Kronenfeld, J.J. (2019), "Underserved and Socially Disadvantaged Groups and Linkages with Health and Health Care Differentials", Underserved and Socially Disadvantaged Groups and Linkages with Health and Health Care Differentials (Research in the Sociology of Health Care, Vol. 37), Emerald Publishing Limited, pp. 3-11. https://doi.org/10.1108/S0275-495920190000037002Download as .RIS
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This chapter provides an introduction to Volume 37 in the Research in the Sociology of Health Care series, “Underserved and Socially Disadvantaged Groups and Linkages with Health and Health Care Differentials.” The beginning of this chapter will briefly review some of the more important material about underserved and socially disadvantaged groups in consideration of health and health care differentials. The second part of this chapter will review the overall contents of the volume and the structure of the volume.
Underserved and Socially Disadvantaged Groups and Other Social Factors as Linked to Health Disparities and Health Care Disparities
When one uses the terms underserved and socially disadvantaged groups, it could mean many different things. In this volume, it mostly means people of color including Asian Americans and Latinx Americans, as well as rural Americans, and aging populations. In addition, it means issues related to women and gender both as recipients of care and providers of care. Also, a few chapters look at issues of underserved groups outside of the American context. In addition, many of the chapters relate to a variety of other social factors, including but not limited to components of socioeconomic status (SES) such as income, education and occupation, demographic social factors such as age and gender and factors linked to the family such as marriage or divorce and factors linked to employment such as job stress or unemployment. The literatures covering these different groups and factors are huge, and the literature on health inequalities and health care inequalities is also quite large. This chapter will not cover any of this in a comprehensive manner but will focus in a brief section on what we mean by health and health care inequalities. There is also a brief section on the linkage of a few major social factors such as income, education and race and ethnicity with health and health care inequalities.
Health Inequalities, Health Care Inequalities, and Health Disparities
One area of growing interest within medical sociology in the past 20 years has been research in health disparities and this is also true within public health and medicine as well as medical sociology more specifically. The interest in health care disparities has expanded beyond researchers to also become an area of high interest to providers of care and policymakers, especially within the United States. The definition of health disparities or differences in health care is important to review. The Institute of Medicine (IOM) defines health care disparities as differences in treatment or access between population groups that cannot be justified by different preferences for services or differences in health (McGuire, Alegria, Cook, Wells, & Zaslavsky, 2006). Within the United States, much of the focus on health care disparities has turned to differences in access and quality across racial and ethnic groups, although these are not the only social characteristics that are of interest either sociologically or from a policy perspective. Differences based on SES and its components including education and income are of both research and policy interest. Beyond research and thinking about policy implications, health care disparities matter even more if they result in health disparities, defined as differences in health outcomes across population groups (Schnittker & McLeod, 2005).
One interesting study that demonstrates the growth in research about social differences in health and health disparities was summarized well by the Adler and Rehkopf (2008) review of US disparities in health by examining literature for the term “health disparities” and finding that while this was a key word in only one article in 1980, and fewer than 30 in the 1990s, it went up to over 400 articles from 2000 to 2004. If the term “health inequalities” was used instead, the pattern of increase was similar.
The United States is not the only country with growing interest in this topic. Great Britain and more recently some European countries also have interest in the topic. Interest in the topic in Great Britain goes back to 1980, when the Black Report was one of the first in that country to apply the term inequality to an examination of health differences. In the United States in this same time period, studies did link together death and health information with information on SES from sources such as the Current Population Study, the US Census, and Social Security Administration records (Kitagawa & Hauser, 1978; Kliss & Scheuren, 1978).Within the US, some of these earlier studies and traditions in various fields including sociology of research into variation in health, health care utilization and health services issues by SES and race/ethnicity led to the now well-known efforts in the United States to examine and try to eliminate health disparities due to race/ethnicity and SES in the Healthy People series. From the federal government level, one of the pushes for more research on health care inequalities came from the passage of Public Law 106–129, the Health Care Research and Quality Act of 1999. A first National Health Care Disparities Report came out in 2005 and built on previous efforts in the federal government, especially Healthy People 2010 (U.S. Department of Health & Human Services, 2000) and the IOM Report, Unequal Treatment: Confronting Racial and Economic Disparities in Health Care (Smedley, Stith, & Nelson, 2003). Elimination of disparities in health was a goal of Healthy People, 2010. Unequal Treatment extensively documented health care disparities in the United States and focused on those related to race and ethnicity, but not on SES, a weakness of the report. The IOM report on Unequal Treatment also looked at factors related to providers of care and argued that providers’ perceptions and, from that, their attitudes toward patients can be influenced by patient race or ethnicity (Smedley et al., 2003).
