SOCIAL DETERMINANTS OF HEALTH
The concept of health and wellbeing has evolved since the dawn of human civilization. Once believed to be influenced by mystical or supernatural forces, modern scientists now agree on several key factors that undeniably determine the level of health and wellness of an individual. The goal of this paper is to examine the role of ethnicity in that determination, and to pay specific attention to how this affects Hispanic-Latino populations in America.
Defining the terms
A founding principle of United States domestic policy, as declared by Thomas Jefferson, is fairness through equality. These truths, in America, are held to be self-evident: that all men were created equal and are endowed with certain unalienable rights. Access to basic health care is now undoubtable one of these rights – as is evident by the Emergency Medical Treatment and Labor Act of 1986, the Americans with Disabilities Act of 1990, and the Patients’ Bill of Rights of 1995 (updated in 2010). Thus, health equality, in the United States, means equal access to health care services regardless of race, ethnicity, gender, age, sexual preference, economic status, education, or disability. Health equity, on the other hand, means that all individuals should deserve equal opportunities to lead full, healthy lives, and should deserve equal opportunities to the unalienable rights of life, liberty, and the pursuit of happiness. While equality was unanimously declared by the thirteen united States of America in 1776, equity – the very means to equality – is still somewhat a controversial issue, as is evident by disagreements over “Affirmative Action” and certain policies of the Affordable Care Act.
The term race has traditionally been applied to delineate groups of humans, along stereotyped morphological and phenotypic lines typically attributed to evolutionary sub-speciation or other such inherited group biology. Corresponding taxonomical attempts to classify human population divergence has resulted in several unsatisfactory ambiguities and inconsistencies. Problems with the concept of race and ascribing consistent racial nomenclature have led to alternative ways of thinking about human diversity.
The term ethnic is also used to demarcate groups of people. This concept was first used by sociologists to describe the waves of immigrant populations in and around the United Stated during the Great Depression (Marable, 2000). Ethnicity avoids some of the subjective complications associated with racial classification while retaining the ability to categorize natural anthropologic aggregates, by objectively allowing affiliates to self-identity group association; and unlike race, the concept of ethnicity recognizes that biological and cultural differences distinguish populations.
An ethnic group is a subgroup of a larger social system whose members “have common ancestral, racial, physical, or national characteristics and who share cultural symbols such as language, lifestyle, religion, and other characteristics that are not fully understood or shared by outsiders” (Andrews & Boyle, 1999, p. 59). Ethnic identities are fluid over time, reflecting how people think about themselves and external political forces (Nagel, 1994, p. 155). Ethnic groups feel similarities that not only bind their members together, but also separate them from other groups (Stark, 2004, pp. 257-258). Such similarities are often centered on a shared common history or distinctive culture that may be, but not necessarily, associated with nationality; and as such, ethnic identity, is often perceived as inherent, but is actually a phenomenon relative to the surrounding population. For example, whenever Columbian-American or Argentinian-American families take pride in their ethnic heritage, they may be focusing on their national roots; but, for example, families in Columbia may be focusing on their Afro-Colombian, indigenous, or gypsy (Romani) roots when they take pride in their ethnic heritage (Federal Research Division of the Library of Congress [FRDLC], 2010, p. 34).
About 33 percent of Americans self-identity as belonging to as ethnic minority (factfinder, 2008), and Latinos make up about 15% of the U.S. population and are the fastest growing minority – expected to make up nearly one-fourth of the population by 2050 (census.gov, 2014). Although many diversities exist among Hispanic populations, in vernacular dialog the terms Hispanic, Latino, and Spanish are frequently used interchangeably. Preferences for various ethnic terms change over time, and an increasing number of people are identifying themselves in terms of more than one ethnic tradition. For example, many people who are considered Hispanic or Latino by the Census Bureau are identifying themselves as Mexican-American, Cuban-American, and so forth. In fact, many people actually dislike the terms Hispanic and Latino because these are terms that the dominant culture has used to lump together groups that historically have not identified with one another and may have many strong dissimilarities; but if they had to choose, some people prefer the term Latino over Hispanic because they view Latino as recognizing the diversity of Latin American countries (Granados, 2000). Nevertheless, the term Hispanic has lately gained more acceptance, and was preferred by the majority of registered Latino voters (Granados, 2000).
Health inequities in ethnic groups
“Healthy People 2020” identifies five key domains of concern: economic stability, education, health and health care, neighborhood and built environment, and social and community context. Each of these determinants is comprised of several critical components. Factors related to economic stability are poverty, employment, food security, and housing stability. Education factors include high school graduation, enrollment in higher education, language and literacy, early childhood education and development. Elements related to social and community context are social cohesion, civic participation, perceptions of discrimination and equity, and incarceration/institutionalization. Health and health care is determined by access to health care, access to primary care, and health literacy. Finally, neighborhood and built environment variables are access to healthy foods, quality of housing, crime and violence, and environmental conditions (healthypeople.gov, 2015). Ethnic minority groups, immigrants, and non-English speakers are particularly vulnerable to these five areas.
