Education, Social Factors, and Health Beliefs in Health and Health Care Services: Volume 33

This chapter provides both an introduction to the volume and a brief review of literature on education and other social factors and health beliefs in health care services.

Literature review.

The chapter argues for the importance of greater examination of education, other social factors, and health beliefs in the use of health care services.

Reviews the issues of education, social factors, and beliefs and previews this volume.

This study evaluates cross-national differences in public beliefs about the causes of health and the role of these beliefs in shaping attitudes regarding health policy.

The study uses data from the 2011 International Social Survey Program, which includes questions on health and health care, asked in 29 countries. Respondents were asked about four specific causes of poor health (i.e., genes, behavior, the environment, and poverty). Respondents were also asked about their attitudes regarding three aspects of health policy: their support for government-provided care, the perceived fairness of income disparities in medical treatment, and their support for providing health care to noncitizens.

The study has three findings. First, the study reveals the global reach of a multicausal view. The four beliefs about the causes of poor health are positively correlated in all countries. However, there is considerable cross-national variation in the average support for specific causes. Although in some countries proximate causes, such as genes, are endorsed more frequently than distal causes, such as poverty, this is by no means a uniform pattern. Support for genetic causes is high, but genetic reductionism is rare. Second, the study reveals that health beliefs are fundamentally political beliefs. The single most important determinant of beliefs about the causes of health is the country in which the respondent resides, exceeding in influence religion, education, and even personal experiences with health and health care. Third, the study reveals that the political connotations of health beliefs vary between countries, especially beliefs regarding genes. In general, those who endorse behavioral arguments favor less government involvement in health care and are more accepting of income disparities in the quality of care. Those who endorse the environment and poverty, meanwhile, tend to support a stronger role of government. Yet, the magnitude of these associations varies and, in the case of genetic arguments, even the direction of the association varies. Genetic arguments are frequently associated with support for a stronger role of government, but genetic arguments also are occasionally associated with support for the exclusion of noncitizens from the health care system.

International survey research is valuable for exploring the scope of patterns revealed in a limited set of countries, but it is difficult to pinpoint the source of cross-national differences.

The study demonstrates the importance of national context in shaping health beliefs, as well as the role of beliefs regarding the causes of health in setting the stage for public receptivity to government-provided care. The study also illustrates the value of thinking about beliefs about genes as reflecting larger projects of biocitizenship, at least in some countries.

Recently, the institutional performance model has been used to explain the increased distrust of health care system by arguing that distrust is a function of individuals’ perceptions on the quality of life in neighborhood and social institutions. We examined (1) whether individuals assess two dimensions of distrust consistently, (2) if the multilevel institutional performance model explains the variation of distrust across neighborhoods, and (3) how distrust patterns affect preventive health care behaviors.

Using data from 9,497 respondents in 914 census tracts (neighborhoods) in Philadelphia, we examined the patterns of how individuals evaluate the competence and values distrust using the Multilevel Latent Class Analysis (MLCA), and then investigated how neighborhood environment factors are associated with distrust patterns. Finally, we used regression to examine the relationships between distrust patterns and preventive health care.

The MLCA identified four distrust patterns: Believers, Doubters, Competence Skeptics, and Values Skeptics. We found that 55 percent of the individuals evaluated competence and values distrust coherently, with Believers reporting low levels and Doubters having high levels of distrust. Competence and Values Skeptics assessed distrust inconsistently. Believers were the least likely to reside in socioeconomically disadvantaged and racially segregated neighborhoods among these patterns. In contrast to Doubters, Believers were more likely to use preventive health care, even after controlling for other socioeconomic factors including insurance coverage.

Our findings suggest that distrust patterns are a function of neighborhood conditions and distrust patterns are associated with preventive health care. This study provides important policy implications for health care and future interventions.

Low health literacy is a hidden epidemic. Identifying individuals with low health literacy is a formidable barrier to eliminating disparities and improving health care quality and health outcomes. However, screening individual patients for low health literacy can be prohibitively expensive, time consuming, and inefficient. Focusing on communities, rather than individuals, provides opportunities for action. Identifying geographic areas with large numbers of individuals with low health literacy can enable stakeholders to focus interventions in areas of greatest need. Creating such a measure also sheds light on health literacy as a community or neighborhood-level resource that contributes to health disparities and can inform health interventions.

