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Here are 2 truisms. Rich countries have better health than poor countries, and medical care improves health. Consider, then, the case of the United States, which is among the richest countries in the world and spends more than any other country on medical care, US $6350 per person in 2005.1 Does the United States then have the best health? Not quite. Life expectancy from birth to age 65 years is one useful measure of premature mortality: the United States ranks 36th in the world for men and 42nd for women.2 If not by greater national income or more spending on medical care, how should the task of improving health in the United States be approached? Pay attention to the social determinants of health.
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. 2009;301(11):1169-1171 (doi:10.1001/jama.2009.363) JAMA
Michael G. Marmot; Ruth Bell
Commission on Social Determinants of Health
Action on Health Disparities in the United States:
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3. National Center for Health Statistics. Health, United States, 2007: With Chart-
book on Trends in the Health of Americans. Hyattsville, MD: National Center for
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Education and health calculator.
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ert Wood Johnson Foundation to the Commission to Build a Healthier America.
Princeton, NJ: Robert Wood Johnson Foundation; 2008. http://www Accessed Febru-
ary 9, 2008.
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personal choice, environmental exposures, and health care. In: Scutchfield FD,
Keck W, eds. Principles of Public Health Practice. 3rd ed. Clifton Park, NY: Del-
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both matter. Health Aff (Millwood). 2005;24(2):343-352.
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resolving racial disparities: an analysis of US mortality data. Am J Public Health.
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11. Smolensky E, Danziger S, Gottschalk P. The declining significance of age: trends
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Washington, DC: Urban Institute Press; 1988:29-54.
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Rev. 2002;92:999-1012.
13. Cole BL, Fielding JE. Health impact assessment: a tool to help policy makers
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related mortality: U.S. trends, 1989-2005. Am J Prev Med. 2009;36(2):126-
Action on Health Disparities
in the United States
Commission on Social Determinants of Health
Michael G. Marmot, FRCP
Ruth Bell, PhD
health than poor countries, and medical care im-
proves health. Consider, then, the case of the
United States, which is among the richest coun-
tries in the world and spends more than any other country
on medical care, US $6350 per person in 2005.1Does the
United States then have the best health? Not quite. Life ex-
pectancy from birth to age 65 years is one useful measure
of premature mortality: the United States ranks 36th in the
world for men and 42nd for women.2If not by greater na-
tional income or more spending on medical care, how should
the task of improving health in the United States be ap-
proached? Pay attention to the social determinants of health.
Commission on Social Determinants of Health
Because of concern with global health inequity the director-
general of the World Health Organization established the
Commission on Social Determinants of Health (CSDH) in
2005. The CSDH produced recommendations, based on evi-
dence, about what could be done to further the cause of health
equity.3The CSDH highlighted inequities between coun-
tries—life expectancy at birth in Zambia (41.2 years) is half
that of Japan (82.4 years)4—but also health inequities within
countries (such as the United States) that can be dramatic.
Within the Scottish city of Glasgow, there is a 28-year gap
in life expectancy between the richest and poorest areas;
among the poorest, male life expectancy is 8 years less than
the average life expectancy in India.3The gap in life expec-
tancy between men in Washington, DC, and in suburban
Maryland is 17 years.3Rich countries have no cause for com-
placency. The CSDH was oriented to countries at low, me-
dium, and high income.5
The gap between top and bottom highlights the magni-
tude of the difference in health outcomes but the CSDH em-
phasized the graded relation between socioeconomic posi-
tion and health, the social gradient that exists within
countries.6A previous comparison of men and women aged
55 to 64 years demonstrated the social gradient in health
and showed higher illness rates in the United States than in
England,7consistent with shorter life expectancy to age 65
years in the United States. At every point along the scale of
income or education, the health of Americans was worse than
that of the English.
Author Affiliations: International Institute for Society and Health and Depart-
ment of Epidemiology and Public Health, University College London, London, En-
gland. Dr Marmot was chair of the World Health Organization Commission on
Social Determinants of Health, 2005-2008. Dr Bell is a senior research fellow at
University College London and was a member of the Commission on Social De-
terminants of Health Secretariat.
