Variations in health care (by place, race, class, gender)

Idea: Inequalities in people’s health and how they are treated are associated with place, race, class, gender, even after conditioning on other relevant variables.

The issues here are not only variations or disparities, but also how to measure, track, and talk about those variations.
Krieger et al. started the the Public Health Disparities Geocoding Project because socioeconomic data is often lacking in US public health surveillance systems. Socioeconomic deprivation contributes to racial/ethnic health disparities in more than half of the cases studied.
Davey Smith advises against using ethnicity as a proxy for socioeconomic position and advocates for incorporating both in quantitative models.
Alter et al. conclude that despite Canada’s Universal Health Care System a individual’s socioeconomic status affected access to cardiac services and increased the prevalence of mortality.
Gawande describes how medical costs can be high even in poor areas; this results from the overuse of medicine from over-treating patients and over-prescribing tests and procedures.
Marmot and Wilkinson argue that researchers should look beyond material privation to examine psychosocial effects on variation in health outcomes, particularly relative deprivation concerning individual agency and control.
Wright et al.’s study of asthma among children in low-income urban settings found a correlation between asthma, stress, and exposure to violence that suggests the need for addressing these intervening variables. However, smoking was not found to be associated with asthma attack incidence.

The articles by Bassuk, Dunn, Egede, Roger raise additional perspectives.

(This post continues a series laying out a sequence of basic ideas in thinking like epidemiologists, especially epidemiologists who pay attention to possible social influences on the development and unequal distribution of diseases and behaviors in populations [see first post in series and contribute to open-source curriculum http://bit.ly/EpiContribute].)

References

Alter, D. A., C. D. Naylor, et al. (1999). “Effects of socioeconomic status on access to invasive cardiac procedures and on mortality after acute myocardial infarction.” New England Journal of Medicine 341: 1359-1367.
Bassuk, S. S., L. F. Berkman, et al. (2002). “Socioeconomic Status and Mortality among the Elderly: Findings from Four US Communities.” American Journal of Epidemiology 155: 520-533.
Davey-Smith, G. (2000). “Learning to live with complexity: Ethnicity, socioeconomic position, and health in Britain and the United States.” American Journal of Public Health 90: 1694-1698.
Dunn, J. R. and S. Cummins (2007). “Placing health in context.” Social Science & Medicine 65: 1821-1824
Egede, L. E. and D. Zheng (2003). “Racial/Ethnic Differences in Adult Vaccination Among Individuals With Diabetes.” American Journal of Public Health 93(2): 324-329.
Gawande, A. (2009). “The cost conundrum: What a Texas town can teach us about health care.” The New Yorker (1 June).
Krieger, N., J. T. Chen, et al. (2005). “Painting a truer picture of US socioeconomic and racial/ethnic health inequalities: The Public Health Disparities Geocoding Projec.” American Journal of Public Health 95: 312-323.
Marmot, M. and R. G. Wilkinson (2001). “Psychosocial and material pathways in the relation between income and health: a response to Lynch et al ” British Medical Journal 322: 1233-1236.
Roger, V. L., M. E. Farkouh, et al. (2000). “Sex Differences in Evaluation and Outcome of Unstable Angina.” Journal of the American Medical Association 283: 646-652.
Wright, R. J., H. Mitchell, et al. (2004). “Community Violence and Asthma Morbidity: The Inner-City Asthma Study ” American Journal of Public Health 94: 625-632.

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