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Appendix D Overview of Health Disparities--Nancy E. Adler, Ph.D.
Pages 121-174

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From page 121...
... Others compare the health of specific groups with that of the overall population, asking whether a given group Background paper prepared for the Institute of Medicine's Committee on the Review and Assessment of the National Institute of Health's (NIH's) Strategic Research Plan to Reduce and Ultimately Eliminate Health Disparities.
From page 122...
... were critical of an approach that simply examined health extremes, without including a comparison of social groups that experience social disadvantage. They argued that although examining extremes in health may provide a good starting point, these additional analyses will be key to understanding disparities.
From page 123...
... Some diseases (e.g., sickle cell anemia in African Americans) have a strong genetic component, whereas differences in the prevalence of other diseases are likely due more directly to social disadvantage.
From page 124...
... Table D-2 presents the number of papers published from 2000 to 2004 that use the term health disparities as a key word, along with the terms race, ethnicity, SES, or components of these (e.g., African American or black, Asian, Hispanic or Latino, occupation, education, income) as well as gender or sex and rural.
From page 125...
... Defining Health Disparity Groups The Minority Health and Health Disparities Research and Education Act of 2000 defines health disparity populations (or groups) as those for which "there is a significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality or survival rates." As discussed earlier, which group is identified as being a disparity group will differ depending on which of the above health indicators is used.
From page 126...
... However, the extent of the male-female difference could also be due to modifiable conditions that reflect social disadvantage. It is possible that greater hardships faced by women as the result of discrimination in the workplace, exposure to sexual harassment and abuse, and so forth lessen the biological advantage they might otherwise enjoy.
From page 127...
... One is that African Americans show more adverse health outcomes on each one of the indicators. They have the greatest morbidity and mortality on every reported indicator, and the gap is often substantial.
From page 128...
... Whites show poorer outcomes than groups other than African Americans on most of the reported health indicators (e.g., overall cancer
From page 129...
... Asian Americans or Pacific Islanders show the most favorable profile. They experience the lowest rates of infant mortality, overall cancer mortality and death from lung and breast cancer, and coronary heart disease mortality.
From page 130...
... also show variation in disparities when examining subgroups in relation to specific diseases. They examined rates of death from coronary heart disease and from all causes broken down into more precise subgroups of Asians.
From page 131...
... At the same time, the large, persistent, and consistent disadvantage suffered by African Americans across diseases suggests that some common mechanisms systematically affect this group's health. It also suggests that more attention should be paid to crosscutting factors that systematically affect African Americans' health.
From page 132...
... Most of the population resides in the distribution between about $15,000 and $40,000 of income, which is above the poverty line. Thus, if one limited research to those below the poverty line as a disparity group, such research would not incorporate an understanding of the largest segment of the population in which disparities occur.
From page 133...
... More recent data suggest that the association between income inequality and health may occur in the United States, but to a lesser extent in other countries, and may vary by time period.
From page 134...
... Table D-8 provides information on death rates for those who did not graduate from high school (< 12 years) , high school graduates (12 years)
From page 135...
... Solid line with squares adjusted for demographic variables. Solid line adjusted for socioeconomic status and demographic variables.
From page 136...
... For African Americans, however, death rates are less different across levels of urbanization, although they are still higher in non-metropolitan than in medium or large metropolitan areas. There are differences in health indicators such as self-rated health and limitation of activity by residence area.
From page 137...
... for mortality rates for suicide and for a range of risk factors (e.g., smoking, limitation of activity, and obesity)
From page 138...
... TABLE D-11 Limitation of Activity Due to Chronic Conditions, 2002, by Race/Ethnicity and Geographic Locale Percent with Any Activity Limited All Poor Near Poor Nonpoor White, all 12.1 Non-Hispanic white 12.4 25.3 19.5 9.7 African American 14.9 Non-Hispanic African American 15.0 25.0 17.9 10.0 American Indian 19.4 Asian 6.4 Hispanic, Latino 10.7 16.4 12.2 7.7 Total 12.4 22.9 17.5 9.5 Residence Within MSA Outside MSA Urban/rural 11.4 15.9 Area of country Northeast 11.8 Midwest 13.1 South 12.7 West 11.5 NOTE: MSA, metropolitan statistical area. SOURCE: National Center for Health Statistics, 2004.
From page 139...