Corresponding Author: Michael G. Marmot, FRCP, Department of Epidemiology,
University College London, 1-19 Torrington Pl, London, England WC1E 6BT (m
©2009 American Medical Association. All rights reserved. (Reprinted) JAMA, March 18, 2009—Vol 301, No. 11 1169
at CDC-Information Center on March 19, 2009 www.jama.comDownloaded from
The CSDH call for action on social determinants of
health also applies to differences between ethnic groups.
It has been estimated that in the United States 886 202
deaths could have been averted between 1991 and 2000 if
mortality rates between white and black individuals had
been equalized.8
Health inequities between the worst off and the best off
in rich countries and the social gradient in health imply that
the focus should not only be on absolute material depriva-
tion. The poor of Glasgow or Washington, DC, are not poor
by global standards. In Glasgow and in Washington, DC,
tap water is fit to drink, food is rarely contaminated and is
plentiful, and although there are a few exceptions, no one
lives in squatter settlements. In India 76% of the popula-
tion live on $2 a day or less4; yet men in India, on average,
have longer life expectancy than the poorest men of Glasgow
and about the same as men in Washington, DC.
This comparison with India shows how powerful the ac-
tion of social determinants can be—rivaling the effects of
material deprivation—a lesson also conveyed by the gradi-
ent in health observed in both rich and poor economies. A
further and crucial implication of the gradient is that ineq-
uities in health apply to everyone below the top socioeco-
nomic position. Therefore, social action should deal with
the entire gradient, and all of society, not only with those
at the bottom.
Evidence shows that the slope of a health gradient is not
fixed; it is responsive to political, social, and economic
changes. The gradient in adult mortality by educational level
worsened in Russia after 1992 following the political, so-
cial, and economic upheaval caused by the breakup of the
Soviet Union.9In the United States, the gradient in life ex-
pectancy by socioeconomic deprivation has worsened for
both men and women since 1980.10
Health and Health Inequities
in the United States
The Commission’s recommendations for action to pro-
mote health equity are based on 3 principles of action: im-
prove the circumstances in which people are born, grow,
live, work, and age; tackle the inequitable distribution of
power, money, and resources—the structural drivers of con-
ditions of daily life—globally, nationally, and locally; and
measure the problem, evaluate action, and expand the knowl-
edge base.3
Several themes from the CSDH report that are, among oth-
ers, highly relevant to inequities within the United States
are as follows.
Health Care. Globally, every year at least 100 million in-
dividuals are forced into poverty because of out-of-pocket
health expenditures.3In the United States, the maldistribu-
tion of availability of health care rightly claims much atten-
tion. But this should not distract from attention to other
social determinants of health. The United States spends
about 2.5 times more per person on medical care than the
English. In the comparison of English and US adults, re-
ferred to above, more than 90% of participants had health
insurance.7Nevertheless, the Americans had worse health
than did the English.
Equity From the Start. The CSDH placed great empha-
sis on early childhood development and education. The
relation between education and health in adult life is clear.
To the extent that this relation is causal, it is important to
improve the education of children, particularly those born
to parents who themselves have low educational attain-
ment. A recent Organisation for Economic Co-operation
and Development (OECD) report11 gives scant encourage-
ment to the United States. It evaluated math scores of
15-year-olds in relation to their parents’ education. Those
whose parents had low educational achievement per-
formed worse than those whose parents were highly
educated—but the deficit in the United States was greater
than the average for all OECD countries. In Sweden, for
example, parents’ educational status made less difference
to the math scores of 15-year-olds.
Fair Financing. Within countries, observational data
show that income is correlated with mortality and life
expectancy; however, between rich countries, there is
little relation between a country’s national income and
life expectancy. An interpretation, then, of the correlation
of income to mortality within a rich country such as the
United States is that income is a marker of relative posi-
tion within society; relative position, in turn, is related to
social conditions that are important for health including
good early childhood development, access to good-
quality education, rewarding work with some degree of
autonomy, decent housing, and a clean and safe living
Increasing levels of income inequality in a society are likely
to lead to a worsening of the relative position of those with
lower standing in the socioeconomic hierarchy. This is not
to enter the debate as to whether income inequality, per se,
is related to a country’s overall level of life expectancy. It is
to say, however, that if relative position worsens, condi-
tions for those at the bottom will be relatively worse than
for those at the top.
