"Health Equity...is when everyone has the opportunity to "attain their full potential" and no one is "disadvantaged from achieving this potential because of their social position or other socially determined circumstance."
- Centers for Disease Control and Prevention
This opportunity for good health is not uniformly available across Colorado and the United States due to unequal access to quality health care services, safe neighborhoods, affordable healthy food, non-toxic environments and racial/ethnic equality. This unequal access to the necessary elements of what leads to good health is referred to as "health inequity."
This chapter, formally titled "Health Disparities," has been renamed to reflect the growing consensus supporting our imperative to reduce preventable differences in health outcomes resulting from unjust systemic problems and practices. These differences in health status and health outcomes among socioeconomically underrepresented groups of people experienced over time are known as health disparities. Inequities in health outcomes, such as cancer incidence, stage at diagnosis, survival, mortality and quality of life, are shown to exist across the entire range of social groups. The interrelation of race/ethnicity, socioeconomic status (SES), education level, insurance status, quality health care access, behavioral choices, immigrant status, language and literacy, geographic place of residence, environmental issues, disability status, age, sex and sexual orientation, all contribute to inequalities in cancer health care. These factors, among others, form a complex set of interactions that influence the outcome of cancer health care in a way the disproportionately affects minorities living in Colorado and throughout the United States.
"Health equity cannot be achieved without addressing the health of all racial and ethnic groups. There is a powerful link between social factors and health. Social and economic policies have a direct impact on the health and well-being of those who live and work under those policies. Interventions and policies that purport to promote health must be based on evidence and result in action, and they must address daily living conditions and issues related to power, money and resources." - 2010 National Plan for Action: Changing Health Outcomes- Achieving Health Equity; National Partnership for Action, U.S. Department of Health & Human Services
Approaches to reducing cancer health inequities must consider the complexity of these factors and should address as many of them as possible simultaneously. For example, while we know that poverty plays a major role in cancer detection and survival rates for Coloradans, an intervention only including financial assistance in accessing health care would not be sufficient to change cancer outcomes because of the impact of additional factors, including health beliefs, health literacy and health service use.
WHAT DOES THIS MEAN?
- The frequency with which something, such as cancer, appears in a particular population or area. The number of newly diagnosed cases occurring during a specific time period.
- Death rate:
- The number of deaths in the population divided by the average population (crude death rate).
- Survival rate:
- to be determined (reference: MedicineNet.com)
Health inequities in Colorado and the United States are mostly experienced by poor communities, particularly communities of color. Cancer incidence and death rates in Colorado have been measured and reported for blacks (African Americans) and Hispanics (Latinos), showing that each bears an unequal cancer burden when compared to other ethnic groups, particularly whites (Caucasians). For example, the black population of Colorado has the highest lung cancer incidence rate of any population, the highest death rates for cancer overall, and the highest rates for lung, breast, colorectal and prostate cancers. When compared to other racial/ethnic groups in Colorado, Hispanic females have the highest incidence and second highest death rates of cervical cancer. Hispanic males have a higher incidence and death rate of colorectal cancer than males or females of any other race/ethnicity group in Colorado.
Nationally, American Indians and Alaska Natives (AI/AN) have the lowest five-year cancer survival rates of any population in the United States. Similarly, Asian communities have some of the lowest cancer incidence and death rates. Asian women experience very high incidence and the highest death rates from cervical cancer. In Colorado, this issue is compounded by the relatively small numbers of individuals among certain groups who have cancer, the misclassification of race/ethnicity, and data collection and reporting challenges. Institutional challenges in measuring and reporting cancer outcomes in these populations can stymie the ability to understand the impact of cancer on these groups and design and fund interventions to reach them.
Social Determinants of Health that Affect Cancer Inequities across the Cancer Continuum
Epidemiologic research has found factors associated with race/ethnicity that affect health status and risk, but are independent of biological differences among groups. Historical and current discrimination in the nation's political, economic and social institutions and systems represent some of the determinants of racial/ethnic health disparities. Inequity can be found in the educational system, labor and housing markets, credit and lending institutions, and health care systems. Even bias that is unintentional on the part of medical researchers or providers is potentially harmful. Underlying bias has been shown to result in under-treatment and different treatment recommendations of black adults for particular medical conditions. Analysis of national data-sets have shown that particular groups receive cancer treatments at later times or not at all.