... At each level of income, for example, African Americans and Hispanics have lower net worth and live in worse neighborhoods than whites. For example, among the lowest quintile of income, whites have a net worth of almost $50,000, whereas the net worth of African Americans and Hispanics is a little more than $7000.
From page 140...
... 140 Hispanic 49% 22% 19% 6% 4% Asian 26% 19% 19% 25% 11% African American 26% 30% 28% 9% 7% omen W White 13% 32% 30% 14% 11% school. Hispanic 50% graduate 19% 19% 7% 5% Grad, degree; Asian 18% 15% 21% 25% 21% bachelor's 4.
From page 141...
... noted that generalizations about rural health largely capture the experience and outcomes of whites, because whites make up 84 percent of rural populations, African Americans comprise 8 percent, nonblack Hispanics comprise 5 percent, and Asians/Pacific Islanders and American Indians/Native Alaskans comprise less than 2 percent each. There are differences in racial/ethnic composition of TABLE D-14 Life Expectancy at Age 25, U.S.
From page 142...
... For example, Coughlin (2002) presented a deeper analysis of a finding of lower rates of cancer screening for African Americans versus whites in the overall population.
From page 143...
... The increased likelihood holds for all three ethnic groups, although the difference between urban and rural rates is less for Hispanics than for whites or African Americans. Given the predominance of whites in rural areas, the data suggest that to understand the relatively poorer health outcomes of whites compared with other groups on some health indicators, area of residence should be examined.
From page 144...
... More than 45 million Americans lack health insurance. African Americans and other disadvantaged racial and ethnic groups; individuals with less education, income, and in low-wage occupations; and those in rural areas are less likely to have health insurance, have poorer access to health care, and receive poorer quality of care.
From page 145...
... For example, in the United States, African Americans are more likely to be hypertensive than are European Americans -- a difference that has sometimes been thought to reflect a genetic predisposition to hypertension among African Americans. If this were the case, one would expect to find a greater prevalence of hypertension among populations for blacks compared with European Americans wherever they lived.
From page 146...
... Some environmental exposures result from the built environment. In urban areas, residential segregation has resulted in African Americans being concentrated in high-poverty areas with substandard housing.
From page 147...
... At the negative end, a number of studies illustrate the health risks of social isolation: The data show that the relative risks of mortality for the socially isolated range from l.9 to 4 times greater than that for individuals who have greater social connections (Berkman and Glass, 2000; House et al., 1988)
From page 148...
... were associated with lower neighborhood death rates for total mortality, as well as death from heart disease and other causes for white men and women, and to a less consistent extent for African Americans (though no association was found with cancer deaths)
From page 149...
... Racism and the history of discrimination in the United States have consequences in many domains of life that affect health for African Americans and may account for the findings that this group shows poorer health on nearly every indicator. One effect of racism and discrimination has been limited educational, occupational, and economic opportunities that contribute to the overrepresentation of African Americans in lower-SES categories.
From page 150...
... Thus, although tobacco use may serve as an important mechanism in disparities associated with SES, it does not appear to be a major contributor to the relatively poorer health of African Americans. Rates of obesity show a very different pattern, varying both by race/ethnicity, SES, and gender.
From page 151...
... Given this, differential stress exposure may be an important mechanism by which social disadvantage affects health. Stress can directly affect health through biological pathways as discussed below.
From page 152...
... Initial research testing this concept has shown that allostatic load is related, on the one hand, to race/ethnicity and SES and, on the other, to health. Among participants in the CARDIA sample, allostatic load scores are higher among African Americans than among whites and are greater among those with less education than among the more educated (Seeman, 2004)
From page 153...
... . This framework, as shown in Figure D-4, ranges from microdeterminants (e.g., pathophysiologic pathways, genetic and constitutional factors, and individual risk factors)
From page 154...
... Such concentrated poverty, in turn, has implications for both physical and social environments that have health effects as described earlier. Another model of the determinants of health, which puts somewhat more focus on the life course, was proposed by Hertzman (1999)
From page 155...
... provided a model that depicts the Social Material Factors Structure Work Social Environment Psychological Brain Health Behaviors Neuroendocrine and immune response Pathophysiological Early Changes life Organ impairment Genes Well-Being Culture Mortality Morbidity FIGURE D-6 Social determinants of health. The model links social structure to health and disease via material, psychosocial, and behavioral pathways.