Real earnings of US working men whose starting full-
time salaries were below the median declined between 1980
and 2005, while real earnings increased for men earning
higher incomes.11 By contrast, real earnings increased be-
tween 1980 and 2003 across all income deciles in the United
Kingdom, although the income of higher earners increased
more than that of lower earners.11 The United States has the
third highest poverty rate (50% median income) in OECD
countries, below Turkey and Mexico and well above aver-
age for OECD countries. Furthermore, the United States
ranks fourth in the OECD for disposable income inequal-
ity.11 Market income and disposable income inequalities and
poverty rates are susceptible to government economic and
social policy choices.
1170 JAMA, March 18, 2009—Vol 301, No. 11 (Reprinted) ©2009 American Medical Association. All rights reserved.
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The Individual and Society
The way society is organized through political choices in-
fluences health outcomes, but the individual is not lost in
the CSDH’s approach,12 which emphasizes collective and in-
dividual empowerment, including material, psychosocial,
and political empowerment. Individuals need basic mate-
rial conditions for health, control over their lives, and ac-
tive participation in decisions that affect their lives. The aim
of public policy should be to create the social conditions to
meet these needs.3
Putting Social Determinants of Health
Into Practice to Improve Population Health
Positioning health equity as a key performance indicator in
all social and economic policy making has the potential
to drive significant reductions in health inequities.3
How would this work in practice? Early childhood
development—including the physical, social-emotional,
and language-cognitive domains—is among the key areas
for action described by the CSDH.3President Obama’s com-
mitment to prioritize early childhood education is therefore
The current global economic crisis brings work and em-
ployment conditions into sharp focus. Since December 2007,
the start of the recession, 3.6 million jobs have been lost in
the United States.13 Job insecurity, unemployment, and de-
terioration of working conditions are all potentially harm-
ful to population health and require urgent attention.
Former CSDH commissioners Wilensky and Satcher14 hold
the view that action across the social determinants may gain
bipartisan support in the United States. The Robert Wood
Johnson Foundation has set up the Commission to Build a
Healthier America with a strong focus on what can be done
across the social determinants of health.15
The CSDH’s findings and recommendations are neces-
sarily general because of their global application. The rec-
ommendations require “translation” into specific policies
for particular country contexts. Several countries are in the
process of doing this: Chile, Brazil, Argentina, Sri Lanka,
Thailand, and a number of European countries. In En-
gland, Prime Minister Gordon Brown16 said: “[T]he health
inequalities we are talking about are not only unjust,...they
also limit the development and the prosperity of commu-
nities, whole nations, and even continents.” He an-
nounced an independent review of health inequalities in En-
gland (chaired by M.G.M.) that is taking the CSDH’s
recommendations and developing evidence-based strategy
across social and economic policy areas to improve health
equity. Other countries around the world are taking ac-
tion.3What is needed? Put simply: leadership from the top
of government, action across social and economic policy
areas, and participation from communities across society.
Action needs to take place at local, regional, national, and
global levels.
The international response to the current global finan-
cial crisis provides the opportunity for the international com-
munity to recommit to a more representative multilateral
system with fairer participation by all countries and the op-
portunity to place health equity at the heart of multilateral
policy development in areas including trade, finance, re-
sponses to climate change, and international security. The
United States has a leading role internationally. A world of
hope and expectation rests on the new US president. How
will President Obama respond to the commission’s call to
Financial Disclosures: None reported.
Funding/Support: Dr Marmot is supported by an MRC research professorship. The
CSDH was established by the World Health Organization and received financial
support from the International Development Research Centre, Open Society In-
stitute, Public Health Agency of Canada, Purpleville Foundation, Robert Wood
Johnson Foundation, Swedish National Institute of Public Health, United King-
dom Government, and the World Health Organization.
Role of the Sponsor: The organizations did not participate in preparing, review-
ing, or approving this manuscript.
