Social Sources of Disparities in Health and Health Care and Linkages to Policy, Population Concerns and Providers of Care: Volume 27

This chapter provides an introduction to volume 27, Research in the Sociology of Health Care, Social Sources of Disparities in Health and Health Care and Linkages to Policy, Population Concerns and Providers of Care. It introduces the topic of social sources of disparities in health and health care and discusses the approach to this issue in the United States based on federal government efforts as well as based on research by medical sociologists, political scientists, epidemiologists and researchers in health care more generally, such as those in public health. This chapter serves as an introduction to the volume also. As such, the chapter explains the organization of the volume and briefly comments on each of the chapters included in the volume.

For nearly two decades, researchers across the disciplines of social science and medicine have grappled with how to conceptualize and measure race to better explain racial inequality. Improvements have been made, but most scholars continue to assume that a “correct” measure of race exists or that different estimates between measures are essentially quantitative errors. However, obtaining different estimates from different measures of race might instead suggest that there are substantively different explanations for the disparities. I explore this possibility by revisiting conventional findings about racial differences in reported health screenings using data from the 1988 National Survey of Family Growth, which includes both the respondent's self-identification and how she was classified by the survey interviewer. Regression results indicate that differences in interviewer-classified race are more closely related to disparities in health screenings than self-identification; these findings complement recent research on the role of racial discrimination and implicit prejudice in clinical encounters and highlight the importance of using multiple measures of race in health care research.

This study investigates racial and ethnic patterns in perceived non-adherence among American White, Black, Hispanic, and Asian health care users, using data from a national sample of recent health care users (N=5,124). We estimated multivariate logistic regression models of perceived non-adherence for all respondents and by respondents’ race/ethnicity. The results revealed that Blacks and Hispanics respectively had 39 percent and 36 percent lower odds of perceived non-adherence compared to Whites, but the odds of perceived non-adherence were 91 percent higher among Blacks who reported having experienced racial/ethnic bias in health care when compared to other Blacks. Good physician–patient communication was associated with a 63 percent lower odds of perceived non-adherence among Whites and Hispanics. The results suggest that compared to Whites, Blacks and Hispanics are less, not more, likely to report perceived non-adherence.

This study examines the variation in preventable hospitalization rates of Medicaid children in California to extend our understanding of racial and ethnic disparity in primary care quality. The results show that primary care quality varies substantially by race and ethnicity even when financial access is ensured by Medicaid. Moreover, the domain of primary care that minority children experience disadvantage varies by race and ethnicity. Compared to white children, African-American children lack continuity and comprehensiveness of care that is necessary for the management of chronic conditions. Hispanic children, on the contrary, have inadequate first contact care. Asian children experience a better quality of care overall than white children. Independent of race, a primary language other than English has a protective effect on preventable hospitalization rates, indicating that language need not be a barrier to quality primary care for racial and ethnic minority groups. The possible reasons underlying the observed differences in health outcome by race/ethnicity and primary language are discussed.

Complementary and alternative medicine (CAM) as a topic of research and as an approach within the health care delivery system has become increasingly accepted. Aided by the holistic movement, and after a century and a half of striving for legitimacy, CAM is also increasingly becoming more accepted by mainstream medicine. This chapter reviews the social sources of disparities in use of CAM, with a greater focus on English-speaking countries, and especially the US. This chapter will briefly highlight the basic underlying principles of CAM as linked to its history and discuss types of CAM. The major focus of this chapter will be a review of the literature on social factors and use of CAM, looking at such factors as age, gender, socioeconomic status, race/ethnicity and immigration status, and health status. As part of this, we will also discuss the integration of CAM and conventional care. In conclusion, future directions for social science research in CAM will be discussed, specifically elaborating on the importance of the social sciences linking CAM with other growing interests in health and wellness.

