Search

Research into the role of place in shaping inequalities in health has focused largely on examining individual and/or localised drivers, often using a context-composition framing. Whilst this body of work has advanced considerably our understanding of the effects of local environments on health, and re-established an awareness of the importance of place for health, it has done so at the expense of marginalising and minimising the influences of macro political and economic structures on both place and health. In this paper, we argue that: (i) we need to scale up our analysis, moving beyond merely analysing local horizontal drivers to take wider, vertical structural factors into account; and (ii) if we are serious about reducing place-based health inequalities, such analysis needs be overtly linked to appropriate policy levers. Drawing on three case studies (the US mortality disadvantage, Scotland's excess mortality, and regional health divides in England and Germany) we outline the theoretical and empirical value of taking a more political economy approach to understanding geographical inequalities in health. We conclude by outlining the implications for future research and for efforts to influence policy from 'scaling up' geographical research into health inequalities. • Health-place research commonly examines focuses individual and/or localised drivers. • Health geography should 'scale up' analysis of health-place relationships. • Research needs to account for wider, vertical and structural factors. • Political economic approaches add value to insight on geographic health inequalities. • Considers the policy implications of taking a political economy approach. [ABSTRACT FROM AUTHOR]

Abstract Previous research findings across a variety of nations show that affiliation with the conservative party is associated with greater longevity; however, it is thus far unclear what characteristics contribute to this relationship. We examine the political party/mortality relationship in the United States context. The goal of this paper is two-fold: first, we seek to replicate the mortality difference between Republicans and Democrats in two samples, controlling for demographic confounders. Second, we attempt to isolate and test two potential contributors to the relationship between political party affiliation and mortality: (1) socioeconomic status and (2) dispositional traits reflecting a personal responsibility ethos, as described by the Republican party. Graduate and sibling cohorts from the Wisconsin Longitudinal Study were used to estimate mortality risk from 2004 to 2014. In separate Cox proportional hazards models controlling for age and sex, we adjusted first for markers of socioeconomic status (such as wealth and education), then for dispositional traits (such as conscientiousness and active coping), and finally for both socioeconomic status and dispositional traits together. Clogg's method was used to test the statistical significance of attenuation in hazard ratios for each model. In both cohorts, Republicans exhibited lower mortality risk compared to Democrats (Hazard Ratios = 0.79 and 0.73 in graduate and sibling cohorts, respectively [p < 0.05]). This relationship was explained, in part, by socioeconomic status and traits reflecting personal responsibility. Together, socioeconomic factors and dispositional traits account for about 52% (graduates) and 44% (siblings) of Republicans' survival advantage. This study suggests that mortality differences between political parties in the US may be linked to structural and individual determinants of health. These findings highlight the need for better understanding of political party divides in mortality rates. Highlights • Republicans have greater longevity compared to Democrats, adjusting for demographics. • This relationship is partly explained by Republican's higher socioeconomic status. • This relationship is partly explained by Republican's personal responsibility ethos. [ABSTRACT FROM AUTHOR]

Abstract Our paper explores how legal status stratification shapes the health and health care of low-income patients with chronic illnesses in the U.S. healthcare safety net. Drawing on data from over two years of ethnographic fieldwork at urban safety-net clinics, we examine efforts by Complex Care Management (CCM) teams to stabilize patients with uncontrolled chronic illnesses through primary care-integrated support. We show that stratified citizenship and geographic variability correspond to different possibilities for health care. We suggest an approach to immigration as a structural determinant of health that accounts for the complex, stratified, and changing nature of citizenship status. We also highlight how geographical differences and interactions among local, state, and federal policies support the notion that citizenship is stratified across multiple tiers with distinctive possibilities and constraints for health. While county-based health plans at each of the study sites include residents with varying legal status, lack of formal legal status remains a substantial obstacle to care. Many immigrants are unable to take full advantage of primary and specialty care, resulting in unnecessary morbidity and mortality. In some cases, patients have returned to their country of origin to die. While CCM teams provide an impressive level of support to assist immigrant patients in navigating healthcare and immigration bureaucracies, legal and geographic stratification limit their ability to address broader aspects of these patients' social context. Highlights • Immigration status shapes the health of chronically ill U.S. safety net patients. • Local, state, and federal policies differentially stratify legal status and health. • Ethnography illustrates health impacts of stratified legal status. • Complex care management patients lacking legal status face obstacles to care. • Legal and geographic stratification impede immigrant CCM patients' health. [ABSTRACT FROM AUTHOR]