From page 156...
... 156 of for Health clarity those to For el parall NOTE: Income age. exactly be and should Assets/Wealth and sex/gender, would Occupation these but race/ethnicity, variables, Education incorporating subsequent health to of Parental Position Socioeconomic sex/gender 2000.
From page 157...
... Although a major pathway from race/ ethnicity to health runs through these socioeconomic contributors to health status, race and ethnicity also directly impact health. This is consistent with findings showing that socioeconomic disadvantage accounts for much of the association of race/ethnicity with health but that there is a residual effect of race/ethnicity on a number of health outcomes, even when SES is adjusted for.
From page 158...
... Psychological Dispositions 5. Social Roles and Productive Activities Physical/Chemical and Social Environmental Hazards FIGURE D-8 Environmental, psychosocial, and biological pathways linking SES to diabetes mellitus, coronary heart disease, and well-being.
From page 159...
... 159 s ents health. Ev to Function Function y e rajectorieT yrev tality Outcomes Health SES sicaly Disease Reco Relapse Mor Cognitiv Ph Secondar from Health Disease pathways of & model to s to ousv Care ens ens vior Ner Endocrine Health & cinog athog Access Exposure P Beha Response and Medical Car Health-Related Central System Status Course Life & Socioeconomic ces in t Capacity hostility)
From page 160...
... Also depicted, with varying explicitness, are the developmental processes involved in the pathways linking sociodemographic factors to health. The arrow at the bottom of the MacArthur Network model in Figure D-9 indicates that these processes change over time and cumulate over the
From page 161...
... powerfully affects children's educational attainment and opportunity. Educational attainment, in turn, is a major determinant of adult income and occupation and also affects health behavior and the development of what researchers term health capital.
From page 162...
... In this model, the term Period, Cohort, and Geography Class, Race, and Gender School and Workplace and Peers Peers Family of Family of Origin's Destination's Social Social Capital Capital Child's Adult's Social Social Capital Capital Child's Health Adult's Health Capital Capital FIGURE D-12 The development of individual social capital over the life course and its relationship with individual health capital. Individual social capital comprises cognitive and social skills, coping strategies, self-esteem, attitudes, and values.
From page 163...
... . This stunting of social capital may contribute to poor school functioning, health habits, and health outcomes (e.g., teenage pregnancy)
From page 164...
... In examining a range of reports on overall mortality and on the prevalence of specific diseases, including the data used in the NIH Health Disparities Strategic Plan, Fiscal Years 2004­2008, the only racial/ethnic group that shows consistently poorer health across a range of indicators is African Americans. A caveat, however, is that the available data may not provide a full and accurate estimate of disparities.
From page 165...
... Policies to eliminate health disparities need to be informed by scientific understanding of their causes. The empirical and conceptual approaches to date have revealed that the poorer health of African Americans is largely, but not wholly, accounted for by socioeconomic disadvantage.
From page 166...
... Reverse causation is less plausible for education; disease later in life does not change earlier educational attainment. However, the life course models presented above suggest that health disparities early in life may, in turn, affect educational attainment that could both limit later SES and affect adult health.
From page 167...
... One unexplained finding is why African Americans show more adverse outcomes in relation to physical health but often show lower rates of mental illness. The pattern of associations with SES and race/ethnicity can also vary for different stages of disease.
From page 168...
... At the same time, African Americans show poorer health outcomes even when SES is adjusted for. There may be more impact from research on socioeconomic disadvantage because it is the more powerful effect and is more amenable to intervention.
From page 169...
... Additionally, to the extent possible, measures of psychosocial and behavioral variables that are likely to mediate these effects should be included. Strategies that involve the measurement of risk factors and preclinical indicators of disease states will be particularly important, as these may provide information on common underlying pathways to multiple diseases, as well as information on disease-specific risk states that can suggest strategies for earlier intervention.
From page 170...
... 2004. The importance of place of residence: Examining health in rural and nonrural areas.
From page 171...
... 2000. Social cohesion, social capital, and health.
From page 172...
... 2003. A further study of life expectancy by socioeconomic factors in the National Longitudinal Mortality Study.
From page 173...
... 2000. Sex by Age by Educational Attainment for the Population 18 Years and Over [Census 2000 Summary File 4­Sample Data]
From page 174...
... 174 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH Yang RC, Mills PK, Riordan DG.


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