Causes Of Health Inequalities Research Articles

The great health challenge: levelling up the U.K.

AbstractAround the world, there are persistent and growing health inequalities both between and within countries. The U.K. Government’s flagship policy for addressing inequalities is called ‘Levelling Up’. One of its missions is to narrow the gap in healthy life expectancy (HLE) between the healthiest and unhealthiest areas in England and to improve overall HLE by 5 years by 2035. We show that smoking is one of the major causes of health inequalities. We find a 17-year difference in HLE between local authorities, and that the number of years spent in ill health tended to be greatest in areas with the highest mortality from smoking-related disease. Our aim is to see if the 5-year target could be achieved, assuming there were drastic controls on the sale and consumption of tobacco. We show that never smokers enjoy six more years of good health at age 20 than current or ex-smokers. A complete ban on smoking would lead to a 2.5-year improvement in HLE, and also lengthen the working lives of both men and women. We conclude that while a complete tobacco ban is significant, other public health measures are needed for the full achievement of the target. The paper briefly considers wider issues and suggestions for further research and its international significance.

Promoting social justice in the capitalist academy? Health equity and the Johns Hopkins University Michael Bloomberg School of Public Health

The past two decades have seen increasing mentions of health equity and the importance of addressing the social determinants of health in USA public health statements. Yet, there is little uptake of these concepts into USA public policy. We see this, in part, as being due to the unwillingness of the USA public health community – including its network of Masters of Public Health Programs – to address the fundamental cause of health inequities: the United States’ capitalist economic system which skews the distribution of the social determinants of health in favour of the wealthy and powerful. We illustrate this reluctance by examining how the Bloomberg School of Public Health of Johns Hopkins University conceptualises the promotion of health equity through its International Declaration of Health Rights. Nothing in the Declaration considers how the economic system threatens health yet it is presented as a model for public health education. We review its shortcomings and show how revision to it is unlikely since the School is endowed by its namesake billionaire Michael Bloomberg who has denounced any attempts at redistributing wealth and income in the service of public health. Evidence of how public health messaging is already shaped by powerful economic interests embedded within the United States’ capitalist system substantiates concerns that have been raised about such branding and its effects on public health discourse and action.

UTERINE FIBROIDS AND THE CORRELATION WITH BLACK WOMEN

Uterine fibroids are common benign tumors in the uterus of women of reproductive age and can cause symptoms such as heavy menstrual bleeding, pelvic pain and increased abdominal volume. Studies have shown a higher prevalence of uterine fibroids in black women compared to women of other ethnicities. Understanding the causes of this disparity is fundamental to developing more effective prevention and treatment strategies. Investigating the relationship between the incidence of uterine fibroids and black ethnicity, analyzing the genetic and social factors that may contribute to this correlation and proposing measures to reduce the incidence of uterine fibroids in black women are the aims of this study. This is a systematic literature review using an exploratory and narrative method, with qualitative and quantitative premises. The databases used were PubMed, Scielo, Scopus, Web of Science and the Virtual Health Library. The articles analyzed were selected by exclusion and inclusion criteria, which are set out here, using the health sciences descriptors “uterine fibroids”, “black women and uterine fibroids”, “genetic factors and uterine fibroids” and “environmental factors and uterine fibroids”, reaching a total of 617 articles searched and 9 used in this study. Genetic studies have suggested a genetic predisposition to the development of uterine fibroids in black women, with the identification of genetic variants associated with a higher risk. In addition, social factors such as limited access to quality healthcare, socioeconomic inequalities and exposure to psychosocial stressors may also play an important role. Lack of access to preventive healthcare and unequal access to effective treatments may contribute to a higher prevalence of uterine fibroids in black women. Measures to reduce this disparity include promoting equitable access to healthcare, reproductive health education and public policies that address the underlying causes of health inequalities. The correlation between uterine fibroids and black women highlights the need for integrated approaches that consider both genetic and social factors. Promoting equity in access to health care and implementing public policies aimed at women’s health are key to reducing the incidence of uterine fibroids and improving the quality of life of black women.

