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Public/Community Health and Nursing Practice Caring for Populations, 3rd Edition
TABLE OF CONTENTS
UNIT I Basis for Public Health Nursing Knowledge and Skills Chapter 1 Public Health and Nursing Practice Chapter 2 Optimizing Population Health Chapter 3 Epidemiology and Nursing Practice Chapter 4 Introduction to Community Assessment Chapter 5 Health Program Planning Chapter 6 Environmental Health UNIT II Community Health Across Populations: Public Health Issues Chapter 7
Health Disparities and The Social Determinants of Health
Chapter 8 Chapter 9
Health and Vulnerable Populations
Communicable Diseases Chapter 10 Noncommunicable Diseases Chapter 11 Mental Health Chapter 12 Substance Use and the Health of Communities Chapter 13 Injury and Violence UNIT III Public Health Planning Chapter 14 Health Planning for Local Public Health Departments Chapter 15 Health Planning for Acute Care Settings Chapter 16 Health Planning for Primary Care Settings Chapter 17 Health Planning with Rural and Urban Communities Chapter 18 Health Planning for Maternal-Infant and Child Health Settings Chapter 19 Health Planning for School Settings Chapter 20 Health Planning for Occupational and Environmental Health
Chapter 21 Health Planning, Public Health Policy, and Finance Chapter 22 Health Planning for Emergency Preparedness and Disaster Management
Community Health Across Populations: Public Health Issues II
UN I T
Chapter 7 Health Disparities and the Social Determinants of Health Karen Bankston, Christine Savage, and Gordon Lee Gillespie
LEARNING OUTCOMES After reading the chapter, the student will be able to: 1. Differentiate the constructs of health disparity, equity, and inequality from a local to global perspective. 2. Discuss the magnitude of health disparities, both in the United States and internationally.
3. Define and explain the role of the social determinants of health (SDOH), social capital, and social justice in the health of populations. 4. Discuss the construct of racism as an institutional or structural issue and its impact on health equity.
KEY TERMS Advocacy Discrimination Disparity Equity Food insecurity Health disparity Health gradient
Health inequity Infant mortality rate (IMR) Marginalization
Social determinants of health (SDOH) Social gradient Social justice Socioeconomic status (SES) Structural racism
Systemic racism Universal Declaration of Human Rights Vulnerability Vulnerable populations
Poverty Racism Social capital
■ Introduction It has been said that one can tell the health of a commu- nity by measuring the health of its children. According to the World Health Organization (WHO), 5.0 million children died before age 5 years in 2020. 1 In addition, the infant mortality rate (IMR) globally reflects approxi- mately 27.4 deaths per 1,000 live births. The IMR was the highest in the WHO African Region (49.5 per 1,000 live births compared with 6.5 per 1,000 live births in the WHO European Region). 2 Why is there such a disparity , or great difference, between these regions? Is there any- thing that can be done to reduce this and other gaps in health outcomes between populations? Why are some
populations at greater risk for adverse health outcomes compared with other populations? Answering these questions involves understanding the underlying social determinants of health (SDOH) -related gaps in health outcomes between populations. For example, whereas the IMR in the United States was 5.6 per 1,000 live births, the difference between white infants and black infants was 4.5 and 10.5 per 1,000 live births, respectively, in 2019. 3 Equity is the underlying construct behind optimum health as a basic human right. To explore this in more detail, consider three people—one tall, one medium height, and one short—wanting to watch a ball game over a fence (Fig. 7-1). If all three people are provided with a box that is the same height, this represents the
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interventions to reduce or eliminate the disparity. Health inequity describes avoidable gaps in health outcomes. 4 For example, persons with type 2 diabetes who cannot afford the cost of medication and therefore are unable to take it as prescribed will experience higher hemoglobin A1C levels and experience more adverse outcomes. The inequity in access to diabetic medications may be a major driver in the disparity in outcomes between lower- and middle-income persons. Drivers of health inequities are linked to the vulnerability experienced by some popula- tions based on the SDOH, including where they stand in the social hierarchy related to income, education, occu- pation, gender, race or ethnicity, and other factors. 5 ■ WHY IT MATTERS: Social Determinants of Health Nursing Practice Focus: SDOH contribute to health outcomes. Things to Consider: Systemic inequities have been shown to contribute to health inequities. The National Academies of Sciences, Engineering, and Medicine re- port that whereas individual-level behavioral factors are associated with health outcomes, upstream influences that impact where individuals live, learn, work, play, worship, and age also affect a wide range of health and quality of life outcomes and risks. 6 These characteris- tics, the SDOH, must be considered when assessing, planning, and implementing health-care interventions. What Does It Mean for the Nurse? Nurses can consider the following questions: • How will the nurse assess for a patient’s availability of safe housing and transportation? • How will the nurse consider the impact of racism, discrimination, and violence in the patient’s ability to be healthy? • How will the nurse determine the role of education, job opportunities, and income in relation to health outcomes? • How will the nurse evaluate how a patient’s language and literacy skills impact their ability to adhere to a treatment plan? • How will the nurse use available data to develop a plan of care for patients?
