Causes Of Health Inequalities Research Articles

Maternal Experiences of Racial Discrimination, Child Indicators of Toxic Stress, and the Minding the Baby Early Home Visiting Intervention.

Racism is a significant source of toxic stress and a root cause of health inequities. Emerging evidence suggests that exposure to vicarious racism (i.e., racism experienced by a caregiver) is associated with poor child health and development, but associations with biological indicators of toxic stress have not been well studied. It is also unknown whether two-generation interventions, such as early home visiting programs, may help to mitigate the harmful effects of vicarious racism. The purpose of this study was to examine associations between maternal experiences of racial discrimination and child indicators of toxic stress and to test whether relationships are moderated by prior participation in Minding the Baby (MTB), an attachment-based early home visiting intervention. Ninety-seven maternal-child dyads (n = 43 intervention dyads, n = 54 control dyads) enrolled in the MTB Early School Age follow-up study. Mothers reported on racial discrimination using the Experiences of Discrimination Scale. Child indicators of toxic stress included salivary biomarkers of inflammation (e.g., C-reactive protein, panel of pro-inflammatory cytokines), body mass index, and maternally reported child behavioral problems. We used linear regression to examine associations between maternal experiences of racial discrimination and child indicators of toxic stress and included an interaction term between experiences of discrimination and MTB group assignment (intervention vs. control) to test moderating effects of the MTB intervention. Mothers identified as Black/African American (33%) and Hispanic/Latina (64%). In adjusted models, maternal experiences of racial discrimination were associated with elevated salivary interleukin-6 and tumor necrosis factor-α levels in children, but not child body mass index or behavior. Prior participation in the MTB intervention moderated the relationship between maternal experiences of discrimination and child interleukin-6 levels. Results of this study suggest that racism may contribute to the biological embedding of early adversity through influences on inflammation, but additional research with serum markers is needed to better understand this relationship. Improved understanding of the relationships among vicarious racism, protective factors, and childhood toxic stress is necessary to inform family and systemic-level intervention.

Future smoking prevalence by socioeconomic status in England: a computational modelling study

BackgroundThe difference in smoking across socioeconomic groups is a major cause of health inequality. This study projected future smoking prevalence by socioeconomic status, and revealed what is needed to achieve...

Rethinking the use of ‘vulnerable’

Rethinking the use of ‘vulnerable’

Diminishing Disparities in U.S. Crisis Standards of Care: Medical and Legal Challenges

Despite a decade of planning and development of crisis standards of care (CSC) in the U.S., real-time experiences during the COVID-19 pandemic and other disasters have highlighted shortcomings involving potentially disparate outcomes among patients across racial, ethnic, socioeconomic, and other groups. Diverse causes of health inequities underlie critical distinctions in medico-legal approaches to allocating scarce resources. What is medically-warranted to save patients’ lives must be balanced against anti-discrimination laws. In this Commentary we examine medical and legal challenges implicated in real-time allocations of limited resources to promote public health, offering a unified approach to diminish disparate impacts among patients.

Diminishing disparities in U.S. crisis standards of care: Medical and legal challenges.

Despite a decade of planning and development of crisis standards of care (CSC) in the U.S. [1], real-time experiences during the COVID-19 pandemic and other disasters have highlighted shortcomings involving potentially disparate outcomes among patients across racial, ethnic, socioeconomic, and other groups. Diverse causes of health inequities underlie critical distinctions in medico-legal approaches to allocating scarce resources. What is medically-warranted to save patients’ lives must be balanced against anti-discrimination laws.

COVID-19 pandemic: a unique opportunity to ‘build back fairer’ and reduce health inequities in the Eastern Mediterranean Region

Evidence has shown that some of the major causes of health inequities arise from the conditions in which people are born, grow, live, work and age, in addition to a wider set of forces and systems shaping individuals' and societies' health and well-being. Such conditions are known as the 'social determinants of health'. However, efforts to address these determinants have remained challenging and unsatisfactory in many parts of the world, including in the Eastern Mediterranean Region. Policies to contain the ongoing COVID-19 pandemic have further exposed and amplified the existing and even created new dimensions in social and health inequities, as we elaborate further below. Meanwhile, the pandemic offers a unique opportunity to tackle inequities and build back fairer.

A Review of the State of the Science of HIV and Stigma: Context, Conceptualization, Measurement, Interventions, Gaps, and Future Priorities.