Impacts of income inequality and the mediation role of reporting delays on COVID-19 deaths during 2020 and 2021 in Hong Kong: an observational study

ObjectiveTo estimate the impacts of demographic factors and income disparities on the case fatality rate (CFR) of COVID-19 in Hong Kong, taking into account the influence of reporting delays (ie,...

US Medical-Legal Partnerships to Address Health-Harming Legal Needs: Closing the Health Injustice Gap.

The medical-legal partnership (MLP) model is emerging across the USA as a powerful tool to address the adverse social conditions underlying health injustice. MLPs embed legal experts into healthcare teams to address health-harming legal needs with civil legal remedies. We conducted a narrative review of peer-reviewed articles published between 2007 and 2022 to characterize the structure and impacts of US MLPs on patients, providers, and healthcare systems. We found that MLPs largely serve vulnerable patient populations by integrating legal experts into community-based clinical settings or children's hospitals, although patient populations and settings varied widely. In most models, healthcare providers were trained to screen patients for legal needs and refer them to legal experts. MLPs provided a wide range of services, such as assistance accessing public benefits (e.g., Social Security, Medicaid, cash assistance) and legal representation for immigration and family law matters. Patients and their families also benefited from increased knowledge about legal rights and systems. Though the evidence base remains nascent, available studies show MLPs to be associated with greater access to care, fewer hospitalizations, and improved physical and mental health outcomes. Medical and legal providers who were engaged in MLPs reported interdisciplinary learning, and healthcare systems often experienced high returns on investment through cost savings and increased Medicaid reimbursement. Many MLPs also conducted advocacy and education to effect broader policy changes related to population health and social needs. To optimize the MLP model, more rigorous research, systematic implementation practices, evaluation metrics, and sustainable funding mechanisms are recommended. Broader integration of MLPs into healthcare systems could help address root causes of health inequity among historically marginalized populations in the USA.

The stories about racism and health: the development of a framework for racism narratives in medical literature using a computational grounded theory approach

IntroductionThe scientific study of racism as a root cause of health inequities has been hampered by the policies and practices of medical journals. Monitoring the discourse around racism and health inequities (i.e., racism narratives) in scientific publications is a critical aspect of understanding, confronting, and ultimately dismantling racism in medicine. A conceptual framework and multi-level construct is needed to evaluate the changes in the prevalence and composition of racism over time and across journals.ObjectiveTo develop a framework for classifying racism narratives in scientific medical journals.MethodsWe constructed an initial set of racism narratives based on an exploratory literature search. Using a computational grounded theory approach, we analyzed a targeted sample of 31 articles in four top medical journals which mentioned the word ‘racism’. We compiled and evaluated 80 excerpts of text that illustrate racism narratives. Two coders grouped and ordered the excerpts, iteratively revising and refining racism narratives.ResultsWe developed a qualitative framework of racism narratives, ordered on an anti-racism spectrum from impeding anti-racism to strong anti-racism, consisting of 4 broad categories and 12 granular modalities for classifying racism narratives. The broad narratives were “dismissal,” “person-level,” “societal,” and “actionable.” Granular modalities further specified how race-related health differences were related to racism (e.g., natural, aberrant, or structurally modifiable). We curated a “reference set” of example sentences to empirically ground each label.ConclusionWe demonstrated racism narratives of dismissal, person-level, societal, and actionable explanations within influential medical articles. Our framework can help clinicians, researchers, and educators gain insight into which narratives have been used to describe the causes of racial and ethnic health inequities, and to evaluate medical literature more critically. This work is a first step towards monitoring racism narratives over time, which can more clearly expose the limits of how the medical community has come to understand the root causes of health inequities. This is a fundamental aspect of medicine’s long-term trajectory towards racial justice and health equity.

