Health Disparities, a Social Determinant of Health and Risk: Considerations for Health and Risk Messaging
- Nancy Grant HarringtonNancy Grant HarringtonCollege of Communication and Information, University of Kentucky
Health disparities are differences in health outcomes between socially disadvantaged and advantaged groups. This essay provides a brief review of the voluminous literature on health disparities, with a focus on several major threads including populations of interest, incidence and prevalence of morbidity and mortality, determinants of health, health literacy and health information seeking, media influences on health disparities, and efforts to reduce disparities. Populations of interest tend to be defined primarily by socioeconomic status (income/education), race, ethnicity, and sex or gender; however, differences in sexual orientation, immigrant status, geography, and physical and mental disability are also of concern. Determinants of health can be categorized along a number of dimensions, but common designations consider behavioral, social, and environmental factors that lead to health disparities, as well as differences in access to health care and health services. Of central interest to communication researchers, differences in health literacy and health information seeking are revealed between advantaged and disadvantaged groups. Media influences involve the effects of access or exposure to different kinds of health information on the health behavior and health outcomes of different groups, as well as the effects of health disparity media coverage on public support for initiatives to reduce health disparities. Efforts to reduce health disparities are extensive and involve government and foundation efforts and research-driven interventions.
Taking a broader view, this essay briefly discusses trends in scholarship on health disparities, noting the precipitous increase in academic journal article publications on the topic, including the publication of journals specifically focused on publishing health disparities scholarship. Future directions for research are suggested, and recommendations for interventions to improve health disparities offered by the Principal Investigators of the 10 Centers for Population Health and Health Disparities are presented. Finally, an annotated list of primary sources (books, special issues of journals, reports) and a list of sources for further reading are offered to provide a starting point for beginning scholars to orient themselves to research in health disparities.
- Communication Studies
Broadly speaking, health disparities are differences in health outcomes between socially disadvantaged and advantaged groups. It is of interest to note that the term “health disparities” is most commonly used in the United States, whereas other countries tend to use the terms “health inequities” or “health inequalities” (Carter-Pokras & Baquet, 2002).
There are multiple definitions of health disparities available. The U.S. Centers for Disease Control and Prevention (CDC, 2011) presents a concise definition: “Health disparities are differences in health outcomes between groups that reflect social inequalities” (p. 1). The U.S. Department of Health and Human Services (USDHHS, 2008), in its Healthy People 2020 initiative, provides a more comprehensive definition:
A health disparity is 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.(p. 28)
A definition from Braveman (2006) highlights the role of policy and social advantage in potentially ameliorating health disparities:
A health disparity/inequality is a particular type of difference in health or in the most important influences on health that could potentially be shaped by policies; it is a difference in which disadvantaged social groups (such as the poor, racial/ethnic minorities, women, or other groups that have persistently experienced social disadvantage or discrimination) systematically experience worse health or greater health risks than more advantaged groups.(p. 180)
Central to all of these definitions is the idea that health disparities stem from disadvantage and, as such, they are unnecessary and avoidable and, therefore, unjust and unfair (Whitehead, 1992). Braveman (2014) emphasizes this point in her discussion of health disparities and health equity, noting that in this context, health disparities are not merely differences in health status; rather, they are differences stemming from inequity:
Health equity and health disparities are intertwined. Health equity means social justice in health (i.e., no one is denied the possibility to be healthy for belonging to a group that has historically been economically/socially disadvantaged). Health disparities are the metric we use to measure progress toward achieving health equity. A reduction in health disparities (in absolute and relative terms) is evidence that we are moving toward greater health equity. Moving toward greater equity is achieved by selectively improving the health of those who are economically/socially disadvantaged, not by a worsening of the health of those in advantaged groups.(p. 7)
Health disparities can be considered along several fronts, including populations of interest; incidence and prevalence of morbidity and mortality; determinants of health; health literacy and health information seeking; media influences on health disparities; and efforts to reduce health disparities, including government/foundation efforts and research-driven interventions. The following sections address each of these fronts.
Health disparities are a global issue, and many different groups of people are affected by them. Differences can be found according to socioeconomic status (income/education), race, ethnicity, sex or gender, sexual orientation, immigrant status, geography, and physical and mental disability. Of course, many of these factors tend to be correlated, both complicating and exacerbating the problem.
Socioeconomic status, as defined by income and education, may be the most important factor underlying health disparities. Simply put, poorer, less educated populations are less healthy than more affluent, educated populations. These results hold globally. In the United States, for example, a study investigating differences in mortality between 1960 and 1986 found disparities in death rates between low and high socioeconomic status groups; although the overall death rate fell over the two and a half decades in question, the disparities due to income and education actually increased (Pappas, Queen, Hadden, & Fisher, 1993). A study investigating socioeconomic inequalities in health in 22 European countries found that mortality rates were higher and self-assessments of health were lower for groups with lower socioeconomic status (Mackenbach et al., 2008). A meta-analysis of 29 studies from 10 Asian countries found that lower socioeconomic status as measured by income, education, and occupation was related to higher overall mortality and mortality due to cardiovascular disease and cancer (Vathesatogkit, Batty, & Woodward, 2014).
