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.
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. 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. These inequities may include differences in the "presence of disease, health outcomes, or access to health care" between populations with a different race, ethnicity, sexual orientation or socioeconomic status.
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.
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.
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.
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.
Maintenance of good health through the utilization of proper
healthcare resources can be quite costly and therefore unaffordable to
certain populations.
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.
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.
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.
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".
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. 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.
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
study showed that community healthcare approaches fared far
better than individual approaches in the prevention of heart disease
mortality.
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. 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.
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%).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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. Also African American women were 34% more likely to die from breast cancer than their white counterparts.
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. 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. Slavery has contributed to disparate health outcomes for generations of African Americans in the United States.
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.
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.
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.
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.
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.
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.
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.
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, 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. 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.
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.
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.
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".
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.
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.
This discrimination can take the form of verbal abuse, disrespectful
conduct, refusal of care, the withholding of health information,
inadequate treatment, and outright violence. 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. They also reportedly faced "homophobic verbal harassment from healthcare workers when presenting for STI treatment".
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.
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.
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.
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.
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.
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.
Seventeen European states mandate sterilization of individuals who seek
recognition of a gender identity that diverges from their birth gender.
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.
A 2010 survey of transgender and gender-variant people in the United
States revealed that transgender individuals faced a significant level
of discrimination.
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.
In Kuwait, there have been reports of transgender individuals being
reported to legal authorities by medical professionals, preventing safe
access to care.
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.
The stigmatization represented particularly in the transgender
population creates a health disparity for LGBT individuals with regard
to mental health. 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.
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.
These mental health facts are informed by a history of anti-LGBT bias in health care. 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. 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.
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
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.
It is incorrectly assumed that LGBT women have a lower incidence of
cervical cancer than their heterosexual counterparts, resulting in lower
rates of screening.
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.
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."
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. 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.
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.
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.
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.
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.
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.
Physicians tend to offer invasive procedures to male patients more than female patients.
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. Lastly, men are more likely to have severe chronic conditions and a lower life expectancy than women in the United States.
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. 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.
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. 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. 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.
Women have better access to healthcare in the United States than they do in many other places in the world.
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.
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. 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.
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. Recently, gender-based disparities have decreased as females have begun to receive higher-quality care.
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.
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.
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.
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.
The estimated 3 million girls who are subjected to FGM each year
potentially suffer both immediate and lifelong negative effects. Immediately following FGM, girls commonly experience excessive bleeding and urine retention. 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. 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.
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. The environment that surrounds us can influence individual behaviors and lead to poor health choices and therefore outcomes.
Minority neighborhoods have been continuously noted to have more fast
food chains and fewer grocery stores than predominantly white
neighborhoods.
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.
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.
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.
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.
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.
Housing conditions can create varying degrees of health risk that lead
to complications of birth and long-term consequences in the aging
population.
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.
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.
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.
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.
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.
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.
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.
Disparities in access to health care
Reasons for disparities in access to health care are many, but can include the following:
- Lack of universal health care or health insurance coverage. Without health insurance, patients are more likely to postpone medical care, go without needed medical care, go without prescription medicines, and be denied access to care. Minority groups in the United States lack insurance coverage at higher rates than whites. This problem does not exist in countries with fully funded public health systems, such as the examplar of the NHS.
- Lack of a regular source of care. Without access to a regular source of care, patients have greater difficulty obtaining care, fewer doctor visits, and more difficulty obtaining prescription drugs. Compared to whites, minority groups in the United States are less likely to have a doctor they go to on a regular basis and are more likely to use emergency rooms and clinics as their regular source of care. In the United Kingdom, which is much more racially harmonious, this issue arises for a different reason; since 2004, NHS GPs have not been responsible for care out of normal GP surgery opening hours, leading to significantly higher attendances in A+E
- Lack of financial resources. Although the lack of financial resources is a barrier to health care access for many Americans, the impact on access appears to be greater for minority populations.
- Legal barriers. Access to medical care by low-income immigrant minorities can be hindered by legal barriers to public insurance programs. For example, in the United States federal law bars states from providing Medicaid coverage to immigrants who have been in the country fewer than five years. Another example could be when a non-English speaking person attends a clinic where the receptionist does not speak the person's language. This is mostly seen in Hispanic people who do not speak English.
- Structural barriers. These barriers include poor transportation, an inability to schedule appointments quickly or during convenient hours, and excessive time spent in the waiting room, all of which affect a person's ability and willingness to obtain needed care.
- The health care financing system. The Institute of Medicine in the United States says fragmentation of the U.S. health care delivery and financing system is a barrier to accessing care. Racial and ethnic minorities are more likely to be enrolled in health insurance plans which place limits on covered services and offer a limited number of health care providers.