Examining structural racism as the fundamental cause of health inequities among the Indigenous Māori, Native Hawaiian, and Pacific Island peoples in the U.S. and Aotearoa New Zealand: Perspectives from key informant community leaders

Examining structural racism as the fundamental cause of health inequities among the Indigenous Māori, Native Hawaiian, and Pacific Island peoples in the U.S. and Aotearoa New Zealand: Perspectives from key informant community leaders

The modifying effects of cardiovascular risk factors on the relationship between lifetime discrimination and cognitive function: Study of Healthy Aging in African Americans (STAR)

AbstractBackgroundDiscrimination is a root cause of health inequities contributing to the excess burden of cognitive impairment among Black Americans. Using the Study of Healthy Aging in African Americans (STAR) we examined whether the effect of lifetime discrimination on late‐life cognitive decline was magnified by early adulthood cardiovascular risk factors.MethodSTAR enrolled long‐term Kaiser Permanente Northern California members ages 50+ who identify as Black/African American. In early adulthood, participants completed Multiphasic Health Check‐ups (MHC; 1964‐1985) where systolic blood pressure (BP), total cholesterol, and body mass index (BMI) were assessed. A latent class analysis identified groups based on responses to the Major Experiences of Discrimination Scale and gender. Standardized z‐scores for executive function (EF) and verbal episodic memory (VEM) were measured over 3 waves (2018‐2022) using the Spanish and English Neuropsychological Assessment Scales. Linear mixed models with random intercepts and slopes associated latent class with cognitive decline adjusting for age at MHC, age at baseline cognitive assessment, education, and assessment mode (in‐person/telephone). Separate models tested class*cardiovascular risk factor interactions.ResultParticipants (n = 646) averaged 27.7(SD = 7.3) years of age at MHC and 68.5(SD = 8.8) at baseline cognitive assessment (Table 1). Four latent classes were identified: men reporting widespread discrimination (Class‐1men; 12%), women reporting widespread discrimination (Class‐2women; 22%), men and women reporting unfair police treatment (Class‐3police; 17%), and men and women reporting little/no discrimination (Class‐4no_discimination; 49%). Using Class‐4no_discimination as reference, those in Class‐2women had significantly higher baseline EF (β(95% CI):0.18(0.03,0.34)) while Class‐1men (β:0.04(‐0.15,0.23)) and Class‐3police (β:‐0.08(‐0.25,0.09)) did not differ (Figure 1). Class‐2women (β:0.17(0.00,0.33)) had higher baseline VEM compared to Class‐4no_discrimination while Class‐1men (β:‐0.40(‐0.60,‐0.19)) and Class‐3police (β:‐0.27(‐0.46,‐0.09)) had significantly lower (Figure 1). There were no differences in rate of decline. There was a systolic BP*class interaction (p = 0.04) where 5 mm Hg higher systolic BP in early adulthood was associated with worse EF for Class‐3police (β:‐0.07(‐0.12,‐0.02)) compared to Class‐4no_discrimination while Class‐1men and Class‐2women did not differ (Figure 2). This pattern was similar for VEM but non‐significant (interaction p = 0.07). We found no interactions with total cholesterol or BMI.ConclusionFor Black Americans, discriminatory experiences may differentially impact late‐life cognition, and elevated systolic BP in early adulthood may exacerbate this harm.

Scoping Review to Identify Social Determinants of Maternal Health in Morocco.

To understand the mechanism of health inequities and their influence on maternal health, the Commission on Social Determinants of Health (CSDH) provides a framework to identify structural and intermediate causes of health inequity. This review maps and describes the current socioeconomic determinants of maternal health in Morocco according to the CSDH framework. A scoping study was carried out from six databases (Springer, Web of Science, Pubmed, Science Direct, Jstor, and Cochrane library) based on quantitative and qualitative research done since 1990. Structural factors such as women's employment and economic status, education level, culture, and gender equity were influenced by intermediary factors such as place of residence, age at marriage, maternal age at childbirth, and parity (either alone or in conjunction with other variables). Together these factors worked to influence maternal health service usage or affected maternal health outcomes. Power dynamics were identified in a variety of social situations that impacted access to health care for women across socioeconomic categories. Studies reveal how social determinants impact maternal health in Morocco. Addressing these determinants is required for sustainably improving maternal and infant health in Morocco.

