A model for understanding disparities in health and health
care
Scott Commins &
Dr. Raymond Greenberg
Figure 1 - Survival of males to the age of 65 in Harlem, Bangladesh, and among U.S. Whites in 1980(NEJM, 1990; 174).
Figure 2 - Life expectancy (in years) at birth
by race and sex, United States, 1998.(Source: Health, United States, 2000)
WhiteMale
BlackMale
BlackFemale
Lif
e e
xp
ecta
ncy
at
bir
th (
years
)
WhiteFemale
60
65
70
75
80
75
68
80
75
Life Expectancy
RACE
Cause of Death
Figure 3 - Age-adjusted death rates from all causes by race and sex,
United States, 1998.(Source: National Vital Statistics Reports 2000;
48 (11): 63)
WhiteMale
BlackMale
BlackFemale
Death
s p
er
100,0
00
pers
on
s
WhiteFemale
250
500
750
1000
562
885
355
541
Figure 4 - Age-adjusted death rates from heart disease by race and sex,
United States, 1998.(Source: Natl. Vital Stat. Rep. 2000; 48 (11): 63)
WhiteMale
BlackMale
BlackFemale
Death
s p
er
100,0
00
pers
on
s
WhiteFemale
50
100
150
200
250
162
232
88
147
50
Figure 5 - Age-adjusted death rates from
cancer by race and sex, United States, 1998.
(Source: Natl. Vital Stat. Rep. 2000; 48 (11): 63)
WhiteMale
BlackMale
BlackFemale
Death
s p
er
100,0
00
pers
on
s
WhiteFemale
0
75
150
225
144
208
104129
0
Figure 6 - Age-adjusted death rates from
stroke by race and sex, United States, 1998.
(Source: Natl. Vital Stat. Rep. 2000; 48 (11): 64)
WhiteMale
BlackMale
BlackFemale
Death
s p
er
100,0
00
pers
on
s
WhiteFemale
0
10
20
30
40
50
25
47
22
37
0
Figure 7 - Age-adjusted death rates from diabetes mellitus by race and sex, United States, 1998.
(Source: Natl. Vital Stat. Rep. 2000; 48 (11): 63)
WhiteMale
BlackMale
BlackFemale
Death
s p
er
100,0
00
pers
on
s
WhiteFemale
0
10
20
30
14
29
11
29
0
Figure 8 - Age-adjusted death rates from hypertension by race and sex,
United States, 1998.(Source: Natl. Vital Stat. Rep. 2000; 48 (11): 63)
WhiteMale
BlackMale
BlackFemale
Death
s p
er
100,0
00
pers
on
s
WhiteFemale
0
5
10
2
8
2
7
0
II. What is it about race?
• Understanding the basics:
Do racial differences existin socioeconomic
indicators?
Figure 9 - People living in poverty by race,
United States, 1999.(Source: US Census Bureau)
White Black0
10
20
30%
in P
over
ty
8
24
0
Figure 10 - Educational attainment of adults
25 years or older by race, United States, 2000.
(Source: US Census Bureau)
< H SGrad
H SGrad
SomeCollege
CollegeGrad +
0
10
20
30
40BlackWhite
21
12
35 34
27 26
17
28
%
0
Figure 11 - Quintiles of household income by race,
United States, 1999.(Source: US Census Bureau)
I II III IV V0
50
100
150
BlackWhite
Inco
me
inThousa
nds
of D
ollar
s
0
III. Do the differences in SES
indicators affect health?• Proposing a model:
How do we examine the cause(s) of disparities in health?
SubstandardLiving
Conditions
Unemployment
PoorNutrition
Risk-PromotingLifestyle
DiminishedAccess to
Health Care
Poverty/Lower SES
Figure 12 - Percentage of persons under age
65 years with private medical insurance
by income, United States, 1997.(Source: Health, United States, 2000)
% of Poverty Level<100100-149150-199200+
Pri
vate
Med
ical
Insu
ran
ce (
%)
0
25
50
75
100
24
42
64
88
0
Figure 13 - Percentage of persons under
age 65 years with private medical insurance by race, United States,
1997.(Source: Health, United States, 2000)
White Black
Pri
vate
Med
ical
In
su
ran
ce (
%)
0
25
50
75 74
56
0
Figure 14 - Percentage of persons 18 years
or older with 2 or more emergency room
visits in the past year, United States, 1998.
(Source: Health, United States, 2000)
Poor NearPoor
Non-Poor
Pers
on
s w
ith
tw
oor
more
ER
vis
its/y
ear
(%)
0
5
10
1513
10
5
0
Figure 15 - Percentage of children less than
18 years old with no usual source of health care, United States, 1997-98.