In this paper, we present novel evidence of the extent to which intergenerational mobility is generalized or specific across domains of human and health capital. That is, do children who experience greater mobility in one domain (e.g., income) also experience mobility in other domains (education, health status, health behaviors, crime). Using rich data in Add Health, we find evidence against generalized mobility—families that are more mobile in one domain are not more mobile in others. We then ask a place-based version of this question, motivated by Chetty et al. (2014)'s work showing high levels of geographically-based income mobility in the US. The school-based sampling combined with parent-child links across many outcome domains of the Add Health allows us to use a common dataset between the two analyses. Like our individual-based results, we find limited evidence of generalized mobility by place—indeed, most estimates suggest close-to-zero correlations between many of the ten domains we explore. • Theoretically, intergenerational mobility could be generalized or specific. • Empirically, we find more evidence of specific mobility. • People and places with high income mobility may not have high health mobility. [ABSTRACT FROM AUTHOR]

Whites in the USA are the dominant racial group, with greater than average access to most material and social rewards. Yet, while whites have better outcomes than other racial groups on some health indicators, whites paradoxically compare poorly on other measures. Further, whites in the USA also rank poorly in international health comparisons. In this paper, we present a framework that combines the concept of whiteness—a system that socially, economically, and ideologically benefits European descendants and disadvantages people in other groups—with research from a variety of fields in order to comprehensively model the social factors that influence whites' health. The framework we present describes how whiteness and capitalism in the USA shape societal conditions, individual social characteristics and experiences, and psychosocial responses to circumstances to influence health outcomes. We detail specific examples of how social policies supported by whiteness, the narratives of whiteness, and the privileges of whiteness may positively and negatively affect whites' health. In doing so, we suggest several areas for future research that can expand our understanding of how social factors affect health and can contribute to the patterns and paradoxes of whites' health. By expanding research to include theoretically-grounded analyses of the dominant group's health, we can achieve a more complete picture of how systems of racial inequity affect health. [ABSTRACT FROM AUTHOR]

There has been a great deal of state-level legislative activity focused on immigration and immigrants over the past decade in the United States. Some policies aim to improve access to education, transportation, benefits, and additional services while others constrain such access. From a social determinants of health perspective, social and economic policies are intrinsically health policies, but research on the relationship between state-level immigration-related policies and Latino health remains scarce. This paper summarizes the existing evidence about the range of state-level immigration policies that affect Latino health, indicates conceptually plausible but under-explored relationships between policy domains and Latino health, traces the mechanisms through which immigration policies might shape Latino health, and points to key areas for future research. We examined peer-reviewed publications from 1986 to 2016 and assessed 838 based on inclusion criteria; 40 were included for final review. These 40 articles identified four pathways through which state-level immigration policies may influence Latino health: through stress related to structural racism; by affecting access to beneficial social institutions, particularly education; by affecting access to healthcare and related services; and through constraining access to material conditions such as food, wages, working conditions, and housing. Our review demonstrates that the field of immigration policy and health is currently dominated by a “one-policy, one-level, one-outcome” approach. We argue that pursuing multi-sectoral, multi-level, and multi-outcome research will strengthen and advance the existing evidence base on immigration policy and Latino health. [ABSTRACT FROM AUTHOR]