The role of payment and financing in achieving health equity.

The aim was to identify healthcare payment and financing reforms to promote health equity and ways that the Agency for Healthcare Research and Quality (AHRQ) may promote those reforms. AHRQ convened a payment and financing workgroup-the authors of this paper-as part of its Health Equity Summit held in July 2022. This workgroup drew from its collective experience with healthcare payment and financing reform, as well as feedback from participants in a session at the Health Equity Summit, to identify the evidence base and promising paths for reforms to promote health equity. The payment and financing workgroup developed an outline of reforms to promote health equity, presented the outline to participants in the payment and financing session of the July 2022 AHRQ Health Equity Summit, and integrated feedback from the participants. This paper did not require novel data collection; the authors collected the data from the existing evidence base. The paper outlines root causes of health inequity and corresponding potential reforms in five domains: (1) the differential distribution of resources between healthcare providers serving different communities, (2) scarcity of financing for populations most in need, (3) lack of integration/accountability, (4) patient cost barriers to care, and (5) bias in provider behavior and diagnostic tools. Additional research is necessary to determine whether the proposed reforms are effective in promoting health equity.

Integrating Social Care into Healthcare: A Review on Applying the Social Determinants of Health in Clinical Settings.

Despite the substantial health and economic burdens posed by the social determinants of health (SDH), these have yet to be efficiently, sufficiently, and sustainably addressed in clinical settings-medical offices, hospitals, and healthcare systems. Our study contextualized SDH application strategies in U.S. clinical settings by exploring the reasons for integration and identifying target patients/conditions, barriers, and recommendations for clinical translation. The foremost reason for integrating SDH in clinical settings was to identify unmet social needs and link patients to community resources, particularly for vulnerable and complex care populations. This was mainly carried out through SDH screening during patient intake to collect individual-level SDH data within the context of chronic medical, mental health, or behavioral conditions. Challenges and opportunities for integration occurred at the educational, practice, and administrative/institutional levels. Gaps remain in incorporating SDH in patient workflows and EHRs for making clinical decisions and predicting health outcomes. Current strategies are largely directed at moderating individual-level social needs versus addressing community-level root causes of health inequities. Obtaining policy, funding, administrative and staff support for integration, applying a systems approach through interprofessional/intersectoral partnerships, and delivering SDH-centered medical school curricula and training are vital in helping individuals and communities achieve their best possible health.

An Invitation to Imagine: Conclusion of the HPP Series "What Is Anti-Racism in Health Promotion Practice?"

Throughout Volume 24 (2023) of Health Promotion Practice, we presented responses to our Call for content addressing the question, "What is Anti-Racism in Health Promotion Practice?" With Editorial Board colleagues, Aditi Srivastav Bussells and Carlos Rodríguez-Diaz, we (Keon L. Gilbert and Kathleen M. Roe) sought frameworks for action and practical examples that would catalyze, support, and (re)invigorate the field in response to the urgent need to eliminate racism as a cause of inequalities in health. This conversation with artist Wriply Bennett concludes the series. We invite scholars and practitioners to review all 17 contributions to the series and to continue to ask - and address - the question 'What is anti-racism in our practice, scholarship, and lives?"

Gender Differences in Migrant Workers Health in China.