- Scarcity of providers. In inner cities, rural areas, and communities with high concentrations of minority populations, access to medical care can be limited due to the scarcity of primary care practitioners, specialists, and diagnostic facilities. In the UK, Monitor (a quango) has a legal obligation to ensure that sufficient provision exists in all parts of the nation.
- Linguistic barriers. Language differences restrict access to medical care for minorities in the United States who are not English-proficient.
- Health literacy. This is where patients have problems obtaining, processing, and understanding basic health information. For example, patients with a poor understanding of good health may not know when it is necessary to seek care for certain symptoms. While problems with health literacy are not limited to minority groups, the problem can be more pronounced in these groups than in whites due to socioeconomic and educational factors. A study conducted in Mdantsane, South Africa depicts the correlation of maternal education and the antenatal visits for pregnancy. As patients have a greater education, they tend to use maternal health care services more than those with a lesser maternal education background.
- Lack of diversity in the health care workforce. A major reason for disparities in access to care are the cultural differences between predominantly white health care providers and minority patients. Only 4% of physicians in the United States are African American, and Hispanics represent just 5%, even though these percentages are much less than their groups' proportion of the United States population.
- Age. Age can also be a factor in health disparities for a number of reasons. As many older Americans exist on fixed incomes which may make paying for health care expenses difficult. Additionally, they may face other barriers such as impaired mobility or lack of transportation which make accessing health care services challenging for them physically. Also, they may not have the opportunity to access health information via the internet as less than 15% of Americans over the age of 65 have access to the internet. This could put older individuals at a disadvantage in terms of accessing valuable information about their health and how to protect it. On the other hand, older individuals in the US (65 or above) are provided with medical care via Medicare.
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. In contrast, the Hispanic population had the largest problem communicating with their provider, 33% of the time.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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. Physicians are unaware of their implicit biases.
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.
Lack of preventive care
According
to the 2009 National Healthcare Disparities Report, uninsured Americans
are less likely to receive preventive services in health care. 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.
Studies have shown that use of professional interpreters have
significantly reduced disparities in the rates of fecal occult testing,
flu immunizations and pap smears. 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).
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:
- Advocacy. Advocacy for health equity has been identified as a key means of promoting favourable policy change. EuroHealthNet carried out a systematic review of the academic and grey literature. It found, amongst other things, that certain kinds of evidence may be more persuasive in advocacy efforts, that practices associated with knowledge transfer and translation can increase the uptake of knowledge, that there are many different potential advocates and targets of advocacy and that advocacy efforts need to be tailored according to context and target. As a result of its work, it produced an online advocacy for health equity toolkit.
- Provider based incentives to improve healthcare for ethnic populations. One source of health inequity stems from unequal treatment of non-white patients in comparison with white patients. Creating provider based incentives to create greater parity between treatment of white and non-white patients is one proposed solution to eliminate provider bias. These incentives typically are monetary because of its effectiveness in influencing physician behavior.
- Using Evidence Based Medicine (EBM). Evidence Based Medicine (EBM) shows promise in reducing healthcare provider bias in turn promoting health equity. In theory EBM can reduce disparities however other research suggests that it might exacerbate them instead. Some cited shortcomings include EBM’s injection of clinical inflexibility in decision making and its origins as a purely cost driven measure.
- Increasing awareness. The most cited measure to improving health equity relates to increasing public awareness. A lack of public awareness is a key reason why there has not been significant gains in reducing health disparities in ethnic and minority populations. Increased public awareness would lead to increased congressional awareness, greater availability of disparity data, and further research into the issue of health disparities.
- The Gradient Evaluation Framework. The evidence base defining which policies and interventions are most effective in reducing health inequalities is extremely weak. It is important therefore that policies and interventions which seek to influence health inequity be more adequately evaluated. Gradient Evaluation Framework (GEF) is an action-oriented policy tool that can be applied to assess whether policies will contribute to greater health equity amongst children and their families.
- The AIM framework. In a pilot study, researchers examined the role of AIM—ability, incentives, and management feedback—in reducing care disparity in pressure-ulcer detection between African American and Caucasian residents. The results showed that while the program was implemented, the provision of (1) training to enhance ability, (2) monetary incentives to enhance motivation, and (3) management feedback to enhance accountability led to successful reduction in pressure ulcers. Specifically, the detection gap between the two groups decreased. The researchers suggested additional replications with longer duration to assess the effectiveness of the AIM framework.
- Monitoring actions on the social determinants of health. In 2017, citing the need for accountability for the pledges made by countries in the Rio Political Declaration on Social Determinants of Health, the World Health Organization and United Nations Children's Fund called for the monitoring of intersectoral interventions on the social determinants of health that improve health equity.
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.
In June 2018, the European Commission launched the Joint Action Health Equity in Europe. 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, mental health, drug abuse, obesity,
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.
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.
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.
This is also true of the difference between mortality across all
occupational classes in highly equal Sweden as compared to less-equal
England.
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