Federal government focus on these efforts has continued, and much of it is discussed in the Healthy People 2020 publications, much of which is now easily obtainable through United States government websites including access to data from the 2020 objectives (U.S. Department of Health & Human Services, 2019). For the 2020 effort, the report points out that in Healthy People 2000, the goal was to reduce health disparities among Americans, and in Healthy People 2010 the goal was to eliminate, not just reduce, health disparities. By Healthy People 2020, that goal was expanded even further: to achieve health equity, eliminate disparities, and improve the health of all groups. Healthy People 2020 defines health equity as attaining the highest level of health for all people. In addition, the Centers for Disease Control and Prevention (CDC) is another US federal agency that works on issues of health differences and health disparities in addition to many other concerns about diseases. In a special report they issued in 2011, the agency consolidated the most recent national data available on disparities in mortality, morbidity, behavioral risk factors, health care access, preventive health services, and social determinants of critical health problems in the United States by using selected indicators (Truman et al., 2011).
One of the newest federal government-related efforts to focus on health equity is an effort by the Centers for Medicare & Medicaid Services (CMS). They have collaborated with a wide variety of stakeholders to support work in all three areas of their path to equity: increasing the understanding and awareness of disparities and their causes, developing and disseminating solutions, and implementing sustainable actions. To increase understanding and awareness of disparities, CMS sponsored a special issue of Health Services Research (James, 2019) with a goal of contributing to the conversation on health disparities and emphasizing the value of continuing research in this area (Caro, 2019). This is an important new publication to consult related to these concerns.
Beyond the role of the federal government, private foundations such as the Commonwealth Foundation have programs that focus on health differences and health disparities (Commonwealth Fund, 2015). The goals of the Commonwealth Fund’s Program on Health Care Disparities are to improve the overall quality of health care delivered to low-income and minority Americans, and to eliminate racial and ethnic health disparities. In addition to issues of health differences and health disparities as many of these reports have examined, another issue related to health disparities has to do with dissatisfaction with the health care system. Recent research that compares the United States with other countries reports that Americans often report low levels of satisfaction and it does not appear to be correlated with per capita health expenditures as it is in many other countries (Hero, Blendon, Zaslavzk, & Campbell, 2016). There is also variation in satisfaction by factors such as income, with greater income associated with greater satisfaction.
Underserved and Socially Disadvantaged Groups
Many social factors are important in health and health care inequalities. Among the most important factors are aspects of SES such as education, income, and occupation, because these factors often create and shape patterns of disease, patterns of health care utilization, and patterns of inequalities. People who have greater advantages in SES live longer than those without such advantages (Kunst, Feikhe, Mackenbach, & the EU Working Group on Socioeconomic Inequalities in Health, 1998). This is true at the beginning of life in terms of differences in infant mortality as well as across the lifespan (Gortmaker & Wise, 1997). It has also been true across time and is true in many different countries, not just the United States.
More recent research in medical sociology has especially focused on some broader approaches to SES and other social factors, an approach now known as the fundamental cause approach (Link & Phelan, 1995; Link & Phelan, 1996). This is a sociologically based explanation for persistent associations between SES and disease. The argument is that the reason SES is so consistently associated with disease is that resources such as knowledge, money, power, and prestige, all factors embodied in the SES concept, can be used in many different ways and in many different situations to avoid risks for diseases and even death. More socioeconomically advantaged people can better avoid risks and also take up protective strategies to improve health and well-being and can modify these over time to take advantage of new knowledge and approaches in the medical arena. This makes the relationship a dynamic one. If new risk factors emerge, for example, such as lack of exercise or changes in nutritional information, those with the most resources are better able to avoid risks and take advantage of protective factors. The same is true for knowledge about new treatments; the most advantaged people not only often have better health insurance that allows people to use the treatments, but are more likely to learn about the treatments, seek out health providers who familiar with such treatments and be able to pay for the treatment with their own resources if the new treatments are not yet covered by standard health insurance.
Turning away from more theoretical discussions to actual data, the United States government reports have recently been working on ways to create some simpler indicators of such factors as health-related quality of life. They have developed the HALex score which provides one individual-level measure of health-related quality of life (HRQL) that can be used to monitor health status as well as examine inequalities in morbidity across time and groups (Truman et al., 2011). This measure provides a numerical based measure that combines information on self-rated health and activity limitation as reported in nationally representative surveys. The scores on HALex can theoretically range from 1.00 for persons who have no activity limitation and are in excellent health to 0.10 for persons who are limited in activities of daily living (ADL) and are in poor health. For example, a person in excellent health with ADL disabilities is considered as healthy, with an assigned HALex score of 0.47, as is a person in poor health with no disabilities. The average HALex and inequality for HALex among US adults for 1997–2007 is estimated to show a declining trend from 0.8766 in 1997 to 0.8662 in 2007. During the same period, health inequality among individual persons, as measured by the Gini index for HALex, fluctuated, varying from 0.084 to 0.093, and experienced an overall declining trend from 0.093 in 1997 to 0.087 in 2007.