Of course, factors beyond socioeconomic status also come into play. For example, racial and ethnic minorities tend to be less healthy than their majority counterparts. In its latest comprehensive report on health disparities, the CDC considered a wide spectrum of health behaviors and outcomes ranging from environmental hazards and behavioral risk factors to various markers of morbidity and mortality. The report found disparities “between race and ethnic groups across all of the health topics examined” (CDC, 2013, p. 184). In terms of sex differences, women tend to fare better than men. The clearest indicator is in mortality rates, where women consistently live longer than men, and the difference holds internationally (Harvard Medical School, 2010). Additional examples of health disparities between groups by socioeconomic status, race/ethnicity, sex, and other factors will become apparent in the section on morbidity and mortality that follows.
Incidence and Prevalence of Morbidity and Mortality
Morbidity refers to illness and disease, whereas mortality refers to death. This section reviews a sample of meta-analytic studies that explore different aspects of disparities in morbidity and mortality. It reveals the extent to which disparities pervade all aspects of health, including physical health, mental health, and survival.
A meta-analysis of 35 studies of chronic kidney disease found that low socioeconomic status was associated with four indicators of kidney disease: low glomerular filtration rate (eGFR), high albuminuria, low eGFR/high albuminuria, and renal failure; results held regardless of the measure of socioeconomic status used (Vart, Gansevoort, Joosten, Bültmann, & Beijneveld, 2015). A meta-analysis of rheumatic heart disease that involved 37 populations found a relationship between level of social inequality and prevalence of the disease; prevalence increased with age, but there were no differences by sex (Rothenbühler et al., 2014). A meta-analysis of 64 studies of lung cancer incidence found that risk for the disease increased among people with lower socioeconomic status as evidenced by three different indicators: low education, low occupation status, and low income (Sidorchuk et al., 2009). A meta-analysis of 35 studies involving women in Australia, Canada, New Zealand, and the United States found that although there were no differences in risk of cervical dysplasia or carcinoma in situ between indigenous and nonindigenous populations, indigenous women had a “markedly higher” risk of invasive cervical cancer and related mortality (Vasilevska, Ross, Gesink, & Fisman, 2012); this finding parallels results from studies of women from lower and higher socioeconomic status in the United States, which find that poor women are more likely to be diagnosed with cervical cancer at later stages, thus putting them at greater risk for mortality. A meta-analysis of 155 studies that looked at the prevalence of dental caries found that lower socioeconomic status, as indicated by levels of education, occupation, or income, was associated with higher risk of having lesions or experience with dental caries; the relationship appeared to be stronger in more developed countries (Schwendicke et al., 2015). A meta-analysis of 20 studies of pediatric food allergy prevalence in the United States found that although prevalence of food allergy has increased overall, increases were greater among non-Hispanic Black children (Keet et al., 2014).
In shifting to aspects of mental health, a meta-analysis of 12 studies that considered migration, social mobility, and mental health found that migrants who experienced “downward social mobility” were more likely to experience mental disorders than those who either had no change in their socioeconomic status or experienced an increase in socioeconomic status (Das-Munshi, Leavey, Stansfeld, & Prince, 2012). A meta-analysis of 21 studies that looked at mental health among cancer patients found that U.S. Hispanics experienced worse distress, depression, social health-related quality of life, and overall health-related quality of life than non-Hispanic Whites (Luckett et al., 2011). Although these particular meta-analyses suggest that disadvantaged groups may suffer from worse mental health, it should be noted that on the whole Hispanics and non-Hispanic Blacks have a lower risk for mental illness than non-Hispanic Whites (Breslau et al., 2006; Mezuk et al., 2013), although their access to mental health care may be worse (McGuire & Miranda, 2008).
Meta-analyses also have found differences in disease survival by ethnicity and sex. Two studies that focused on non-small cell lung cancer provide clear examples. An analysis of survival outcomes of patients with advanced stage non-small cell lung cancer found that Asian patients fared consistently better than Caucasian patients in terms of overall survival rates, as well as across a number of indices of response to chemotherapy (Soo et al., 2011). Another meta-analysis of 39 studies of non-small cell lung cancer found greater survival rates among women than men (Nakamura et al., 2011).
There are several important points to keep in mind when considering differences in morbidity and mortality. One is the basis on which groups are being compared. Adler (2006) notes how different countries tend to use different categories to distinguish between advantaged and disadvantaged groups. For example, the United Kingdom tends to use occupation whereas the United States tends to use race/ethnicity. Another is the point of comparison or the reference group used in a study. In considering various definitions of health disparities, Carter-Pokras and Baquet (2002) observed three approaches: “(1) comparison with the non-minority or majority population … (2) comparison with the general population … and (3) differences among segments of the population” (p. 492). A third point is whether differences are being measured in absolute (rate difference) or relative (rate ratio) terms—terms that may lead to similar or different conclusions depending on the aspect of health being measured. A report from the Rockefeller Foundation and the Swedish International Development Cooperation Agency (2001, p. 4) recommends five steps to follow when assessing health disparities, quoted here:
Define which aspect(s) of health to measure
Identify the relevant population groupings across which to compare health status
Choose a reference group or “norm” against which to compare the health of different groups
Decide whether to measure inequality using absolute or relative differences in health status between population groups
Select among alternative “social weights” for preferences that are built into health measures
Determinants of Health
There are numerous theoretical models in the literature that explain the etiology of health disparities. These models can be categorized into socioenvironmental, psychosocial/behavioral, and biogenetic/physiological (LaVeist, 2005; see also Diez Roux, 2012 and Dressler, Oths, & Gravlee, 2005). Although a review of these theoretical models is beyond the scope of this entry, it is important to note that communication researchers should pay particular attention to those that highlight factors most amenable to communication interventions. Such factors would be those that (a) are related to the disparate health outcomes targeted for change, (b) are malleable, and (c) are potentially able to be improved by communication strategies such as tailored interventions or mass media campaigns.
