Health Disparities: Untangling a complex web of causalities

Here in the United States we call them "health disparities. "Elsewhere around the globe, the terms "health inequality" or "health inequity" are commonly used.

Whatever the label, the National Institutes of Health defines them as "differences in the incidence, prevalence, mortality and burden of diseases and other adverse health conditions that exist among specific population groups." In some way they affect every ethnic, racial, gender and socioeconomic group. That means they affect all of us.

Finding out why health disparities exist is challenging. There is no quick fix or "magic bullet," Health Science Center scientists conducting research in the Southeast concede, because the problems associated with health disparities are complex and interconnected. All they can do is share what they're learning in an effort to better understand what one calls "a complex web of causalities."

CAUSALITY: HEALTH INSURANCE

R. Paul Duncan, Ph.D., chair of health services research, management and policy at the College of Public Health and Health Professions, is best known for his studies of access to various forms of medical and dental care.

"Two things are germane to health disparities health insurance coverage and health care," said Duncan, who has been the principal investigator on a series of surveys focused on health care and health insurance coverage in Florida. "Disparities in health insurance lead to disparities in access to health care, which lead to disparities in health. What we can do about health disparities and what a lot of people see as inequalities are really about access to insurance."

Duncan said even the employed struggle with obtaining health insurance coverage. Seventy-five percent of people without health insurance are either employed themselves or in a family unit where at least one person is employed.

"It's another disparity right in our face, and it's a double whammy!" he explained. "They have a connection to the work force that should allow them to get health insurance coverage, but they don't because employers don't offer it at all or the employee's share is so expensive that they can't afford to pick it up."

Ultimately, lack of insurance also leads to lost productivity and wages because people don't have access to the health care they need, Duncan said, a problem the marketplace will have to resolve.

CAUSALITY: COMMUNITY BASED APPROACH

Allyson Hall, Ph.D., research director of the UF Center for Medicaid and the Uninsured, said she doesn't look at disparities per se but rather access to care and the need for a strong community base.

Hall, also a research associate professor of health services research, management and policy, worked for the Commonwealth Fund and the United Hospital Fund of New York before joining the UF faculty in 2003.

"I'm fearful that as a nation we're not tackling this problem holistically," she said. "We're not really addressing day to day poverty what it means and how it affects people. Poverty itself involves a myriad of issues like substandard housing, not having access to good food and being depressed. These problems are real, but we're not addressing them and how they, too, affect health."

Florida has to think about tackling health disparities from the local level, Hall said, and factor in regional sets of circumstances.

Immigrants to this country also face particular challenges as they assimilate into the local culture, Hall said, a situation that often creates the so called immigrant paradox. Ironically, even though many immigrants are poor, they may have had a healthier lifestyle in their home countries than in the United States.

"After living in the U.S. for awhile, their health may start to deteriorate; for example, their cholesterol levels start creeping up probably because they're eating more hamburgers," Hall said. "That means that we're not supporting the good health practices that these immigrants bring with them when they move here."

CAUSALITY: DISEASE STAGE AT DIAGNOSIS

Health disparities are not just a matter of who gets care. They're also linked to when patients get care. How far a disease has spread or advanced when it's diagnosed is a widely accepted predictor of how patients will do over the long term, especially for those with cancer.

A report on the oral health of Americans, published in 2000 by the Office of the Surgeon General, showed there are socioeconomic, racial and ethnic groups that face disparities in terms of health status and access to care in almost every domain of oral health, said Scott Tomar, D.M.D., Dr.P.H., chair of the department of community dentistry and behavioral science and an associate professor in the College of Dentistry.

"These disparities are huge and they're just the nature of dental public health at this point in time, where we're seeing both large gains and persistent disparities in oral health status throughout most of the country," he said.

One of Tomar"s research studies focuses on oral cancer, and he notes that nationwide, the incidence of oral cancer is slightly higher among blacks than among whites. In Florida, the rate of new cases of oral cancer is actually about the same for blacks and whites, he said. But at diagnosis, UF researchers have found, black men are twice as likely as white men to be in advanced stages of cancer.

"Because of that, survival rates for these men are about half those of whites," Tomar said. "So here we have groups experiencing about the same cancer incidence rate but huge disparities in outcomes."

Similar stage of disease disparities in cancer outcomes surfaced in a study led by Charles Rosser, M.D., an assistant professor of urology in the UF College of Medicine Jacksonville.

"Even though prostate cancer mortality rates nationwide have been steadily declining during the past 10 years, that's not the case for inner city men here," said Rosser. "We found that inner city black men are almost twice as likely to be diagnosed with prostate cancer as whites and are four times more likely to be in advanced stages of the disease at diagnosis."