Stigma is a fundamental cause of health inequities. As such, stigma is a major barrier to HIV prevention, care, and treatment. This review will examine the concept of stigma, explicating the mechanisms of action of HIV-related stigma while also examining intersectional stigma and structural stigma. Instruments to measure HIV-related stigma and its mechanisms of action, as well as stigma enacted and experienced by HIV health care providers, will also be reviewed. This article will conclude with a review of stigma interventions, gaps in the literature, and priorities for future HIV, intersectional, and structural stigma research.

Application of an antiracism lens in the field of implementation science (IS): Recommendations for reframing implementation research with a focus on justice and racial equity.

Despite the promise of implementation science (IS) to reduce health inequities, critical gaps and opportunities remain in the field to promote health equity. Prioritizing racial equity and antiracism approaches is critical in these efforts, so that IS does not inadvertently exacerbate disparities based on the selection of frameworks, methods, interventions, and strategies that do not reflect consideration of structural racism and its impacts. Grounded in extant research on structural racism and antiracism, we discuss the importance of advancing understanding of how structural racism as a system shapes racial health inequities and inequitable implementation of evidence-based interventions among racially and ethnically diverse communities. We outline recommendations for explicitly applying an antiracism lens to address structural racism and its manifests through IS. An anti-racism lens provides a framework to guide efforts to confront, address, and eradicate racism and racial privilege by helping people identify racism as a root cause of health inequities and critically examine how it is embedded in policies, structures, and systems that differentially affect racially and ethnically diverse populations. We provide guidance for the application of an antiracism lens in the field of IS, focusing on select core elements in implementation research, including: (1) stakeholder engagement; (2) conceptual frameworks and models; (3) development, selection, adaptation of EBIs; (4) evaluation approaches; and (5) implementation strategies. We highlight the need for foundational grounding in antiracism frameworks among implementation scientists to facilitate ongoing self-reflection, accountability, and attention to racial equity, and provide questions to guide such reflection and consideration. We conclude with a reflection on how this is a critical time for IS to prioritize focus on justice, racial equity, and real-world equitable impact. Moving IS towards making consideration of health equity and an antiracism lens foundational is central to strengthening the field and enhancing its impact. There are important gaps and opportunities that exist in promoting health equity through implementation science. Historically, the commonly used frameworks, measures, interventions, strategies, and approaches in the field have not been explicitly focused on equity, nor do they consider the role of structural racism in shaping health and inequitable delivery of evidence-based practices/programs. This work seeks to build off of the long history of research on structural racism and health, and seeks to provide guidance on how to apply an antiracism lens to select core elements of implementation research. We highlight important opportunities for the field to reflect and consider applying an antiracism approach in: 1) stakeholder/community engagement; 2) use of conceptual frameworks; 3) development, selection and adaptation of evidence-based interventions; 4) evaluation approaches; 5) implementation strategies (e.g., how to deliver evidence-based practices, programs, policies); and 6) how researchers conduct their research, with a focus on racial equity. This is an important time for the field of implementation science to prioritize a foundational focus on justice, equity, and real-world impact through the application of an anti-racism lens in their work.

Stigma and substance use disorders: A clinical, research, and advocacy agenda.

The United States is currently experiencing an opioid epidemic, with deaths due to opioid overdoses persisting in many communities. This epidemic is the latest wave in a series of global substance use-related public health crises. As a fundamental cause of health inequities, stigma leads to the development of substance use disorders (SUDs), undermines SUD treatment efforts, and drives persistent disparities within these crises. Given their expertise in mental and behavioral health, psychologists are uniquely positioned to play a frontline role in addressing SUD stigma. The goal of this paper is to set an agenda for psychologists to address SUD stigma through clinical care, research, and advocacy. To set the stage for this agenda, key concepts are introduced related to stigma and SUDs, and evidence is reviewed regarding associations between stigma and substance use-related outcomes. As clinicians, psychologists have opportunities to promote resilience to stigma to prevent the development of SUDs, and leverage acceptance and mindfulness approaches to reduce internalized stigma among people with SUDs. As researchers, psychologists can clarify the experiences and impacts of stigma among people with SUDs over time and adapt the stigma-reduction toolbox to address SUD stigma. As advocates, psychologists can call for changes in structural stigma such as policies that criminalize people with SUDs, protest the intentional use of SUD stigma, and adopt stigma-free language in professional and social settings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Social policies and change in education-related disparities in mortality in Japan, 2000-2010.