There is growing concern among US-based clinicians, patients, policy makers, and in the media about the personal and community health risks associated with opioids. Perceptions about the efficacy and appropriateness of opioids for the management of chronic non-cancer pain (CNCP) have dramatically transformed in recent decades. Yet, there is very little social scientific research identifying the factors that have informed this transformation from the perspectives of prescribing clinicians. As part of an on-going ethnographic study of CNCP management among clinicians and their patients with co-occurring substance use, we interviewed 23 primary care clinicians who practice in safety-net clinical settings. In this paper, we describe the clinical and social influences informing three historic periods: (1) the escalation of opioid prescriptions for CNCP; (2) an interim period in which the efficacy of and risks associated with opioids were re-assessed; and (3) the current period of “opioid pharmacovigilance,” characterized by the increased surveillance of opioid prescriptions. Clinicians reported that interpretations of the evidence-base in favor of and opposing opioid prescribing for CNCP evolved within a larger clinical-social context. Historically, pharmaceutical marketing efforts and clinicians' concerns about racialized healthcare disparities in pain treatment influenced opioid prescription decision-making. Clinicians emphasized how patients' medical complexity (e.g. multiple chronic health conditions) and structural vulnerability (e.g. poverty, community violence) impacted access to opioids within resource-limited healthcare settings. This clinical-social history of opioid prescribing practices helps to elucidate the ongoing challenges of CNCP treatment in the US healthcare safety net and lends needed specificity to the broader, nationwide conversation about opioids. [ABSTRACT FROM AUTHOR]

While the overall impact of the COVID-19 pandemic on U.S. population health has been devastating, it has not affected everyone equally. The risks of hospitalization and death from the disease are relatively low for the population as a whole, but much higher for specific subpopulations defined by age, health status, and race or ethnicity. The extent to which Americans perceive these disparities is an open question, with potentially important political implications. Recognition of unequal impacts may prime concerns about justice and fairness, making Americans more concerned and willing to support government intervention. On the other hand, belief that the pandemic primarily threatens "other people" or out-groups may reduce, rather than increase, a person's concern. Partisanship and media consumption habits are also likely to play a role in these perceptions, as they do in most issues related to COVID-19. In this paper, we use original survey data from the Cooperative Election Study (N = 1000) to explore Americans' perceptions of which groups are most harmed by the pandemic, the demographic and political determinants of these perceptions, and the relationship of these perceptions with their opinions about COVID-related mitigation policy. We find that, on average, people perceived accurately that certain groups (e.g., Black Americans, older people) were more affected, but these group perceptions varied by demographic and political characteristics of respondents. We find, in contrast with recent experimental evidence, that the perception that populations of color were harmed was associated with more support for pandemic mitigation strategies. More research should investigate the relationships among pandemic politics and the racial dynamics of the target populations most affected. • In fall 2020, survey participants recognized groups harmed by COVID based on age. • They had lower recognition of racial groups harmed, lowest for Native Americans. • Perceptions of groups harmed varies by information exposure and politics. • Perceiving group disparities was associated with more support for pandemic policy. • The racial dynamics surrounding the politics of COVID-19 requires more attention. [ABSTRACT FROM AUTHOR]

Abstract: This paper utilizes eighteen months of ethnographic and interview research undertaken in 2003 and 2004 as well as follow-up fieldwork from 2005 to 2007 to explore the sociocultural factors affecting the interactions and barriers between U.S. biomedical professionals and their unauthorized Mexican migrant patients. The participants include unauthorized indigenous Triqui migrants along a transnational circuit from the mountains of Oaxaca, Mexico, to central California, to northwest Washington State and the physicians and nurses staffing the clinics serving Triqui people in these locations. The data show that social and economic structures in health care and subtle cultural factors in biomedicine keep medical professionals from seeing the social determinants of suffering of their unauthorized migrant patients. These barriers lead clinicians inadvertently to blame their patients – specifically their biology or behavior – for their suffering. This paper challenges the focus of mainstream cultural competency training by showing that it is not the culture of the patient, but rather the structure and culture of biomedicine that form the primary barriers to effective multicultural health care. [Copyright &y& Elsevier]