Disclaimer: The views presented in this Commentary are those of the authors and
do not necessarily represent the views, decisions, or stated policy of the World
Health Organization.
Additional Contributions: We thank all those who contributed to the work of the
Commission on Social Determinants of Health (2005-2008).
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©2009 American Medical Association. All rights reserved. (Reprinted) JAMA, March 18, 2009—Vol 301, No. 11 1171
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... In the U.S., marginalized racial and ethnic communities are more likely to have inadequate housing, lower quality education, an unclean environment, and negative health outcomes, even when controlling for personal characteristics [15][16][17]. Exposure to pollution and environmental contaminants is higher among these marginalized groups, highlighting continued instances of environmental injustice [14]. Research has shown that race and ethnicity are related to a community's obesity rates, exposure to air pollution, lack of access to green spaces, and lower overall life satisfaction [14,15,18,19]. ...
... We also consider the role of socioeconomic status, encompassing education, income, and home ownership. The U.S. has above-average rates of poverty and disposable income inequality compared to other developed countries [16]. Homeownership historically represents higher levels of SES; it is directly associated with wealth accumulation, community building, neighborhood stability, and overall economic well-being [20,21]. ...
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This study investigates the relationships between environmental health literacy, the characteristics of people (race, ethnicity, and socioeconomic status) associated with health disparities, and people’s willingness to engage in protective behaviors against environmental health threats. Environmental health literacy is a framework for capturing the continuum between the knowledge of environmental impacts on public health, and the skills and decisions needed to take health-protective actions. We pay particular attention to three dimensions of environmental health literacy: factual knowledge (knowing the facts), knowledge sufficiency (feeling ready to decide what to do), and response efficacy (believing that protective behaviors work). In June 2020, we collected survey data from North Carolina residents on two topics: the viral infection COVID-19 and industrial contaminants called per- and polyfluoroalkyl substances (PFAS). We used their responses to test stepwise regression models with willingness to engage in protective behaviors as a dependent variable and other characteristics as independent variables, including environmental health literacy. For both topics, our results indicated that no disparities emerged according to socioeconomic factors (level of education, household income, or renting one’s residence). We observed disparities in willingness according to race, comparing Black to White participants, but not when comparing White to American Indian, Alaska Native, Asian, Native Hawaiian, or Pacific Islander participants nor Hispanic to non-Hispanic participants. The disparities in willingness between Black and White participants persisted until we introduced the variables of environmental health literacy, when the difference between these groups was no longer significant in the final regression models. The findings suggest that focusing on environmental health literacy could bridge a gap in willingness to protect oneself based on factors such as race/ethnicity and socioeconomic status, which have been identified in the environmental health literature as resulting in health disparities.
... This literature has shown that low education is a risk factor for tobacco use in pregnancy [21,29,35,41]. Extensive work by Marmot [42][43][44][45], Link and Phelan [46][47][48], Ross and Mirowsky [13,14,49,50] and others [51] have shown SES as protective against risk behaviors such as tobacco. ...
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Educational attainment is among the most substantial protective factors against cigarette smoking, including during pregnancy. Although Minorities’ Diminished Returns (MDRs) of educational attainment, defined as weaker protective effect of education for racial and ethnic minority groups compared to Non-Hispanic Whites, has been demonstrated in previous studies; such MDRs are not tested for cigarette smoking during pregnancy. To better understand the relevance of MDRs to tobacco use during pregnancy, this study had three aims: firstly, to investigate the association between educational attainment and cigarette smoking in pregnant women; secondly, to compare racial and ethnic groups for the association between educational attainment and cigarette smoking; and thirdly, to explore the mediating effect of poverty status on such MDRs, among American adults during pregnancy. This cross-sectional study explored a nationally representative sample of pregnant American women (n = 338), which was taken from the Population Assessment of Tobacco and Health (PATH; 2013). Current smoking was the outcome. Educational attainment was the independent variable. Region and age were the covariates. Poverty status was the mediator. Race and ethnicity were the effect modifiers. Overall, a higher level of educational attainment (OR = 0.54, p < 0.05) was associated with lower odds of current smoking among pregnant women. Race (OR = 2.04, p < 0.05) and ethnicity (OR = 2.12, p < 0.05) both showed significant interactions with educational attainment on smoking, suggesting that the protective effect of educational attainment against smoking during pregnancy is smaller for Blacks and Hispanics than Non-Hispanic Whites. Poverty status fully mediated the above interactions. In the United States, highly educated pregnant Black and Hispanic women remain at higher risk of smoking cigarettes, possibly because they are more likely to live in poverty, compared to their White counterparts. The results suggest the role that labor market discrimination has in explaining lower returns of educational attainment in terms of less cigarette smoking by racial and ethnic minority pregnant women.