In Colorado, school-age children of color score significantly lower than white (Caucasian or white, non-Hispanic) children on standardized tests. Gaps in high school graduation rates between white students and students of color are greater than in many other states. Post high school education attainment is lower among black and Latino youth. American Indian data are unmeasured or unknown. The impact of lower educational attainment is profound and long-lasting. Education influences job attainment, income potential, work site benefits and occupation. In addition, a person's ability to read, understand and act on medical information and instructions is hampered at lower educational levels.
Lastly, an important component of health equity work is to diversify the public health and medical services workforce. Increased educational attainment at the post-secondary level is necessary for work in all sectors of the health care industry from medical assistants to public health and research.
Income strongly influences health for all people. As income increases, the percentage of people reporting fair or poor health decreases. In all domains, economic disparities limit people's ability to be healthy, both directly (e.g., lacking money to buy medicine) and indirectly (e.g., emotional stress from coping with chronic financial instability). An updated report entitled "Cancer & Poverty in Colorado 1995 - 2006", prepared by the Comprehensive Cancer Program of the Colorado Department of Public Health and Environment, reveals a stark difference in cancer stage at diagnosis and survival of Coloradans by neighborhood poverty level. The report highlights the reality that Colorado, like the nation as a whole, shows a link between cancer outcomes and poverty. The report delineates two of the social determinants of cancer-related health disparities: race/ethnicity and poverty. Another important element is wealth. Wealth measures assets and the ability of an individual to accumulate property, such as real estate, savings and investments. Wealth can protect individuals and families from life's emergencies, hardships and economic cycles. Particular communities of color have been locked out of the ability to accumulate wealth due to discriminatory practices in home ownership, small business lending and other means to accumulate assets, wealth and protection against poverty.
Unemployment rates in Colorado are higher for all racial/ethnic minority groups than for the majority population. Unemployment can affect health through a loss of income and health insurance and can cause great mental anguish – all factors that can delay or prevent the detection of cancer at an early stage, when it is most treatable. Because of educational disparities and opportunity limitations, workers of color are under-represented in professional positions and over-represented in manual labor and service jobs that pay less and are much less likely to provide health coverage. Additionally, growing occupational health research indicates that workers of color may disproportionately work in unsafe and unhealthful conditions without proper training, protections or notification of risks.
Racial/ethnic minority populations in Colorado lack health insurance at higher rates than the majority population. The Hispanic population experiences the highest uninsured rate, with one in four Latinos lacking coverage. The immigrant population, both documented and undocumented, is less likely to receive employer or publicly provided health care. Under-insurance refers to having insurance that does not adequately cover health care costs or has limited benefits. Under-insurance affects access when policies do not cover pre-existing conditions, when co-payments and deductibles cause delays in care, or when certain categories of benefits, such as cancer prevention and early detection services, are not covered.
Culture is not the same as race/ethnicity, although cultures and cultural beliefs may exist within racial or ethnic groups. Cultural beliefs about health and illness can impact the communication style and relationship between patient and provider in the health care setting. Health care professionals sometimes lack the cultural awareness, sensitivity, cultural competence and training to communicate effectively with people of diverse backgrounds. A lack of cultural competence on the part of health care providers can negatively affect the care of patients and cause adverse health outcomes that widen the gap in health disparities experienced by communities of color.
A perfect example is seen in American Indian cultures. There are more than 560 federally recognized tribes, with more than 200 different tribes reported to the 2000 Census for Colorado and approximately 100 different tribes reported to the 2000 Census for the Denver metro area. Despite being considered as one American Indian ethnic group, cultural beliefs among these tribes are very diverse.