Data from the National Survey of Family Growth suggest that poor women and women of color are more likely than privileged women to use long-lasting contraception such as sterilization, intrauterine devices (IUD), and Depo Provera. This disparity is noteworthy because long-lasting methods can and have been used coercively. To analyze this disparity, I constructed multivariate binary logistic regression models for female sterilization, IUD, and Depo Provera using the most recent National Survey of Family Growth available (Cycle 6, conducted by the National Center for Health Statistics (NCHS) in 2002). I examined the effect of both personal factors, including age, parity, and number of marriages, and social factors, including education and health coverage. Personal factors were strong predictors but could not explain racial and economic disparities that exist among contraceptive users. This analysis found that education and health coverage were also important variables. Even controlling for personal factors, women with less education were more likely to be sterilized or use Depo Provera than women with a bachelor's degree or more. Women covered by Medicaid or public, government, or military coverage were more likely to use Depo Provera than women with private insurance. Women covered by Medicaid were also more likely to be sterilized since 2000. And uninsured women were more likely to use an IUD than women with private health insurance. However, none of the independent variables completely erased the effect of race and income, suggesting further research is necessary to understand the disparity in use of long-lasting contraceptives.

The association between education and health is one of the most robust empiric findings over the past several decades. At each higher level of education, prevalence of most types of chronic disease decreases. However, understanding of the mechanisms through which education is related to chronic disease is limited. Specifically, the literature provides little evidence of the explanatory factors in the pathways linking education and health. Better scientific understanding of the pathways through which education influences health may help to explain the well-documented association between socioeconomic position (SEP) and health and could lead to improved intervention strategies for health disparities. We review the potential pathways through which education may influence health and the evidence that explicitly tests these hypothesized pathways and provide direction for future research in this field.

There is growing evidence to suggest that childhood deprivation is linked to social inequalities and has important consequences for health in later life. Past studies tend to focus on the influence of cumulative deprivation on the risk of developing a particular disease. This study adds to the literature by exploring how deprivation in childhood may be linked to how people (who already have a disease) self-manage their condition in later life. Questionnaires and focus groups were analysed to explore this relationship (n=91) among coronary heart disease patients living in a deprived urban area of Northern England. The results suggest that childhood deprivation may influence health behaviours and lifestyle in later life especially with regard to diet, health locus of control and doctor visits.

This chapter attempts to clarify the underlying mechanisms of the relationship between socioeconomic status and health outcomes. Former studies of this relationship have largely focused on the materialist predictors of health outcomes, examining variables such as income, access to healthcare, or quality of housing. The current study, by contrast, looks at individuals’ behaviors and attitudes, particularly in relation to physicians, and their impact on the quality of care patients receive. Using data from a sample of 64 hemodialysis patients in a middle-class suburb of Long Island, I examined the effect of comfort and ease with doctors and willingness to engage them on patient compliance. The findings suggest that patients who are more comfortable asking their doctors how they feel, and those that push for more information in general, tend to be more compliant, and therefore enjoy better and more successful patient outcomes.

Nursing facility inspections routinely produce statistics revealing sharp disparities in care at both the facility and the state level. But whether high rates of deficiencies are more indicative of stringent enforcement of standards, leading to improved care, or ongoing poor quality care remains unclear. Until this question is answered, families of nursing facility residents, responsible public officials and interested professionals, are all unable to make sound decisions about long-term care quality. We employ cross-sectional, panel data to compare states on multiple indices of both care quality and enforcement stringency. We use the multi-method-multi-trait approach to distinguish these concepts. We find that low rates of deficiencies are positively associated with independent measures of high quality care. But, a prominent nursing facility enforcement index likely registers poor quality care more than stringency of enforcement since it is associated positively with independent indices of poor quality care and negatively with independent measures of enforcement. Attentive publics can have reasonable confidence that low rates of deficiencies indicate high quality care. High rates tend to reflect glaring deterioration in care quality. They are less signals of stringent enforcement than of obviously poor care which prompts more visible enforcement activities. Sadly, there is little evidence suggesting that these enforcement measures improve state-level care quality and thus reduce cross-state disparities in the quality of nursing facility long-term care. However, at least some of the factors responsible for sharp disparities in nursing facility care lie within the capacity of states to rectify even in the short term.