Prior research suggests that racial inequalities in health vary in magnitude across societies. This paper uses the largest nationally representative samples available to compare racial inequalities in health in the United States and Canada. Data were obtained from ten waves of the National Health Interview Survey (n = 162,271,885) and the Canadian Community Health Survey (n = 19,906,131) from 2000 to 2010. We estimated crude and adjusted odds ratios, and risk differences across racial groups for a range of health outcomes in each country. Patterns of racial health inequalities differed across the United States and Canada. After adjusting for covariates, black-white and Hispanic-white inequalities were relatively larger in the United States, while aboriginal-white inequalities were larger in Canada. In both countries, socioeconomic factors did not explain inequalities across racial groups to the same extent. In conclusion, while racial inequalities in health exist in both the United States and Canada, the magnitudes of these inequalities as well as the racial groups affected by them, differ considerably across the two countries. This suggests that the relationship between race and health varies as a function of the societal context in which it operates. [ABSTRACT FROM AUTHOR]

While migrants are widely believed to be positively selected on health, there has been very little empirical exploration of the actual health differential between migrants and non-migrants. This paper explored: 1) the extent of health selection by comparing US immigrants from 19 sending countries to their non-migrating counterparts still residing in the countries of origin; 2) country-level correlates of health selection; and 3) whether country-level health selection accounted for differences in self-rated health between immigrants and US-born Whites. We combined nationally-representative international data with data from US immigrants from the 2003–2007 Current Population Survey. The health selectivity measure was the Net Difference Index (NDI), which compares the distribution of self-rated health between migrants and non-migrants. We calculated Spearman correlation and bivariate regression coefficients between the NDI and economic, health, distance, and migration characteristics of the sending countries. We used generalized estimating equation models to examine the association between country-level health selection and immigrants' current self-rated health. We found immigrants from South America to show the most positive health selection. Health selection was significantly correlated with visa mode of entry, where family networks decrease, but work-related networks increase health selection. There was little evidence that country-level health selection explained differences in the self-rated health of US immigrants relative to US-born Whites. Our findings do not support the idea that country-level health selection underlies the “healthy immigrant effect”. [ABSTRACT FROM AUTHOR]

Recent research has found that children who attended pre-kindergarten programs in childhood were more likely to be healthy as adults. One intuitive way of improving population health and longevity may therefore be to invest in pre-kindergarten programs. However, much of the research linking pre-kindergarten programs to health is very recent and has not been synthesized. In this paper, I review the mechanisms linking pre-kindergarten programs in childhood to adult longevity, and the experimental evidence backing up these linkages. I conclude with a critical exploration of whether investments in pre-kindergarten programs could also serve as investments in public health. [ABSTRACT FROM AUTHOR]

Social scientists have long demonstrated that socioeconomic resources benefit health. More recently, scholars have begun to examine the potential stratification in the health returns different groups receive for a given resource. Motivated by fundamental cause theory, this paper examines homeownership as a salient health resource with potentially stratified benefits. Homeowners have significantly greater housing quality, wealth, neighborhood quality and integration, and physical and mental health than renters. However, there are compelling theoretical reasons to expect the health advantage of homeownership to be unequally distributed across racial and ethnic groups. Regression analyses of 71,874 household heads in the United States from the 2012 March Current Population Survey initially suggest all homeowners experience a significant health advantage. Further examination finds robust evidence for a homeowner health advantage among Whites, on par with the difference between the married and divorced. The advantage among minority households is considerably smaller, and not significant among Latinos or Asians. Conditioning on a broad array of observable characteristics, White homeowners emerge as exceptionally healthy compared to White renters and all minority groups. This leads to the unexpected finding that racial/ethnic differences in health are concentrated among homeowners. The findings demonstrate the interactive nature of racial/ethnic stratification in health through both access to and returns from socioeconomic resources. [ABSTRACT FROM AUTHOR]