The usual chance of presenting with advanced disease is maybe 5 percent nationwide, Rosser said.

"Our study sample showed 16 percent for blacks and 3.8 percent for whites a statistically significant finding," he said. "Once the cancer has spread beyond the prostate, we're not looking to cure the disease we're just looking to slow its growth. The study identifies a disparity in prostate cancer screening and detection among men of differing social strata that is especially worrisome at a time when the underserved especially blacks stand to benefit most from such programs."

CAUSALITY: ACCESS TO SCREENING

Amal Khoury, Ph.D., and her colleagues in the public health program are working hard to close the gap in health disparities for underserved women who are members of minority groups, have low income or live in rural areas. For example, the researchers hope to understand the barriers that prevent underserved women from receiving breast cancer care. A main concern: a lack of access to screening.

"We have effective screening methods, such as mammograms and breast exams, to detect breast cancer at early stages," said Khoury, an associate professor of health services research, management and policy. "But not everyone has access to them."

Black, Native American and Hispanic women face a greater risk of dying after a breast cancer diagnosis than white women. Through focus group interviews with black women aged 40 or older who have low incomes, UF researchers have identified several obstacles for these women, including the fear of finding cancer, the cost of screening and treatment and the lack of awareness of screening benefits and guidelines.

"We're also studying the referral behaviors of primary care physicians, as a doctor's recommendation is a key factor in whether or not a woman gets breast cancer screening," said Khoury.

Uninsured women and those who miss annual checkups are less likely to be referred to screening. Other barriers to making referrals include physicians' time constraints and reliance on other providers to deliver primary care.

"Everything about health disparities is interconnected," Khoury added. "A complex web of causalities leads to disparities."

Single mothers and women moving from the safety net of welfare to working world are especially vulnerable to becoming caught in that web.

Shawn Kneipp, Ph.D., A.R.N.P., an associate professor in the College of Nursing, investigates how health disparities may be exacerbated or alleviated by welfare policy. She has found that women on welfare often contend with health issues that, if not addressed while in social programs, make it difficult for them to transition to a full time job.

Kneipp recently received a $1.4 million NIH grant to conduct an innovative community-based participatory research study intended to improve the health of women transitioning from welfare to work and extend employment duration.

"If health needs aren't addressed as women make the transition from welfare into employment, you often have the 'revolving door' issue of losing employment and returning to welfare. Health issues have been identified in previous studies as a reason why women have difficulty maintaining employment after a welfare exit," Kneipp said. "In our current study we want to create a uniform intervention to address the health needs of women in Welfare Transition Programs that could be implemented nationally."

CAUSALITY: GEOGRAPHIC RESIDENCE

Another UF study is the first to statistically relate region of residence to measures of child health outcomes.

"Hurricane Katrina gave the world a glimpse of the disparities in the South," said Jeffrey Goldhagen, M.D., M.P.H., an associate professor of community pediatrics at the College of Medicine Jacksonville. "Our research documents just how profoundly these disparities impact the health of children in the region."

The research shows that children living in the South are up to three times more likely to battle poor health and its consequences including obesity, teen pregnancy and death than those in all other regions of the country, even if they receive the same medical care.

"In fact, we now believe that where a child lives may be one of the most powerful predictors of child health outcomes and disparities," Goldhagen said.

The poor health outcomes documented in the study included low birth weight, teen pregnancy, death and other problems such as mental illness, asthma, obesity, tooth decay and school performance.

Children who live in eight of the 10 states the researchers defined as the Deep South (Mississippi, Louisiana, Arkansas, Tennessee, Alabama, Georgia, North Carolina and South Carolina), are two to three times more likely to die or have other health problems compared with children living in some states in other regions of the country, Goldhagen said. The reasons for these risks are complex and are related to social, economic and other public policies in the South, he said.

"These policies, which consign 50 percent of children to poverty, neglect quality early education, generate huge income disparities, result in homelessness and limit access to quality nutrition and critical health services, may differentiate children in the South from those in other regions," he said.

A TANGLED WEB

The more tangled the web of causalities, the more challenging health disparities become and the more we learn that they're not necessarily what we assume they are.

"They're insidious and they're everywhere, but there's an important distinction between a health-care difference and a disparity," Duncan said.

He gave this example: There are huge differences in rates of mammography between men and women, and no one would argue that that constitutes a disparity. But, if there are differences in rates of mammography between black women and white women, then that difference becomes a disparity.

How some differences are just differences and how others are disparities is an important and fairly subtle question that deals with questions of fairness, social justice and whether there is some reasonable medical explanation for the difference, he said.

"If there is a medical explanation, the difference is not necessarily a disparity," said Duncan. "That's where much of the discussion should take place, and it frequently doesn't."