concept of “equality.” Although they were all given the same resource to view the game, the shortest person is still not able to see the game. If, instead, they are pro- vided with boxes at varying heights based on their stature, all of them get to see the game. Then there is “eq- uity” among the three persons. Furthermore, if the fence is removed, as depicted in the third picture, all structures have been dismantled and allow for all to be empowered. Health Disparity and Inequity When health equity does not exist, there are often dif- ferences in health outcomes. The terms used to describe gaps in health outcomes include health disparity and health inequity . Health disparity exists when “a health outcome is seen to a greater or lesser extent between pop- ulations.” 4 The IMR (see Chapter 18) provides a prime example of disparity, with higher rates between countries or between racial or ethnic groups within a country. Iden- tifying a disparity is the first step in understanding the underlying risk factors and the development of possible Figure 7-1 Equality, equity, and liberation. (Source: Equality/Equity/Liberation image is a collaboration between Center for Story-Based Strategy & Interaction Institute for Social Change)
Addressing health inequity requires providing peo- ple the opportunity for optimal health. This may require more services for those who have noncommunicable
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chronic diseases and are on a fixed income compared with persons in general good health and who are in higher income brackets. Nurses address health inequity in a va- riety of ways, beginning with advocacy . For example, nurses on the front lines with patients who have difficulty affording their prescriptions advocate for those patients by identifying pharmacies that provide assistance, as well as other sources of help to pay for medications. Nurses also advocate for health-care policies aimed at address- ing health inequalities at the local, state, and national levels. They also actively provide improved care for those in need through nurse-managed clinics or by working as outreach nurses for the public health department. Comparing life expectancy between countries helps to further demonstrate the health disparity between coun- tries. The world life expectancy in 2020 was 73.2 years; however, Hong Kong’s estimated life expectancy was 85.3 years, whereas the estimated life expectancy in the Central African Republic was 54.4 years. 7 For the United States, the estimated life expectancy in 2020 was 77.3 years, a decline from 78.8 in 2019. 8 There is also health dispar- ity among populations within a country. These dispar- ities are frequently seen as a health gradient wherein there is a series of progressively increasing or decreasing differences. The health gradient reflects the relationship between health and income at the population level, with health gradually improving as income improves. The WHO uses the term social gradient , which refers to “a gradient in health that runs from top to bottom of the socioeconomic spectrum. This is a global phenomenon, seen in low-, middle-, and high-income countries. The so- cial gradient in health means that health inequities affect everyone.” 5 The WHO utilizes the example of maternal mortality to describe the social gradient (see Chapter 18). A comparison of the maternal mortality rate reflects Af- rican nations with the greatest burden: South Sudan with 1,150 maternal deaths per 100,000 live births compared with several European nations (i.e., Italy, Belarus, Norway, Poland) with two maternal deaths per 100,000 live births. 9 Caution must be taken when interpreting the under- lying risk factors contributing to the disparity. On the surface, it might appear that the disparity is because of genetic differences or physical attributes, when in fact much of the health disparity between groups is driven by factors such as socioeconomic status (SES) , racism , and discrimination. Poverty and access to resources such as food, shelter, sanitation, education, and health care all play a role in improving life expectancy. Other risk factors also must be considered. Changes in the en- vironment play a role in life expectancy. For example, life expectancy has been declining in high-income countries,
partially because of the rise in opioid overdoses in younger persons (see Chapter 12). 10 Additionally, the decline in life expectancy between 2019 and 2020 can be attributed to deaths from the COVID-19 pandemic. In California, during the height of the COVID-19 pandemic (March 2020 to December 2020), the age-adjusted mor- tality rate because of COVID-19 was 30.0 per 100,000 workers. 11 Of these deaths, age-adjusted mortality rates were significantly higher for persons working in occupa- tions considered essential personnel (e.g., construction workers, truck drivers, farmers, cooks and food service workers, custodial staff, bus drivers). Within these oc- cupational groups, mortality was highest for black and Hispanic workers. Thus, where a person lives, the work a person does, level of vulnerability, and individual health behaviors play a role in increasing or decreasing an indi- vidual’s risk for premature death. A common characteristic of persons experiencing health inequities—such as people with low incomes or marginalized persons, underrepresented racial and eth- nic groups, and women—is a lack of political, social, or economic power. 12 Thus, to be effective and sustainable, interventions need to focus on addressing power as a de- terminant of health that drives health inequities. Subse- quently, the imbalance of power and patient centeredness must be aligned to develop actions that will remedy a par- ticular health inequity. Systemic changes, such as law re- form or changes in economic or social relationships, can empower groups and lead to improved health outcomes. Vulnerable groups with a higher level of risk of experi- encing adverse health outcomes are also less apt to have a voice in creating opportunities to reduce health inequity. An article published in the New York Times in August of 2021 13 described the persistence of racial inequities that exist in the United States despite the enactment of the Affordable Care Act. The article states that although access to care has improved, racial health gaps have not. In fact, it offers that the system is comprised of medical “haves” and “have nots.” In a related study published in the Journal of the American Medical Association, one ac- tion reported that may be contributing to the gap is the different patterns of obtaining health care. 14 Specifically, white Americans are more likely to have a primary care physician than members of underrepresented groups, who would then obtain their care in emergency depart- ments (EDs) and hospitals. This was a finding among var- ious racial and ethnic groups, even when there was no difference in the type of health insurance or coverage. In a different study, preparedness for serious illness varied greatly based on perceived discrimination, medical mis- trust, and race or ethnicity. 15 The authors found that black
