Health Disparities – Understanding The Underserved

• Health disparities are differences in health due to socioeconomic and environmental factors.  
• Health disparities are complex and often generational until systematically addressed. 
• Addressing health disparities is multi-layer deep involving acknowledgment by healthcare personnel, communities, and state and federal policy change. 

Different groups and communities can have markedly different levels of health. Some populations can have higher rates of cancer, while others might be more likely to be obese or use tobacco.  

These differences in health or medical conditions are called health disparities, and they can have a profound impact on the public health of a community.  

Healthy People 2020 defines health disparity as a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.  

Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their 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.  

These health disparities negatively impact whole groups of people that already face significantly more obstacles to maintaining good health, often because of specific social or economic factors, such as:  

• Socioeconomic status or income 
• Race or ethnicity 
• Age 
• Sex or gender 
• Geography, ex. rural vs. urban 
• Disability 
• Sexual orientation 
• Immigrant status 
• Religion 
• Mental health status 

Historically, these characteristics have been linked to discrimination or exclusion. 

When a particular group of people doesn’t have the same kind of access to health care, education, or healthy behaviors, it can cause them to fall behind their peers on all kinds of health measures. These disparities can often persist for generations.

Impact of Health Disaparities

The negative repercussions of health disparities go beyond just the individual and extend to their children, communities, and society at large. Health disparities are often self-perpetuating.  

Unemployed, low-income individuals are less likely to have access to health insurance. If they’re unable to afford health care, they could get sicker, making them even less able to find a new job, and so on. Getting healthy and out of poverty becomes increasingly difficult.  

This downward spiral can impact future generations, too.  

Health disparities, however, cost Americans more than lives and livelihoods. Persistent gaps in health-related outcomes can also have economic consequences.  

One study in North Carolina estimated that the state could save $225 million a year if disparities in diabetes could be eliminated. Another report estimated that reducing health disparities on a national scale could have saved the United States nearly $230 billion between 2003-2006. 

Examples of Health Disparities

Health disparities exist all over the world, including in the United States. It affects every age, race/ethnicity, and sex.  

Here are just a few examples:  

• Infant mortality: Babies born to Black women in the United States die at more than double the rate of babies born to white women. 
• Dementia: Black people also have the highest risk for dementia, and are twice as likely to develop Alzheimer’s disease than whites in the United States.
• Cancer: People with lower incomes and education levels are more likely to get cancer and to die from it compared to their more affluent peers, and that gap appears to be widening. 
• Obesity: Even after controlling for family income, rates of obesity in Black women and Mexican-American men are substantially higher than in other races or ethnic groups. 
• Smoking: Native American/Alaska Native men and women have disproportionately higher rates of smoking, as do individuals living below the federal poverty level and those who are unemployed. 
• Binge drinking: Young white men are more likely than other groups to binge drink (5+ drinks in a two-hour period). 

Causes of Health Disparities

Like many aspects of public health, the root causes of health disparities are complex.  

Health is influenced by so many factors that it can be difficult to pinpoint just why a gap between two groups is so wide.  

That said, disparities are often the result of health inequities, that is, differences in how resources are distributed among different groups.

These resources could be tangible, like in the case of physical parks where kids can exercise safely, or intangible opportunities, such as being able to see a doctor when ill.  

Disparities often have multiple root causes, but there are a few major inequities in the United States that are known to contribute to health gaps between groups.

Income Inequality

The U.S. health care system is one of the most expensive in the world, spending roughly twice as much on health care as other high-income nations.  

On average, the country as a whole spent an estimated $10,348 per person in 2016, and health care spending accounts for nearly 18% of the U.S. gross domestic product (GDP). 

Americans pay more for health services like clinic visits, hospital stays, and prescription drugs. A growing income gap between the rich and the poor in the United States has made it harder for poor Americans to keep up. 

While top incomes skyrocketed between 1980 and 2015, real wages for low-income individuals fell, making it increasingly difficult for poor people in the US to afford basic medical care or engage in healthy behaviors. This, in turn, makes it harder to stay healthy let alone treat and manage health conditions. 

Systemic Discrimination or Exclusion

Social stimulants like racism, sexism, ableism, classism, or homophobia can perpetuate inequities by prioritizing one group over another.  

These forces are so deeply ingrained in cultural practices and norms that many people might not realize they’re happening.  

Oftentimes, these forces are the result of past inequities that still affect communities today. Take, for example, mid-20th-century discriminatory housing practices.  

These policies forced many minority families into neighborhoods without nearby access to community resources, like public transportation, quality education, or job opportunities all of which can affect a family’s financial stability and could lead to long-term health issues. 