Objectives: This study aimed to explore the distribution and differences in the health status of migrant workers in China by gender and age. In addition, it investigated the causes of health inequalities among them. Methods: This paper analyzes the differences in health status across age groups for migrant workers of different genders based on the data from the China Migrant Dynamic Survey in 2018. It also empirically assesses how education level and health insurance impact gender-related health inequalities. Results: The results suggest that female migrant workers in China have significantly lower health levels than males. Furthermore, these differences in health are exacerbated with age. This disparity may be attributed to lower participation in social insurance participation and less educational attainment among female migrant workers than their male counterparts. Conclusion: The government should take effective practical measures to increase the social insurance participation rate of female migrant workers. Moreover, investing in female education to reduce health inequality among migrant workers is essential.

The inverse relationship between income and the prevalence of dementia in high-income nations

Dementia continues to be a serious problem worldwide. A negative relationship between the prevalence of dementia and the level of socioeconomic status (SES), such as income can be observed in most countries. The aim of the study in this paper is to explore the possible pathways that contribute to this negative relationship. This article analyses and presents three possible causes of health inequalities between SES gradients in dementia and possible solutions to them, through a large collection of articles. Differences in health literacy, housing levels and social support caused by SES such as different incomes lead to social inequalities in health through behavioral/cultural pathway material pathway and psychosocial pathway respectively.

Intersectional Stigma as a Fundamental Cause of Health Disparities: A case study of how drug use stigma intersecting with racism and xenophobia creates health inequities for Black and Hispanic persons who use drugs over time.

Recent evidence points to racial and ethnic disparities in drug-related deaths and health conditions. Informed by stigma, intersectionality, intersectional stigma, and fundamental cause theories, we aimed to explore whether intersectional stigma was a fundamental cause of health. We document key events and policies over time and find that when progress is made new mechanisms emerge that negatively affect health outcomes for Black and Hispanic persons. We then focus on intersectional stigma targeting Black and Hispanic persons who use drugs. We document that when a person, or group of people, occupy multiple stigmatized identities the processes of stigmatization and scapegoating are particularly persistent and pernicious since people and groups can be stigmatized and scapegoated on varying intersections. We propose that an intersectional stigma framework allows for a better understanding of observed patterns over time, thereby providing a better guide for policies and interventions designed to reduce disparities. As a framework, intersectional stigma aims to recognize that when different sources of stigma collide, a new set of circumstances is created for those who reside in the intersection. We conclude that intersectional stigma is a fundamental cause of health inequities and provide policy recommendations aimed at dismantling intersectional stigma processes and mitigating the effects of intersectional stigmas to ultimately promote better health outcomes for Black and Hispanic persons who use drugs.

Continuity of Trust: Health Systems' Role in Advancing Health Equity Beyond the COVID-19 Pandemic.

Given COVID-19's disproportionate impact on populations that identify as Black, Indigenous, and People of Color (BIPOC) in the United States, researchers and advocates have recommended that health systems and institutions deepen their engagement with community-based organizations (CBOs) with longstanding relationships with these communities. However, even as CBOs leverage their earned trust to promote COVID-19 vaccination, health systems and institutions must also address underlying causes of health inequities more broadly. In this commentary, we discuss key lessons learned about trust from our participation in the U.S. Equity-First Vaccination Initiative, an effort funded by The Rockefeller Foundation to promote COVID-19 vaccination equity. The first lesson is that trust cannot be "surged" to meet the needs of the moment until it is no longer deemed important; rather, it must predate and outlast the crisis. Second, to generate long-term change, health systems cannot simply rely on CBOs to bridge the trust gap; instead, they must directly address the root causes of this gap among BIPOC populations.

Antiracist Structural Intervention at the Emory University Institutional Review Board.

Although racial and ethnic categories are social constructs without inherent biologic or genetic meaning, race and ethnicity impact health outcomes through racism. The use of racial categories in biomedical research often misattributes the cause of health inequities to genetic and inherent biological differences rather than to racism. Improving research practices around race and ethnicity is an urgent priority and requires education as well as structural change. We describe an evidence-based intervention for an institutional review board (IRB). Our IRB now requires all biomedical study protocols to define racial and ethnic classifications they plan to use, to state whether they are describing or explaining differences between groups, and to provide justification for any use of racial or ethnic group variables as covariates. This antiracist IRB intervention is an example of how research institutions can help ensure the scientific validity of studies and avoid the unscientific reification of race and ethnicity as inherently biological or genetic concepts.