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tool. 18 In July 2021, because of an inadequately devel- oped global plan for COVID-19 vaccines and therapeu- tics, only 83 countries were able to administer at least one dose of a COVID-19 vaccine in more than 30% of their population, leaving 133 countries with vaccine rates below 30%, which highlights the disparity. 18 Low- and middle-income countries were unable to achieve the research, surveillance, development, manufacturing, and distribution processes necessary to meet the needs of their respective populations. Health Disparity in the United States Comparing groups based on racial and ethnic categories provides a starting point for illustrating health dispari- ties in the United States, with the strong caveat that this does not mean that these differences are attributable to genetic differences but rather differences in availability of resources. Again, the IMR illustrates significant differ- ences in birth outcomes. Although the overall IMR for the United States in 2019 was 5.58 per 1,000 live births, it was almost double for blacks (10.46 per 1,000 live births) and much lower for Asians (3.51 per 1,000 live births) (Fig. 7-2). 3 Yet when the data are examined based on geography, differences in IMR by state range from less than 3.21 per 1,000 live births (New Hampshire) to 8.71 per 1,000 live births (Mississippi). 3 Access to resources, distribution of resources, rurality, and pov- erty are important risk factors for infant deaths and help explain the differences seen between racial groups that have a higher percentage living in poverty. When ■ WHY IT MATTERS: Disparities Nursing Practice Focus: Disparities are amenable to change by addressing SDOH. Things to Consider: Although the term disparities is often interpreted to mean racial or ethnic dispari- ties, many dimensions of disparity exist in the United States, particularly in health. If a health outcome is seen to a greater or lesser extent among populations, there is disparity. Race or ethnicity, sex, sexual iden- tity, age, disability, income, and geographic location all contribute to an individual’s ability to achieve good health. What Does It Mean for the Nurse? It is impor- tant to recognize the impact that social determinants have on the health outcomes of specific populations. Healthy People strives to improve the health of all groups. 4
and Hispanic persons are more likely to have ineffective communication with health-care providers, possibly be- cause of medical mistrust, which can result in providers and patients not discussing how to manage chronic dis- ease. This lack of communication or miscommunication suggests that disparities may be because of inconsistent management by providers of chronic disorders, such as diabetes, heart failure, and asthma, which are prevalent in patients who belong to an underrepresented group. In order to address this problem, nurses and health-care providers need to be aware of their unconscious bias to- ward persons based on their race, ethnicity, income, and insurance status. Doing so will lead to developing com- munication strategies that aid in relationship building between the patient and the nurse. Being purposeful and empathetic in patient conversations can help to build trust between patients and persons providing care. ■ CELLULAR TO GLOBAL At the cellular level, the APOE-e4 genotype has been identified as the greatest risk factor for developing Alzheimer’s disease. 16 Although women globally have nearly a double lifetime risk of developing Alzheimer’s disease by age 65, it is not known if this disparity is because of a biological difference, such as a biological woman’s susceptibility to the influence of APOE-e4 based on an interaction with estrogen, or an influence of the SDOH. 17 Given that women may be more likely to work part time without health insurance and have lower income, they might not have the finances to af- ford medications, which would delay the onset or pro- gression of Alzheimer’s disease compared with men. Health Disparity Globally Health disparities are seen across the globe, affecting di- verse patient populations. Multiple factors contribute to these disparities, including age, geography, and SES, as well as discrimination based on gender, sexual identity, race, and ethnicity. These disparities are facilitated by so- cial and economic inequities across and within countries. Some examples of global inequities include death from preventable diseases such as malaria, tuberculosis, and pneumonia, as well as challenges in managing chronic disorders such as hypertension and type 2 diabetes. An example of the impact of global health disparities was demonstrated with the implementation of access processes for COVID-19 vaccines. Specifically, the pol- icies that govern the ability to develop, distribute, and achieve therapeutics were unstable as an essential health
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Rate per 1,000 live births
12
10
8
6
4
2
0
Non-Hispanic Black
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Hispanic
Non-Hispanic White
Asian
Figure 7-2 U.S. infant mortality rates by race and ethnicity, 2019. (Source: Reference [3])
70
65
60
55
50
Primary care physicians
45
0
2007 Year
2002
2003 2004 2005 2006
2008 2009 2010 2011 2012
NOTE: Primary care physicians include those in family and general practice, internal medicine, geriatrics, and pediatrics. SOURCES: CDC/NCHS, National Ambulatory Medical Care Survey (NAMCS) and NAMCS, Electronic Health Records Survey. Figure 7-3 Number of primary care physicians per 100,000 population: United States, 2012. (Source: Reference [19])
examining the number of primary care physicians by state, New Hampshire had 43.9 per 100,000 population, compared with Mississippi with 26.5 per 100,000 popu- lation (Fig. 7-3). 19 The rate of physicians does not take into account the rurality or distance required to travel to see a primary care physician. Although IMR is just one
example of health disparity among groups in the United States, it underscores the rationale for continuing to promote health equity as a priority. Healthy People 2030 (HP 2030) continues to include elimination of health disparity as a priority, as it has since Healthy People was first initiated.
