorities in health management. The Institute’s mission is to advance diversity, inclusion and health equity. It is our vision to empower all health organizations to ensure equitable care for all persons."
- Mapping Life Expectancy - VCU Center on Society and HealthThe following series of life expectancy maps illustrate that opportunities to lead a long and healthy life can vary dramatically by neighborhood. In some cases, life expectancy can differ by as much as 20 years in neighborhoods only about five miles apart from one another. The aim of these maps is to serve as a resource—raising awareness of factors that shape health and spurring discussion and action on a complex web of factors that influence health.
- MedlinePlusMedlinePlus is THE primary consumer health information resource available today. It is sustained by the NLM, and contains information for a vast number of populations, including those who often experience inequities in health and healthcare.
- National Stakeholder Strategy for Achieving Health EquityA massive report that details the participants in a stakeholder strategy for equitable health, areas of growth, affected communities, health disparities across populations, and pathways for change.
- Promising Practicesfeatures summaries of programs and practices that are proven to improve outcomes for children. All programs have been reviewed for quality and to ensure that they have evidence of positive effects. Programs are assigned to one of three evidence level categories (Proven, Promising, or Other Reviewed Programs) according to a number of evidence criteria.
- Reducing Disparities in Health Care - AMAIn 2004, the Commission to End Health Care Disparities was established by the AMA and the National Medical Association to address gaps in health care. The National Hispanic Medical Association joined shortly after. In June of 2016, the commission was retired, but the resources and materials produced by the commission are available on this page for physicians.
- Vulnerable Populations - Footprint Map (Community Commons)This detailed, interactive map lists vulnerable populations by zip code, with a focus on poverty and proximity to healthcare.
- WHO World Conference on Social Determinants of HealthThe World Conference on Social Determinants of Health brought together Member States and stakeholders to share experiences on policies and strategies aimed at reducing health inequities. The event provided a global platform for dialogue on how the recommendations of the WHO Commission on Social Determinants of Health (2008) could be taken forward.
Understanding implicit bias
- Implicit Bias in Healthcare Professionals: A Systematic ReviewImplicit biases involve associations outside conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender. This review examines the evidence that healthcare professionals display implicit biases towards patients.
- How to reduce implicit bias (white paper)This white paper provides guidance on how health care organizations can reduce health disparities related to racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.
- Unconscious Bias in Academic MedicineThere is ample evidence that unconscious bias in medicine can have life-altering consequences. It can affect the type and quality of care certain patients receive, as well as the training and career opportunities available to people identified with certain ethnic, cultural, and other underrepresented groups.
Leveraging empathy and humanities to combat bias
Current and emerging research supports the use of empathy and empathic thinking as an intervention to reduce bias in patient-provider interactions (Stewart, 1995; Stewart, et al., 2000; Reiss, 2015; Ariso, 2018). This is a fairly unsurprising idea, in general, but even as empathy is regarded as necessary to care, it is increasingly less likely to be taught in biomedical education. As a result, students are actually less empathetic after leaving medical school than entering it.
Students at the Phoenix Biomedical Campus are invited to integrate empathy more fully into their education and future practice. Through programs like University of Arizona's College of Narrative Medicine and Health Humanities, students from both NAU and UA learn to "promote compassionate clinical care and value for the patient’s story through narrative medicine methods." In other words, students are encouraged to build empathy, and in doing so, to acknowledge biases (Ross & Lypson, 2015). Cross-institutional opportunities include Celebrating the Humanities through Art (ChArt), a peer-reviewed literary journal published by the Phoenix Biomedical Campus community, and Stories in Medicine, a narrative medicine blog.
Resources for integrating empathy with care
- Addressing and Confronting Bias (Online Workshop)This course offers an array of interventions that health professionals committed to addressing their own biases can try out and hopefully adopt. The suggested approaches focus on both conscious and unconscious biases. However, a greater emphasis has been placed on those interventions that address implicit bias, because it is virtually impossible to act on feelings, attitudes, and behaviors that are outside of one’s conscious awareness until they are brought into awareness.
- Patient- and Family-Centered Care: A Systematic Approach to Better Ethics and Careemphasizes respect for patient values in individual care decisions as well as the role of patients and families as advisors and essential partners in improving care practices. It is characterized by a two-way partnership, the importance of which is growing with the movement from payment for volume to payment for value.
