SES-Related Health Disparity

Health disparity can be defined as the inequities and differential access to medical care plaguing various groups, resulting in disproportionate outcomes (Riley, 2012). Socioeconomic imbalance, in particular, can have especially pertinent implications on the livelihoods of millions of Americans.

Socioeconomic status (SES) is linked to higher mortality among a host of major health problems including, but not limited to, cardiovascular disease, hypertension, arthritis, diabetes, and cancer (Pamuk, 1998). SES can be divided into three main components: education, income, and occupation. However, it should be noted that although each represents a different facet of the equation, they are all inextricably linked and influence one another.

Higher educated individuals are more likely to have better access to health-positive resources and information (Adler & Newman, 2002). For example, such people may be more aware of whom to reach out to or numbers to call when in need of help. But this is not just limited to higher education: early educational experiences at all levels may also affect critical periods in youth development that could translate to long-term consequences (Hertzman, 1999). Moreover, education serves as the gateway to opportunity and as an indicator for future earning potential. Undoubtedly, higher levels of income allow families to provide more nutritious meals, recreational activities, sanitary protection, and necessary medicines. That said, what’s interesting is that, “although effects are largest for those living in poverty, gradients of disparity are seen across the socioeconomic spectrum” (Marmot et. al, 1991, p.1390). This is important to note because that means broad redistributive economic policies don’t always necessarily offer the impact to alleviate these concerns.

Generally, healthcare disparities across SES can be broken down into distinct age cohorts. Because of this, inequalities faced as a child not only directly affect the child in that moment but also trickle down as the child ages, resulting in an increasingly heavy burden that must be overcome. Neonatal care and childcare aren't typically focused on when discussing inequities but have been shown to play a crucial role in development. In utero, the fetus is exposed to all types of ailments since the health of the fetus is intertwined with the health of the mother. Thus, a mother’s low SES, along with that of the father, is associated with low birth weight and infant mortality (Fiscella & Williams, 2004). 

Figure 1. Low-birthweight live births in United States in 1996 among mothers 20 years of age and over by mother’s education, race, and Hispanic origin

This may be due to a myriad of risk factors, such as unplanned pregnancy, single and/or adolescent motherhood, smoking, urogenital tract infections, maternal chronic illness, and overall inadequate prenatal care (Weissman et. al, 2003). As alluded to before, the downstream effects of inequality on children in these situations result in higher exposure rates to household smoking, higher rates of asthma, learning disabilities, developmental delays, and child abuse (Fiscella & Williams, 2004). Overcrowding in the household and unstable parental marital status also contribute to this. 

Progressing to adolescence, higher rates of pregnancy, STI’s, depression, suicide, and sexual abuse are all associated with lower SES. Many things we take for granted in a position of privilege like stronger health profiles, more family involvement, more physical activity, safer homes, and higher school achievement are positively correlated with higher SES (Fiscella & Williams, 2004). It is easy to see now why SES plays such a major role by the time adulthood is reached: low SES individuals in particular have so many determinants and obstacles they must hurdle in order to overcome the hand they are dealt with. Time only exacerbates the disparities, further driving a wedge between their ambitions and reality.

Researchers have delved more deeply into why this occurs in order to possibly offer some explanation. The dominant tenet has been the notion of social causation, which ties into the aforementioned downstream effects from fetal stages to adulthood. Formally known as the Barker hypothesis, fetal growth restriction based on SES “likely predisposes a person to disparities in adult health”, resulting in higher rates of obesity, hypertension, diabetes, and cardiovascular disease (Fiscella & Williams, 2004). This restriction arises from childhood abuse, lack of family structure, environmental toxins, etc. The social fabric of communities in lower SES is torn apart or at the very least damaged, making it hard for it to be sewn back together. The risk factors become additive and take a serious toll on adulthood. In fact, it has been demonstrated that reduced mental functioning in adults can be traced back to inadequate cognitive stimulation and neglect. This can affect their relationships on almost every level due to their emotional development and risk-taking behaviors being compromised (Andersson, 1996). On top of this, their current lives are afflicted with adverse environmental effects of inner cities, such as passive pollution and smoking, which show up as heightened cardiovascular and psychological repercussions (Chen & Matthews, 2001).

Resource deprivation also reveals the imbalance from SES. This ranges from “financial hardship, low literacy, limited access to health care, or social marginalization”, all of which point to chronic stress (Fiscella & Williams, 2004). The stress starts to build up to the point where, literally and figuratively, the deck is stacked against you. This chronic stress can lead to neurophysiological changes, such as hippocampal atrophy, a condition in which the brain’s center for learning and emotion is compromised (Seeman et. al, 2004). This can be contrasted with individuals of higher SES, who have “improved psychological coping, including self-efficacy and perceived control, which in turn is associated with improved health and reduced mortality” (Fiscella & Williams, 2004). 