... At the societal level, job insecurity, unemployment, and deterioration of working conditions are important social determinants that can affect physical and mental health (Manseau, 2014;Marmot & Bell, 2009). Economic stability has been compromised as the U.S. economy slowed during COVID-19 leading to lost jobs, salary reductions, and unpaid leaves (Logan, 2020). ...
Background Protection motivation to practice preventive behaviors is necessary for sustained mitigation during coronavirus disease 2019 (COVID-19); however, limited research exists on the ecological sources of influence for COVID-19 protection motivation. Aim To explore sources of influence (family health, media consumption, and loss of work hours) on COVID-19 protection motivation. Method An online quantitative survey of U.S. adults ( N = 501) aged 18 years or older was administered using Qualtrics with participants recruited through Amazon Mechanical Turk. Data were collected on constructs related to the protection motivation theory and theory of planned behavior as well as sources of influence and intention to socially distance and socially isolate during COVID-19. Constructs were further defined through exploratory and confirmatory factor analyses. Structural equation modeling was used to determine relationships between constructs. Results A two-factor model was identified with threat appraisal as one factor and subjective norms appraisal, coping appraisal, and behavioral intention loading as another factor. Higher news media consumption and loss of work hours due to COVID-19 were both significant predictors of increased threat appraisal. Family healthy lifestyle and family health resources were significantly related to increases in the subjective norms, coping appraisal, and behavioral intention appraisal factor. Conclusions Family health, news media consumption, and loss of work hours are associated with COVID-19 protection motivation. COVID-19 protection motivation might be enhanced through policies and messaging that can affect ecological sources of influence.
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Background High-risk pregnancies require increased health and care resources to reduce the severe perinatal consequences. The adoption of a health-promoting lifestyle and social determinants is an important strategy for achieving the desired outcomes of pregnancy. This study aimed to compare intermediate determinants of social health in low and high-risk pregnant women. Methods This unmatched case-control study was performed with a ratio of 1: 2 and 300 pregnant women including 200 healthy and 100 pregnant women with gestational hypertension were included using the available sampling technique. Data were collected using socio-demographic and obstetrics, Health-promoting behaviors, Self-efficacy, Perceived stress, and Social support questionnaires by the self-report method. Results There was no significant difference in the demographic characteristics between the two groups, except for the spouse's education status. The total score of health-promoting behaviors and social support in the healthy group was significantly higher than women with gestational hypertension. However, the perceived stress in women with gestational hypertension was significantly higher than in the healthy group. In the multivariate analysis, those women with high stress [AOR 1.13, 95% CI (1.08–1.18)] and whose Spouse’s Educational status was low [AOR 4.94, 95% CI (1.54–15.81)] had higher odds of gestational hypertension than women who haven’t respectively. The development of gestational hypertension was decreased by increasing the score of social support [AOR 0.96, 95% CI (0.93–0.98)]. The results showed that the two variables of social support (β=0.331) and self-efficacy (β=0.215) have the greatest impact on the score of health-promotion behaviors, respectively. Based on regression analysis, 21.2% of the health-promotion behaviors changes could be explained by three independent variables. Conclusion Women with gestational hypertension have unhealthier lifestyles. Having a high level of stress is a risk factor for gestational hypertension but Social support has a protective effect on it. Recognizing the risk factors of gestational hypertension could help the determination of high-risk cases and it is important to pay attention to women's psychosocial to create appropriate sources of social support and provide the necessary action to reduce stress.