We applied regression coefficients from a predictive model of health literacy to US Census data to estimate health literacy scores for census geographic areas in Missouri. We then created maps displaying the variability in health literacy levels. Finally, we compared areas identified by the predictive model to those identified on the basis of educational attainment alone.

Areas identified by the predictive model as having the lowest health literacy were substantially different from those identified using educational attainment alone, suggesting that a multivariate approach using a limited set of widely available predictors is considerably more accurate.

This study demonstrates a cost-effective and feasible method for estimating and mapping community-level health literacy. Predicting and mapping areas of low health literacy is relatively straightforward and inexpensive and makes complex data readily accessible to many stakeholders. Such maps can also identify and prioritize geographic areas for intervention by health care and public health providers. Moreover, this focus on community-level health literacy may help foster stakeholder collaboration, leading to efficient resource use that is targeted effectively and resulting in a positive return on investment for stakeholders.

To evaluate the extent to which a person’s educational attainment moderates the relationship between his or her objective markers of health and self-rated health (SRH).

I use 10 years’ worth of data from the National Health and Nutrition Examination Survey (NHANES 1999–2009; N = 30,823) to examine how diagnosed medical conditions, health behaviors, and biomarkers are differentially associated with SRH by educational attainment. I use regression analysis to evaluate these relationships.

Results show that while medical conditions are negatively associated with SRH equally across education levels, behaviors and biomarkers have stronger association with SRH among individuals with greater education. Those with more education are more likely to have had their blood pressure and cholesterol checked in recent months. They are also more likely to correctly identify themselves as overweight when their body mass index exceeds 25.

The chapter’s findings indicate that education may play a role in how people interpret and evaluate their own health. Real differences in how people evaluate their health can impact the conclusions that researchers can draw when comparing SRH between education groups. In addition these results can motivate further research in the causes of health disparities. Self-evaluation of health can potentially influence how people monitor and manage their health. Differences in self-evaluation between levels of educational attainment could contribute to disparities in health and mortality.

This chapter examines the relationship between self-rated health, objective markers of health, and education in a novel framework.

This study examines Filipino Americans with high levels of psychological distress. We report on whether ethnic identity, discrimination, and nativity are predictors for help-seeking from a medical professional.

We derived our data from the Filipino American Community Epidemiological Study which surveyed Filipino adults living in the United States (N = 2,285). We used OLS regression to examine the association between psychological distress and help-seeking among US-born Filipinos and immigrants.

The majority of US-born and foreign-born Filipinos sought help for psychological distress from a lay person. Years spent in the United States, ethnic identity, and discrimination were strong predictors for help-seeking. US-born Filipinos were more likely to seek help. Those with low ethnic identity and experienced medium to high discrimination were less likely to seek help.

Our findings suggest that years in United States, ethnic identity and discrimination are associated with help-seeking. Future research should consider factors such as social support and acculturation to examine whether these contribute to psychological distress and help-seeking.

Sociology promotes and describes public health, helping to explain macro-social dynamics of mental health care through studies of organizations, networks, and systems of care.

This chapter summarizes sociological research on mental health care organizations and systems, illustrating a macro-social perspective by examining the problem of transitions in care for young adults. Summary findings from a regional mental health services research project describe a system of care that includes 100 organizations. This system helps young adults with mental health needs.

The scope and management of care involves a focus on modes of treatment supported by research evidence and delivered effectively by people with cultural competencies. Care and continuity of care are delivered through coordinated systems of inter-organizational networks, linking organizations and providers. Active inter-organizational linkages are needed to support mental health for young adults during challenging and sometimes difficult transitions.

This research summarizes original and regional data on mental health care organizations within a regional system of care. Practical implications include support for the importance of coordination, transition planning, and cultural competence within and among organizations. Sociological and original research on organizations and systems should continue to elaborate the needs and values of mental health services for regional planning and public health.

This study set out to examine whether personal religiosity was in any way associated with adolescents’ propensity to seek out formal mental health care.

Using the National Longitudinal Study of Adolescent Health (Add Health), this study uses logistic regression models to test for an association between personal religiosity and mental health services use net of depressive symptomology and demographic controls.

Results showed a negative, statistically significant relationship between personal religiosity and mental health services use. Highly religious adolescents had lower odds of having seen a mental health professional compared to their less religious counterparts even after controlling for depressive symptomology.