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Health Marginalization Disparities in health are often multifactorial and include access to care, income, and marginalization. For example, access to care is an initial assumption for health dispar- ities in maternal health outcomes. Assari and Zare dis- cuss that access to care, along with proximity to care and health-care use, when similar between white and black persons still yielded a considerable disparity. 20 They pos- ited that other factors, such as marginalization of an un- derrepresented group, may be driving health disparities. Discrimination occurs when a marginalized person or group of persons is treated as insignificant or peripheral. In health care, discrimination occurs when patients are not offered care such as pain medications with the same frequency as nonmarginalized patients. It is important for nurses to critically reflect and explore how their conscious and unconscious biases can affect care, how health-care services are offered, frequency of services of- fered, and differences between groups, whether based on race, sex, gender orientation, or another characteristic. Social Determinants of Health The SDOH are the social and environmental conditions in which people are born, live, learn, work, play, worship, and age. 21 The SDOH are organized into five categories: neighborhood and built environment (see Chapter 6), social and community context, economic stability, ed- ucation access and quality, and health-care access and quality (Fig. 7-4). 21 The determinants are not only asso- ciated with risk for communicable and noncommuni- cable disease, but they are also associated with risk for mental health disorders, substance use disorders, injury, and violence. According to the WHO, SDOH account for “the unfair and avoidable differences in health status seen within and between countries.” 22 For all health-care providers, including nurses, un- derstanding SDOH and integrating that knowledge into plans of care results in improved outcomes. When pa- tients come to the hospital for care, it is not always easy to understand the context of their daily lives because nurses are not interacting with them in their home environment. Yet with increasingly short hospital stays, nursing care that incorporates this context in the nursing plan of care and discharge instructions becomes even more impor- tant. Subsequently, communication between the patient and the nurse about their living arrangements is imper- ative. Often, patients go home with complex instruc- tions and a need for medical supplies yet lack the health literacy (see Chapter 2) or the resources to implement
Figure 7-4 Social determinants of health. (Source: Reference [21])
those instructions. This can result in poor outcomes and a return to the hospital. At the tertiary prevention level, addressing this health inequity may include requesting an order for a home health nurse or home health aide on discharge, thus helping vulnerable patients improve their ability to self-manage the disease. On the secondary prevention level, nurses in public health departments are on the front line with screening programs for vulnerable populations at high risk for disease, such as lead poison- ing or sexually transmitted infections. On the primary level, nurses provide education to at-risk populations. As explained in Chapter 2, understanding the SDOH is essential to help identify persons at risk, as well as de- signing an intervention at the individual or community level that considers how the social and environmental conditions in which people live affect their ability to achieve optimal health. During the development of the HP 2030 goals and objectives, an increased emphasis on the SDOH was added to enable stakeholders to identify opportunities to achieve health equity. 23 Neighborhood and Built Environment SDOH related to the neighborhood and built environ- ment focus on where a person lives. 24 This includes their housing, neighborhood, and the physical environment in which they live. Lack of access to potable drinking water within a neighborhood is associated with infectious disease and
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poor child growth. Although most persons would not consider access to potable drinking water a problem in the United States, there are many communities where access to potable water is a problem. Two examples are Flint, Michigan, and rural Alaska, where this remains problematic. 25 Many communities in rural Alaska require a boat, airplane, or snowmobile to access. These commu- nities are less likely to have treated or well water piped to their homes. They are more likely to haul small amounts of water in and sewage out. Mosites and colleagues found that rural Alaskans without piped water tended to sup- plement their water intake using sugar-sweetened bever- ages, which can lead to obesity and other health-related concerns. 25 This relationship between lack of piped water and consumption of sugar-sweetened beverages reflects the importance of having an adequate built environment for the promotion of health. In Flint, Michigan, the state governor appointed an unelected emergency manager because of the city’s financial crisis. 26 As a strategy to re- duce expenses, the city’s water supply was switched to the Flint River in 2014. Over the next year, residents were instructed to boil their water several times, high levels of lead were detected in the water supply, and an outbreak of Legionnaire’s disease occurred. It was later determined that the water supply coming from the Flint River was not being treated as effectively as the prior water supply and led to leaching of lead from the city’s outdated wa- ter pipes. Although the water supply was returned to its original source, residents were still being encouraged in 2022 to filter their water because of the corrosive damage that had occurred to their pipes. Social Context and Community SDOH related to social context and community focus on the characteristics of the contexts in which people live, learn, work, and play in order to achieve health and well-being. 24 The social context describes the settings in which people engage with each other, including groups they choose to interact with and where they work. Also referred to as the social environment, it includes the cultural traditions and behaviors of the members of a group. Within a defined community (see Chapter 4 for definition) there exists a diversity of ethnic traditions in conjunction with shared community cultural traditions. The cohesiveness of a community, or lack thereof, can impact the health and safety of community members. Issues such as neighborhood safety, discrimination, or poverty can result in challenges for persons with fewer resources. Community support can help mitigate these issues. HP 2030 has a specific goal to increase social and community support.
