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Challenges and Opportunities in Health Disparities

Challenges and Opportunities in Health Disparities

Health disparities represent a critical challenge in the pursuit of equitable healthcare. This special theme issue confronts the stark realities of unequal health outcomes across different populations. It explores the multifactorial causes of these disparities, from socioeconomic factors to systemic biases in healthcare delivery. By highlighting innovative research, policy analysis, and community-based interventions, this issue seeks to uncover the opportunities that lie in addressing these inequities. The contributions within offer a platform for dialogue and action, aiming to catalyze change and promote health equity. Through shared knowledge and collaborative efforts, we can work towards a future where health justice is not an ideal, but a reality for all.

Holmes, L., Deepika, K., Williams, J., Ogundele, B., Philipcien, G., Enwere, M., Jain, S., Dasari, N., Alur, R. S., Adhikari, R., & Ogungbade, G. (2022)

Abstract

Purpose: Historically until date, viral pathogens remain very challenging with respect to transmission, severity, mortality and survival with respect to sub-population variances. While racial disparities in cumulative incidence (CmI) and mortality from the influenza pandemics of 1918 and 2009 implicated Blacks with survival disadvantage relative to Whites in the United States, COVID-19 currently indicates comparable disparities. We aimed to: assess COVID-19 CmI by race, determine the Black–White case fatality (CF) and risk differentials, and apply explanatory model for mortality risk differentials.


Methods: COVID-19 data on confirmed cases and deaths by selective states health departments were assessed using a cross-sectional ecologic design. Chi-square was used for CF independence, while binomial regression model for the Black–White risk differentials.

Results: The COVID-19 mortality CmI was disproportionate among Blacks/AA with 34% of the total mortality in the United States, albeit their 13% population size. The COVID-19 CF was higher among Blacks/AA relative to Whites; Maryland, (2.7% vs. 2.5%), Wisconsin (7.4% vs. 4.8%), Illinois (4.8% vs. 4.2%), Chicago (5.9% vs. 3.2%), Detroit (Michigan), 7.2% and St. John the Baptist Parish (Louisiana), 7.9%. Blacks/AA compared to Whites in Michigan were 15% more likely to die, CmI risk ratio (CmIRR) = 1.15, 95% CI, 1.01–1.32. Blacks/AA relative to Whites in Illinois were 13% more likely to die, CmIRR = 1.13, 95% CI, 0.93–1.39, while Blacks/AA compared to Whites in Wisconsin were 51% more likely to die, CmIRR = 1.51, 95% CI, 1.10–2.10. In Chicago, Blacks/AA were more than twice as likely to die, CmIRR = 2.24, 95% CI, 1.36–3.88.

Conclusion: Substantial racial/ethnic disparities are observed in COVID-19 CF and mortality with Blacks/AA disproportionately affected across the United States.

Agrawal, A. (2023)

Abstract

Equitable care has been recognized as one of the six core components of quality for over two decades, yet scant attention has been paid to understand and address healthcare disparities in the US. There is long-standing evidence of substantial health disparities and poor health outcomes along race, ethnicity and income levels in the US. The COVID-19 pandemic both exacerbated and exposed these inequities and catalyzed a national imperative to achieve equitable healthcare. The objective of this article is to provide a case study of a resource-challenged safety net hospital’s journey to advance health equity in Chicago. Humboldt Park Health (HPH) is a 200-bed independent community teaching hospital located on the West side of Chicago serving a multiracial, multilingual and socioeconomically disadvantaged population. Our journey started with the formation of a multidisciplinary health equity committee in 2021, reporting to the Board of Trustees, that was charged with formulating a strategy, developing an evidence-based framework and priorities for action, and implementing the action plan. We addressed four groups of stakeholders: our patients, our people, our organization, and our community. Our actions to advance equity have included (a) collection of patients’ demographic data such as race, ethnicity, language, sexual orientation, and gender identity; (b) assessment of social determinants of health (SDOH) along with connecting patients with social services; (c) the development of health disparities dashboards for various ambulatory preventive measures for stratification of quality data along race, ethnicity and language; (d) focus on LGBTQ+ community’s access to well-informed and sensitivity-trained behavioral health service providers, and (e) organization-wide training to embed the concepts of diversity, equity and inclusivity in the fabric of the organization. Other initiatives include the building of a community wellness center and a 100-unit affordable housing complex in the community. Digital health equity is an important domain that is being addressed by the launch of a patient portal to empower patients by providing them access to their information, and remote patient monitoring solutions. The next phase of our work involves evaluation studies to understand the impact of our interventions on health disparities and outcomes in our community.