Data restrictions required that we limit our analysis to one specific form of mental health services: talk therapy. Nevertheless, this study suggests that religiosity represents a potentially important consideration in addressing the mental health needs of adolescents.

To our knowledge, this is the first study in which a nationally representative sample of adolescents is used to examine the relationship between personal religiosity and mental health services use.

A fairly consistent finding in research on trust in physicians is that racial and ethnic minorities cite lower levels than whites. This research typically samples only health care users, which limits our understanding of what underlies distrust. It remains unclear whether the distrust is generalized, which is distrust that is unrelated to using health care regularly or recently.

Using data from the Health Information National Trends Survey, multivariable logistic regressions assessed whether racial and ethnic differences in distrust (1) are equivalent among health care users and non-users; (2) regardless of respondents’ health and socio-economic status; and (3) manifest in other health information sources.

Racial and ethnic minorities are less likely than whites to trust physicians as health information sources. These racial and ethnic differences are equivalent among health care users and non-users, regardless of respondents’ health and socio-economic status. The racial and ethnic patterns do not manifest when predicting trust in other health information sources (Internet, family or friends, government health agencies, charitable organizations).

Data are derived from a cross-sectional survey, which makes it difficult to account comprehensively for self-selection into being a health care user. Despite the limitations, this research suggests that racial and ethnic minorities possess a generalized distrust in physicians, necessitating interventions that move beyond improving health care experiences.

Many researchers have surmised that a generalized distrust in physicians exists among racial and ethnic minorities. This chapter is the first to explicitly examine the existence of such distrust.

Professional interpreter use improves care in patients with limited English proficiency (LEP) but inequalities in outcomes remain. We explore the experience of US Latinos with LEP and diabetes in language discordant care.

We conducted in-depth interviews of 20 low-income Latino patients with diabetes and LEP. We interviewed participants in Spanish, digitally recorded and transcribed interviews, and read transcripts to identify themes and interpret meanings using interpretive phenomenology as theoretical framework.

While patients preferred, and experienced greater trust in, language concordant clinical encounters, they did not believe that language discordance affected outcomes because they felt that these depended largely on their compliance with physicians’ recommendations. Patients also downplayed structural barriers to care and outcomes. Self-blame was paradoxically encouraged by physicians’ praise vis-à-vis favorable outcomes.

Limitations include small and convenience sample and limited generalizability. However, findings illustrate communicational dynamics between patients and clinicians with important implications for health care practice and policy. They support the perception that trust develops best within language concordant care, which underscores the importance of recruiting clinicians with diverse language skills. They highlight the importance of sensitizing clinicians to the social determinants of health, which may be overlooked when treating patients with conditions requiring substantial self-management, like diabetes. Language barriers in health care must be understood in the broader context of structural inequalities in health care. The necessary emphasis on self-management may (inadvertently) strengthen the hegemonic view that places responsibility for diabetes outcomes on patients’ ability to self-manage their condition to the neglect of social/political determinants of diabetes.

Studies have quantitatively examined the effects of language discordant care on diabetes outcomes, yet few have done so qualitatively. To our knowledge, no study has attempted to understand the experience of language discordance from the perspective of LEP patients with diabetes and how this experience may explain observed differences in outcomes.

As the new Patient Protection and Affordable Care Act (ACA) achieves full implementation in 2014–2015, public perceptions regarding improvement in access and quality of care due to the ACA provide a fertile area for sociological research. The aim of this chapter is to determine if race is independently associated with perceptions of quality of care and access to care after ACA implementation. And, secondarily, we examined if such a relationship remained stable after considering SES (education and income) alone and SES with other relevant individual characteristics.

Data come from a telephone survey of a representative sample of Georgia residents aged 18 years or older. For each domain of the dependent variables (quality of care and access to care), three models were fitted with a nested design. The first model included only race. The second model included only race and SES. Model 3 included race, SES, and the following individual characteristics: (1) self-rated health status; (2) sense of coherence (SOC; a construct used to explain why some people are more disposed than others to illness after stressful situations); (3) travel time to doctor’s office; (4) importance of short wait times as doctor’s office; (5) political affiliation; and (6) geographic location (rural/non-rural).

Race was significantly associated with both the quality of care and the access to care. Non-White respondents were more likely to perceive improvements to both as a result of the ACA. Likewise, respondents with either higher education or income were also more likely to perceive improvements in quality and access as a result of the ACA. However, these associations were partly explained by respondents’ self-reported political affiliations.