- Project Impliciton-profit organization and international collaboration between researchers who are interested in implicit social cognition - thoughts and feelings outside of conscious awareness and control. The goal of the organization is to educate the public about hidden biases and to provide a “virtual laboratory” for collecting data on the Internet.
Health Literacy
"Health literacy is an evolving concept" used to frame the ability of individuals and communities to inform their own health. (WHO, 2016) It is a key component to health disparities and social determinants of health in that health literacy tools and understandings can help to reduce the disparities experienced as a result of negative social determinants.
Health literacy interventions include:
- learning how to find and evaluate online health information
- learning how to interpret medical information (including insurance)
- developing techniques for communicating with providers
- access to online information retrieval options
- developing mhealth apps for patient use
- promoting community engagement and political action
- developing an awareness of health needs for specific populations
Because there are so many components to health literacy, the term itself is often challenged, and has been described at times as critical health literacy, health education, and health information literacy. While all of these terms are useful, they are more appropriately categorized as parts of health literacy rather than the thing itself.
Providers, community organizers, policy makers, and information professionals can all seek to improve community health by bringing health literacy practices into their practice. The following links provide information about health literacy trends, health needs, health literacy programs and services, and health literacy integration.
Resources for health literacy
- Attributes of a health literate organizationAn important tool for individuals who will play an organizational leadership role in a clinical environment.
- Community Health Maps (NLM)"Community Health Maps (CHM) provides information about low/no cost mapping tools. It was developed by the National Library of Medicine (NLM) with a focus on increasing capacity within under-served and other at-risk communities. The CHM workflow can also be used by individuals and organizations needing to collect, analyze, and visualize mapping data."
- Easy to read handouts, brochures, & factsheets (NNLM)From the Network of National Libraries of Medicine (NNLM), patient handouts on a number of health-related topics, in both English and Spanish.
- Find good health information (MLA)From the Medical Library Association, information about how to find and evaluate online health information.
- Glossary of health insurance terms (Healthcare.gov)A full list of the terms used in application materials, plan certificates, and benefits summaries at Healthcare.gov.
- Health-focused resources for public librarians (PLA)A website from the Public Library Association, dedicated to programming and other library services that promote health literacy and healthy lifestyles.
- Health Literacy Data Map (UNC)The UNC Health Literacy Data Map allows users to search for health literacy data across all zip codes in the United States.
- Health Literacy Definition (NNLM)Health literacy definitions from the NNLM, specifically geared to librarians.
- The Health Literacy of America’s Adults Results From the 2003 National Assessment of Adult Literacy"The 2003 National Assessment of Adult Literacy (NAAL) assessed the English literacy of adults in the United States. Included in the assessment were items designed to measure the health literacy of America’s adults. The assessment was administered to more than 19,000 adults (ages 16 and older) in households or prisons. Unlike indirect measures of literacy, which rely on self reports and other subjective evaluations, the assessment measured literacy directly through tasks completed by adults."
- How to write easy-to-read health materials (MedlinePlus)"Medical concepts and language can be complex. People need easily understandable health information regardless of age, background or reading level. MedlinePlus offers guidelines and resources to help you create easy-to-read health materials."
- Informing Health: Health Literacy is more than a HandoutThis video, from individuals at NAU, ASU, and UA, includes interviews with providers and patients involved in health information literacy outreach and education
- National action plan to improve health literacy"The National Action Plan to Improve Health Literacy seeks to engage organizations, professionals, policymakers, communities, individuals, and families in a linked, multi-sector effort to improve health literacy."
- National Health Education Standards (CDC)These standards are designed for individuals who are promoting health literacy in primary and secondary education.
- PRISM Readability Toolkit"Program for Readability In Science and Medicine (PRISM)* is a Group Health Research Institute initiative to improve the quality of print materials used in communication with research participants."
- Top health websites (MLA)A list of the top health websites for finding health-related information, as organized by the Medical Library Association (MLA).
- WebAIM (Web Accessibility in Mind)"It is not easy to write clearly and simply, but it is important to try. Users are more likely to understand your writing if you take the time to organize your thoughts and write them in the clearest, simplest form possible, taking into account your audience. To maximize understandability for people with cognitive disabilities, limit the text, add appropriate illustrations, and avoid indirect or implied meanings (such as sarcasm or parody). In the end, nearly everyone benefits from clarity and simplicity."