Nutrition and access to healthy foods are examples of the relationship between social context and commu- nity. One of the HP 2030 objectives under the social and community support goal is to eliminate very low food security in children. Addressing this objective within a community would require building support for existing programs available to the community, such as the School Breakfast Program, a federally assisted meal program, as well as understanding the challenges facing families within the community. It also includes understanding other components of a community’s context that con- tribute to food insecurity , including the number of fam- ilies experiencing poverty, population growth, access to food outlets with healthy food choices, and rising food prices. 27-29 Helping individuals and families to maximize their access to healthy food is thus linked to the social context of the community in which they live. ■ CULTURAL CONTEXT Addressing food insecurity requires understanding the cultural context of food. Culture plays a central role in what people eat. 30 According to Park and colleagues, the cultural element of food “describes traditional and local food knowledge and food practices that interact with values, pleasures, taste, and memories. It includes both the personal and regional foci.” 31 Food culture should be incorporated into programs aimed at increasing healthy eating and addressing food insecurity. 31 Mingay, Hart, Yoong, and Hure proposed a concept of food culture that can be applied to pub- lic health practice that helps to identify a positive food culture and the negative elements that currently impact healthy eating in modern culture. They argue that understanding food culture is a key component to enabling “population-wide and sustained improve- ments to the way we eat, and how we think and feel about food.” 32 Economic Stability SDOH related to economic stability focus on the finan- cial resources people have. 24 These financial resources include income, cost of living, and SES, which impact a person’s health. The onset of COVID-19 led to economic stability globally. Soon after the pandemic onset in March 2020, millions of persons lost their jobs. 33 By October 2021, there were still approximately 20 million households re- porting the impact of economic instability: not having
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enough food to eat, being behind on rent, 33 and having difficulty covering usual expenses. People who had been working in lower-wage jobs before the pandemic were most likely to be unemployed as of October 2021, pri- marily because these positions had been abolished. An- other factor that impacts economic stability is chronic disease. The Centers for Disease Control and Prevention (CDC) estimates that every 40 seconds someone in the United States experiences a stroke, 34 which can leave the person unable to provide for their own activities of daily living. This situation would necessitate that some- one else, typically a family member, provides caregiving. Persons serving as caregivers are usually an unpaid fam- ily member. Caregiving can have a direct and indirect economic impact on the family unit. The direct impact is the loss of wages and increased costs of living for the person requiring caregiving, as well as the loss of wages for the caregiver who may no longer be able to work full time. 35 The indirect impact is the cost to the caregiver’s well-being because the caregiver may be spending their previous recreational time providing care. Without res- pite from caregiving, the caregiver may experience per- sonal health consequences and a subsequent increase in personal health-care expenses. ◆ HEALTHY PEOPLE 2030 Category: Social Determinants of Health Area: Economic Stability Goal: Help people earn steady incomes that allow them to meet their health needs. Objective: Reduce the proportion of people living in poverty. Level, Baseline. SDOH‑01 Topics Covered: Community, Poverty, Access to Affordable Food, Housing, Education, and Health Care. Using Healthy People 2030 in Your Work: Identify needs and priority populations. 1. What proportion of the community is living in poverty? 2. What populations are living in poverty based on age, ethnicity, education level, gender, or other demographic marker? 3. What services are available to those living in poverty? 4. What are the gaps in services and programs, and what are the current priorities? 5. What role might an organization providing health care to the community play in reducing the proportion of people living in poverty?
