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Article

Education is strongly associated with better health and longer lives. However, the extent to which education causes health and longevity is widely debated. We develop a human capital framework to structure the interpretation of the empirical evidence and review evidence on the causal effects of education on mortality and its two most common preventable causes: smoking and obesity. We focus attention on evidence from randomized controlled trials, twin studies, and quasi-experiments. There is no convincing evidence of an effect of education on obesity, and the effects on smoking are only apparent when schooling reforms affect individuals’ track or their peer group, but not when they simply increase the duration of schooling. An effect of education on mortality exists in some contexts but not in others and seems to depend on (i) gender, (ii) the labor market returns to education, (iii) the quality of education, and (iv) whether education affects the quality of individuals’ peers.

Article

Paula S. Nurius and Charles P. Hoy-Ellis

Evolving understandings of stress have literally transformed how we think about health as contextualized within complex and multilevel transactions between individuals and their environment. We present core concepts of stress through the lens of life-course and life-span perspectives, emphasizing appraisal-based and biobehavioral models of stress response systems. We describe theories of allostatic load, embodiment, epigenetics, weathering processes, and accelerated aging that operationalize mechanisms through which stress affects health and contributes to health disparities. In addition to social determinant and life-span developmental perspectives on stress and health, we emphasize the value of health-promotive factors that can serve to buffer stress effects. Social work has important roles in targeting health-erosive stress from “neurons to neighborhoods”.

Article

Valire Carr Copeland and Sandra Wexler

Despite technological advances and changes in healthcare delivery, some groups in the United States continue to have better health-related outcomes than others. This article discusses health disparities—differences in health status and healthcare utilization that are influenced by complex social structural, economic, and cultural factors. Illustrations are offered of health disparities found among diverse populations in this country. The “problem” with health disparities is then explored. From an ethical standpoint, health disparities can be seen as unjust. From a cost perspective, health disparities exact not just a financial toll that is borne by society, but individual, group, and community consequences, as well. From a human rights vantage, health disparities can further disadvantage people who are already vulnerable and marginalized—health disparities can cost people their lives. Factors contributing to health disparities, commonly referred to as social determinants, are reviewed. Finally, future directions, including social workers’ role as advocates, are considered.

Article

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.

Article

Daniel S. Gardner and Caroline Rosenthal Gelman

Minority and immigrant elders constitute a greater proportion of the population than ever before and are the fastest growing segment of the older population. Within these racial and ethnic groups there is considerable variation with regard to age, gender, country of origin, language, religion, education, income, duration of U.S. residency, immigration status, living arrangements, social capital, and access to resources. The authors summarize research on older adults regarding racial and ethnic disparities, barriers to health and social service utilization, and dynamics of family caregiving. Implications are offered for social-work practice, policy, and research.

Article

Grace Christ

The ability of medical technology to prolong life over the past century has forced an examination of the experience and care of the dying. Many diseases that once were expected to follow a sloping illness trajectory with predictable deterioration and ultimately death are now more commonly experienced as chronic illnesses. They require more medical and other resources and challenge the family's ability to cope for much longer periods. The knowledge, value, and skill base of social work, and its broad range of practice sites make it uniquely suited to contribute to the movement to improve the care of the dying. The Social Work Hospice and Palliative Care Network were formed in 2007 to advance and give voice to social work's expertise in this area and to promote its development in practice, education, research, and policy.

Article

There are an estimated 300 million indigenous peoples worldwide. Although there is ample evidence of worse health and social outcomes for the majority of indigenous peoples, compared to their non-indigenous counterparts, there has yet to be a review of racism as a determinant of indigenous health using global literature. Racism constitutes unfair and avoidable disparities in power, resources, capacities, or opportunities centered on ethnic, racial, religious, or cultural differences that can occur at three levels: internalized, interpersonal, or systemic. For indigenous peoples this is closely related to ongoing processes of colonization. Available research suggests that at least a third of indigenous adults experience racism at least once during their lives and that about a fifth of indigenous children experience racism. For indigenous peoples, racism has been associated with a considerable range of health outcomes, including psychological distress, anxiety, depression, suicide, posttraumatic stress disorder, asthma, physical illness, obesity, cardiovascular disease, increased blood pressure, excess body fat, poor sleep, reduced general physical and mental health, and poor oral health, as well as increased alcohol, tobacco, and marijuana use and underutilization of medical and mental healthcare services. Disparities in medical care experienced by indigenous patients compared to non-indigenous patients have also been found. Existing studies indicate that avoidant and passive coping tends to exacerbate the detrimental health impacts of racism for indigenous peoples, whereas active coping ameliorates the ill-health effects of racism. Reducing individual and interpersonal racism can be achieved by (a) providing accurate information and improving awareness of the nature of racism and racial bias; (b) activating values of fairness, reconciling incompatible beliefs, and developing antiracist motivation; (c) fostering empathy and perspective-taking and confidence in regulating emotional responses; (d) improving comfort with other groups and reducing anxiety; and (e) reinforcing antiracist social norms and highlighting personal accountability. There are five key areas for combating systemic racism in organizations and institutions: (a) institutional accountability; (b) diversity in human resources; (c) community partnership; (d) antiracism and cultural competence training; and (e) research and evaluation.