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Environmental justice (EJ) is a broad discipline that attempts to understand and redress unfair exposure to unhealthy environmental conditions. EJ is often made measurable with indicators, however the capabilities and the limitations of EJ indicators can be difficult for policy makers to understand. Using an exploratory review of EJ literature, this paper performs a research translation role by clarifying the key terms used to describe EJ indicators and by providing conceptual frameworks for developing locally valid EJ indicators for government and community. Issues such as the position of EJ in the context of the social determinants of health, indicator development, and definitions are explored. The exploratory literature review highlighted the potential and limitations of EJ indicators for measuring the extent and impact of EJ issues on human health and the environment. We found that EJ indicators are invariably (1) composed of two or more measures, and (2) developed iteratively, in consultation with those affected. To aid governments and communities, we present both a top-down and a bottom-up framework for developing EJ indicators, with the bottom-up framework guiding the combination of measures from four different core elements; environment, demography, epidemiology and procedures. A list of evidence-based example measures, from the literature, for developing EJ indicators is also provided. It is anticipated that the frameworks and list of EJ example measures will provide guidance for efficiently developing locally relevant EJ indicators.
The advances in pediatric cancer outcomes over the last quarter century are some of the most successful in modern medicine. Improved diagnostics and novel therapies have led to continued increases in the survival rates of most patients; however, not all populations have benefitted equally. Compared to White children, Black, Indigenous, People of Color patients with cancer more often present with advanced stage illness, less frequently participate in clinical trials, and are more likely to be lost to follow-up once therapy is complete. Proposed hypotheses for these disparities include both biologic and nonbiologic factors, and a growing body of research suggests that barriers influencing care from diagnosis through survivorship are important. In this article, we consider how primary pediatricians can help reduce disparities over the cancer continuum by identifying vulnerable populations, considering potential diagnoses, referring to cancer centers, and following up with patients through survivorship in partnership with the oncology team. [Pediatr Ann. 2022;51(1):e22-e26.].
Despite common perceptions to the contrary, pandemic diseases do not affect populations indiscriminately. In this paper, we review literature produced by demographers, historians, epidemiologists, and other researchers on disparities during the 1918–20 influenza pandemic and the Covid-19 pandemic. Evidence from these studies demonstrates that lower socio-economic status and minority/stigmatized race or ethnicity are associated with higher morbidity and mortality. However, such research often lacks theoretical frameworks or appropriate data to explain the mechanisms underlying these disparities fully. We suggest using a framework that considers proximal and distal factors contributing to differential exposure, susceptibility, and consequences as one way to move this research forward. Further, current pandemic preparedness plans emphasize medically defined risk groups and epidemiological approaches. Therefore, we conclude by arguing in favour of a transdisciplinary paradigm that recognizes socially defined risk groups, includes input from the social sciences and humanities and other diverse perspectives, and contributes to the reduction of health disparities before a pandemic hits.
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Background Screening in primary care for unmet individual social needs (e.g., housing instability, food insecurity, unemployment, social isolation) is critical to addressing their deleterious effects on patients’ health outcomes. To our knowledge, this is the first study to apply an implementation science framework to identify implementation factors and best practices for social needs screening and response. Methods Guided by the Health Equity Implementation Framework (HEIF), we collected qualitative data from clinicians and patients to evaluate barriers and facilitators to implementing the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE), a standardized social needs screening and response protocol, in a federally qualified health center. Eligible patients who received the PRAPARE as a standard of care were invited to participate in semi-structured interviews. We also obtained front-line clinician perspectives in a semi-structured focus group. HEIF domains informed a directed content analysis. Results Patients and clinicians (i.e., case managers) reported implementation barriers and facilitators across multiple domains (e.g., clinical encounters, patient and provider factors, inner context, outer context, and societal influence). Implementation barriers included structural and policy level determinants related to resource availability, discrimination, and administrative burden. Facilitators included evidence-based clinical techniques for shared decision making (e.g., motivational interviewing), team-based staffing models, and beliefs related to alignment of the PRAPARE with patient-centered care. We found high levels of patient acceptability and opportunities for adaptation to increase equitable adoption and reach. Conclusion Our results provide practical insight into the implementation of the PRAPARE or similar social needs screening and response protocols in primary care at the individual encounter, organizational, community, and societal levels. Future research should focus on developing discrete implementation strategies to promote social needs screening and response, and associated multisector care coordination to improve health outcomes and equity for vulnerable and marginalized patient populations.