As part of the same research efforts, agencies within the government have been examining the socioeconomic circumstances of persons and the places where they live and work because studies have indicated that these strongly influence their health. The risk for mortality, morbidity, unhealthy behaviors, limited access to health care, and poor quality of care increases with decreasing socioeconomic circumstances. The two most common indicators used are educational attainment and family or household income. To assess disparities in the prevalence of non-completion of high school and poverty, the CDC analyzed data from the 2005 to 2009 Integrated Public Use Microdata Series – Current Population Survey (IPUMS-CPS). This provides a cross-sectional monthly household survey of a representative sample of the civilian, non-institutionalized US household population and is conducted jointly by the US Census Bureau and the Bureau of Labor Statistics. Group disparities in age-standardized prevalence of non-completion of high school and poverty (poverty income ration (PIR) <100% of federal poverty level (FPL)) were assessed according to sex, race/ethnicity, age, education, PIR, and disability (Beckles & Truman, 2011). In the 2009 population, statistically significant disparities were identified in non-completion of high school for all characteristics studied. Except for non-Hispanic Asian/Pacific Islander males, the absolute differences between the age-standardized percentages of each non-white racial/ethnic group and non-Hispanic whites who had not completed high school were statistically significant. The degree of racial/ethnic relative disparity varied markedly among the non-white racial/ethnic groups, ranging from three to nine times greater for Hispanics than for other groups. During 2009, the group disparities in poverty observed were similar to those for non-completion of high school No statistically significant differences were identified between relative disparities in poverty observed for 2005 and 2009.
This section has presented only a small bit of the data linked to social factors and health and health care that is available from US government sources. Because this introduction to this material is in no way comprehensive, these paragraphs are illustrative of the types of information available on CDC and other US government websites such as the Healthy People reports. They are excellent sources for researchers interested in pursuing these topics in greater depth.
Also, previous volumes in this series have presented brief reviews of issues linked to gender and health and health care as well as to race and ethnicity (Kronenfeld, 2012; Kronenfeld, 2015; Kronenfeld, 2016). Consultation of the introductory essays to these volumes will also provide additional information as do the literature review sections of a number of the chapters in this volume.
Review of Contents of the Volume
This volume is divided into five parts. The first part is the introduction to this volume and contains only this chapter. The second part is on mental health related issues and contains three chapters, all of which look partially at mental health issues as related to issues of race and ethnicity. The chapter by Bennefield explores mental health pathways for girls of color. The purpose of this study was to examine whether girls of color had more or less social support than their peers and whether that affected their likelihood of experiencing the symptoms of anxiety and depression. Using data from the National Comorbidity Survey, Adolescent Supplement, path analysis found that among adolescents with both low and high SES, girls of color had significantly less family support. Despite this fact, they were not more likely to experience symptoms of anxiety and depression. The second chapter by Valles looks at familial support and mental health services use and especially examines differences among first and second generation Asian American and Latinx Older Adults. She finds that familial support partially attenuates the relationship between immigrant generation and mental health service use, but only for Latinx groups. Furthermore, the effect of familial support did not vary by age, suggesting that familial support is not significantly different for older adults than that of those younger in age. The last chapter in this part by Rivera, Molina, and Nicdao examines psychological distress differentials as a function of subjective social status among Latino subgroups in the United States. Data used were from the Latino sample (N = 2,554) of the National Latino and Asian American Study (NLAAS). A series of weighted multivariable linear regressions were the main analytical approach. Results showed that subjective social status was associated with reduced psychological distress. The chapter also demonstrates how the associations analyzed varied by Latino sub-ethnicity, an important step to fully understand the different social processes associated with the mental health of different Latina/o groups.