Do physician perceptions of patient “deservingness” factor into the decision to prescribe opioid analgesics? Using a data set of 398 physicians randomly selected from the American College of Emergency Physicians (ACEP) membership list, we explore how a range of patient social context variables influence a physician's decision to prescribe opioids for three conditions: ankle fracture, back pain, and migraine headache. Being hurt running from the police, former and current drug or alcohol use, and frequent emergency room (ER) visits reduce the likelihood of opioid prescription. Having a reliable relationship with a primary care provider and being injured in a ladder fall or intramural collegiate basketball game increase the likelihood of opioid prescription. Factor analyses for each of the three conditions reveal two scales: socially stigmatizing characteristics and socially accepted characteristics. Discussion centers on what places people at risk for inadequate pain control. Our work contributes to the expanding literature on social conditions as a fundamental cause of illness.

Purpose – A structured comparison, based on underlying social ecological constructs, provides the framework for this preliminary investigation of the commonalities and differences between three emerging approaches to health disparities: community-based participatory research (CBPR), community-focused health outreach (CFHO), and community health promotion programs (CHPP).

Methodology/approach – A conceptual review and preliminary analysis at the macrolevel of major community trends that focus on eliminating health disparity outcomes.

Findings – Each of the three community health approaches share similar purposes using community-focused collaborative efforts, but involve different change agents, levels of partnership, timeframes, social participation, and implementation methodologies.

Research limitations/implications – Additional in-depth literature reviews and meta-evaluations highlighting the contributions of each of the three approaches (CPBR, CFHO, and CHPP) are strongly recommended.

Practical implications – Interested community stakeholders can monitor results and impacts of each of the three approaches within their environments.

Originality/value of paper – Past reviews have concentrated on isolating individual contributing social causes of health disparities. This analysis introduces three emerging trends that currently function within community-based frameworks as potential mechanisms for helping the health disadvantaged.

Information gathered from a sample of residents in four rural Pennsylvania communities is used to test the net effects of household resources (financial assets, supports, and community ties) upon respondents’ physical health and emotional well-being. Size and composition of households, types, and extent of insurance coverage, age, and aspects of household liquidity had major net effects upon physical health. Some measures of liquidity, a range of supports, and community ties had net impacts upon emotional well-being. The importance of considering the collective health needs of rural households in relation to their affordability and sustainability is stressed. The public policy implications of our results are discussed.

This chapter examines the use of routine health care and disparities by socioeconomic status among Vietnamese New Orleanians. It also assesses how these differences may have changed as the result of Hurricane Katrina, which struck the Gulf Coast in late summer 2005, devastating the infrastructure of the health care system of New Orleans. Data for this study come from a panel of Vietnamese New Orleanians who were interviewed in 2005, just weeks before the hurricane, and followed up twice near the disaster's anniversary in 2006 and 2007. Findings show a steep declining trend in routine health care after the hurricane, compared to 2005. Marked differences in health care were already apparent in 2005 (before Katrina) between education levels, homeownership, and health insurance coverage. These differences were significantly reduced one year after the hurricane. We argue, however, that the reduction in disparities was not due to improved health care services or improved health care practice. Instead, it was likely due to the influx of free health care services that were provided to meet urgent needs of hurricane survivors while the area's infrastructure was devastated. By 2007, these free health care services were no longer widely available. Routine health visits dropped further and the temporary reduction in disparities disappeared. This chapter also underlines ongoing shortages of essential health care services for Vietnamese New Orleanians. Efforts need to ensure that all members of this community receive the full array of comprehensive and culturally appropriate health care as they continue to rebuild from the Katrina disaster.