Research on disadvantage across generations typically focuses on the resources that parents pass on to their children. Yet, social disadvantage might also result from the transmission of adverse experiences from children to their parents. This paper explores one such adverse experience by examining the influence of a son's incarceration on his mother's health. Using panel data from the 1979 National Longitudinal Survey of Youth and its young adult follow up (n = 2651 mothers; 18,390 observations), the paper shows that mothers are more likely to suffer health limitations after a son is incarcerated. A time-distributed fixed effects analysis indicates that the effect on maternal health may persist or even grow over time. Rather than a short-term shock whose effect soon diminishes, a son's incarceration is a long-term strain on mothers' health. The disproportionate incarceration of young men in disadvantaged communities is thus likely to contribute to cumulative adversity among mothers already at risk of severe hardship. More broadly, the results suggest how children's adverse experiences may influence parental well-being, producing further disadvantage across generations. • Mothers experience significant health decline after their son's incarceration. • Harmful effect on maternal health may persist or even grow over time. • Fixed effects analysis better accounts for confounding than prior studies. • Racial disparities in incarceration contribute to racial disparities in health. • Young adults' adverse experiences can influence parental disadvantage. [ABSTRACT FROM AUTHOR]

Although local policies aimed at reducing childhood health inequities can benefit from local data, sample size constraints in population representative health surveys often prevent rigorous evaluations of child health disparities and health care patterns at local levels. Electronic Health Records (EHRs) offer a possible solution as they contain large amounts of information on pediatric patients within a health system. In this paper, we consider the suitability of using EHRs from a large health system to study local children's health by evaluating the extent to which the EHRs capture the county's child population. First, we compare the demographic characteristics of Duke University Health System pediatric patients who live in Durham County, NC (USA) to the child population estimates in the 2015–2019 American Community Survey. We then examine geographic variation in census tract rates of children captured in the EHR data and estimate negative binomial models to assess how tract characteristics are associated with these rates. We also perform these analyses for the subset of pediatric patients who have a well-child encounter. We find that the demographic characteristics of pediatric patients captured by the EHRs are similar to those of the county's child population. Although the county rate of children captured in the EHRs is high, there is variation across census tracts. On average, census tracts with higher concentrations of non-Hispanic Black residents have lower capture rates and tracts with higher concentrations of poverty have higher capture rates, with the poorest tracts showing the largest racial gap in rates of children captured by EHRs. Our findings suggest that EHRs from a large health system can be used to assess children's population health, but that EHR-based evaluations of children's health disparities and health care patterns should account for differences in who is captured by the EHRs based on census tract characteristics. • EHRs from a large health system are suitable for studying local children's health. • Local children in EHRs are demographically similar to county population estimates. • Rates of children captured in health system differ by census tract characteristics. • EHR-based analyses should adjust for local differences in capture rates. [ABSTRACT FROM AUTHOR]

This paper presents the first longitudinal study of sex disparities in COVID-19 cases and mortalities across U.S. states, derived from the unique 13-month dataset of the U.S. Gender/Sex COVID-19 Data Tracker. To analyze sex disparities, weekly case and mortality rates by sex and mortality rate ratios were computed for each U.S. state, and a multilevel crossed-effects conditional logistic binomial regression model was fitted to estimate the variation of the sex disparity in mortality over time and across states. Results demonstrate considerable variation in the sex disparity in COVID-19 cases and mortalities over time and between states. These data suggest that the sex disparity, when present, is modest, and likely varies in relation to context-sensitive variables, which may include health behaviors, preexisting health status, occupation, race/ethnicity, and other markers of social experience. • First report of findings from unique longitudinal dataset of sex-disaggregated COVID-19 data in U.S. states. • Sex disparities in COVID-19 are highly heterogeneous in magnitude and direction and vary across states and over time. • Gender-related and other social and contextual factors likely shape COVID-19 sex disparities. • Single-factor approaches are ill-positioned to explain patterns in sex disparities in COVID-19 outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Research from across disciplines has demonstrated that social and political contextual factors at the national and subnational levels can impact the health and health behavior risks of individuals. This paper examines the impact of state-level social capital and ideology on individual-level health outcomes in the U.S. Leveraging the variation that exists across states in the U.S., the results reveal that individuals report better health in states with higher levels of governmental liberalism and in states with higher levels of social capital. Critically, however, the effect of social capital was moderated by liberalism such that social capital was a stronger predictor of health in states with low levels of liberalism. We interpret this finding to mean that social capital within a political unit—as indicated by measures of interpersonal trust—can serve as a substitute for the beneficial impacts that might result from an active governmental structure. [Copyright &y& Elsevier]