Article

Michele Rountree and Courtney McElhaney Peebles

Communities of color are disproportionately burdened by the prevalence of HIV/AIDS. Research has shown that race and ethnicity in the United States are population characteristics that correlate with other fundamental determinants of health outcomes. This entry will chronicle the history of the epidemic, report the disparate impact of the disease affecting communities of color, and acknowledge the social determinants of health that contribute to the vulnerability of risk. A call to address the imbalance of health inequities, with a complement of individual-level interventions and new approaches that address the interpersonal, network, community, and societal influences of disease transmission, is discussed.

Article

Sub-Saharan Africa has the world largest proportion of adults and children living with AIDS. To mitigate the multiple consequences of the epidemic, novel forms of governance arose as international organizations usurped the roles traditionally played by states; new funding streams emerged that led to asymmetries in biomedical resource allocation; and diverse partnerships among international agencies, nation-states, and local and international nongovernmental organizations emerged. Global health actors attempted to define AIDS policy and programming as an apolitical biomedical intervention. However, political dynamics were evident in the negotiations between international donors and African state bureaucracies in setting AIDS policy agendas and the contestations between African and international social movements and global health agencies over AIDS treatment drug prices and access to treatment interventions across the continent. During the first two decades of the African AIDS epidemic (1980–2005) the dominant approach to AIDS disease mitigation was the focus on AIDS prevention, and across sub-Saharan Africa standardized prevention interventions were introduced. These interventions were founded upon limited evidence and ultimately these programs failed to stem rates of new HIV infections. Social movements comprising coalitions of local and international activists and scientists brought extensive pressure on global health institutions and nation-states to reform their approach to AIDS and introduce antiretroviral therapy. Yet the path toward universal provision of antiretroviral treatment has been slow and politically contentious. By the second decade of the 21st century, antiretroviral therapy interventions together with AIDS prevention became the dominant policy approach. The introduction of these initiatives led to a significant decline in AIDS-related mortality and slowed rates of transmission. However, health disparities in treatment access remain, highlighting ongoing shortcomings in the political strategies of global health agencies and the public health bureaucracies of African states.

Article

David S. Jones

Few developments in human history match the demographic consequences of the arrival of Europeans in the Americas. Between 1500 and 1900 the human populations of the Americas were traBnsformed. Countless American Indians died as Europeans established themselves, and imported Africans as slaves, in the Americas. Much of the mortality came from epidemics that swept through Indian country. The historical record is full of dramatic stories of smallpox, measles, influenza, and acute contagious diseases striking American Indian communities, causing untold suffering and facilitating European conquest. Some scholars have gone so far as to invoke the irresistible power of natural selection to explain what happened. They argue that the long isolation of Native Americans from other human populations left them uniquely susceptible to the Eurasian pathogens that accompanied European explorers and settlers; nothing could have been done to prevent the inevitable decimation of American Indians. The reality, however, is more complex. Scientists have not found convincing evidence that American Indians had a genetic susceptibility to infectious diseases. Meanwhile, it is clear that the conditions of life before and after colonization could have left Indians vulnerable to a host of diseases. Many American populations had been struggling to subsist, with declining populations, before Europeans arrived; the chaos, warfare, and demoralization that accompanied colonization made things worse. Seen from this perspective, the devastating mortality was not the result of the forces of evolution and natural selection but rather stemmed from social, economic, and political forces at work during encounter and colonization. Getting the story correct is essential. American Indians in the United States, and indigenous populations worldwide, still suffer dire health inequalities. Although smallpox is gone and many of the old infections are well controlled, new diseases have risen to prominence, especially heart disease, diabetes, cancer, substance abuse, and mental illness. The stories we tell about the history of epidemics in Indian country influence the policies we pursue to alleviate them today.

Article

Peter A. Newman

AIDS (acquired immunodeficiency syndrome) is the most deadly epidemic of modern times. Since HIV (human immunodeficiency virus), the virus that causes AIDS, was first identified in the United States in 1981, nearly 1 million Americans have been diagnosed with AIDS and 530,756 have died. Forty million people are living with HIV worldwide. Although AIDS is still a fatal disease, new drug therapies have greatly slowed the course of disease progression and enhanced quality of life for persons living with HIV. Nevertheless, monumental disparities persist within the United States and between the developed and developing worlds in this two-tiered epidemic.