Researcher Camara Phyllis Jones used a gardening analogy in the American Journal of Public Health to illustrate just how this happens. Imagine, for example, two flower boxes: One with new, nutrient-rich soil and another with poor, rocky soil. Seeds planted in the nutrient-rich soil will flourish, while seeds in the poorer soil will struggle. As the flowers go to seed, the next generation will drop into the same soil, experiencing similar struggles or success. As this happens year after year, one box of flowers will always be more vibrant than the other due to the original condition of the soil.  

When people are separated and given different resources to start with, that is going to have an impact for generations to come. 

Environmental Factors

Many health outcomes are the result of personal choices, like eating healthy foods or getting enough exercise. But many of those choices are shaped, influenced, or made for us by the environment in which we live.  

Environmental health is the physical, chemical, and biological forces that can impact our health, and they can be a driving force behind health disparities. It’s hard for people to eat healthy food, for example, when they don’t have access to it in their neighborhood.  

Neglected Tropical Diseases (NTDs) are an example of environmentally-driven health disparities. This collection of 20+ conditions primarily impact the poorest of the poor, both in the United States and worldwide, often due to a lack of clean water or bathrooms.  

These conditions make it harder for kids to learn and adults to work, exacerbating the effects of poverty on people’s health and well-being.

How to Address Health Disparities

Causes of health disparities are often multi-layered, therefore solutions would need to address not only the root cause of a given disparity but also the context that made it possible in the first place.  

The U.S. government laid out a set of goals to be achieved that will improve the health of Americans by the year 2020 (the Healthy People 2020 objectives) with the aim to reduce health disparities by addressing key factors known as social determinants of health. 

Many things in our social circles and environment can impact our behaviors and limit our ability to make healthy choices. These include things like cultural norms (ex. distrust of authority figures) or community design (ex. bike lanes).

There are dozens of social factors exacerbating health disparities, but the Healthy People 2020 objectives have put just five social determinants of health front and center; which are economic stability, education, social and community context, health and healthcare, and neighborhood and built environment.  

Improving Economic Stability

Economic stability refers to things like food security, income or wealth, housing stability, and employment opportunities, and research shows addressing some of these issues could help reduce disparities associated with a whole range of health issues. Providing housing assistance, for example, has been shown to improve both the psychological and physical health of individuals.  

Similarly, providing influenza vaccination in poorer neighborhoods could help reduce gaps in hospitalization due to flu. And increasing economic opportunities for financially insecure women might help prevent the disproportionately high number of cases of HIV in that population.    

Quality Education

Investing in things like language and literacy, early childhood education, high school graduation, and higher education could help close health gaps in a number of ways.  

Increased access to center-based early childhood education, for example, has been shown to decrease crime and teen births. High school completion programs also have strong returns on investment, often resulting in improved economic benefits that exceed any costs associated with the program, in part because of averted health care costs. 

Social and Community Context

While not always apparent, social influences and dynamics can significantly impact the health of both individuals and the overall community. These include things like incarceration, discrimination, civic participation, and social cohesion.  

Because incarceration can disrupt families and impact access to things like education, employment, and housing, some researchers have called for policy changes that address sentencing laws that disproportionately impact certain Black communities as a means to reduce several disparities.   

Neighborhood and Environment

Just like a person’s social environment can impact their health and well-being, so can their physical surroundings.  

Improving access to healthy foods, supporting healthy eating behaviors, improving the quality of housing, reducing crime and violence, and protecting the environment are all things that can be done to improve the environmental health of a community and reduce health disparities as a result.  

One important example of ways the United States could reduce health disparities in obesity rates is addressing the issue of food deserts and food swamps.  

Building partnerships between local governments, food retailers (such as grocery stores), and communities could help bring more affordable and healthier food options to areas where such foods are scarce.  

This, combined with increased targeted education on why and how to incorporate healthy foods into a family’s favorite meals, could go a long way to cutting disparities in obesity rates.

Expand Healthcare Access and Health Literacy

Helping ensure people are able to see a medical professional when they’re sick is important for curbing health disparities. But perhaps equally important is their ability to see a doctor when they’re healthy.  

Many medical issues in the United States could be prevented with routine, preventive care like health screenings, vaccinations, and lifestyle changes. 

The Affordable Care Act attempted to expand access to primary care by making it easier to get health insurance and requiring insurance companies to cover the whole cost of preventative services, like blood pressure screenings and obesity counseling.  

The law also called on medical and public health professionals to address health literacy by ensuring everyone can obtain, understand, and communicate information essential to health decisions. More than 28 million people, however, still lack health insurance, and more can be done to ensure increased access to health care in the United States. 

The Bottom Line

Health disaparities outline the inequalities within specific patient demographics. These differences include income, discrimination, and envrionmental factors.

Taking action against health disparities includes closing the gap in areas of economic stability, education, social and community resources, healthcare and health literacy, and improving neighborhoods and one’s envrionement.

Full understanding of health disaparities can better help a nurse understand the who, what, when, where, why, and how when examining their patients.

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