Jones, T., Wisdom-Chambers, K., Freeman, K., & Edwards, K. (2023)

Abstract

Background: In the United States (US), Black/African American women suffer disproportionately from breast cancer health disparities with a 40% higher death rate compared to White women. Mammography screening is considered a critical tool in mitigating disparities, yet Black women experience barriers to screening and are more likely to be diagnosed with advanced-stage breast cancer. The purpose of this study was to assess the relative frequency of mammography screening and to examine perceived and actual barriers to screening among women who receive care in our nurse-led community health center.

Methods: We conducted a survey examining frequency of mammography screening and beliefs about breast cancer including perceived susceptibility, perceived benefits, and perceived barriers to mammography screening, guided by the Champion Health Belief Model.

Results: A total of 30 Black/African American women completed the survey. The mean age of the participants was 54.3 years ± 9.17 (SD); 43.3% had a high school education or less; 50% had incomes below $60,000 per year; 26.7% were uninsured; 10% were on Medicaid; and only 50% were working full-time. We found that only half of the participants reported having annual mammograms 16 (53.3%), 1 (3.3%) every 6 months, 8 (26.6%) every 2-3 years, and 5 (16.7%) never had a mammogram in their lifetime. Frequently cited barriers included: ‘getting a mammogram would be inconvenient for me’; ‘getting a mammogram could cause breast cancer’; ‘the treatment I would get for breast cancer would be worse than the cancer itself’; ‘being treated for breast cancer would cause me a lot of problems’; ‘other health problems would keep me from having a mammogram’; concern about pain with having a mammogram would keep me from having one; and not being able to afford a mammogram would keep me from having one’. Having no health insurance was also a barrier.

Conclusion:  This study found suboptimal utilization of annual screening mammograms among low-income Black women at a community health center in Florida and women reported several barriers. Given the high mortality rate of breast cancer among Black/African American women, we have integrated a Patient Navigator in our health system to reduce barriers to breast cancer screening, follow-up care, and to facilitate timely access to treatment, thus ultimately reducing breast cancer health disparities and promoting health equity.

Yang, X., Chow, M., Gandhi, Y., Nguyen, J., To, B., & Lim, M. a. W. T. (2023)

Abstract

Background: People with disabilities and complex health needs have poorer oral health when compared to the rest of the population, with being able to find oral health professionals willing to provide treatment often identified as the main barrier. Despite this, our understanding of the barriers that oral health professionals face when treating these patients remains limited. This is crucial to overcoming the challenge of reducing oral health disparities faced by these vulnerable populations.

Aim: To provide an overview of barriers reported by oral health professionals in regards to treating patients with disabilities and complex health needs in the published literature.

Methods: Primary studies were searched for through PudMed, Ovid and Scopus databases using a search strategy developed by the research team. Articles were screened according to PRISMA guidelines and against inclusion and exclusion criteria.

Results: Eighteen studies fulfilled the criteria for evaluation, including studies using both qualitative and quantitative approaches. General dentists were most frequently included in the studies, but patient populations were highly variable, with the majority relating to people with disability. The reported barriers could be classified into three main areas: clinician, patient, and environment-related.

Conclusion: There are only a small number of studies reporting on barriers perceived by oral health professionals to impact on their ability to treat people with disabilities and complex health needs. While lack of training or experience was a factor underlying many of the reported concerns, studies raised concerns about clinicians being inadequately resourced or supported to provide this care. These are areas the dental profession will need to consider in order to address current oral health disparities experienced by people with disability and special health care needs.

Ozah, E., Akerele, W., & Tagar, E. (2023)

Abstract

Background: Coronavirus disease had a devastating effect on the World, with significant disruption in healthcare, the burgeoning impact is still unfolding. The inequities and fragilities amongst nations particularly low and medium economic countries whose patients are dependent on out of pocket expenditure to access healthcare, has occasioned varied consequence of the pandemic on patients in the health care setting and it has reshaped how health care is practiced.

Aims: The aim of this review article was to assess the impact of Coronavirus disease on health care utilization by non -COVID patient during the pandemic.

Methods: The review article was carried out with a search engine focused on articles related to impact of Coronavirus disease published between December 2019 till date, which were identified and reviewed.