Persistent socioeconomic disparity in mortality is a widely observed phenomenon despite improvements in the economic standard of living and the prevailing universal healthcare coverage policy. In this study, we selected Japan as a case in which public universal coverage has maintained horizontal equity in healthcare access while demographic and economic challenges have affected the life chances of vulnerable subpopulations over the past decade. We assessed the changing trends in the education-related disparity in mortality over a decade across demographic subpopulations for different causes of death, with the goal of generating social policy lessons to contribute to closing the mortality gap. Using a deterministic data merge between nationwide census and death records, we estimated age- and sex-specific mortality rates for 14 causes and their education-related gradients with absolute and relative indices of inequality in 2000 and 2010 via Poisson regression. Estimation parameters were standardized to the age structure of the sub-population of high school graduates in 2000 as the reference. The results demonstrated that the relative gaps in all-cause mortality persisted despite a decrease in the average mortality rate over the study period. The absolute gaps in mortality increased for preventable causes of death associated with lifestyle behavior choices. The average mortality worsened among socioeconomically vulnerable populations such as youth and women, who were left behind in the existing social/economic policy. External causes of death such as suicide and traffic accidents showed decreasing absolute gaps in a subpopulation targeted by universal social and labor policy measures. These change patterns indicate that, compared with a high-risk approach, a universal policy approach to dealing with societal and fundamental causes of health inequality seems more effective in reducing the education-related mortality gap in both absolute and relative terms.

Education, health behavior, and working conditions during the pandemic: evidence from a German sample

ABSTRACT Education is a main cause of health inequality because it influences health behavior as well as structural conditions that impact health, such as living and working conditions. We examine how different educational groups reacted to the beginning of the COVID-19 pandemic in Germany by looking at health-related behavior – social distancing, increased hygiene, and mask wearing – as well as changes in working conditions – work from home, reduced working hours, and not working – as a structural indicator that can mitigate the risk of infection. More than three quarters of respondents in all educational groups complied with recommended social distancing and hand hygiene behaviors, and differences by education did not exceed ten percentage points. Regarding working conditions, highly educated respondents had a likelihood of over 45 percent to work from home during the pandemic. This number decreased to 17 and 11 percent for those with intermediate and low levels of education, respectively. It seems that education-based inequalities in the risk of infection with COVID-19 do not primarily stem from differences in health behavior but rather from structural causes, that is, inability to practice social distancing at work.

Community nurses and chronic disease in Israel: Professional dominance as a social justice issue.

Chronic diseases are major causes of health inequalities. Community nurses can potentially make large contributions to chronic illness prevention and management in Israel but may be obstructed by professional dominance of physicians. However, insufficient research exists about community nursing in Israel, and how it may differ from other countries. This study aims to document chronic disease-related community nursing roles in Israel, identify changes and trends in community nursing roles that may increase social justice, and understand how the roles and trends in community health nursing in Israel may differ from developments in other countries. In-depth interviews were performed with 55 Israeli health system professionals, and 692 nurse care-givers were asked open-ended questions. Interview answers were analyzed to find themes and trends. The study found that community nurse roles in Israel have expanded, especially for chronic disease control. Commonalities exist with countries such as the United States and the UK, albeit with important differences. However, continued conflicts with physicians exist, which can limit nurses' contributions to reducing health inequalities. Community nurses' importance is growing. Enabling them to overcome professional dominance and improve chronic disease control can help reduce health inequalities in Israel and elsewhere.

Climate change and COVID-19: reinforcing Indigenous food systems

Climate change and COVID-19: reinforcing Indigenous food systems

Health Equity’s Missing Substance: (Re)Engaging the Normative in Public Health Discourse and Knowledge Making