Factors contributing to health disparities are many and multifaceted. In the literature, these factors are known as “determinants of health.” Healthy People 2020 (n.d.) identifies policymaking, health services, social factors (which include social and physical determinants), individual behavior, and biology and genetics as the major categorical determinants of health. The CDC (2013) offers a slightly different categorization, considering social determinants of health, environmental hazards, access to health care and preventive services, and behavioral risk factors.
Examples of all of these determinants are extensive. In terms of policy, requiring seatbelt use, restricting smoking areas, and increasing tax on alcoholic beverages all can have a positive impact on health. Health services involve access to and affordability of preventive services and medical treatment, which can be significant barriers for the disadvantaged. Social determinants vary widely, ranging from one’s social network and the associated norms and attitudes to socioeconomic conditions, including income and transportation. Physical determinants implicate the built environment, which can either facilitate or impede health promotion, and environmental hazards, such as poor air or water quality. Individual behavioral risk factors are numerous, involving such things as alcohol, tobacco, and other drug use and risky sexual behavior resulting in sexually transmitted infections and unplanned/early pregnancy. Although some biological or genetic disparities are (currently) unavoidable, such as differences due to aging or prevalence of certain diseases among certain groups (e.g., sickle cell anemia among Blacks), disadvantage can engender biological/genetic disparities that otherwise could have been avoided, such as mental retardation among lower income children exposed to lead in municipal water and cancers resulting from exposure to environmental toxins.
There is overlap among these factors, of course, and they are interrelated. The important point is that socially advantaged and disadvantaged groups have different levels of access and exposure to and experience with these determinants of health, and that is what leads to health disparities. The studies briefly reviewed next provide examples of the extent to which different groups have different experiences with the variety of determinants of health.
Danaei et al. (2010) studied the impact of four preventable risk factors (smoking, high blood pressure, high blood sugar, and body fat) on life expectancy across eight subgroups in the United States known as the “eight Americas” (Asians, below-median-income Whites living in the Northland, middle America, poor Whites living in Appalachia and the Mississippi Valley, Native Americans living on reservations in the West, Black middle-America, poor Blacks living in the rural South, and Blacks living in high-risk urban environments). The authors presented results not only by the eight subgroups but also by sex and age (30–59 years and 60+ years). On the whole, results showed that Whites had the lowest blood pressure and Southern rural Blacks had the highest blood pressure. Asians consistently had the lowest body fat (as measured by body mass index), blood sugar levels, and smoking rates. Highest body fat was found among Western Native American men and Southern rural Black women. Highest blood sugar levels were apparent in Western Native American men and younger women and older Southern rural Black women. Smoking rates were highest among younger poor White men in Appalachia and the Mississippi Valley, older Western Native American and high-risk urban Black men, and Western Native American women. If these risk factors were reduced to their “optimal levels,” life expectancy would increase on the whole by approximately 4.9 years in men and 4.1 years in women. The greatest gains would be seen among Southern rural Blacks (6.7 years for men and 5.7 years for women).
Moving beyond an exclusive focus on the United States, Fleischer, Diez Roux, and Hubbard (2012) considered body mass index and smoking behavior across 70 countries using data from the 2002–2003 World Health Surveys, looking for instances of disparities by urbanicity and education. Results of their meta-analysis found that in the least urban countries, higher levels of education were associated with higher levels of body mass index but in the most urban countries, higher levels of education were associated with lower levels of body mass index. In terms of smoking, lower levels of education were associated with higher levels of smoking among men regardless of level of country urbanicity and among women in least urban countries; higher levels of education were associated with higher levels of smoking among women in the most urban countries.
Infectious disease is of great concern worldwide. The extent to which infectious disease spreads at different rates among different groups is of interest, as is whether there are differences in vaccination rates by population groups. As might be expected, there are health disparities in both cases. For example, the Ethnic Minority Meta-Analysis (EMMA) project, an international study designed to explore racial/ethnic differences in HIV infection among injection drug users, found that ethnic minorities who inject drugs were slightly more than twice as likely to be infected with HIV as ethnic majority injection drug users (Des Jarlais et al., 2012). Among women, most cases of cervical cancer can be prevented by the Human Papillomavirus (HPV) vaccine. In a meta-analysis of 29 studies looking at HPV vaccine uptake among young adolescent women, results showed that young Black women were less likely than young White women to be vaccinated and that young women in the United States who did not have health insurance were less likely to be vaccinated than young women with health insurance (Fisher, Trotter, Audrey, MacDonald-Wallis, & Hickman, 2013).