Education Access and Quality SDOH related to education access and quality focus on a person’s educational attainment and the context of learning. 24 For example, a person’s language literacy, early childhood education and development, and overall educational attainment impact a person’s ability to ob- tain their optimal health and well-being. Researchers from the CDC’s Center for Surveillance, Epidemiology, and Laboratory Services studied the rela- tionship between eighth-grade school achievement and health. 36 They found that an increase in eighth-grade test scores was associated with an increase in income at age 40 as well as an increase in life expectancy. This relationship relays the need for children to strive for ed- ucational excellence as well as remain in school through high school graduation. The greater students’ educa- tional experience and attainment are, the greater the likelihood the students will later obtain employment with a “living wage” to be able to lead healthy, long lives. As an example, Sheehan and colleagues implemented a community-based youth development program for black, low-income children. 37 The researchers found that program participants reported having good to ex- cellent health, graduating from college, having money left at the end of the month, and having a better standard of living than their parents, in contrast to black children from the same neighborhood who did not participate in the program. The implications of this study show that encouraging participation in childhood education can lead to improved health in adulthood. Health-Care Access and Quality SDOH related to health-care access and quality focus on a person’s access to health-care services as well as understanding of services available for primary, sec- ondary, and tertiary prevention. 24 Availability of health insurance coverage and health literacy, as well as pri- mary care access, also contribute to health-care access and quality. The COVID-19 pandemic changed health-care access, particularly with the proliferation of telehealth services. Medical students at the MedZou Community Health Clinic converted from in-person visits to telehealth vis- its from March 2020 through March 2021 after the sus- pension of all in-person visits because of the COVID-19 pandemic. 38 Patients using the telehealth services were significantly more likely to be 45 years of age or older, which was somewhat surprising given the stereotype that older adults do not adopt and use technology as easily as younger persons. However, older adults are in
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through these relationships.” 41 Social capital further de- scribes “trust in individuals and organizations within the community, number and strength of ties to the neighborhood and community organizations, extent of civic engagement, voting patterns, trust in healthcare providers, etc.” 41 Essentially, as people or groups in- crease the number of trusted relationships within their community, their social capital, and ultimately their health, increases. 42 This improvement in health can re- sult from gaining access to higher education and finding higher-income employment, both of which are SDOH. The Safe Aging Coalition is an example of how a group addressed elder abuse. Community members, including social workers, a bank manager, a county sheriff, an ED nurse manager, a county assistant prose- cutor, and several older adults, convened monthly over the course of a year. During those monthly meetings, the coalition members developed trusting relationships with one another. They accomplished this through sto- rytelling about their experiences witnessing elder abuse and wanting to be proactive in its prevention and mit- igation. Each coalition member agreed to bring three additional persons to attend a regional symposium on elder abuse prevention. Symposium topics included fi- nancial, emotional, and physical abuse of older adults. The coalition officially became a 501(c)(3) not-for-profit organization and established formal partnerships with the Council on Aging, regional bank, sheriff’s depart- ment, prosecutor’s office, and regional health system. Over time, the coalition was able to develop program- ming, which was regularly attended by older adults and their family members, and implement an intervention to provide emergency sheltering for older adults identified by police officers, social workers, or emergency nurses as victims of physical abuse. The coalition was effective based on the social capital developed among the coali- tion members and their leveraging of their relationships with other agencies. Social Justice Addressing health disparities comes under the umbrella of social justice , defined by the Merriam-Webster dic- tionary as “a state or doctrine of egalitarianism.” 43 In other words, because health disparities represent a lack of equality in health outcomes among groups, it is im- portant to adopt a doctrine of social justice related to health and to strive to promote equitable opportunities to maximize the health of individuals and communities. The Commission on the Social Determinants of Health convened by the WHO in 2005 concluded that “social
fact quickly adopting the use of smartphones and tab- lets to access health information via the Internet. 39 This access to e-health information allows older adults to ob- tain information on disease symptoms, trajectories, and treatments. Thus, older adults as well as younger persons can increase their access to health care through the use of telehealth services, particularly if they live in remote areas with few to no primary care providers. Although the adoption of technology through apps, smartphones, and tablets has increased, some groups still experience a “digital divide.” 40 Unfortunately, there are still com- munities, particularly in rural areas, where the access to Wi-Fi is limited. This prevents people in those commu- nities from obtaining information only available online. Another concern is that persons with limited English literacy may experience a greater challenge following directions when attempting to access telehealth ser- vices. Public health nurses can help promote access to telehealth by providing telehealth directions in multiple languages, fundraising to obtain free telehealth devices to be used by low-income persons, and ensuring that other barriers to the use of telehealth are mitigated. 40 ◆ HEALTHY PEOPLE 2030 Category: Social Determinants of Health Area: Health-Care Access and Quality Goal: Increase access to comprehensive, high-quality health-care services. Objective: Decrease the proportion of adults who report poor communication with their health-care provider. Level, Baseline. HC/HIT-02 Topics Covered: Interpersonal Communications, Health Information Technology, Social Marketing, Informed Decision Making. Using Healthy People 2030 in Your Work: Identify needs and priority populations. 1. What communication methods are used routinely? 2. Are electronic health systems available for commu- nication with health-care providers? 3. Is health-care providers’ use of communication methods adjusted to the needs of patients? 4. Are communication methods age and culturally appropriate? Social Capital Social capital , defined by Puro and Kelly, is “the pres- ence and strength of social networks and relationships between people or groups, and the resources obtained
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UNIT II ■ Community Health Across Populations: Public Health Issues
justice is a matter of life and death.” 44 Although this re- port was completed nearly two decades ago, the gaps in life expectancy among countries remain. In fact, the United Nations, during the February 2022 World Day of Social Justice, described the significance of social justice as an action to improve the status of people globally. The organization pointed out that the advent of COVID-19 showcased the vulnerability of workers in informal economies, thus enhancing poverty and other inequali- ties that negatively impact people. 45 Unfortunately, there continues to be a major issue at the policy level, with the United States continuing to debate whether health is a right or a privilege. At the global level, distribution of needed health services continues to be hampered by poverty, war, and fragile infrastructure in low-income countries. The Intersection of Race, Poverty, and Place Although blacks account for only 13.4% of the U.S. pop- ulation, they account for almost 40% of persons infected with HIV when there is no biological or genetic basis for the difference (Fig. 7-5). 46 The driving factors are a “nexus of race, poverty, and place,” as demonstrated in 2014 by Gaskin and colleagues. 47 Race is a social con- struct with no biological foundation and is not a useful clinical marker for disease. However, there is evidence that demonstrates that racial inequity, developed through structural and systemic racism, facilitates many of the disparities that are experienced. 48 The Aspen Institute defines structural racism as a system in which public policies, institutional practices, cultural representations, and other norms work to reinforce racial group inequity.
