Social Factors Social Factors MatterMatter

Class, Race and Gender Class, Race and Gender in Health Outcomesin Health Outcomes

Differences between the wealthy Differences between the wealthy and poor nations in the worldand poor nations in the world

Children in poorer nations have a Children in poorer nations have a higher risk of dying than in wealthier higher risk of dying than in wealthier nations.nations. 98% of child deaths (10.5 million) occur 98% of child deaths (10.5 million) occur

in the poorer nations of the world.in the poorer nations of the world. Life expectancy and mortality Life expectancy and mortality

figures have gotten worse in the figures have gotten worse in the past ten years for Africa.past ten years for Africa.

Infectious and parasitic diseases are Infectious and parasitic diseases are the main causes of death in poorer the main causes of death in poorer nationsnations

Adults tend to die of non-communicable Adults tend to die of non-communicable diseases in the richer nations (9 of 10 people).diseases in the richer nations (9 of 10 people).

Poorer nations of Latin America, Asia and the Poorer nations of Latin America, Asia and the Western Pacific see 3 out of 4 deaths from Western Pacific see 3 out of 4 deaths from non-communicable diseases. non-communicable diseases.

In Africa only 1 in 3 deaths result from non-In Africa only 1 in 3 deaths result from non-communicable disease.communicable disease. 80% of the nearly 3 million deaths from AIDS occur 80% of the nearly 3 million deaths from AIDS occur

in sub-Saharan Africa.in sub-Saharan Africa.

Leading causes of death in Leading causes of death in children in developing children in developing

countriescountries 1 Perinatal conditions 1 Perinatal conditions 2 Lower respiratory infections 2 Lower respiratory infections 3 Diarrhoeal diseases 3 Diarrhoeal diseases 4 Malaria 4 Malaria 5 Measles 5 Measles 6 Congenital anomalies 6 Congenital anomalies 7 HIV/AIDS 7 HIV/AIDS 8 Pertussis (whooping cough)8 Pertussis (whooping cough) 9 Tetanus 9 Tetanus 10 Protein-energy 10 Protein-energy

Class and healthClass and health

People in lower classes tend to have more People in lower classes tend to have more health problems including psychiatric health problems including psychiatric disordersdisorders

Disparity in wealth and health is getting worseDisparity in wealth and health is getting worse

Employees within the same firm will have Employees within the same firm will have health outcomes consistent with their rank in health outcomes consistent with their rank in the firmthe firm

Class Matters: Heart Attacks, and Class Matters: Heart Attacks, and What Came NextWhat Came Next http://www.nytimes.com/indexes/200http://www.nytimes.com/indexes/200

5/05/15/national/class/5/05/15/national/class/

Unequal Treatment: Unequal Treatment: Confronting Racial and Ethnic Disparities Confronting Racial and Ethnic Disparities

in Healthcarein Healthcare

Institute of MedicineInstitute of Medicine

Access (e.g., insurance status, ability to pay for healthcare) Access (e.g., insurance status, ability to pay for healthcare) is is thethe most important predictor of the quality of healthcare most important predictor of the quality of healthcare across racial and ethnic groupsacross racial and ethnic groups

It is difficult – even artificial – to separate access-related It is difficult – even artificial – to separate access-related factors from social categories such as race and ethnicityfactors from social categories such as race and ethnicity

The bulk of research on healthcare disparities has focused The bulk of research on healthcare disparities has focused on black-white differences – more research is needed to on black-white differences – more research is needed to understand disparities among other racial and ethnic minority understand disparities among other racial and ethnic minority groupsgroups

Caveats – Caveats – Unequal TreatmentUnequal Treatment

Non

-Min

orit

y

Min

orit

yDifference

Clinical Appropriateness and Need

Patient Preferences

The Operation of Healthcare Systems and the Legal and Regulatory Climate

Discrimination: Biases andPrejudice, Stereotyping, andUncertainty

Disparity

Qua

li ty

o f H

e al th

Car

eFigure 1: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care

Populations with Equal Access to Health Care

Evidence of Racial and Ethnic Evidence of Racial and Ethnic Disparities in HealthcareDisparities in Healthcare

Disparities consistently found across a wide range of Disparities consistently found across a wide range of disease areas and clinical servicesdisease areas and clinical services

Disparities are found even when clinical factors, such as Disparities are found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and stage of disease presentation, co-morbidities, age, and severity of disease are taken into accountseverity of disease are taken into account

Disparities are found across a range of clinical settings, Disparities are found across a range of clinical settings, including public and private hospitals, teaching and non-including public and private hospitals, teaching and non-teaching hospitals, etc.teaching hospitals, etc.