Article

Mary E. Rogge

The concept of environmental justice gained currency in the public arena during the latter part of the 20th century. It embodies social work's person-in-environment perspective and dedication to people who are vulnerable, oppressed, and poor. The pursuit of environmental justice engages citizens in local to international struggles for economic resources, health, and well-being, and in struggles for political voice and the realization of civil and human rights.

Article

Serious inequalities in health abound the world over. For example, there are marked differences in average life expectancy both between and within countries. Individual life expectancy varies by more than 30 years between the highest national average and the lowest. Even worldwide, average life expectancy lags more than 10 years below the highest national average. Within single countries, inequalities in life expectancy between the top and bottom groups of men, for example, have been recorded at 7 years in England and Wales and at almost 15 years in the United States, albeit using rather differently constituted groups. Intuitively, these inequalities in health will strike many observers as unjust. But why are they unjust, if they are? Are inequalities in health unjust per se? If not, what makes some inequalities in health unjust, but not others? According to an influential analysis, inequalities in health are unjust when they are avoidable, unnecessary, and unfair. Thus, if an inequality in health is inevitable, it is not unjust. Following this analysis means that answering these questions requires a combination of empirical and normative understanding. On the empirical side, some understanding of the socially controllable causes of health is required. On the normative side, various dimensions of fairness have to be understood. In addition, some appreciation of the interaction between these two sides is needed.. Each side of the question is fairly complicated. With respect to the requirements of fairness, three subsidiary controversies can be distinguished. To begin with, should a general principle of equality be applied directly to the case of health? An alternative approach traces the injustice of avoidable inequalities in health to the independent injustice of their social causes instead. Next, should inequalities be defined across social groups (such as class or race within countries or, indeed, countries themselves)? If so, which groups? An alternative is to define inequalities across individuals. Finally, should equality be defined in comparative terms (as is traditional)? An alternative is to define the requirements of fairness non-comparatively (as a matter of “priority” to the worst off). Even if a given inequality in health is avoidable, some resolution of all three controversies is needed to decide whether that inequality is unfair.

Article

Building and sustaining relationships fundamentally requires mutual trust based on authentic and reciprocal communication. Successful academic and community partnerships require a deep understanding of the needs of all stakeholders facilitated through dialogue and ongoing communication strategies. This dialogue is especially crucial to address health disparities and bridge the divide between academics and other professionals and the communities they serve. Innovative and sound health communications and community engagement approaches can help to address this divide. For those working with communities to improve health, Community Based Participatory Research (CBPR) principles can serve as a compass to guide those efforts of building on the strengths and resources within the community and ensuring co-learning to address social inequities. Moreover, using innovative and interactive health communication strategies, such as community forums, photovoice projects, and the development of culturally sensitive and relevant messaging, can empower and engage the community, facilitating long-lasting relationships between the academic institutions and communities that ultimately address the unique concerns and values of those most in need.

Article

Colleen Galambos

This entry provides an overview of the state of health care in the United States. Service delivery problems such as access and affordability issues are examined, and health care disparities and the populations affected are identified. A discussion of two primary government-sponsored health care programs—Title XVIII (Medicare) and Title XIX (Medicaid), and the Patient Protection and Affordable Health Care Act—are reviewed along with various health care programs and major existing service delivery systems. Ethical conflicts in providing health care, and new directions and challenges are discussed, along with future roles for social workers.

Article

When it comes to health and risk, “place” matters. People who live in lower-income neighborhoods are disproportionately affected by obesity and obesity-related diseases like heart disease, hypertension, and diabetes; asthma; cancers; mental health issues; etc., compared to those that live in higher-income communities. Contributing to these disparities are individual-level factors (e.g., education level, health literacy, healthcare access) and neighborhood-level factors such as the socioeconomic characteristics of the neighborhood; crime, violence, and social disorder; the built environment; and the presence or absence of health-enhancing and health-compromising resources. Social determinants of health—for example, social support, social networks, and social capital—may improve or further complicate health outcomes in low-income neighborhoods. Social support is a type of transaction between two or more people intended to help the recipient in some fashion. For instance, a person can help provide someone who is grieving or dealing with a newly diagnosed health issue by providing emotional support. Informational support may be provided to someone trying to diagnose, manage, and/or treat a health problem. Instrumental support may come in the help of making meals for someone who is ill, running errands for them, or taking them to a doctor’s appointment. Unfortunately, those who may have chronic diseases and require a lot of support or who otherwise do not feel able to provide support may not seek it due to the expectation of reciprocity. Neighborhood features can enable or constrain people from developing social networks that can help provide social support when needed. There are different types of social networks: some can enhance health outcomes, while others may have a more limiting or even a detrimental effect on health. Social capital results in the creation of resources that may or may not improve health outcomes. Communication infrastructure theory offers an opportunity to create theoretically grounded health interventions that consider the social and neighborhood characteristics that influence health outcomes. The theory states that every neighborhood has a communication infrastructure that consists of a neighborhood storytelling network—which includes elements similar to the social determinants of health—embedded in a communication action context that enables or constrains neighborhood storytelling. People who are more engaged in their neighborhood storytelling networks are in a better position to reduce health disparities—for example, to fight to keep clinics open or to clean up environmental waste. The communication action context features are similar to the neighborhood characteristics that influence health outcomes. Communication infrastructure theory may be useful in interventions to address neighborhood health and risk.