Abstract: Research suggests that income inequality is inversely associated with health. This association has been documented in studies that utilize variation in income inequality across countries or across time from a single country. The primary criticism of these approaches is their inability to account for potential confounders that are associated with income inequality. This paper uses variation in individual experiences of income inequality among immigrants within the United States (U.S.) to evaluate whether individuals who moved from countries with greater income inequality than the U.S. have better health than those who migrated from countries with less income in equality than the U.S. Utilizing individual-level (March Current Population Survey) and country-level data (the United Nations Human Development Reports), we show that among immigrants who have resided in the U.S. between 6 and 20 years, self-reported health is more favorable for the immigrants in the former category (i.e., greater income inequality) than those in the latter (i.e., lower income inequality). Results also show that self-reported health is better among immigrants from more developed countries and those who have more years of education, are male, and are married. [Copyright &y& Elsevier]

Abstract: Sleeping, dreaming, and health or well-being are all closely related phenomena from an experiential and cultural point of view, and yet all three are often studied in isolation from one another. In this paper, I use an ethnographic and clinical lens to compare and contrast patterns of sleeping and dreaming and their relationship to health in a rural Indonesian society and among urban middle class people in the US. I demonstrate how culturally shaped patterns of sleeping and dreaming become linked through social practice and the implication of these practices for health and well being. I underscore, in particular, the seamless connection between waking and non-waking life, how daytime activities affect patterns of sleeping and dreaming, but also how the emotional and behavioral residues of the night affect daytime life and experience. Data for the Indonesia case were collected during extended fieldwork in 1981–1983, while the U.S. data come from my ongoing part-time private practice of psychotherapy and psychoanalysis. [Copyright &y& Elsevier]

Abstract: Over the course of the 20th century, Mexico-U.S. migration has emerged as an important facet of both countries, with far reaching economic and social impacts. The health of Mexican immigrants in the U.S. has been well studied, but relatively less is known about the health of returned migrants to Mexico. The objectives of this paper are twofold. Relying on health data pertaining to two stages of the life course, early life health (pre-migration) and adult health (post-migration) from the Mexican Migration Project gathered between 2007 and 2009, we aim to assess disparities in adult health status between male returned migrants and male non-migrants in Mexico, accounting for their potentially different early life health profiles. While we find evidence that returned migrants had more favorable early life health, the results for adult health are more complex. Returned migrants have a higher prevalence of heart disease, emotional/psychiatric disorders, obesity, and smoking than non-migrants but no differences are found in self-rated health, diabetes, or hypertension. [Copyright &y& Elsevier]

Abstract: This paper assesses how the relationship between health and educational attainment has changed over the last three decades. We examine trends in disease prevalence and self-reported health using the US National Health Interview Survey for five chronic conditions—arthritis, diabetes, heart disease, hypertension, and lung diseases. The sample is limited to non-Hispanic Whites ages 40–64 to focus on the value of education and not changing representation of minority populations. We find that health benefits associated with additional schooling rose over time by more than ten percentage points as measured by self-reported health status. This can be attributed to both a growing disparity by education in the probability of having major chronic diseases during middle age, and better health outcomes for those with each disease. The value of education in achieving better health has increased over the last 25 years; both in protecting against onset of disease and promoting better health outcomes amongst those with a disease. Besides better access to health insurance, the more educated increasingly adapted better health behaviors, particularly not smoking and engaging in vigorous excercise, and reaped the benefits of improving medical technology. Rising health disparities by education are an important social concern which may require targeted interventions. [Copyright &y& Elsevier]