Disparities in care are associated with higher mortality Disparities in care are associated with higher mortality among minorities (e.g., Bach et al., 1999; Peterson et al., among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1995)1997; Bennett et al., 1995)

What is the Evidence that Physician What is the Evidence that Physician Biases and Stereotypes May Influence the Biases and Stereotypes May Influence the Clinical Encounter?Clinical Encounter?

van Ryn and Burke (2000) - study conducted in actual van Ryn and Burke (2000) - study conducted in actual clinical settings found that doctors are more likely to clinical settings found that doctors are more likely to ascribe negative racial stereotypes to their minority ascribe negative racial stereotypes to their minority patients. These stereotypes were ascribed to patients patients. These stereotypes were ascribed to patients even when differences in minority and non-minority even when differences in minority and non-minority patients’ education, income, and personality patients’ education, income, and personality characteristics were considered.characteristics were considered.

Finucane and Carrese (1990) - Physicians more likely to Finucane and Carrese (1990) - Physicians more likely to make negative comments when discussing minority make negative comments when discussing minority patients’ cases.patients’ cases.

What is the Evidence that Physician What is the Evidence that Physician Biases and Stereotypes may Influence the Biases and Stereotypes may Influence the Clinical Encounter (cont’d)?Clinical Encounter (cont’d)?

Rathore et al. (2000) – found that medical students were Rathore et al. (2000) – found that medical students were more likely to evaluate a white male “patient” with more likely to evaluate a white male “patient” with symptoms of cardiac disease as having “definite” or symptoms of cardiac disease as having “definite” or “probable” angina, relative to a black female “patient” with “probable” angina, relative to a black female “patient” with objectively similar symptoms.objectively similar symptoms.

Abreu (1999) – found that mental health professionals and Abreu (1999) – found that mental health professionals and trainees were more likely to evaluate a hypothetical patient trainees were more likely to evaluate a hypothetical patient more negatively after being “primed” with words associated more negatively after being “primed” with words associated with African American stereotypes.with African American stereotypes.

Among Medicare Beneficiaries Enrolled in Managed Care Plans, African Americans Receive Poorer Quality of Care (Schneider et al., JAMA, March 13, 2002

20

30

40

50

60

70

80

Percent Receiving Services

BreastScreening

Eye Exams BetaBlockers

Follow-up

Health Service

WhitesBlacks

What are potential sources of What are potential sources of disparities in care?disparities in care?

Health systems-level factors – financing, Health systems-level factors – financing, structure of care; cultural and linguistic structure of care; cultural and linguistic barriersbarriers

Patient-level factors – including patient Patient-level factors – including patient preferences, refusal of treatment, poor preferences, refusal of treatment, poor adherence, biological differencesadherence, biological differences

Disparities arising from the clinical encounterDisparities arising from the clinical encounter

Differences are RealDifferences are Real

Physicians hold stereotypes that affect Physicians hold stereotypes that affect treatmenttreatment

Differences in treatment and outcome Differences in treatment and outcome CANNOT be explained away by other CANNOT be explained away by other factorsfactors

Bias and racism lead to real differences in Bias and racism lead to real differences in the treatment and outcome of minoritiesthe treatment and outcome of minorities

The National Coalition for The National Coalition for Women with Heart Women with Heart DiseaseDisease

38% of women and 25% of men will die within one year of a first 38% of women and 25% of men will die within one year of a first recognized heart attack. recognized heart attack.

35% of women and 18% of men heart attack survivors will have 35% of women and 18% of men heart attack survivors will have another heart attack within six years. another heart attack within six years.

46% of women and 22% of men heart attack survivors will be 46% of women and 22% of men heart attack survivors will be disabled with heart failure within six years. disabled with heart failure within six years.

Women are almost twice as likely as men to die after bypass Women are almost twice as likely as men to die after bypass surgery. surgery.

Women are less likely than men to receive beta-blockers, ACE Women are less likely than men to receive beta-blockers, ACE inhibitors or even aspirin after a heart attack.inhibitors or even aspirin after a heart attack.

More women than men die More women than men die of heart disease each of heart disease each year,year,

yet women receive only: yet women receive only:

33% of angioplasties, stents and bypass 33% of angioplasties, stents and bypass surgeries surgeries

28% of inplantable defibrillators and 28% of inplantable defibrillators and 36% of open-heart surgeries 36% of open-heart surgeries

Women comprise only 25% of Women comprise only 25% of participants in all heart-related research participants in all heart-related research studies. studies.

Important Points to Important Points to ConsiderConsider

Social class (which relates to occupation) is the Social class (which relates to occupation) is the most important predictor of health outcomes.most important predictor of health outcomes.

Rates of disease and death differ between regions Rates of disease and death differ between regions of the world.of the world.

Racism of health professionals explains Racism of health professionals explains differences in health care between whites and differences in health care between whites and minorities.minorities.

Sexism leads to higher rates of death among Sexism leads to higher rates of death among women with respect to heart disease.women with respect to heart disease.