One of the focal points of inequality that has been more recently discussed with COVID-19 wreaking havoc has been differential access to quality healthcare--or any form of healthcare, for that matter. Amidst a pandemic, the flaws in the system truly uncover themselves, as lower rates of preventative care, fewer cardiac and vascular procedures, and worse outcomes from these procedures haunt lower SES individuals (Fiscella & Williams, 2004). Hallmarks of healthcare, like insurance and prescriptions, are prospects simply no longer readily available.

The challenges of overcoming these barriers are daunting. Safety nets embedded within society for the vulnerable in the form of community clinics and federally qualified health centers present limitations. Inability to retain physicians and struggles to keep afloat financially typically mark the downfall of these centers. It’s difficult to recruit specialists in needed fields because of higher wages elsewhere. And even when these challenges are taken care of, other unique issues to healthcare pose hindrances. A major one is low levels of health literacy, specifically in the context of a physician not being able to explain treatment and talk through the best course of action with their patient (Schillinger et. al, 2003). The physician probably already is dealing with a patient with high levels of morbidity due to their low SES, so language, literacy, and cultural barriers only complicate things further. Although it may seem like an insignificant issue, administrative impediments play a larger role than one might think (Fiscella & Williams, 2004). Due to the higher levels of uncertainty in the daily lifestyles of these individuals, it becomes more difficult to plan an appointment or to build a sound, recurring schedule. Forced to worry about not having a form of transportation or an unforeseen eviction, that diabetes monthly checkup no longer takes precedence.

Clearly, SES is strongly coupled with the disparity in health risk. It is important to realize that this issue is not just tied to income and occupation, but race, geographic location, sexual orientation, among others, as well, and each factor warrants its own discussion. Systematic differences in the health of certain groups are just a microcosm of wider societal issues that place extraordinary levels of distress on such groups.

References

[1] Riley, W.J. (2012). Health disparities: gaps in access, quality and affordability of medical care. Trans Am Clin Climatol Assoc, 123, 167-174.

[2] Pamuk, E., Makuc, D., Heck, K., Reuben, C., & Lochner, K. (1998). Socioeconomic Status and Health Chartbook. Health, United States, 1998.

[3] Adler, N. E., & Newman, K. (2002). Socioeconomic Disparities In Health: Pathways And Policies. The Determinants of Health, 21(2), 60-76. https://doi.org/10.1377/hlthaff.21.2.60

[4] C. Hertzman. (1999). Population Health and Human Development. Developmental Health and the Wealth of Nations, 21–40.

[5] Marmot, M. G., Smith, G. D., Stansfeld, S., Patel, C., North, F., Head, J., White, I., Brunner, E., & Feeney, A. (1991). Health inequalities among British civil servants: the Whitehall II study. Lancet (London, England), 337(8754), 1387–1393. https://doi.org/10.1016/0140-6736(91)93068-k

[6] Fiscella, K., & Williams, D. R. (2004). Health disparities based on socioeconomic inequities: implications for urban health care. Academic medicine: Journal of the Association of American Medical Colleges, 79(12), 1139–1147. https://doi.org/10.1097/00001888-200412000-00004

[7] Weissman, J. S., Moy, E., Campbell, E. G., Gokhale, M., Yucel, R., Causino, N., & Blumenthal, D. (2003). Limits to the safety net: teaching hospital faculty report on their patients' access to care. Health affairs (Project Hope), 22(6), 156–166. https://doi.org/10.1377/hlthaff.22.6.156

[8] Andersson, H. W., Sommerfelt, K., Sonnander, K., & Ahlsten, G. (1996). Maternal child-rearing attitudes, IQ, and socioeconomic status as related to cognitive abilities of five-year-old children. Psychological reports, 79(1), 3–14. https://doi.org/10.2466/pr0.1996.79.1.3

[9] Chen, E., & Matthews, K. A. (2001). Cognitive appraisal biases: an approach to understanding the relation between socioeconomic status and cardiovascular reactivity in children. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine, 23(2), 101–111. https://doi.org/10.1207/S15324796ABM2302_4

[10] Seeman, T. E., Crimmins, E., Huang, M. H., Singer, B., Bucur, A., Gruenewald, T., Berkman, L. F., & Reuben, D. B. (2004). Cumulative biological risk and socio-economic differences in mortality: MacArthur studies of successful aging. Social science & medicine (1982), 58(10), 1985–1997. https://doi.org/10.1016/S0277-9536(03)00402-7

[11] Schillinger, D., Piette, J., Grumbach, K., Wang, F., Wilson, C., Daher, C., Leong-Grotz, K., Castro, C., & Bindman, A. B. (2003). Closing the loop: physician communication with diabetic patients who have low health literacy. Archives of internal medicine, 163(1), 83–90. https://doi.org/10.1001/archinte.163.1.83

Figure: Pamuk, E., Makuc, D., Heck, K., Reuben, C., & Lochner, K. (1998). Socioeconomic Status and Health Chartbook. Health, United States, 1998, 1(22), 64.