Health Literacy and Health Information Seeking
In recent years, interest in health literacy has burgeoned. Health literacy is defined as “the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (USDHHS, 2012). People with low health literacy may not understand information they receive from their health care providers or from media sources, so the question of whether or not health literacy is related to health disparities is of interest. A systematic review of the literature by Mantwill, Monestel-Umaña, and Schultz (2015) asked precisely this question. The authors included 36 studies in their review, 31 of which were conducted in the United States. They found that most studies that investigated the relationship between health literacy and health disparities focused on racial/ethnic disparities. Health outcomes included self-reported health status, cancer-related outcomes, medication adherence and management, disease control, preventive care, and end-of-life decisions. Findings were not very revealing and seemed to be limited by individual study-level methodological issues, such as choice of health literacy measure and inadequately described health disparity outcome. The authors conclude that “the evidence on the role of health literacy on disparities in still mixed and, for most outcomes, very limited” (p. 16).
The Health Information National Trends Survey (HINTS) conducted by the National Cancer Institute’s Division of Cancer Control and Population Sciences surveys a nationally representative sample of Americans to assess how they seek information about cancer. Increased access to information can improve understanding, decision making, and health outcomes, so determining the extent to which there are health disparities in information seeking is important. HINTS provides an extremely useful source of data to explore such questions. Two studies provide examples of the kinds of analyses possible.
Using the 2005 HINTS data, Zhao (2010) explored differences in cancer information seeking between U.S. and foreign-born populations. He found differences between the groups on the whole and between U.S. Hispanics and foreign-born Hispanics. In particular, foreign-born respondents were less likely to have other people seek cancer information for them, had lower self-efficacy for seeking information, were more likely to think seeking information took a lot of effort and to feel frustrated, thought information was harder to understand, were less likely to trust information from newspaper and magazines, and were more likely to hold negative cancer-related beliefs such as “everything causes cancer” and people cannot lower their cancer risk. Comparing Hispanics only, Zhao found that foreign-born respondents were less likely to seek information for themselves and less likely to trust information from their doctor or the Internet; most of the differences found for the groups on the whole also held for the Hispanic subgroups.
Using the 2007 HINTS data, Kontos, Emmons, Puleo, and Viswanath (2012) explored the relationship between Internet use and knowledge about HPV and the HPV vaccine. They found that respondents who did not use the Internet had less awareness of the HPV vaccine and were less likely to know that HPV causes cervical cancer. Parsing the respondents into “general health information seekers” and “cancer information seekers” revealed interesting subtleties. Among the general health information seekers, respondents who did not use the Internet had less awareness of the HPV vaccine, were less likely to know that HPV causes cervical cancer, and were less likely to know that HPV was sexually transmitted; among cancer information seekers, however, no differences emerged between those who used the Internet and those who did not.
Media Influences on Health Disparities
Broadly speaking, the media can have an influence on health disparities in two ways. First, different groups can have access or be exposed to different kinds of health information, which may either exacerbate or potentially ameliorate disparities depending on the nature of the coverage. Second, the way the issue of health disparities is depicted in the media may have impact on public support for initiatives to reduce health disparities.
Coverage of Health Information
A clear example of the differences in health information covered by ethnic- versus general-audience media comes from Cohen et al. (2008), who studied differences in cancer coverage in newspapers targeted to Black audiences and newspapers meant for a general audience. The analysis compared health news stories from 23 weekly Black newspapers to stories from a sample of 12 daily general audience newspapers and considered the extent to which there were differences in cancer coverage, reporting of types of cancer, reporting of disparities, inclusion of local information, and inclusion of “personally mobilizing” information. Results showed that Black newspapers were more likely to feature cancer stories and that those cancer stories were more likely to include disparity information, local information, and personal mobilization information. The authors observe that their findings “confirm research suggesting that Black newspapers tailor their newswriting to give readers more personally relevant and local information” (p. 433), which may prove beneficial in promoting cancer prevention.
Coverage of Health Disparities
The way the media cover the issue of health disparities can have an impact on public response to the issue. In a comprehensive review article, Niederdeppe, Bigman, Gonzales, and Gollust (2013) pursued four objectives: “(a) identify key outcomes and audiences for communication about health disparities; (b) describe what is known about public awareness of health disparities; (c) review selected research on the content of communication about health disparities in the mass media, the effects of that communication, and opportunities for use of mass media technology in communication about health disparities; and (d) identify priorities for future research to understand how communication about health disparities can shape concern and action to reduce health disparities” (pp. 8–9). The authors drew several important conclusions from their review. First, American audiences have very little awareness of health disparities, do not think the issue is very important, and tend to put responsibility for health at the individual level rather than the social level (as in social determinants of health). Second, coverage of health disparities in the news is very limited and tends to focus on disparities among African Americans. Third, there are several different strategies for communicating about health disparities (comparing different social groups, emphasizing specific groups, framing the causes of disparities, using narratives) and each has, not surprisingly, different outcomes. Fourth, there is potential in digital media to disseminate information about health disparities.