Results of this study show that public perceptions toward the ACA and its impact on quality and access to care seem to differ based on an individuals’ race, income level and political affiliation. This may be a reflection of the media blitzkrieg that surrounds the ACA rather than a direct consequence of the policy itself. A concerted effort to develop communication strategies and outreach efforts by race and SES that can better educate the general population on the ACA may alleviate some of the reservations that are inherent to any major policy implementation, especially in terms of healthcare quality and access.

Past research indicates that blacks are less trusting of physicians than are whites; yet, researchers have not examined within group differences in physician trust by religious denomination – an effort that is complicated by the high correlated nature of race and religion. To better understand black-white differences in physician trust, this chapter examines heterogeneity in trust levels among blacks associated with religious designations that distinguish Black Protestants from other ethnoreligious groups.

Using data from the 2002 and 2006 General Social Surveys, this study adopts an intersectional (i.e., race x religion) typology of religious denomination to understand the black-white gap in physician trust. Weighted multivariate linear regression is employed.

Black-white differences in physician trust are identified only when religious affiliation is considered but not when religious affiliation is omitted. Blacks who are affiliated with Black Protestant churches are more trusting than other religious groups, including Evangelical Protestants, Mainline Protestants, and blacks who are affiliated with other faiths.

This chapter indicates that there is more heterogeneity in trust levels among blacks than between blacks and whites. Moreover, the findings suggest that religion can play an important role in bridging the trust gap between blacks and the medical sciences.

U.S. health policy promotes HIV testing and linkage to care (test-and-treat) with an emphasis on high risk groups such as convicted offenders. We sought to identify whether or not laws for mandatory HIV disclosure to sexual partners are a barrier to HIV testing among offenders under community supervision.

A total of 197 probationers and parolees were surveyed in a closed/item-open-ended item methodology on two reporting days in Alabama. Three main questions were asked: (1) What do offenders know about HIV? (2) What do they know about the law? (3) Do they support mandatory disclosure and HIV testing? Data for the quantitative items were analyzed with SPSS and matched with open-ended responses for explanatory purposes.

Testing and criminalization of non-disclosure were fully supported as key elements of HIV prevention. This support was framed by conceptions of HIV as a killer disease, of people with HIV as potential murderers, and by low self-awareness of HIV risk.

While the study involved only a single group of convicted offenders in a southern state, the results suggest that disclosure laws legitimize HIV stigma and undermine test-and-treat strategies among communities at risk.

The research is the first of its kind to investigate possible links between HIV criminalization and barriers to HIV prevention and care among convicted offenders.

The purpose of this study is to investigate the informal micro-level mechanisms through which caregivers maximize their health literacy and caregiving skill-set, particularly in cases of emergent, pervasive health disorders. Specifically, I investigate how important micro-level social factors, such as lay self-education and local community networks, mitigate extensive experiences of medical uncertainty that are associated with caring for a child with autism. This study theorizes a series of processes of becoming lay health care professionals (HCP), which serve as effective health care interventions and ways to secure vital resources for patients and their families.

This study uses qualitative research methods in the form of 50 individual intensive interviews with primary caregivers of at least one child under the age of 18 with an official autism diagnosis, as well as two years of participant-observation at two primary sites that are autism parent and caregiver resource meetings, both located in Northern California.

This study first demonstrates the major institutional limits and gaps involved in health-related caregiving for children with autism. Next, I define the processes through which caregivers challenge these institutional constraints and fight for life altering resources for their families, which include becoming a lay diagnostician and expert caregiver. Here, I demonstrate a sophisticated set of health literacy skills and key local community-based ties that caregivers develop and rely on, which affords families the tools to overcome diverse institutional obstacles in health-seeking and health care access.

The families in this study are predominantly white, middle-class, and reside in California. For future research, the scope of the study could be expanded by increasing the sample size and including greater geographic and demographic diversity.

This study contributes vital, yet missing, pieces to the autism puzzle, which currently focuses on prevention, the fight for a so-called “cure,” and the role of vaccines in disorder prevalence. In the meantime, families are living with autism each day and are struggling for understanding and knowledge, and to secure adequate support services. In doing so, this study sheds light on current institutional gaps and limits in health care and delivery for children with autism, and suggests specific effective health care interventions applicable to other cases of emergent illnesses and disorders.