Objectives: Prior studies have found that adverse childhood experiences (ACEs) are associated with asthma prevalence and onset, presumably related to stress and increased inflammation. We hypothesized that ACEs may be associated with asthma severity as well. We studied the 2016-2017 U.S. National Survey of Children's Health dataset to explore the relationship between ACEs and pediatric asthma severity. Methods: We analyzed children ages 0-17 years-old who had current caregiver-reported asthma diagnosed by a healthcare provider. We reported descriptive characteristics using chi-square analysis of variance (ANOVA) and used multivariable regression analysis to assess the relationship of cumulative and individual ACEs with asthma severity. Survey sampling weights and SAS survey procedures were implemented to produce nationally representative results. Results: Our analysis included 3,691 children, representing a population of 5,465,926. Unadjusted analysis demonstrated that ACEs - particularly household economic hardship, parent/guardian served time in jail, witnessed household violence, or victim/witness of neighborhood violence - were each associated with higher odds of moderate/severe caregiver-reported asthma. After controlling for confounders possibly associated with both exposure (ACEs) and outcome (asthma severity), children who witnessed parent/adult violence had higher adjusted odds of caregiver-reported moderate/severe asthma. (1.67, CI 1.05-2.64, p=0.03) CONCLUSIONS: Intrafamilial witnessed household violence is significantly associated with caregiver-reported moderate/severe asthma.
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The Obama administration faces daunting challenges to reform health care. The authors, commissioners on the World Health Organization's Commission on the Social Determinants of Health, believe that strategies to improve health by affecting the social determinants may gain bipartisan support. These determinants-including the effects of poverty, education, the treatment of women, employment opportunities, and limited access to medical care for some-are as important in promoting health, if not more so, than the direct medical determinants of health. Focusing on these determinants makes more sense than waiting until people become sick and seek care, and it often costs much less.
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The US health system spends far more on the "technology" of care (e.g., drugs, devices) than on achieving equity in its delivery. For 1991 to 2000, we contrasted the number of lives saved by medical advances with the number of deaths attributable to excess mortality among African Americans. Medical advances averted 176,633 deaths, but equalizing the mortality rates of Whites and African Americans would have averted 886,202 deaths. Achieving equity may do more for health than perfecting the technology of care.
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The United States spends considerably more money on health care than the United Kingdom, but whether that translates to better health outcomes is unknown. To assess the relative heath status of older individuals in England and the United States, especially how their health status varies by important indicators of socioeconomic position. We analyzed representative samples of residents aged 55 to 64 years from both countries using 2002 data from the US Health and Retirement Survey (n = 4386) and the English Longitudinal Study of Aging (n = 3681), which were designed to have directly comparable measures of health, income, and education. This analysis is supplemented by samples of those aged 40 to 70 years from the 1999-2002 waves of National Health and Nutrition Examination Survey (n = 2097) and the 2003 wave of the Health Survey for England (n = 5526). These surveys contain extensive and comparable biological disease markers on respondents, which are used to determine whether differential propensities to report illness can explain these health differences. To ensure that health differences are not solely due to health issues in the black or Latino populations in the United States, the analysis is limited to non-Hispanic whites in both countries. Self-reported prevalence rates of several chronic diseases related to diabetes and heart disease, adjusted for age and health behavior risk factors, were compared between the 2 countries and across education and income classes within each country. The US population in late middle age is less healthy than the equivalent British population for diabetes, hypertension, heart disease, myocardial infarction, stroke, lung disease, and cancer. Within each country, there exists a pronounced negative socioeconomic status (SES) gradient with self-reported disease so that health disparities are largest at the bottom of the education or income variants of the SES hierarchy. This conclusion is generally robust to control for a standard set of behavioral risk factors, including smoking, overweight, obesity, and alcohol drinking, which explain very little of these health differences. These differences between countries or across SES groups within each country are not due to biases in self-reported disease because biological markers of disease exhibit exactly the same patterns. To illustrate, among those aged 55 to 64 years, diabetes prevalence is twice as high in the United States and only one fifth of this difference can be explained by a common set of risk factors. Similarly, among middle-aged adults, mean levels of C-reactive protein are 20% higher in the United States compared with England and mean high-density lipoprotein cholesterol levels are 14% lower. These differences are not solely driven by the bottom of the SES distribution. In many diseases, the top of the SES distribution is less healthy in the United States as well. Based on self-reported illnesses and biological markers of disease, US residents are much less healthy than their English counterparts and these differences exist at all points of the SES distribution.