Conclusion: The review article gave an insight to the significant disruptions in health care services amongst patients witnessed across countries of the world, the disparities in the disruptions were due to heterogeneity amongst nations, national policies and health policies during the pandemic and the socioeconomic realities that ensued. Outpatient services witnessed varying reduction across the globe ranging between 30-50%. Sub-Saharan Africa witnessed disruption as much as 50% depending on load of COVID-19 infection amongst populace. The reason for the interruptions across the world was the fear of contracting the disease, access to health care setting due to lock down and shortage of health care personnel, in addition in sub-Saharan Africa, the economic down turn occasioned by the pandemic reduced household income which in turn reduced expenditure on health since most countries were dependent on out of pocket expenditure to fund health care services.

In-patient care was also not spared of the disruptions witnessed even though emergency care was prioritized. Overall, there was a reported reduction in admissions for respiratory diseases due to non- pharmacological measures aimed at stemming COVID-19 infection which was equally effective for other respiratory diseases. In some countries like United States the reduction in hospital admissions was paralleled by increasing mortality particularly amongst Hispanic blacks as more acute and severe cases were deemed to have presented for admissions. Surgical priority was maintaining emergency services and prioritization of cancer care, there was a measurable reduction in surgical procedures as elective surgeries were postponed or cancelled. Most laparoscopic and endoscopic procedures were cancelled because of the perceived notion that they are aerosol generating and could increase transmission of COVID-19 infection from asymptomatic carriers, however US jettisoned cancellation of its surgical procedures after 35 days considering that it could not cope. The psychosocial impact of the pandemic and health care access spiraled into increasing anxiety and depression for both health care workers and patients, while the fear of stigmatization was rife from contracting the disease.

Holmes, L., Deepika, K., Williams, J., Ogundele, B., Philipcien, G., Enwere, M., Jain, S., Dasari, N., Alur, R. S., Adhikari, R., & Ogungbade, G. (2022b)

Abstract

Purpose: Viral infections had been historically observed in chronic disease development and complications including although not limited to hepatitis C, influenza A, cytomegalovirus (CMV), Epstein bar virus (EBV), HIV and herpes simplex. Epidemiologic data had implicated CMV, herpes simplex and hepatitis C in type II diabetes (T2D). With the observed increased incidence T2D in COVID-19 among children and adults, this review aimed to examine scientific literature on immune and endocrine systems dysregulation in T2D and pancreatic neoplasm. 

Materials & Method: A qualitative systematic review (QSR) was utilized in assessing the immune system deregulation and endocrine system involvement in chronic disease development such as T2D. The PubMed was the main search engine in studies identification with several search terms such as “SARS-CoV-2 and T2D”, “COVID-19 and T2D”, SARS-CoV-2 and insulin resistant”, etc.  

Results: Viral pathogens such as CMV, influenza A, and herpes simplex and hepatitis C infections have been implicated in decreased insulin sensitivity (IS) and increased insulin resistant (IR). Similarly, these pathogenic microbes increased the T2D incidence and complications. SARS-CoV-2 a COVID-19 causative pathogen had been observed in increased risk and incidence of T2D among children and adults. While data are not currently available on the precise mechanistic process, SARS-CoV-2 viral infection in T2D incidence may be explained by excess pro-inflammatory cytokines elaboration (cytokine storm) resulting in increased IR and decreased IS, leading to glucose intolerance and T2D. Further COVID-19 may increase pancreatic neoplasm in populations with increased incidence of COVID-19, due to pancreatic beta cells and insulin receptors dysregulation and cellular dysfunctionality as abnormal cellular proliferation.

Conclusions/Recommendation: SARS-CoV-2 a causative pathogen in COVID-19 morbidity is associated with increased incidence of T2D, which is explained in part by immune and endocrine system integration dysregulation, resulting in cytokine storm, decreased IS and increased IR, implying glucose intolerance and T2D. Additionally this pathogenic microbe may result in increasing incidence of pancreatic neoplasm, a malignant neoplasm with the worst prognosis and excess mortality due to late stage at diagnosis and marginalized biomarkers of susceptibility and morbidity.  

Alkhatry, M., Hamadi, H., Alwahedi, A., Muzaki, Z., Ahmed, F., Almasri, B., Housen, F., Bataweel, M., Alabar, E., & Eltayeb, H. (2023b)

Abstract

Obesity poses a multifaceted challenge in the United Arab Emirates (UAE), demanding a comprehensive review of its epidemiology, causes, prevention strategies, and challenges. This article explores the intricate web of factors contributing to obesity, emphasizing a multidisciplinary approach that engages nutritionists, exercise physiologists, behavioral therapists, and surgeons. The epidemiology reveals a concerning rise in obesity rates, necessitating targeted interventions. Demographic influences, cultural dynamics, dietary patterns, sedentary lifestyles, and genetic factors are dissected to provide a nuanced understanding. Health implications extend beyond body weight, impacting public health systems and imposing an economic burden.