Efforts to Reduce Health Disparities
As is easily imagined, there are concerted efforts being made on many fronts to reduce health disparities. Examples will be reviewed below. First, though, it is important to ask whether such efforts have any chance at improving health disparities. Providing a brief highlight of the literature, Harrington (2013) showed the answer is yes:
Koh et al. (2010) reviewed several programs across local, national, and global levels that have been enacted to reduce health disparities and found considerable evidence of positive impact. Examples include reductions in cardiovascular disease and cancer in disadvantaged groups in England and reductions in maternal and child deaths in Ecuador. Buckner-Brown et al. (2011) reviewed a sample of CDC’s Racial and Ethnic Approaches to Community Health programs (CDC, 2012) and identified an array of promising programs designed to address a host of disparities, including asthma, cancer, diabetes, and hepatitis. The authors emphasized the importance of partnerships with governments, businesses, and organizations to help disseminate research-based interventions.(p. 3)
Harrington (2013) also highlighted the importance of the work of communication scholars in these efforts:
Communication scholars have a clear role to play in many of the efforts to reduce health disparities. Freimuth and Quinn (2004) discussed how health communication researchers have expertise in mass media campaigns, entertainment-education programs, media advocacy efforts, new technology initiatives, and interpersonal level interventions such as patient-provider communication training, all of which can be brought to bear on the development, testing, and implementation of strategies to reduce disparities. Although there is the possibility that attempts to reduce disparities may actually exacerbate them if interventions are not disseminated and implemented equitably (Koh et al., 2010; Viswanath & Kreuter, 2007), as Perloff (2006, p. 757) observed, bridging the literatures in health communication and health disparities promises to offer “new ideas, syntheses, and applications that may improve the quality of health care.”(p. 3)
With this promise in place, this section provides a brief review of some of the government and foundation level efforts, as well as research-driven interventions, designed to ameliorate health disparities.
Government and Foundation Efforts
In the United States, there are federal agencies tasked with the goal of reducing health disparities. (State- and local-level agencies have similar charges, but a review of these is beyond the scope of this essay.) The National Institutes of Health includes the National Institute on Minority Health and Health Disparities (NIMHD), which was elevated from Institute to Center status in 2010. According to its vision statement, “NIMHD envisions an America in which all populations will have an equal opportunity to live long, healthy and productive lives,” and its mission is “to lead scientific research to improve minority health and reduce health disparities” (NIMDH, n.d.). The Centers for Disease Control and Prevention house an Office of Minority Health & Health Equity (OMHHE). OMHEE envisions “A world where all people have the opportunity to attain the best health possible,” and its mission is to “Advance health equity and women’s health issues across the nation through CDC’s science and programs, and increase CDC’s capacity to leverage its diverse workforce and engage stakeholders toward this end” (OMHHE, n.d.).
Select agencies within the National Institutes of Health also support what are called Centers for Population Health and Health Disparities (CPHHDs). This is a program that was started in 2003 with the support of the National Cancer Institute, the National Institute of Environmental Health Sciences, the National Institute on Aging, and the Office of Behavioral and Social Sciences Research and continued in 2009 by the National Cancer Institute; the National Heart, Lung, and Blood Institute; and the Office of Behavioral and Social Sciences Research. Currently, there are 10 of these centers in the United States. Their objectives are “to develop and test multilevel interventions to reduce health disparities, to use community-based participatory research (CBPR) principles, to train a new generation of transdisciplinary researchers in collaborative team science, and to promote translation and broad dissemination of evidence-based strategies into practice and policy” (Cooper et al., 2015, p. S374).
The Robert Wood Johnson Foundation (RWJF), a philanthropy established in 1972, is the largest such organization in the United States whose work is focused entirely on health. Its mission statement is simply put: “to improve the health and health care of all Americans” (RWJF, n.d.). RWJF focus areas are child and family well-being, health coverage, health leadership and workforce, health system improvement, healthy weight, and health communities. One of its newest initiatives, Building a Culture of Health, is designed to promote and establish a culture change in the United States that makes health a priority for all (RWJF, 2014).
As established in the section on the discussion of the literature below, which revealed a staggering 13,800 academic journal articles published on “health disparities” between 2010 and 2015, research efforts to identify, describe, and reduce health disparities are robust. Below is a sample of meta-analytic studies of interventions designed to reduce a variety of health disparities.
In a meta-analysis of 32 studies designed to determine the effectiveness of smoking cessation interventions among disadvantaged groups, Bryant, Bonevski, Paul, McElduff, and Attia (2011) found evidence of short-term effects for interventions for low income women and long-term follow-up effects among persons with mental illness. The authors’ main conclusions, though, focused on the methodological limitations of the studies, which led to inconsistent findings. Nam, Janson, Stotts, Chesla, and Kroon (2012) conducted a meta-analysis of 12 studies investigating the impact of culturally tailored diabetes education for ethnic minorities. Results showed a positive impact of such interventions compared to usual care, with women who received culturally tailored education showing improvement in their glycemic control. In a meta-analysis of 23 studies involving interventions to encourage ethnic minority women to obtain mammograms, Han et al. (2009) determined that such interventions were effective. Interventions that enhanced access to mammography services had the largest effect; tailored interventions had a larger effect than non-tailored interventions; ethnically matched interventions and culturally matched intervention materials also had positive effects. Durand et al. (2014) investigated whether interventions to promote shared decision making, a core aspect of patient-centered care, could reduce health disparities. Their meta-analysis of 10 studies revealed a positive effect of shared decision making across a variety of outcome variables including patient anxiety, knowledge, satisfaction, and several communication skills (e.g., question asking).