Abstract: Do richer friends and neighbors improve your health through positive material effects, or do they make you feel worse through the negative effect of social comparison and relative deprivation? Using the newly available National Social Life, Health, and Aging Project (NSHAP) data set that reports individuals'' income positions within their self-defined social networks, this paper examines whether there is an association between relative position and health in the US. Because this study uses measures of individuals'' positions within their self-defined social groups rather than researcher-imputed measures of relative position, I am able to more precisely examine linkages between individual relative position and health. I find a relationship between relative position and health status, and find indirect support for the biological mechanism underlying the relative deprivation model: lower relative position tends to be associated with those health conditions thought to be linked to physiological stress. I also find, however, that only extremes of relative position matter: very low relative position is associated with worse self-rated physical health and mobility, increased overall disease burden, and increased reporting of cardiovascular morbidity; very high relative position is associated with lower probabilities of reporting diabetes, ulcers, and hypertension. I observe few associations between health and either moderately high or moderately low positions. This analysis suggests that the mechanism underlying the relative deprivation model may only have significant effects for those at the very bottom or the very top. [Copyright &y& Elsevier]

Abstract: There is renewed interest in understanding how fluctuations in mortality and in health are related to fluctuations in economic conditions. The traditional perspective that economic recessions lower health and raise mortality has been challenged by recent findings that reveal mortality is actually procyclical. The epidemiology of the phenomenon – traffic accidents, cardiovascular disease, and smoking and drinking – suggests that socioeconomically vulnerable populations might be disproportionately at risk of “working themselves to death” during periods of heightened economic activity. In this paper, I examine mortality by individual characteristic during the 1980s and 1990s using the U.S. National Longitudinal Mortality Study. I find scant evidence that disadvantaged groups are significantly more exposed to procyclical mortality. Rather, working-age men with more education appear to bear a heavier burden, while those with little education experience countercyclical mortality. [Copyright &y& Elsevier]

Abstract: The US Institute of Medicine''s (IOM) influential 2003 report has focused attention on disparities in treatment outcomes and health status for American minorities, zeroing in on the role of unconscious bias in the unequal clinical disposition of minority patients. In keeping with the IOM''s focus, current examinations of health disparities in the US tend to explore bias in clinical decision-making to the neglect of the political economic trends that buffet health care safety net sites and create the need for financial shortcuts. This paper recontextualizes the study of health disparities in the US by placing it against the backdrop of private sector trends emphasizing fiscal austerity and increased workforce productivity in health care. The social science literature on workers in human service bureaucracies, only recently applied to health care workers, suggests that higher demands for system “accountability” and worker “efficiency” may encourage providers to take shortcuts by treating individuals as mass categories. This ethnography of a Latino mental health clinic in the Northwestern USA shows that new private-sector measures of “productivity” take a toll on both the Latina clinicians whose invisible work subsidizes the system as well as on particular categories of patients—the uninsured and immigrants with serious psychosocial issues. While clinicians attempt to buffer the impacts of such reforms on patients, they also resort to means to increase their productivity such as firing repeated no-show patients and denial of care to the uninsured. This study is relevant for the health care of the poor in all health care systems considering restructuring along managerial principles to increase system ‘efficiencies.’ [Copyright &y& Elsevier]

The self-help culture, in the context of the U.S. medical system, demands proactive patient behavior as more responsibility for good health falls on the patient. The presence of health/medical information online alters the dynamics of medical encounters and transforms patients into reflexive consumers or consumer-patients who are engaged in personal health management. This paper examined whether using health information obtained from the Internet to manage personal health care (referred as e-health information consumerism) is associated with subjectively reported negative health outcomes in a representative sample of Internet users in the U.S. These outcomes are conceptualized as experiencing (a) adverse affect (feeling worried and anxious) and (b) health problem due to using Internet information. An online survey (n = 710) was conducted with study participants who were recruited from the largest online probability U.S. research panel developed by a non-profit academic research firm, Knowledge Networks. Analyses included multivariate regressions that included the statistical interactions between e-health information consumerism and the communicational and interactional aspects of medical encounters. Parallel models were tested in the gender-stratified subsamples. Results indicate that robust associations exist between e-health information consumerism and patient-reported health outcomes. Respondents who indicated greater satisfaction with medical communication reported lower averages on experiencing worry and a health problem due to e-health information consumerism. While e-health information consumerism is significantly associated with experiencing a self-reported health problem in both men and women, the association with adverse affect is significant only among women. The moderating role of patient satisfaction with medical communication is stronger among women. Interestingly, the moderating role of patient satisfaction with a medical interaction is stronger among respondents who reported higher averages on experiencing a health problem due to e-health information consumerism. e-Health information consumerism can translate into health benefits if the Internet information is deployed to promote a satisfactory medical partnership. • The growth of online health information challenges the parameters of the sick role. • Information pluralism encourages a consumerist orientation towards health. • The Internet may pose a health risk for physical and emotional well-being. [ABSTRACT FROM AUTHOR]