The third part covers four chapters related to other types of health problems, including environmental inequality and health, autism spectrum disorders (ASDs), Hepatitis C and overall perspectives on health, well-being and nutrition. The first chapter by Brailsford and colleagues points out that although theoretical models suggest that race differences in physical health are partially explained by exposures to environmental toxins, there is little empirical evidence to support this. This chapter formally tests whether black–white differences in self-rated physical health are mediated by the embodiment of environmental toxins. It uses cross-sectional data from the National Health and Nutrition Examination Surveys (2007–2008) and conducts ordinary least squares regression to model environmental toxins (from urine specimens) and overall self-rated health as a function of race and ethnicity. The authors find that non-Hispanic black respondents tend to exhibit higher levels of total toxins, lead, and cadmium in their urine and poorer physical health than non-Hispanic whites, even with adjustments for age, gender, and SES. Mediation analyses suggest that blacks may exhibit poorer physical health than whites because they tend to embody higher levels of cadmium.
The other three chapters in this part each look at different types of health problems, but all employ qualitative research approaches to better understand these issues. The second chapter in this part examines ASDs. Joseph-Kent illuminates the experiences of adults diagnosed with ASDs and intellectual disabilities (ID) and their challenges and successes in receiving quality health care services. Individuals with developmental disabilities often experience health issues associated with aging at earlier ages and at higher rates than the general population. This population has a higher incidence of chronic health conditions that require regular medical attention. This chapter is a qualitative study conducted with semi-structured interviews with 12 adults diagnosed with ASD and/or their guardians/caregivers. Some of the adults interviewed experienced negative health outcomes and suboptimal relationships with health care providers; others seemed to have positive relationships. Barriers to accessing health care services existed in many forms.
The chapter on Hepatitis C by Kawakami, Son and Henderson focuses on better understanding the key factors that affect the quality of care that Hepatitis C patients are likely to receive in rural communities. It also discusses how to build a more effective health support system for the rural residents. Using a grounded theory approach, the researchers draw a conceptual map of the occurrence while informants had the opportunity to contemplate and share their thoughts on the issues. Local leaders held a romanticized view toward rural life while the disadvantaged reported a sense of powerlessness to bring about the needed changes to help them battle Hepatitis C. The last chapter in this part by Scheer has a broader focus than some of the other chapters in this part, with the purpose of this study being an exploration of rural children’s own perspectives on health, well-being, and nutrition. Using a qualitative ethnographic research design theoretically informed by the “new” Sociology of Childhood and methodologically informed by constructivist grounded theory, the study uses as subjects fifth-grade students in an elementary school in a small rural school district in central Illinois.
Preliminary findings of this pilot study suggest that many aspects often discussed in the context of pediatric obesity, especially in rural settings, including knowledge or education about healthy eating, increasing physical activity levels, or access to healthy foods, are complex and multifaceted and do not easily lend themselves to standard interventions. Findings also indicate that children’s ideas about healthy eating deviate from their own eating practices. Families’ rules surrounding food selection and consumption as well as rules regarding the use of children’s free time emerge as central categories for analysis.
Part IV has two chapters, both linked to gender concerns in underserved and socially disadvantaged groups.
Part V is the last section and includes three chapters discussing issues linked to health care workers. While the first chapter has a focus gender politics as an important factor for health care workers, the other two chapters examine issues of socially disadvantaged groups who are health care workers, one as vulnerable caregivers in long-term care settings and in the final chapter of the volume, migrant women who work as home care assistants.
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- Part I Introduction to Volume
- Underserved and Socially Disadvantaged Groups and Linkages with Health and Health Care Differentials
- Part II Mental Health Related Issues
- Disadvantage Begets Disadvantage? Exploring Mental Health Pathways for Girls of Color
- Familial Support and Mental Health Service Use: Differences among First- and Second-generation Asian American and Latinx Older Adults
- Psychological Distress Differentials as a Function of Subjective Social Status among Latino Subgroups in the United States
- Part III Other Health Problems
- Race, Environmental Inequality, and Physical Health
- Autism Spectrum Disorders and the Healthcare Experiences of Aging Adults
- Hepatitis C and Support Groups in Rural Communities
- “I Kinda Look Unhealthy, but I’m Not Unhealthy” – Exploring Rural Children’s Perspectives on Health, Well-being, and Nutrition
- Part IV Gender Concerns
- Public Perception on Gender Issues and Women’s HealthCare Concerns Related to Leprosy: Implications for Leprosy Control Program in Southeast Nigeria
- Thalassemic Women’s Biographical Trajectory: Retracing Gender Inequalities in Health Policies
- Part V Health Care Workers
- Work–life Balance in Medical Practice: The Reproduction of Patriarchy and the Politics of Gender
- Vulnerable Caregivers: A Comparison of Direct Care Workers’ Health Risks in Skilled Nursing Facilities and Private Homes
- The Health of Migrant Women Working as Home Care Assistants in Italy: An Analysis of the Most Hazardous Factors of Home Care Work