Discussion of the Literature
Trends in Publication
Academic interest in health disparities has increased precipitously in recent years. The issue of health disparities, as such, seems to have been first brought to the attention of the contemporary academic community in 1965 in a New England Journal of Medicine article, in which the authors described a process for identifying and defining “high-risk groups” in need of health services, in this case women and children in need of maternal and child health services in Buffalo, New York (Anderson, Jenss, Mosher, Randall, & Marra, 1965). More than 10 years passed before the issue was raised again, this time in an editorial appearing in the Journal of the American Medical Association lamenting the “ever-present” impact of racism as a barrier to health (Cornely, 1976). It seems to have taken until the turn of the century before academic health researchers began paying serious attention to issues of health disparities. A literature search of five major databases (MEDLINE, PsycINFO, CINAHL, Psychology and Behavioral Sciences Collection, Academic Search Complete) using “health disparities” as a subject term revealed 19 academic journal articles published between 1965 and 2000, 214 published between 2001 and 2005, 5,828 between 2006 and 2010, and 13,800 between 2010 and 2015. Although this is a very cursory review of the literature using only the macro subject term “health disparities” in five databases, the point remains the same: In recent years, academic interest in health disparities has exploded.
This explosion of interest, however, should be considered with more history in mind. Harvard social epidemiologist Nancy Krieger (2001) wrote a letter to the editor of the International Journal of Epidemiology noting how toward the end of the 20th century, researchers were publishing papers that reported “seemingly new observations” regarding the relationship between socioeconomic status and health status. Krieger argued, however, that such relationships had been revealed long ago, citing studies by Louis René Villérmé in 1826 and Friedrich Engels in 1844 that linked mortality to poverty. She offered the following caution to anyone concerned with alleviating health disparities:
We do a disservice to the weight of evidence, past and present, on social inequalities in health if we suggest that what chiefly hampers efforts to promote social equity in health is a lack of knowledge, whether of the social patterning of health, or trends, or pathways. Better instead to delineate explicitly persisting and changing structural and political determinants of these persisting—and changing—inequalities, including who deliberately or inadvertently benefits from these inequalities, so as to inform efforts to secure social equity in health.(pp. 889–900)
Journals on Health Disparities
Hundreds of academic journals publish research related to health disparities; however, some have a primary focus on the topic. The list below includes four such journals along with their stated scope.
Ethnicity & Health: “Ethnicity & Health is an international academic journal designed to meet the world-wide interest in the health of ethnic groups. It embraces original papers from the full range of disciplines concerned with investigating the relationship between ‘ethnicity’ and ‘health’ (including medicine and nursing, public health, epidemiology, social sciences, population sciences, and statistics). The journal also covers issues of culture, religion, gender, class, migration, lifestyle and racism, in so far as they relate to health and its anthropological and social aspects.” (http://www.tandfonline.com/action/journalInformation?show=aimsScope&journalCode=ceth20)
Journal of Health Disparities Research and Practice: “The Journal of Health Disparities Research and Practice is a refereed online journal that explores the dimensions of health disparities globally. The Journal invites submission of original manuscripts from researchers, public health, behavioral health, clinical and social science experts and practitioner that seek to continue the discussion of health disparities in order to eradicate them.” (http://digitalscholarship.unlv.edu/jhdrp/)
Journal of Immigrant and Minority Health: “The Journal of Immigrant and Minority Health is an international forum for the publication of peer-reviewed original research pertaining to immigrant health. The contributors are expert in diverse fields including public health, epidemiology, medicine and nursing, anthropology, sociology, population research, immigration law, and ethics. The journal also publishes review articles, short communications, letters to the editor, and notes from the field.” (http://link.springer.com/journal/10903)
Journal of Racial and Ethnic Health Disparities: “Journal of Racial and Ethnic Health Disparities aims to report on the scholarly progress of work to understand, address, and ultimately eliminate health disparities based on race and ethnicity. Efforts to explore underlying causes of health disparities and to describe interventions that have been undertaken to address racial and ethnic health disparities are featured. Promising studies that are ongoing or studies that have longer term data are welcome, as are studies that serve as lessons for best practices in eliminating health disparities. Original articles, solicited ‘evolutionary’ reviews presenting the state-of-the-art thinking on problems centered on health disparities, and unsolicited review articles of timely interest will be considered for publication.” (http://www.springer.com/medicine/journal/40615; Note: This journal is identified as the “First journal dedicated to examining and eliminating racial and ethnic health disparities.”)
Future Research and Practice
Future research and practice in health disparities is ripe with opportunity. Broadly speaking, it is important to develop and test theoretical models that will better inform our understanding of the etiology of health disparities so that we can design and implement more effective interventions to reduce them. In doing so, communication researchers must keep communication theory in mind and focus on those etiological factors that would respond to a communication intervention. Related, there are opportunities to advance our knowledge of the effects of tailored interventions and technology-based interventions to reduce health disparities. Methodological advances in identifying, defining, and measuring health disparities are needed to enhance the quality of our research. Researchers also must do a better job in recruiting and retaining racial and ethnic minorities in health and intervention research (Nagler, Ramanadhan, Minsky, & Viswanath, 2013; Rogers & Lange, 2013). In short, more and better research is needed if we are to advance our knowledge and build a cumulative science of health disparities.