Article

Lonnie R. Snowden

This entry describes the extent of the mental health problem in the United States, trends in treatment rates, and evidence that public recognition of mental illness and related interventions is increasing both in the United States and internationally. Emphasis is given to the structure of the mental health system's major sectors, to the key roles that social workers play, and to the challenges they face, outlined at the conclusion of several sections, in providing effective and quality care against the complex backdrop of this system.

Article

Wendy Auslander and Elizabeth Budd

The purpose of this article is to provide an overview of: diabetes and its significance, the differences in types of diabetes, and landmark clinical trials that have resulted in changes in philosophy and treatment of diabetes. Second, a review of the various types of evidence-based and promising behavioral interventions in the literature that have targeted children and adults are presented. Social workers and other helping professionals are uniquely positioned to work collaboratively to improve psychosocial functioning, disease management, and prevent or delay complications through behavioral interventions for children and adults with diabetes.

Article

Since the start of the human immunodeficiency virus (HIV) pandemic, numerous biomedical advances have caused the social-work response to shift from management of a crisis to prevention of an incurable, but treatable chronic disease. About 1.3 million people in the United States and more than 33 million people worldwide are estimated to be living with HIV. Rates of incidence in impoverished, marginalized communities are highest, with the rates continuing to increase among young African American gay and bisexual men. Other communities at high risk are people who are incarcerated, engage in sex work or other kinds of exchange sex, and participate in risky injection-drug use. Minority groups are often impacted because of reduced access to quality medical care and HIV testing. Social workers in HIV prevention work are challenged to educate clients and communities on the sexual risk continuum, provide more interventions that are culturally tailored for disadvantaged at-risk groups, and implement evidence-based HIV prevention and testing programs worldwide. The National HIV/AIDS Strategy now provides structure to funding opportunities for HIV prevention programs, and there is disparate access to effective treatments worldwide for those living with HIV.

Article

It is well documented that African American/Black and Hispanic individuals are underrepresented in biomedical research in the United States (U.S.), and leaders in the field have called for the proportional representation of varied populations in biomedical studies as a matter of social justice, economics, and science. Yet achieving appropriate representation is particularly challenging for health conditions that are highly stigmatized such as HIV/AIDS. African American/Black, and Hispanic individuals, referred to here as “people of color,” are greatly overrepresented among the 1.2 million persons living with HIV/AIDS in the United States. Despite this, people of color are substantially underrepresented in AIDS clinical trials. AIDS clinical trials are research studies to evaluate the safety and effectiveness of promising new treatments for HIV and AIDS and for the complications of HIV/AIDS, among human volunteers. As such, AIDS clinical trials are critical to the development of new medications and treatment regimens. The underrepresentation of people of color in AIDS clinical trials has been criticized on a number of levels. Of primary concern, underrepresentation may limit the generalizability of research findings to the populations most affected by HIV/AIDS. This has led to serious concerns about the precision of estimates of clinical efficacy and adverse effects of many treatments for HIV/AIDS among these populations. The reasons for the underrepresentation of people of color are complex and multifaceted. First, people of color experience serious emotional and attitudinal barriers to AIDS clinical trials such as fear and distrust of medical research. These experiences of fear and distrust are grounded largely in the well-known history of abuse of individuals of color by medical research institutions, and are complicated by current experiences of exclusion and discrimination in health care settings and the larger society, often referred to as structural racism or structural violence. In addition, people of color experience barriers to AIDS clinical trials at the level of social networks, such as social norms that do not support engagement in medical research and preferences for alternative therapies. People of color living with HIV/AIDS experience a number of structural barriers to clinical trials, such as difficulty accessing and navigating the trials system, which is often unfamiliar and daunting. Further, most health care providers are not well positioned to help people of color overcome these serious barriers to AIDS clinical trials in the context of a short medical appointment, and therefore are less likely to refer them to trials compared to their White peers. Last, some studies suggest that the trials’ inclusion and exclusion criteria exclude a greater proportion of people of color than White participants. Social/behavioral interventions that directly address the historical and contextual factors underlying the underrepresentation of people of color in AIDS clinical trials, build motivation and capability to access trials, and offer repeated access to screening for trials, hold promise for eliminating this racial/ethnic disparity. Further, modifications to study inclusion criteria will be needed to increase the proportion of people of color who enroll in AIDS clinical trials.