Social Factors Matter

Class, Race and Gender in Health Outcomes

Important Points to ConsiderImportant Points to Consider Social class (which relates to occupation) is the

most important predictor of health outcomes.

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

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

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

Differences between the wealthy and poor nations in the world

Differences between the wealthy and poor nations in the world

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

occur in the poorer nations of the world.

Life expectancy and mortality figures have gotten worse in the past ten years for Africa.

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

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

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

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

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

in sub-Saharan Africa.

Leading causes of death in

children in developing countries Leading causes of death in

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

Class and HealthClass and Health

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

Disparity in wealth and health is getting worse

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

Class Matters: Heart Attacks, and What Came Next http://www.nytimes.com/indexes/2005

/05/15/national/class/

Unequal Treatment: Confronting Racial and Ethnic Disparities

in Healthcare

Institute 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 Disparities in

Healthcare

Evidence of Racial and Ethnic Disparities in

Healthcare Disparities consistently found across a wide range of

disease areas and clinical services

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

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

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

What is the Evidence that Physician Biases and Stereotypes May Influence the

Clinical Encounter?

What is the Evidence that Physician Biases and Stereotypes May Influence the

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 Biases and Stereotypes may Influence the

Clinical Encounter (cont’d)?

What is the Evidence that Physician Biases and Stereotypes may Influence the

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 disparities in care?

What are potential sources of disparities in care?

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

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

Disparities arising from the clinical encounter

Differences are RealDifferences are Real

Physicians hold stereotypes that affect treatment

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

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

The National Coalition for Women with Heart

Disease

The National Coalition for Women with Heart

Disease 38% of women and 25% of men will die within one year of a first recognized

heart attack.

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

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

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

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

More women than men die of heart disease each year,More women than men die of heart disease each year, yet women receive only:

33% of angioplasties, stents and bypass surgeries

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

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

Important Points to Consider

Important Points to Consider

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

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

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

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