Promoting Health Intervention Strategies from Social and Behavioral Research (2000) / Chapter Skim
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Paper Contribution B: Understanding and Reducing Socioeconomic and Racial/Ethnic Disparities in Health
Paper Contribution B: Understanding and Reducing Socioeconomic and Racial/Ethnic Disparities in Health
Pages 81-124
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From page 81... ...
Williams The initial paper by Kaplan and colleagues and the burgeoning literatures on socioeconomic and racial/ethnic disparities in health establish that such disparities are large, persistent, and even increasing in the United States and other developed countries, most notably the United Kingdom (Marmot et al., 1987, Preston and Haines, 1991, Adler et al., 1993, Pappas et al., 1993, Evans et al., 1994, Williams and Collins, 1995~. Differences across socioeconomic and racial/ethnic groups or combinations thereof range up to 10 or more years in life expectancy and 20 or more years in the age at which significant limitations in functional health are first experienced (see Table 1, House et al., 1990, 1994~.
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From page 82... ...
This paper seeks to elucidate what we already know and need yet to learn about reducing socioeconomic and racial/ethnic disparities in health. We first provide a brief overview of the nature of both socioeconomic and racial/ethnic disparities in health and how they are related to each other.
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From page 83... ...
the "fundamental causes" of corresponding socioeconomic and racial/ethnic disparities in risk factors and hence health and, consequently, also the fundamental levers for reducing these health disparities. Finally, existing evidence strongly suggests that the nature of the socioeconomic and racial/ethnic stratification of individuals can be changed in ways beneficial to health and, coincidentally, to a broad range of other indicators of individual and societal well-being.
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From page 84... ...
It is important, however, that it be utilized more explicitly in future research on the relation of socioeconomic status to health, and especially in thinking about how socioeconomic disparities in health have been or could be reduced. The framework helps, for example, to understand why income is perhaps the strongest and most robust predictor of health (McDonough et al., 1997, Lantz et al., 1998)
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From page 87... ...
However, Figure 1B suggests that most such effects are likely to be channeled through and reinforced by later socioeconomic attainment, and the unique impact of childhood SEP or its sequelae must be evaluated net of later socioeconomic or other experiences. When this is done, the unique effects of childhood SEP on adult health are often found to be small or even nonexistent relative to the effects of later adult socioeconomic attainment and experiences (e.g., *
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From page 88... ...
The next major section of this paper focuses on elucidating the pathways or mechanisms through which both socioeconomic position and race/ethnicity affect health, for better as well as for worse. Due to constraints of space and desire for clarity, Figure 1C fails to represent other important issues for understanding and reducing socioeconomic disparities in health.
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From page 89... ...
Thus, it is most important to understand what accounts for socioeconomic inequalities in health across the broad lower range (e.g., lower 4060%) of socioeconomic position, rather than focusing mainly or only on factors that might explain this relationship across the gradient or at higher levels.
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From page 90... ...
First, there is evidence that modern preventive and therapeutic medical care can account for only a minor fraction of the dramatic improvements in individual and population health over the last 250 years (McKeown, 1976, 1979, 1988, McKinlay and McKinlay, 1977~. Even analysts admiring of the impact of medical science on health, for example, estimate that only about 5 years of the 30-year increase in life expectancy in the United States in the twentieth century has been due to preventive or therapeutic medical care (Bunker et al., 1994~.
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From page 91... ...
Moreover, medical care appears to play a modest role in accounting for racial differences in mortality (Woolhandler et al., 1985, Schwartz et al., 1990) , and other evidence suggests that medical care has a greater impact on the health status of vulnerable racial and low-SES groups than on their more advantaged counterparts (Williams, 1990~.
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From page 92... ...
Socioeconomic Status and Psychosocial and Environmental Risk Factors One factor (e.g., smoking) or a small set of factors (e.g., health behaviors)
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From page 93... ...
Further, they are more likely to have grown up in lower-socioeconomic environments, which may have residual adverse effects on health in adulthood that research is just beginning to examine (e.g., Power et al., 1990~. At this point we are only beginning to explore the causal pathways and complexities that link socioeconomic position to exposure to behavioral, psychosocial, and environmental risk factors and, in turn, link these risk factors to health outcomes.
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From page 96... ...
Prior socioeconomic differences undoubtedly had more to do with differences in exposure to infectious agents and access to medical care than is currently the case. Indeed, many of the currently most important diseases and risk factors such as coronary heart disease and its risk factors of smoking, lack of exercise, and high-fat diet were at one time more characteristic of upper socioeconomic strata, but have become more incident and prevalent in lower socioeconomic strata as these diseases and risk factors have become more deleterious to health.
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From page 97... ...
Subgroups of the Asian and Pacific Islander population also have elevated mortality rates for some health conditions (Lin-Fu, 1993~. For example, the Native Hawaiian population has the highest death rate due to heart disease of any racial group in the United States (Chen, 1993~.
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From page 98... ...
High-income black males have a life expectancy that is 5.3 years longer than low-income white males. Thus, the disproportionate concentration of African Americans at lower SES levels is a major factor behind the overall racial differences in health.
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From page 99... ...
Racism has been a central organizing principle within American society and has played a key role in shaping major social institutions and policies (Omi and Winant, 1986, Quadagno, 1994~. Historically, ideologies about racial groups were translated into policies and societal arrangements that have limited the opportunities and social mobility of stigmatized groups.
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From page 100... ...
Moreover, because of racism, SES indicators are not commensurate across racial groups, which makes it difficult to truly adjust racial differences in health for SES (Kaufman et al., 1997~. There are racial differences in the quality of education, income returns for a given level of education or occupational status, wealth or assets associated with a given level of income, the purchasing power of income, the stability of employment, and the health risks associated with occupational status (Williams and Collins, 1995, Kaufman et al., 1997~.