The Principal Investigators of the CPHHDs wrote an editorial for the American Journal of Public Health in which they presented their “bold new vision” for health disparities intervention research. They offered seven recommendations, quoted here:
Reframe the discussion about health disparities and inequities.
Design and evaluate rigorous multilevel interventions to change both individual behavior and the social, policy, and built environments; assess multidirectional influences of interventions.
Use a social determinants of health framework for health disparities interventions and a “health for all policies” approach to policy interventions targeting socioeconomic advantage.
Improve communication skills and cultural competency of health professionals, researchers, interventionists, and community stakeholders.
Expand efforts to dismantle historical and contemporary drivers of stigmatization and discrimination of persons who are members of disparate populations.
Prioritize community engagement and equitably shared community and researcher power to maximize intervention success and sustainability.
Foster transdisciplinary collaborations that integrate evidence from basic biomedical science with social, behavioral, and population science methodologies in intervention design and outcomes assessment. (Cooper et al., 2015, p. S375)
The following books and special journal issues address the topic of health disparities:
- Barr, D. A. (2014). Health disparities in the United States: Social class, race, ethnicity, and health (2d ed.). Baltimore: Johns Hopkins University Press. This book, consisting of 11 chapters, provides an excellent overview of health disparities in the United States. It includes chapters on defining and measuring health, understanding the relationship between social status and health, and approaches to reducing health disparities.
- Dorling, D. (2013). Unequal health: The scandal of our times. London: The Policy Press. This comprehensive book focuses on health disparities in London, England. It is composed of 48 chapters divided into seven sections addressing topics including a historical review of health disparities since 1817, the National Health Service and social policy, medicine and politics, and aging populations.
- Gwatkin, D. R., Rutstein, S., Johnson, K., Suliman, E., Wagstaff, A., & Amouzou, A. (2007). Socio-economic differences in health, nutrition, and population within developing countries: An overview. Washington, DC: The World Bank. This book, which is available free of cost from the Health, Nutrition, and Population Advisory Service of the World Bank’s Human Development Network (email@example.com) or online as a PDF, presents socioeconomic differences across numerous health, nutrition, and population indicators from 56 countries. Included is information on child illness and mortality, nutritional status, sexually transmitted disease, tobacco and alcohol use, domestic violence, education, and exposure to mass media, among several other topics of interest.
- Marmot, M., & Wilkinson, R. G. (Eds.). (2006). Social determinants of health (2d ed.). Oxford: Oxford University Press. This book explores the role of socioeconomic factors as determinants of health. Its 16 chapters cover issues ranging from early life and the life course to employment and the work environment to ethnic and racial inequalities. The book is noted for its accessibility to students and those without a background in epidemiology.
Special Journal Issues
- Harrington, N. G. (Ed.). (2015). Special issue: Communication strategies to reduce health disparities. Journal of Communication, 63(1), 1–220. This special issue offers 10 original articles addressing a variety of approaches to using communication strategies to reduce health disparities, including individual, patient-provider, and community-level interventions.
- Perloff, R. M. (2006). Introduction: Communication and health care disparities. American Behavioral Scientist, 49(6), 755–884. This special issue presents eight original articles focused on the contributions that the communication discipline can make to reduce inequalities in health care.
The following reports should be of interest to anyone interested in health disparities:
Report of the Secretary’s Task Force on Black & Minority Health (The Heckler Report). This landmark report, commissioned in 1984 by Margaret M. Heckler, the Secretary of the U.S. Department of Health and Human Services, documents the factors that influence health disparities among Blacks, Hispanics, Asian/Pacific Islanders, and Native Americans, and it offers recommendations to reduce them through (a) health information and education, (b) health services, (c) health professions development, (d) cooperative efforts, (e) data development, and (f) a minority health-focused research agenda.
- Heckler, M. M., U.S. Department of Health and Human Services. (1985). Report of the secretary’s task force report on black and minority health volume I: Executive summary. Washington, DC: Government Printing Office.
Independent Inquiry into Inequalities in Health Report. This report investigates health disparities in the United Kingdom related to socioeconomic status, ethnic status, and sex; it also makes recommendations to address the social determinants of health underlying the disparities.
- Acheson, D. (1998). Independent inquiry into inequalities in health report. London: The Stationery Office.
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. This report issued by the Institute of Medicine documents the extent of U.S. health disparities and the factors that contribute to them; it also recommends strategies to reduce health disparities.
- Institute of Medicine. (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: The National Academies Press.
Fair Society, Healthy Lives. This report is the result of an independent review commissioned by England’s Secretary of State for Health to identify evidence-based strategies to reduce health inequalities in the country. Representing the work of the “Strategic Review of Health Inequalities in England post-2010” committee, it documents the nature and extent of health disparities in England and offers recommendations to redress them.
- Marmot, M. (2010). Fair society, healthy lives. London: The Marmot Review. Available at http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review.