(Source: Health, United States, 2000)
Poor NearPoor
Non-Poor
Ch
ild
ren
wit
h n
ou
su
al sou
rce o
fh
ealt
h c
are
(%
)
0
5
10
1512
10
4
0
SubstandardLiving
Conditions
Unemployment
PoorNutrition
Risk-PromotingLifestyle
DiminishedAccess to
Health Care
Poverty/Lower SES
Figure 16 - Percentage of children 1-5 years
old with blood lead levels 10 ug/dl by family income, United States,
1991-94.(Source: NHANES III, 1996)
Ch
ild
ren
wit
h h
igh
blo
od
lead
levels
(%
)
Low Middle High0
5
108
21
0
Figure 17 - Percentage of persons with blood lead levels 10 ug/dl by family income, United States,
1991-94.(Source: NHANES III, 1996)
Pers
on
s w
ith
hig
h b
lood
lead
levels
(%
)
Low Middle High0
3
65
2
1
0
SubstandardLiving
Conditions
Unemployment
PoorNutritio
n
Risk-PromotingLifestyle
DiminishedAccess to
Health Care
Poverty/Lower SES
Figure 18 - Percentage of children age 16
years or less with food insufficiency by
family income, United States, 1988-94.
(Source: NHANES III, 1996)
Ch
ild
ren
wit
hfo
od
in
su
fficie
ncy
(%
)
Low Middle High00
10
2016
20
Figure 19 - Percentage of children 6-16 years old with iron deficiency by family income, United States, 1988-
94.(Source: NHANES III, 1996)
Ch
ild
ren
wit
hir
on
defi
cie
ncy (
%)
Low Middle High0
5
10
6
3
1
0
SubstandardLiving
Conditions
Unemployment
PoorNutrition
Risk-PromotingLifestyle
DiminishedAccess to
Health Care
Poverty/Lower SES
Figure 20 - Unemployment rate of civilian labor force age 20 years or
older by race and sex, United States, July,
2001.(Source: Bureau of Labor Stats., July, 2001)
WhiteMale
BlackMale
BlackFemale
Perc
en
t u
nem
plo
yed
WhiteFemale
0
5
10
3.4
8.9
3.5
7.0
SubstandardLiving
Conditions
Unemployment
PoorNutrition
Risk-PromotingLifestyle
DiminishedAccess to
Health Care
Poverty/Lower SES
Figure 21 - Prevalence of cigarette smoking
among white males 25 years or older by
educational attainment, United States, 1998.
(Source: Health, United States, 2000)
< H SGrad
H SGrad
College Grad +
Pre
vale
nce o
fcig
are
tte
sm
okin
g (
%)
SomeCollege
0
10
20
30
40 3732
25
11
0
Figure 22 - Prevalence of cigarette smoking among adults by employment
status, South Carolina, 1995-96.(Source: SC Prevention Adult Household
Telephone Survey, 1995-96)
0
10
20
30
4033
22
Unemployed Employed
Pre
vale
nce o
f cig
are
tte s
mokin
g(%
)
Figure 23 - Prevalence of cigarette smoking
among persons 25 years or older by race and sex, United States, 1998.
(Source: Health, United States, 2000)
15
20
25
30
35
25
30
22 23
WhiteMale
BlackMale
BlackFemale
Pre
vale
nce o
fcig
are
tte
sm
okin
g (
%)
WhiteFemale
15
Figure 24 - Prevalence of obesity by race and sex, United States, 1988-94.
(Source: Health, United States, 2000)
WhiteMale
BlackMale
BlackFemale
Pre
vale
nce
of
ob
esit
y (
%)
WhiteFemale
10
20
30
40
20 2124
38
10
SubstandardLiving
Conditions
Unemployment
PoorNutrition
Risk-PromotingLifestyle
DiminishedAccess to
Health Care
Poverty/Lower SES
An Illustrative Example:Childhood Lead
Toxicity
IV. Employing the Model
Good Health Care?
You memorized the high lead threshold and used proper medical intervention, but have you addressed the underlying issues?
Probably not, because doing so requires identification of the contributing factors and intervening on numerous levels...
Contributing Factors• Unhealthy environment -
Increased risk of exposure to lead-based paint
• Parental education - Lack of knowledge regarding hazards
• Access to care - Poor screening results in delayed
detection and treatment
Public Health Perspective
• Treating the lead poisoning alone may not besufficient for this child
• Treating this child alone may not be sufficientfor the community