Prevention strategies encompass childhood obesity initiatives, community-based interventions, workplace wellness programs, and government policies. Challenges in implementing these strategies include cultural perceptions of body image, access to healthcare services, socioeconomic disparities, and resistance to change. Cultural sensitivity emerges as a key theme, guiding interventions tailored to align with diverse cultural norms. Multidisciplinary care, leveraging technology, community engagement, and educational programs are explored as integral components of a holistic approach.

This review emphasizes the need for societal commitment, empowering communities and individuals, policy advocacy, and the pivotal role of healthcare professionals in the fight against obesity. Future perspectives call for sustained commitment, research investment, and the integration of technology to pave the way for a healthier UAE. This review also provides a roadmap for forging a healthier future, acknowledging the complexity of obesity, and offering insights into tailored, culturally sensitive interventions.

Bailony, M. R. (2023)

Abstract

This paper examines disparities in obesity treatment and their implications for health equity. A comprehensive literature review was performed using Pubmed, Medline, and Google Scholar to identify studies examining obesity treatment options that reported data on African Americans, Asians, Hispanics, and Caucasians. These studies, published from 2000 to 2022, revealed disparities in behavioral/lifestyle, surgical, and pharmacological interventions for obesity. While a majority of behavioral/lifestyle and surgical treatment studies found disparities in weight loss and clinical outcomes, pharmacological studies found minimal to no evidence of disparities or favorable outcomes for racial and ethnic minorities for weight and cardiometabolic outcomes. All treatment pathways showed disparities in referral rates, access, and engagement/retention. These findings underscore the urgent need to incorporate obesity treatment as a central component in strategies addressing health inequities. By understanding and addressing these disparities, healthcare equity can be improved, ensuring a more inclusive approach to obesity management.

Patel, D. (2023)

Abstract

Background: Blindness describes a condition in which patients have low vision, are legally blind, or totally blind. Disparities in vision health is a public health concern because it decreases quality of life and subsequently leads to a series of other health-related issues. These disparities exist across demographics, socioeconomic status, disease history, genetics, and geographic location, particularly in the urban vs. rural setting. Public health professionals need to shed light on these disparities to properly address them to ensure that individuals affected by blindness can receive proper care.

Objective: To investigate if there are discrepancies or inequalities in vision care in a rural setting vs. urban setting.

Methods: A multivariate binary logistic regression analysis using cross-sectional data from the Vision and Eye Health Surveillance System (VEHSS) was done using SAS Studio. Blindness, the outcome of interest, was defined as best-corrected visual acuity at less than 20/200 in the better-seeing eye. Each demographic subgroup was assessed in the counties included for upstate New York and downstate New York. Prevalence rates are expressed as a percent.

Results: The multivariate binary logistic regression analysis showed that non-Hispanic black individuals from upstate New York and downstate New York were most likely to be blind compared to white, non-Hispanic, any Hispanic, and other individuals. Factors that were significantly associated with blindness include the female gender, individuals aged 65 years and older, non-Hispanic black individuals, and those without Medicare. Residents from upstate New York had a slightly increased likelihood to develop blindness, 1.04 (1.01, 1.07), compared to residents in downstate New York.

Conclusions and Relevance: Blindness prevalence was highest in upstate New York, among non-Hispanic black individuals, the female gender, and individuals 65 years and older. Despite the blindness prevalence highest upstate, the difference was not clinically significant compared to downstate New York, despite a considerably larger number of resources present downstate compared to upstate. Given the severity of blindness as a public health concern, the discrepancies in eye care in urban vs. rural settings need to be investigated further.

Hoel, D. G. (2022)

Abstract

It is becoming well understood that insufficient sun exposure is a risk factor for many adverse health effects. Increased adverse health effects such as cancers and cardiovascular disease have been quantified with respect to measured levels of vitamin D, a marker for sun exposure. Most acquired vitamin D [measured as 25(OH)D level] is a result of ultraviolet radiation from sun exposure. Because of higher levels of melanin in the skin, individuals with darker skin obtain less vitamin D and other beneficial sun-produced biomolecules such as nitric oxide from a given amount of sun exposure. It is the purpose of this paper to report the published observed 25(OH)D levels in Black Americans and the correlated levels of adverse health effects. Our conclusion is that insufficient sun exposure is a major component of the observed health disparities between Black and White Americans, and that Black Americans can significantly attenuate these disparities by having enough additional sun exposure to raise their 25(OH)D levels to 30 ng/mL.