Systemic racism , although similar, is said to exist in the historical, cultural, and social psychological aspects of our society. 49 Although most studies on racism are fo- cused on blacks, other populations may be at risk for demonstrations of racism that differ from those expe- rienced by blacks. Most recently, Asians and Hispanics have been subject to social and economic inequities that have led to health disparities. 50 Although not discrimi- nation based on race or ethnicity, religious profiling has risen to a level of concern, both in the United States and globally. Specifically, the Islamophobia experienced by some Muslim communities can lead to increased stress and disruption of interpersonal relationships that create health disparities and poor health outcomes. Understanding the role of poverty and place and their intersection with race should drive the development of policies aimed at addressing health disparity. Roth- stein describes the impact of government-sponsored segregation and how it has had tragic and long-term consequences for black families. 51 This segregation led to the establishment of communities with a higher level of poverty that are less apt to be able to provide community-level resources, such as grocery stores, parks and recreation facilities, quality schools, and pub- lic transportation. There are also fewer employment op- portunities and limited access to health care. 47 Based on the WHO list of 10 facts on health inequities and their causes, 52 addressing health disparity requires more than improving treatments for specific diseases. Specifically, it defines the causes as “an unequal distri- bution of income, power and wealth.” It requires a more comprehensive approach in which health-care services are linked with social services. 53 Furthermore, it is vitally important to include the community in the development of strategies that are aligned with their values and beliefs to effectuate positive changes in health outcomes. ● APPLYING PUBLIC HEALTH SCIENCE The Case of the Physicianless Children Public Health Science Topics Covered • Community assessment • Health planning Emily, a school nurse in a large community-based public elementary school, recognized the increasing di- versity among the students. Many first-generation immi- grants have moved into the lower-income, working-class community served by the school. Emily found that, among the students, 15 different languages were spoken
Figure 7-5 New HIV infections by race, 2019. (Source: Reference [46])
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Chapter 7 ■ Health Disparities and the Social Determinants of Health
at home as the primary language, particularly among the 40% of the students whose families came from Asia, Africa, South America, and Central America. The make up of the rest of the students is 40% black, 10% second-generation Hispanic, and 10% white. Emily reviewed the health statistics for the population at her school from the beginning of the school year. In this school, she found disparities in disease and illness rates compared with those in other schools in the district: • 32% of students were not completely immunized compared with 3% at other schools. • 51% of students had not received the required physical examination. • There was a higher-than-average rate of failure for the vision and hearing screening tests. • There was a higher absenteeism rate. • 67% of students had not seen a dentist compared with 31% at the other schools. • 24% of the students were overweight but not much more than the students in the other community schools. • Students between 5 and 8 years old had a higher rate of asthma than children of the same age in other schools in the same district. Emily wondered if one of the issues facing these families was access to care. To help determine what barriers to health care the families might be experi- encing, she examined the students’ school records in more detail, as well as resources available within the neighborhood. She found that: • Few students had a primary care physician listed in their school record. • The nearest pediatric and family practice clinics required that families using the bus system make a minimum of two transfers. Emily wished to gather more data from the parents but was challenged by the language barriers and by the fact that most of the parents worked during school hours. She sought interpreters in the community for the different languages spoken at home and then set up focus groups (see Chapter 4) with parents to help find out more about why the students had received less health care than students in the other schools in the district, especially preventive care. Although she was unable to conduct a focus group with all of the different groups within the community, she was able to include immigrant, Hispanic, black, and
white parents. For all of the parents, a central issue was the difficulty of getting to the primary care clinics located outside the neighborhood because it required taking two to three buses with time-consuming trans- fers, and the offices were only open during working hours. They said the clinics were very crowded, and when they finally got to see someone, they often had less than 10 minutes with the care provider. For the non-English-speaking parents, translators were rarely available. The parents, even those with English as their primary language, reported that going to the clinic had little value because often they did not understand what the health-care provider was telling them; the suggested steps for prevention weren’t always possible to carry out (“I can’t afford all that fancy fruit!”); and often min- imal explanation was provided related to any prescrip- tions, including where to get them filled. When their children were really sick, most of the parents used the urgent care clinic in the community, but this required up-front payment, so they often delayed going until their child was really sick, which often meant a trip to the ED. The parents mentioned that the department of public health