Abstract Since 1984, the idea of health equity has proliferated throughout public health discourse with little mainstream critique for its variability and distance from its original articulation signifying social transformation and a commitment to social justice. In the years since health equity’s emergence and proliferation, it has taken on a seemingly endless range of invocations and deployments, but it most often translates into proactive and apolitical discourse and practice. In Margaret Whitehead’s influential characterization (1991), achieving health equity requires determining what is inequitable by examining and judging the causes of inequalities in the context of what is going on in the rest of society. However, it also remains unclear how or if public health actors examine and judge the causes of health inequality. In this article, we take the concept of health equity itself as an object of study and consider the ways in which its widespread deployment has entailed a considerable emptying of its semantic and political content. We point toward equity’s own discursive productivity as well as the quantifying imperative embedded within evidentiary norms that govern knowledge making, and performance management regimes that govern public health practices. Under current conditions of knowledge making and performance evaluation, a range of legitimate action and inaction is produced at the same time that more socially transformative action is legitimately curtailed—not merely by politics, but by the rules of the field in which public health actors work. Ultimately, meaningful progress on a normative ethical idea like health equity will require both substantial philosophical content and an analysis of what is going on in the rest of society.

Cultivating Empathy Through Virtual Reality: Advancing Conversations About Racism, Inequity, and Climate in Medicine

Racism and bias are fundamental causes of health inequities, and they negatively affect the climate of academic medical institutions across the United States. In 2019, the Zucker School of Medicine and Northwell Health piloted a virtual reality (VR) racism experience as a component of professional development for medical school and health system leaders, faculty, and staff. Participants experienced a 60-minute, interactive, large-group session on microaggressions and, as individuals, a 20-minute VR module. These were followed by group reflection and debriefing. The sessions, developed in collaboration with a VR academic team, represented a response to institutional climate assessment surveys, which indicated the need for expanded professional training on cross-cultural communication and enhancing inclusion. In October 2019, 112 faculty and staff participated in the workshop. On a postworkshop survey, completed by 76 participants (67.9%), most respondents (90.8%) reported feeling engaged in the VR experience. Additionally, the majority agreed that VR was an effective tool for enhancing empathy (94.7%), that the session enhanced their own empathy for racial minorities (85.5%), and that their approach to communication would change (67.1%). In open-ended responses, participants frequently conveyed enthusiasm, powerful emotional and physiologic responses, and enhanced empathy. They also suggested more time for follow-up discussions. Next steps include assessing the scalability of the VR module; determining effective complementary engagements; and measuring the module's longitudinal effects on racial empathy, discrimination, and institutional climate. As VR becomes more common in medical education, developing VR modules to address other forms of discrimination (e.g., sexism, homophobia) could also benefit the institutional climates of medical schools and health systems as academic medicine continues to build toward health equity.

Special Report: Hispanic Community and COVID-19—Addressing Health Inequalities Can No Longer Be Delayed

<i>Special Report:</i> Hispanic Community and COVID-19—Addressing Health Inequalities Can No Longer Be Delayed

Racial Discrimination, Inflammation, and Chronic Illness Among African American Women at Midlife: Support for the Weathering Perspective.

It is widely accepted that socioeconomic status (SES) is a fundamental cause of health inequality. There is evidence, however, that race is also a fundamental cause of disparities in health. Based on this idea, the weathering hypothesis developed by Geronimus and her colleagues views the elevated rates of illness and disability seen among Black Americans as a physiological response to the structural barriers, daily slights, and other threats to identity that comprise the Black experience. The current study tests the weathering hypothesis using chronic inflammation as an indicator of biological weathering. Specifically, we examine the extent to which persistent exposure to racial discrimination predicts elevated inflammation and, in turn, diagnosed chronic illness, after taking into account SES and several control variables. This mediation model was tested using zero-inflated Poisson path modeling with five waves of data collected from 391 African American women participating in the Family and Community Health Study (FACHS). A 13-item index was used to assess exposure to racial discrimination across 8years. ELISA blood assays of seven cytokines central to the inflammatory response were used to construct an inflammatory index. Respondents reported their diagnosed chronic diseases. Consonant with the weathering hypothesis, persistent exposure to discrimination predicted inflammation which, in turn, predicted number of chronic diseases. This indirect effect was statistically significant. SES predicted having a chronic disease and the various controls showed no effect. The findings support the idea that race, like SES, is a fundamental cause of health inequalities.