Unlike other aspects of welfare (e.g. income), health has been relatively neglected when it comes to defining and measuring aspects of poverty. The aim of the paper is twofold: first we elaborate how the concept of 'health poverty' can be defined and measured, and second we apply the methodology to study health poverty in a variety of cases. The measurement of health poverty allows us to gain insights into different sorts of health deprivation in society as a whole, and in specific subgroups. We measure poverty by means of the widely adopted Foster-Greer-Thorbecke (FGT) class of indicators and apply this to three different health variables: cardiovascular risk, health status and life expectancy. Moreover, the FGT class is additively decomposable, making it possible to gauge the contribution of specific subgroups to overall poverty. We provide two applications of these methods. Firstly, we examine changes in the risk of cardiovascular disease (CVD) in the United States using two waves of the NHANES survey from 2005-06 and 2013-14 (n = 3,014 and 4,001 respectively) and use a threshold of 20% 10 year CVD risk to define health poverty. Overall our results indicate a slight decline in the proportion at high CVD risk between these periods. Secondly, we apply poverty measures to health status as measured by the SF-6D index and to empirically derived predictions of life expectancy and estimated using 24,820 individuals from the first 15 waves of the Australian HILDA survey. Trends in poverty over time are compared using several thresholds and decomposed by a variety of sub-groups. Measures of health poverty can be an important instrument for focusing the attention on those with the worst health, or highest risk, in a society and should be used more widely. • Health poverty measures are useful to monitor deprivation in the domain of health. • Health poverty measures accord closely with threshold-based practices in medicine. • Poverty measures can be applied to disease risk, life expectancy and quality of life. [ABSTRACT FROM AUTHOR]

Racial disparities in the end-of-life treatment of patients are a well observed fact of the U.S. healthcare system. Less is known about how the physicians treating patients at the end-of-life influence the care received. Social networks have been widely used to study interactions with the healthcare system using physician patient-sharing networks. In this paper, we propose an extension of the dissimilarity index (DI), classically used to study geographic racial segregation, to study differences in patient care patterns in the healthcare system. Using the proposed measure, we quantify the unevenness of referrals (sharing) by physicians in a given region by their patients' race and how this relates to the treatments they receive at the end-of-life in a cohort of Medicare fee-for-service patients with Alzheimer's disease and related dementias. We apply the measure nationwide to physician patient-sharing networks, and in a sub-study comparing four regions with similar racial distribution, Washington, DC, Greenville, NC, Columbus, GA, and Meridian, MS. We show that among regions with similar racial distribution, a large dissimilarity index in a region (Washington, DC DI = 0.86 vs. Meridian, MS DI = 0.55), which corresponds to more distinct referral networks for black and white patients by the same physician, is correlated with black patients with Alzheimer's disease and related dementias receiving more aggressive care at the end-of-life (including ICU and ventilator use), and less aggressive quality care (early hospice care). • Novel application of the dissimilarity index to social network analysis. • Considered a cohort of patients with Alzheimer's disease and related dementias. • Analyzed racial disparities in end-of-life treatment intensity. • Large dissimilarity index is associated with more intensive end-of-life treatments. [ABSTRACT FROM AUTHOR]