provides free immunization clinics and school physicals for a nominal charge, but they pointed out they cannot afford to miss a day of work without pay to bring their children. They wished the clinics were open on Saturday or in the evenings. Based on the data from these focus groups, Emily identified several factors in the health-care system that contrib- uted to the health-care disparity at her school: • Limited access to care • Lack of primary care practitioners in the overburdened clinics • No primary health care in the immediate neighborhood • Health department clinic hours inaccessible to the working population in the community • Limited public transportation • Lack of translators at the clinics She invited parents, teachers, and staff to at- tend a series of early-evening meetings to strategize about how some of these factors could be mitigated to reduce the disparity. She promised to invite a Spanish-speaking interpreter for those parents who could not speak English. Several of the teachers and the school counselor saw this as an important component of school health and also agreed to at- tend. She encouraged the families to bring others from the community. She pointed out that it is really
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UNIT II ■ Community Health Across Populations: Public Health Issues
Public Health Organization Responses to Health Disparities and Inequity Universal Declaration of Human Rights The Universal Declaration of Human Rights , adopted by the General Assembly of the United Nations in 1948, continues to provide the underlying framework for equity in health at the WHO and down through national- and state-level approaches to improving health equity. 54 The Declaration consists of 30 articles that serve as a standard of achievement for all nations to measure compliance with human rights and funda- mental freedoms. Article 25 states, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, medical care and necessary social services, and the right to security in the event of un- employment, sickness, disability, widowhood, old age, or other lack of livelihood in circumstances beyond his control.” 54 Articles 22 to 27 are most specific to equity in health care, examining economic, social, and cul- tural rights (Box 7–1). In 1978, at the International Conference on Primary Care, the Alma-Ata Declaration affirmed these human rights (see Chapter 16). 55 The goal was to see the pro- vision of primary health care to every individual by the year 2000, thus achieving the goal of health care for all. The second section of the Alma-Ata Declaration stated, “The existing gross inequality in the health status of the people particularly between developed and develop- ing countries as well as within countries is politically, socially, and economically unacceptable and is, there- fore, of common concern to all countries.” 55 In the 21st century, the WHO continues to advocate for reducing health inequity based on the concept that health is a fun- damental human right. 5 United States Healthy People 2020 stated that the impact of social and physical determinants of health “affect a wide range of health, functioning, and quality of life outcomes” 56 and provided several examples (Box 7–2). 56 As noted earlier, HP 2030 ’s foundational principles note that “[a]chiev- ing health and well-being requires eliminating health disparities, achieving health equity, and attaining health literacy,” and that “[h]ealthy physical, social, and eco- nomic environments strengthen the potential to achieve health and well-being.” 57 Along with Healthy People, several U.S. national-level organizations have placed health equity as a priority. The
a community issue and not just a school issue. Emily valued the time of all these stakeholders and tried to be organized to help them arrive at some clear out- comes by the end of each meeting. The group had three meetings. Participants offered suggestions and concrete plans to be implemented, with some to be done at the school and others in the community. The suggested collaborative actions included the following: • Improve access to care. • With the partnership of the local public health department, provide an immunization clinic and school physicals one evening a month (or on Saturday) at the school. • Negotiate with one of the primary care clinics outside the community and the board of education to provide a satellite comprehensive clinic at the school, developing underutilized school space. • Provide information at the school about the insurance and other health program eligibilities for children of low-income working parents. • Bridge cultural and literacy gaps. • Develop evening English as a second language (ESL) classes for the parents, coordinated by one teacher at the school, a local social service agency, and volunteers from the local community college. • Start monthly cultural programs organized by the school parent–teacher association to showcase all of the cultures at the school and facilitate more com- munication among the parents. • Create information tools that can be used by people with low health literacy to gain information on common childhood illnesses; health promotion and disease prevention actions; and new skills the fami- lies can use, even with limited resources, to navigate the U.S. health-care system. Offer to share these information tools with the local primary care clinics. • Communicate with the clinics about the need to provide required translation services, either with trained, certified volunteers, including college students, or with a telephone translation service. With the assistance and support of the community, Emily and the planning group were ready to design actions to implement some of these changes. Emily received two neighborhood development grants to help cover program implementation. The next steps in the process included looking for sustainable funding for an ongoing school health program aimed at reduc- ing the gap in access to care.
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