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From page 101... ...
. SOCIOECONOMIC AND RACIAL/ETHNIC CHARACTERISTICS OF SOCIAL SYSTEMS AS DETERMINANTS OF INDIVIDUAL AND POPULATION HEALTH Individuals occupy particular socioeconomic positions and racial/ethnic status within broader systems of socioeconomic and racial/ethnic stratification at the level of communities, metropolitan areas, regions, nations, and even the world.
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From page 102... ...
Evidence of aggregate or ecological correlation between the socioeconomic and racial/ethnic characteristics of areas and the population health parameters of the areas (e.g., mortality rates) are suggestive of context effects, but do not demonstrate them because they fail to control for the characteristics of individuals, which, as shown in Figure 3, may either select people into areas or be shaped by the characteristics of the area.
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From page 104... ...
, reflect strong effects of income inequality per se, operating through variables such as social capital, cohesion, and trust in the population. A large body of conceptual and empirical analyses suggests, on the contrary, that income inequality has its effects primarily via the underlying high level of individuals with relatively low income that necessarily characterizes areas with more unequal incomes, at least given the average levels of income in these populations (Gravelle, 1998, Deaton, 1999, Mellor and Milyo, 1999~.
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From page 105... ...
population have levels of health no better than those of some of the least developed nations in the world (McCord and Freeman, 1990~. The main message we want to deliver is that socioeconomic policy and practice and racial/ethnic policy and practice are the most significant levers for reducing socioeconomic and racial/ethnic disparities and hence improving overall population health in our society, more important even than health care policy.
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From page 107... ...
Further, and paradoxically, the success of efforts to reduce smoking may have contributed, as noted above, to the perplexing pattern from which we began overall improvements in population health but widening socioeconomic and racial/ethnic disparities in health. This is because persons of higher socioeconomic position, especially education, have been much more likely to stop or not start smoking, thus creating a growing inverse association between socioeconomic position and smoking (Moore et al., 1996~.
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From page 108... ...
and risk factors to arise, which may operate via quite different mechanisms and pathways and yet to become rapidly stratified by socioeconomic and racial/ethnic status. Nevertheless, there are opportunities for intervening in pathways and mechanisms that offer promise of reducing socioeconomic and racial/ethnic disparities and hence improving overall population health.
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From page 109... ...
In addition to routine hypertensive care, the second group also attended 12 weekly clinic meetings providing health education with regard to hypertension by a health educator and nurse practitioner. In addition to routine hypertensive care, the third group was visited by community health workers who had been recruited from the immediate community and provided with one month of training to address the diverse social and medical needs of persons with hypertension.
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From page 110... ...
Adaptive Attributes of Disadvantaged Groups One of the major paradoxes in U.S. population health is that African Americans and Latinos are not as disadvantaged on some aspects of health as their socioeconomic positions would lead us to expect.
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From page 111... ...
Several behaviors that adversely affect health status appear to increase with acculturation. These include decreased fiber consumption, decreased breast feeding, increased use of cigarettes and alcohol especially in young women, driving under the influence of alcohol, and use of illicit drugs (Vega and Amaro, 1994~.
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From page 112... ...
The rise of Sweden and then Japan to the highest levels of population health in the world, and the clearly reduced socioeconomic disparities in the case of Sweden, must be significantly attributed to their emphasis on ensuring good conditions of life for all, albeit via different mixes of social policy and provision of private and public goods.
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From page 113... ...
Improved nutrition, probably a result of the income manipulation, appeared to have been the key intervening factor. Evaluation of the long-term effects of early childhood interventions, such as the Perry preschool study, also suggests long-term effects on socioeconomic factors (median income and rates of home ownership)
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From page 114... ...
other major income support program in our country has been the earned income tax credit, but we know of no research on its effects and would certainly see such research as a high priority for the future. Investment in Public Goods and Infrastructure Limited data also indicate that efforts to improve the public goods and infrastructures of communities improve the health of their residents.
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From page 115... ...
These health disparities largely explain why the United States increasingly lags behind other developed and even less developed nations in levels of population health, with the most disadvantaged portions of our population characterized by levels of population health comparable to some of the least developed nations in the world. Socioeconomic and racial/ethnic disadvantages affect almost all forms of disease, almost all behavioral, psychosocial, and environmental risk factors pro
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From page 116... ...
can have only a limited effect on socioeconomic and racial/ethnic disparities in health, though this effect is clearly enhanced if interventions or changes are attentive to the broader social forces that produce these disparities. The greatest past accomplishments and future potential for reducing socioeconomic and racial/ethnic disparities in health and improving overall population health involve improving socioeconomic status and reducing invidious racial/ethnic distinctions themselves, especially among the more disadvantaged portions of the population.
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From page 117... ...
(1993~. A 1993 status report on the health status of Asian Pacific Islander Americans: Comparisons with Healthy People 2000 objectives.
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From page 118... ...
(1990~. Age, socioeconomic status, and health.
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From page 119... ...
(1990~. Racial and gender discrimination: Risk factors for high blood pressure?
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(1996~. Do cardiovascular risk factors explain the relation between socioeconomic status, risk of all-cause mortality, cardiovascular mortality, and acute myocardial infarction?
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From page 121... ...
(1998~. Health, United States, Socioeconomic Status and Health Chartbook.
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From page 122... ...
(1999~. Racial/ethnic disparities in health: The interplay between discrimination and socioeconomic status.
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(1991~. Health insurance coverage and utilization of health services by Mexican Americans, mainland Puerto Ricans, and Cuban Americans.
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(1992~. Income distribution and life expectancy.
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