159
Chapter 7 ■ Health Disparities and the Social Determinants of Health
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
Powered by FlippingBook