Cultural Competence Guides for COVID-19 Messaging in Hispanic Communities.

The Rio Grande Valley in South Texas comprises 5% percent of Texas's population yet 17%of Texas's COVID-19 deaths. We aimed to address underlying mistrust and systemic racism in our Hispanic community that contributes to health inequities by developing a cultural competence guide for public health messaging. We employed a mixed method design (e.g., focus groups, surveys, interviews) to develop and implement a cultural competence guide in an iterative community-informed process. We created a general cultural competence guide, one for the Hispanic community and one for the hard-of-hearing community. Our cultural competence guides provide an interpretation as to whether the message is culturally competent or requires revisions. The guides have the following five categories: content and clarity, emotions and values, audience and inclusivity, call to action, and gestalt. The Hispanic community needs more culturally competent public health messaging to address a key root cause of health inequities surrounding COVID-19. Our novel, concise guides can help organizations and individuals seeking to create culturally sensitive and, therefore, more effective public health messaging for Hispanic or deaf and hard-of-hearing communities.

Leading Change at Berkeley Public Health: Building the Anti-racist Community for Justice and Social Transformative Change

A transformative change grounded in a commitment to antiracism and racial and health equity is underway at the University of California, Berkeley, School of Public Health. Responding to a confluence of national, state, and local circumstances, bold leadership, and a moral and disciplinary imperative to name and address racism as a root cause of health inequities, our community united around a common vision of becoming an antiracist institution. Berkeley Public Health has a long history of efforts supporting diversity, equity, inclusion, belonging, and justice. Building upon those efforts, we pursued an institution-wide initiative, one that creates a more equitable and inclusive school of public health that models and supports the development of future public health leaders, practitioners, scholars, and educators. Grounded in the principles of cultural humility, we recognized that our vision was a journey, not a destination. This article describes our efforts from June 2020 through June 2022 in developing and implementing ARC4JSTC (Anti-racist Community for Justice and Social Transformative Change), a comprehensive, multiyear antiracist change initiative encompassing faculty and workforce development, student experience, curriculum and pedagogy, community engagement outreach, and business processes. Our work is data informed, grounded in principles of change management, and focused on building internal capacity to promote long-term change. Our discussion of lessons learned and next steps helps to inform our ongoing work and antiracist institutional change efforts at other schools and programs of public health.

A Case Analysis of the Equity-Focused Health Impact Assessment on Reducing Health Inequality in Canberra

In relation to COVID-19, people in policy settings are exposed to a number of health inequalities that are interconnected with many complex determinants. However, few Equity-Focused Health Impact Assessment (EfHIA) studies have been highlighted as relevant to the ongoing pandemic. The EfHIA is regarded as a mechanism for identifying multidimensional causes of health inequality and presents an opportunity to improve interventions in the development of policies or programmes. This research uses an EfHIA Community Funding Programme (CFP) conducted in Canberra to evaluate the performance of EfHIA, evaluating its process and influences on reducing health inequality, with the main findings being that this assessment performs well in relation to health promotion. This study provides a systematic literature review of the theoretical and practical literature, with the evidence reviewed suggesting that it is essential to adopt effective EfHIA strategies and tools to address root issues of health inequality in relation to policy. In this regard, this research considers the extent to which positive changes can be attributed to strategies of the EfHIA across. Finally, in pursuit of effectiveness and equity, the twin-track approach of health promotion and health equality should be utilised in making decisions, the EfHIA having been implemented over a short period with only few resources in most cases. More theoretical research and empirical studies are therefore required to contribute to the use of EfHIA tools so as to reduce health inequality in the future.