Health21: An Introduction to the Health for All Policy Framework for the WHO European Region. This report reviews the “Health for All” policy adopted by member states of the World Health Organization’s European Region at the 51st World Health Assembly in May 1998. The policy provides guidance to countries on how to develop national health policies and adopt strategies to reduce health disparities within and across their borders.
- World Health Organization. (1998). Health21: An introduction to the health for all policy framework for the WHO European region. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0004/109759/EHFA5-E.pdf.
Periodic reports from the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC) provide information on health disparities in the United States:
- AHRQ. (2015, May). 2014 national healthcare quality and disparities report. Rockville, MD: Agency for Healthcare Research and Quality. AHRQ Pub. No. 15-0007.
- CDC: Centers for Disease Control and Prevention. (2013). CDC health disparities and inequalities report—United States, 2013. MMWR, 62(Suppl. 3), 1–186.
- Adler, N. A., & Prather, A. A. (2015, July). Determinants of health and longevity. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from http://www.ahrq.gov/professionals/education/curriculum-tools/population-health/adler.html.
- Braveman, P. (2006). Health disparities and health equity: Concepts and measurement. Annual Review of Public Health, 27, 167–194.
- Carter-Pokras, O., & Baquet, C. (2002). What is a “health disparity”? Public Health Reports, 117, 426–434.
- Casas-Zamora, J. A., & Ibrahim, S. A. (2004). Confronting health inequity: The global dimension. American Journal of Public Health, 94(12), 2055–2058.
- Cooper, L. A., Ortega, A. N., Ammerman, A. S., Buchwald, D., Paskett, E. D., Powell, L. H., et al. (2015). Calling for a bold new vision of health disparities intervention research. American Journal of Public Health, 105(S3), S374–S376.
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- McGinnis, J. M., & Foege, W. H. (1993). Actual causes of death in the United States. Journal of the American Medical Association, 270(18), 2207–2212.
- Viswanath, K., & Kreuter, M. W. (2007). Health disparities, communication inequalities, and ehealth. American Journal of Preventive Medicine, 32, S131–133.
- Whitehead, M. (1992). The concepts and principles of equity in health. International Journal of Health Services, 22, 429–445.
- Williams, D. R., Costa, M. V., Odunlami, A. O., & Mohammed, S. A. (2008). Moving upstream: How interventions that address the social determinants of health can improve health and reduce disparities. Journal of Public Health Management Practice, 14(Suppl. 8), S8–S17.
- Adler, N. (2006). Overview of health disparities. In G. E. Thompson, F. Mitchell, & M. B. Williams (Eds.), Examining the health disparities research plan of the National Institutes of Health: Unfinished business (pp. 121–174). Washington, DC: The National Academies Press.
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- Braveman, P. (2014). What are health disparities and health equity? We need to be clear. Public Health Reports, 129(Suppl. 2), 5–8.
- Breslau, J., Aguilar-Gaxiola, S., Kendler, K. S., Su, M., Williams, D., & Kessler, R. C. (2006). Specifying race-ethnic differences in risk for psychiatric disorders in a US national sample. Psychological Medicine, 36(1), 57–68.
- Bryant, J., Bonevski, B., Paul, C., McElduff, P., & Attia, J. (2011). A systematic review and meta-analysis of the effectiveness of behavioural smoking cessation interventions in selected disadvantaged groups. Addiction, 106, 1568–1585.
- Buckner-Brown, J., Tucker, P., Rivera, M., Cosgrove, S., Coleman, J. L., Penson, A., et al. (2011). Racial and ethnic approaches to community health: Reducing health disparities by addressing social determinants of health. Family and Community Health, 34(1S), S12–S22.
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- Centers for Disease Control and Prevention. (2011). CDC health disparities and inequalities report: United States, 2011. Morbidity and Mortality Weekly Report, 60(Suppl.), 1–113.
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- Centers for Disease Control and Prevention. (2013). CDC health disparities and inequalities report—United States, 2013. Morbidity and Mortality Weekly Report, 62(Suppl. 3), 1–186.
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- Cooper, L. A., Ortega, A. N., Ammerman, A. S., Buchwald, D., Paskett, E. D., Powell, L. H., et al. (2015). Calling for a bold new vision of health disparities intervention research. American Journal of Public Health, 105(S3), S374–S376.
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- Diez Roux, A. V. (2012). Conceptual approaches to the study of health disparities. Annual Review of Public Health, 33, 41–58.
- Dressler, W. M., Oths, K. S., & Gravlee, C. C. (2005). Race and ethnicity in public health research: Models to explain health disparities. The Annual Review of Anthropology, 34, 231–252.
- Durand, M.-A., Carpenter, L., Dolan, H., Bravo, P., Mann, M., Bunn, F., et al. (2014). Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis. PLOS One, 9(4), e94670.
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- Neighborhood Considerations for Social Determinants of Health and Risk
- Culture, a Social Determinant of Health and Risk: Considerations for Health and Risk Messaging
- Statistical Evidence in Health and Risk Messaging
- Knowledge and Comprehension
- Government-Driven Incentives to Improve Health
- Public Health and Community Organizing as Agents for Change in Health and Risk Messaging
- Ethical Issues and Considerations in Health and Risk Message Design
- Communications Research in Using Genomics for Health Promotion