Whether a disparity in diabetes-related death across education levels is widening, narrowing, or stable is not known. This analysis examined trends in diabetes-related death by education levels over a 17-year period. The first part of the analysis calculated diabetes-related mortality rates for adults aged 40-64 years and adults aged 65-79 years using U.S. Vital Statistics data from 1989 to 2005 to provide the number of deaths per year in the U.S. (the numerator) and also U.S. Census data to provide the population size (the denominator). The second part of the analysis examined trends by education level in possible mechanisms that link education and diabetes-related mortality using the U.S. National Health and Nutrition Examination Surveys (NHANES) program in 1988-1994 and 1999-2004. Disparity in diabetes-related mortality across education levels widened from the late 1980s to 2005 overall and in the subgroups of men, women, blacks, whites, and Hispanics. Analysis of NHANES data indicated that progress in diabetes care and management (as indicated by HbA1c levels less than 8%) has helped people of all education levels but has been of greater benefit to those with higher education. The reduction of disparities in diabetes-related mortality requires improved policies and interventions that redress the slower pace of improvement in diabetes care and self-management among people with lower education.
1It justifi es its preference for action on social determinants by reasoning that “Contemporary public health interventions have often given primary emphasis to the role of individuals and their behaviours. The Commission recognizes the important role of these factors, but sets them in the wider social context in order to illustrate that behaviour and its social patterning…is largely determined by social factors. We believe that unless action also takes account of the structural drivers of inequity in behaviour, it will not tackle health inequities.” 2 Thereafter, very little attention is given to the potential of individual agency and its eff ect on health. We fully endorse the necessity of structural action, but argue against an approach for achieving good health and reducing health inequalities that has an exclusive focus on social determinants. We believe that the role of the individual should be integrated with the social determinants approach for three reasons. Firstly, plausible, individual-level determinants can be identifi ed and so need to be accepted, not least because they are integrally entwined with social factors. Secondly, we cannot assume that individual change will fl ow as a direct consequence of social and economic change. Finally, the opportunity to infl uence policy depends partly on presenting a message that accords with current government thinking. Social factors such as poverty and its sequelae substantially aff ect people’s abilities to adopt healthy behaviours; individual factors such as functional diff erences and cultural beliefs also facilitate or constrain behaviour change. Attempts to build causal hierarchies and quantify the relative explanatory power of the social versus the individual, however, are vigorously contested. 3
The Commission on Social Determinants of Health, created to marshal the evidence on what can be done to promote health equity and to foster a global movement to achieve it, is a global collaboration of policy makers, researchers, and civil society, led by commissioners with a unique blend of political, academic, and advocacy experience. The focus of attention is on countries at all levels of income and development. The commission launched its final report on August 28, 2008. This paper summarises the key findings and recommendations; the full list is in the final report.
The poor have poor health. At first blush that is neither new nor surprising. Perhaps it should be more surprising than it is. In rich countries, such as the United States, the nature of poverty has changed—people do not die from lack of clean water and sanitary facilities or from famine—and yet, persistently, those at the bottom of the socioeconomic scale have worse health than those above them in the hierarchy. Even more challenging is that socioeconomic differences in health are not confined to poor health for those at the bottom and good health for everyone else. Rather, there is a social gradient in health in individuals who are not poor: the higher the social position, the better the health. I have labeled this “the status syndrome.”1