Building collective power in citizen-led initiatives for health accountability in Guatemala: the role of networks

BackgroundCitizen-led accountability initiatives are a critical strategy for redressing the causes of health inequalities and promoting better health system governance. A growing body of evidence points to the need for putting power relations at the forefront of understanding and operationalizing citizen-led accountability, rather than technical tools and best practices. In this study, we apply a network lens to the question of how initiatives build collective power to redress health system failures affecting marginalized communities in three municipalities in Guatemala.MethodsNetwork mapping and interpretive discussions were used to examine relational qualities of citizen-led initiatives’ networks and explore the resources they offer for mobilizing action and influencing health accountability. Participants in the municipal-level initiatives responded to a social network analysis questionnaire focused on their ties of communication and collaboration with other initiative participants and their interactions with authorities regarding health system problems. Discussions with participants about the maps generated enriched our view of what the ties represented and their history of collective action and also provided space for planning action to strengthen their networks.ResultsOur findings indicate that network qualities like cohesiveness and centralization reflected the initiative participants’ agency in adapting to their sociopolitical context, and participants’ social positions were a key resource in providing connection to a broad base of support for mobilizing collective action to document health service deficiencies and advocate for solutions. Their legitimacy as “representatives of the people” enabled them to engage with authorities from a bolstered position of power, and their iterative interactions with authorities further contributed to develop their advocacy capabilities and resulted in accountability gains.ConclusionsOur study provided evidence to counter the tendency to underestimate the assets and capabilities that marginalized citizens have for building power, and affirmed the idea that best-fit, with-the-grain approaches are well-suited for highly unequal settings characterized by weak governance. Efforts to support and understand change processes in citizen-led initiatives should include focus on adaptive network building to enable contextually-embedded approaches that leverage the collective power of the users of health services and grassroots leaders on the frontlines of accountability.

Rethinking COVID-19 Vulnerability: A Call for LGTBQ+ Im/migrant Health Equity in the United States During and After a Pandemic.

Public health responses to the coronavirus disease 2019 (COVID-19) pandemic have emphasized older adults' vulnerability, but this obfuscates the social and political root causes of health inequity. To advance health equity during a novel communicable disease outbreak, public health practitioners must continue to be attentive to social and political circumstances that inform poor health. Such efforts are especially needed for populations who are exposed to numerous social and political factors that structure health inequity, such as lesbian, gay, bisexual, transgender, or otherwise-queer identifying (LGBTQ+) populations and im/migrant populations. The COVID-19 outbreak is, therefore, a critical time to emphasize root causes of health inequity.

Educational inequality in avoidable mortality in osteoarthritis: a test of fundamental causes theory

Purpose: Persistent socioeconomic inequalities in health across time and place led scholars to propose socioeconomic status (SES) as a fundamental cause of health inequalities. According to the “fundamental causes” theory people with higher SES have access to a broad range of resources that can be used to avoid poor health and hence the association between SES and risk of mortality should be stronger for avoidable causes of death than less avoidable causes. While this theory has been tested in the general population, there is little empirical evidence for specific diseases. We aimed to investigate the validity of this theory among people with osteoarthritis (OA). Methods: Using regional registers, we identified patients with a doctor-diagnosed OA (all sites; ICD-10 codes: M15-M19) during 1998-2013 (n=98,619) among people aged 35-75 on December 31st 2002 who lived in the Skåne region continuously from January 1st 1998 (n=525,829). We followed these from January 1st 2003 or date of first OA diagnosis (whichever occurred last) until death, relocation outside Skåne, or December 31st 2014 (whichever occurred first). Using the list developed by the UK Office for National Statistics (link), we divided avoidable causes of death in 3 categories: amenable to medical interventions (AMI), amenable to public health interventions (APHI), and amenable to both medical/public health interventions (AMPHI). Education was categorized in five levels based on years of schooling: 0-9 years, 10-11 years, 12 years, 13-14 years, and ≥15 years. Each level of education was assigned a fractional rank based on the mean proportion of the population with a lower level of education. We applied Cox regression with age as time scale to estimate relative index of inequality (RII). Results: A total of 94,210 patients (58.9% women) with mean (SD) age 62.5 (9.6) years at entry were included. During a mean follow-up of 6.5 years, there were 9,554 deaths, of these 62.3% were from avoidable causes. While for both avoidable and non-avoidable causes, there were educational inequalities in favour of high educated, the magnitude of relative educational inequality was greater for avoidable than non-avoidable causes (Figure 1). The difference was more profound for AMI, especially among women. Conclusions: The Results suggest that educational attainment is a fundamental cause of inequality in OA. Therefore, preventive and therapeutic interventions with sole focus on mortality risk factors will not lead to eliminating inequalities unless the underlying differences in educational attainment are addressed.