Neparidze, N., Lau, K., Wang, X., Huntington, S. F., Jamy, O., Calip, G. S., Shah, H., Stephens, D. M., Miksad, R. A., Parikh, R. B., Takvorian, S. U., Goyal, G., & Seymour, E. (2024)

Abstract

Background: The COVID-19 pandemic impacted healthcare visit trends, transitioning care to utilize telemedicine. We aimed to investigate if the uptake in telemedicine during pandemic was equitable across racial groups for patients with hematologic malignancies.

Methods: Using the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database we analyzed patients with diagnosis of acute myelogenous leukemia (AML), diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), mantle cell lymphoma (MCL), chronic lymphocytic leukemia (CLL) or multiple myeloma (MM). Patients were categorized into treatment types within lines of therapy: outpatient (oral therapy and outpatient infusions combined with oral therapy) vs. inpatient treatments (chemotherapy, cellular therapy). Monthly visit rates were calculated as the number of visits (telemedicine or in-person [in-clinic treatment administration, vitals, and/or labs]) per active patient per 30-day standardized month. We used time-series forecasting methods on pre-pandemic monthly visit rate data (March 2016 – February 2020) to estimate projected counterfactual monthly visit rates between March 2020 – February 2021.Telemedicine uptake was descriptively analyzed over time (t).

Results: We included 18,924 active patients (2,394 Black and 16,530 White) and 884,504 visits (117,673 Black and 766,831 White). 4,053 AML, 3,468 diffuse large B cell lymphoma, 1,943 follicular lymphoma, 2,151 mantle cell lymphoma, 5,926 chronic lymphocytic leukemia and 7,752 myeloma patients. Black patients had no significant reductions in in-person visit rates throughout the pandemic period compared to the projected rates. Conversely, White patients experienced an 18% (95% PI 9.9% – 25%) lower rate of in-person visits for outpatient therapy during the early pandemic (March – May 2020) (actual monthly visit rate 1.61; projected visit rate 2.0 [95% CI 1.8-2.2]). Telemedicine uptake was significantly higher for White patients compared with Black patients for all diseases and treatment categories between March 2020-February 2021 (t = 9.5, p < 0.01), AML inpatient (t = 2.4, p = 0.04), MM outpatient (Figure 3C) (t = 6.0, p < 0.01) and MM inpatient treatment categories (Figure 3D) (t = 2.3, p = 0.04). 

Conclusions: White patients had significantly higher telemedicine uptake compared with Black patients for all treatment categories. These findings challenge healthcare systems to direct efforts toward reducing the gap in healthcare access.

Jordan, I. K., Sharma, S., Nagar, S. D., & Mariño‐Ramírez, L. (2022)

Abstract

Fifty years ago, Richard Lewontin found that the vast majority of human genetic variation falls within (~85%) rather than between (~15%) racial groups.  This result has been replicated numerous times since and is widely taken to support the notion that genetic differences between racial groups are trivial and thus irrelevant for clinical decision-making.  The aim of this study was to consider how the apportionment of pharmacogenomic variation within and between racial and ethnic groups relates to risk disparities for adverse drug reactions.  We confirmed that the majority of pharmacogenomic variation falls within (97.3%) rather than between (2.78%) the three largest racial and ethnic groups in the United States: Black, Hispanic, and White.  Nevertheless, pharmacogenomic variants showing far greater within than between-group variation can have high predictive value for adverse drug reactions, particularly for minority racial and ethnic groups.  We predicted excess adverse drug reactions for minority Black and Hispanic groups, compared to the majority White group, and considered these results in light of the apportionment of genetic variation within and between groups.  For 85% within and 15% between group variation, there are 700 excess adverse drug reactions per 1,000 patients predicted for a recessive effect model and 300 for a dominant model.  We found high numbers of predicted Black and Hispanic excess adverse drug reactions for widely prescribed platinum chemotherapy compounds, such as cisplatin and oxaliplatin, as well as controlled narcotics, including fentanyl and tramadol.  Our results indicate that race and ethnicity, while imprecise proxies for genetic diversity, correlate with patterns of pharmacogenomic variation in a way that is clearly relevant to medical treatment decisions.  The effects of this variation is particularly pronounced for Black and Hispanic minority groups, owing to genetic differences from the majority White group.  Treatment decisions that are made based on (assumed) White pharmacogenomic variant frequencies can be harmful for minority groups.  Ignoring clinically relevant genetic differences among racial and ethnic groups, however well-intentioned, will exacerbate rather than ameliorate health disparities.