Cultural beliefs also affect how communities perceive public health messages about disease prevention and health promotion. Sometimes community beliefs are labeled as fatalism, which is often based on real experience. Racial/ethnic communities may be unaware of the strengths and weaknesses of traditional dietary or behavioral choices or other customs. More must be understood about the impact of various cultural beliefs and practices on cancer in order to build upon positive influences and address areas of concern with sensitivity and respect. The field of cross-cultural communication provides communication models for respectful negotiation between the health care provider perspective and the cultural beliefs of the patient.
Language and Health Literacy
Language barriers may contribute greatly to cancer-related health disparities among people whose primary language is not English. Language factors can delay and/or inhibit access to cancer services, such as prevention, early detection, treatment and quality of life care. Challenges may include lack of information about available services, fear of jeopardizing immigration status, communicating in prevention and treatment settings and comprehending the U.S. health care system. Patients may not know understand printed health information that is not culturally or linguistically relevant or be aware of their right to an interpreter.
What does this mean?
- Health Literacy:
- the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions (Institute of Medicine).
Difficulty in understanding medical terms and navigating the health care system is not unique to non-English speakers. Our health care system has its own culture, language and norms. English-speaking patients often need assistance in making sense of health care instructions, prescriptions, appointment scheduling and other information. Health literacy is the ability to understand and act on the information related to health and health care. About 36% of US adults have a basic or below basic level of health literacy, according to the 2003 U.S. Department of Education National Assessment of Adult Literacy. This means that a third of American adults would have difficulty understanding most information we use in public health, clinics and hospitals. Instructions, materials and prescription information would be too difficult to understand for a third of all adults. According to the IOM, most people read two grade levels lower than the highest grade they completed. While ethnic minorities are disproportionately represented in low literacy levels, American-born white adults represent the largest number of people in low literacy groups. Tackling health literacy benefits all patients and helps to increase health equity across racial/ethnic and socio-economic groups because of the connection between health literacy, safety and health care quality.
Physical environment, such as living in substandard housing, unsafe neighborhoods or areas with more environmental toxins can contribute to health inequities.
Ongoing issues in certain urban neighborhoods include access to healthy foods or safe places for physical activity and close proximity to industrial centers, major highways and high-crime areas. Groups impacted by disparities reside in these neighborhoods. There are fewer grocery stores where fresh fruits and vegetables are available at a reasonable price. Many families depend on corner convenience shops that primarily sell processed food high in carbohydrates and salt and low in nutritional value. In regard to the physical activity, poorer areas have fewer community recreation centers and even fewer sidewalks, a must for safe neighborhood activity.
African Americans/Blacks and American Indians are overrepresented in the Colorado homeless population. Homeless patients experience multi-leveled barriers to cancer screening, treatment and survivorship services. One classic example is that not having a postal address makes it difficult to apply for and obtain basic benefits, like those available for veterans. Social Security, Medicaid and other benefit programs.
People living in remote areas can experience difficulty accessing health care due to lack of health care providers, transportation barriers, and financial and unemployment issues. For example, uncontrolled diarrhea, a side effect of cancer treatment, is made more difficult when the only transportation option is a long bus ride.
Immigrant and refugee communities are found throughout rural Colorado. Rural providers and the public health and educational system face linguistic and cultural challenges in delivering the same level of service experienced in diverse urban environments.
Joseph A. Salvato states in his popular book Environmental Engineering and Sanitation that Environmental Health is, "The systematic development, promotion, and conduct of measures which modify or otherwise control those external factors in the indoor and outdoor environment which might cause illness, disability or discomfort through interaction with the human system."
According to the CDPHE report, Cancer and Poverty; 1995-2006, "Those from poorer areas had worse survival for all cancers combined for most of the race/ethnicity, gender, and age groups. Five-year survival rates were 8-13 percent lower for persons living in poorer areas." In addition, Coloradans with lower incomes were more likely to smoke tobacco, to be obese, to be less physically active, and to not participate in screening tests for breast, cervical, or colorectal cancer. The people living in poorer neighborhoods and who had no health insurance were also more likely to be diagnosed with cancer at a more advanced stage and were more likely to die within the first 5 years following cancer diagnosis.