One important aspect of the health inequalities among ethnic minorities is socioeconomic status (SES). Compared to high SES families low SES families are less educated, have less prestigious jobs, and have lower incomes. Low SES is associated with many developmental problems, including high infant mortality rates, poor school achievement, and a higher rate of behavioral problems (Gottfried et al., 2003). Because so many outcomes are associated with SES, it is one of the most frequently studied environmental variables.
The unavailability of opportunities, inaccessibility of health care, and disadvantageous occupational and discriminatory factors all contribute to health disparities in the ethnic groups. Education and income are inherently related, and both play parts in the limited opportunities some Hispanic-Latino face. Statistically, the risk for death, chronic diseases, and unhealthy behaviors vary inversely with income and education (Ramirez & de la Cruz, 2003). More than forty percent of Hispanics older than twenty-five have not graduated from high school, twenty-seven percent have less than a ninth grade education (Ramirez & de la Cruz, 2003), and only eleven percent have a bachelor’s degree (US DHHS, 2003). Hispanic-Latinos statistically earn less than non-Hispanic workers earn, and are more likely to live in poverty (Ramirez & de la Cruz, 2003). Even though 80 percent of Latinos are working, more than one-fifth of them live in poverty (Valdez & Posada, 2006). Hispanic-Latinos are more likely to work in service related occupations, are less likely to work in managerial or executive positions, and are more likely to be unemployed than non-Hispanic whites (Ramirez & de la Cruz, 2003). Because Latinos are primarily employed in low-wage, service related jobs, where health insurance and health benefits are mainly lacking, only one-fourth has employer-sponsored health insurance (Valdez & Posada, 2006). Hispanic-Latinos also have to contend with potentially discriminatory treatment and denial of opportunity during the job application, interview, and job offer process (Smedley, Stith, & Nelson, 2003). Additionally, some Hispanics have historically had to contend with housing discrimination, racial profiling, overt racism, legal discrimination, and other forms of systematic discrimination. As a result, available opportunities to equal health care are limited among the disadvantaged members of the Hispanic-Latino population.
Other sources of disparity for Latinos include language, poor health literacy, and undocumented immigration status. A systematic review, examining language barriers in health care for Latino populations, found that access to care, quality of care, and outcomes were all adversely affected (Timmins, 2002). Language is a major factor in health literacy. More than 70 percent of foreign-born Latinos are Spanish dominant, 26 percent of which need an interpreter during healthcare visits (Valdez, & Posada, 2006). One-third of Latinos have difficulty communicating with their doctor, and more than 60 percent have trouble understanding medication instructions (Valdez, & Posada, 2006). An examination of data from the Department of Health and Human Services on healthcare spending found that unauthorized immigrants spend disproportionately less on healthcare than legal and naturalized immigrants (an average of $140 per capita per year, compared to an average of $1,385 for U.S. natives) (Stimpson, Wilson, & Su, 2013).
Application to practice
Ethnic groups, as all other Americans, have a right to equal access to health care and equal non-discriminatory treatment. Nevertheless, every American has the liberty to exercise those rights as they see fit, and the freedom of expression to determine the lifestyle of their choosing in accordance with their beliefs. All of our personal preferences are based on our previous experiences. Our social values and individual choices are often formulated in the context of cultural heritage and traditional practice, and what one culture may consider normal may seem to be highly absurd to another. In the dynamic environment of healthcare delivery, there are only a few unqualified invariants: consent, confidentiality, full disclosure, and the refusal of care. These principals are the foundation of patients’ rights in America. Care must be given to respect the values and beliefs of other cultures, and not to inadvertently violate these basic principles threw ignorance or neglect.
Certain cautions must be considered when caring for ethnic minority patients. Firstly, when discussing ethnic groups, it is appropriate to refer to them by their ethnicity, but when addressing individuals, it is more respectful to refer to them by their ethno-American nationality (i.e., Mexican-American or Spanish-American as opposed to as either Latino or Hispanic). Secondly, it is important to practice with the understanding that certain socioeconomic barriers, that limit the access to care, are beyond the control of those they affect. It is essential that providers transcend their own personal beliefs and the common stigmas associated with low SES to deliver care non-discriminatorily without blame or judgement. A policy of education and empowerment is advised as many ethnic minorities may be unfamiliar with navigating the various fanatical options for funding care, may be unaware of the numerous points of access to care, and unaware of the benefits of a usual source of care. “Healthy People 2020” objectives to improve health and health care include increasing the number of people with insurance, increasing the number of people with primary care providers/ ongoing sources of care, and reducing delay in care (healthypeople.gov -a, 2015). Education and referral for anyone without insurance or a usual source of care is advisable. Fourthly, with non-English speaking patients it is essential to use a qualified medical translator. It is commonplace to have a family member or other staff member to translate when language is a problem, and while such remedies may be convenient, it is potentially an opportunity for miscommunication. As with all healthcare instructions, it is important to tailor the complexity of the language used to fit the level of health literacy of the audience, and subsequently determine their correct understanding with fallow-up questions. Lastly, immigration status is not relevant medical history question, and green cards are not required for medical treatment. Reporting of illegal immigrants in such settings is counterproductive to the community at large and is unadvisable. The common stereotype, of aliens avoiding healthcare for fear of deportation, is unfounded and should be dispelled given the opportunity.
The Hispanic-Latino population, as well as other ethnic groups, has long suffered from health disparities due to inadequate access to quality health care, limited socio-economic opportunities, and sources of disparity. The paradox of American domestic policy – the controversy over equity despite the emphasis on equality – in the delivery of health care to disenfranchised populations, is evident in the Hispanic-Latino population, and is an abject symptom of the fundamental misunderstanding among the relationship between welfare and opportunity. In the modern age of science, technology, and political stability heath inequities deserve equal treatment.
Andrews, M. M., & Boyle, J. S. (1999). Transcultural concepts in nursing care, (3rd ed.). Philadelphia: Lippincott
Federal Research Division of the Library of Congress. (2010). Colombia: A Country Study (5th ed.) Washington DC: U.S. Government Printing Office.
Cacari-Stone, L., Viruell-Fuentes, E., & Acevedo-Garcia, D. (2007). Socio-economic and health care system threats to Latino health: Implications for policy and prevention. California Journal of Health Promotion, 82-104.
Gottfried, A. W., Gottfried, A. E., Bathurst, K., Guerin, D.W., & Parramore, M.M. (2003). Socioeconomic status in children’s development and family environment. Infancy through adolescence. In M.H. Bornstein & R.H. Bradley (Eds). Socioeconomic status, parenting, and child development (pp.189-207). Mahwah, NJ: Erlbaum.
Granados, C. (2000). “Hispanic “vs” Latino “Hispanic Magazine. Retrieved February 21, 2015, from http://www. Hispanicmagasine.com/2000/ dec /Features/latino.html
Marable, M. (2000). We need new and critical study of race and ethnicity. The Chronicle of Higher Education, pp. B4-B7
Nagel, J. (1994).Constructing Ethnicity: Creating and recreating ethnic identity and culture. Social Problems, 41, 152-176.
Ramirez, R. R., & de la Cruz, G. P. (2003). The Hispanic population in the United States: March 2002: Population characteristics. Current Population Reports, P20-545. Washington, DC: US Census Bureau. Retrieved March 24, 2015, from http://www.census.gov/prod/2003pubs/p20-545.pdf
Smedley, B. D., Stith, A. Y., & Nelson, A. R. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press, Institute of Medicine of the National Academies.
q (9th ed.) Belmont, CA: Wadsworth.
Stimpson, J., Wilson, F., & Su, D. (2013). Unauthorized Immigrants Spend Less Than Other Immigrants And US Natives On Health Care. Health Affairs, 32(7), 1313-1318.
Timmins, C. L. (2002). The impact of language barriers on the health care of Latinos in the United States: A review of the literature and guidelines for practice. Journal of Midwifery & Women’s Health, 47:80–96. doi:10.1016/S1526-9523(02)00218-0
U.S. Census Bureau (census.gov). (2014). State & County Quick Facts. Washington, DC: Author. Retrieved February 25, 2015, from http://quickfacts.census.gov/qfd/meta/long_RHI125213.htm
U.S. Census Bureau, American FactFinder, United States. (factfinder). (2008). American Community Survey 1-year estimates. ACS demographic and housing estimates: 2008. Retrieved March 24, 2015, from http://factfinder.census.gov
U.S. Department of Health and Human Services (healthypeople.gov). (2015). Social Determinants of Health. Washington, DC: Author. Retrieved March 24, 2015, from https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/addressing-determinants
U.S. Department of Health and Human Services (healthypeople.gov -a). (2015). Social Determinants of Health. Washington, DC: Author. Retrieved March 24, 2015, from https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/objectives
US Department of Health and Human Services (US DHHS). (2003). Demographics and health disparities. Draft curriculum module 2 for Cultural Competence in the Clinical Care Model Project. Health Resources and Services Administration, Bureau of Primary Health Care. Retrieved March 24, 2015, from http://whqlibdoc.who.int/hq/2001/WHO_SDE_HDE_HHR_01.2.pdf
Valdez, J. & Posada, R. (2006). Strategies for improving Latino healthcare in America. Report of the Latino Healthcare Taskforce. Washington, DC: The Latino Coalition.