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Cultural Backgrounds and Health Inequality

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Ina Grose

on 27 April 2016

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Transcript of Cultural Backgrounds and Health Inequality

Workplace culture makes an organization unique and is the sum of its value, belief, tradition, interaction, behavior, and attitude.

Work environment has a tremendous effect on the health of human beings. Toxic chemicals, working in too hot or cold environment, repetitive movements, heavy load, all these factors can have a damaging effect on workers.

Work place can be a setting where gender, SES, race, and ethnicity inequalities can manifest as health inequality.
Race and ethnicity at work
References:WHO (2006). Messing K, Östilin P. Gender Equality, Work and Health: A review of the evidence. World Health Organization, Switzerland 2006. http://www.who.int/gender/documents/Genderworkhealth.pdf
49% Christian
41.5% Muslim
> 90% Malaria cases worldwide occur in Africa
HIV/AIDS in Africa accounts for:
72% AIDS-Related deaths worldwide
68% new infections among adults worldwide
91% new infections among children worldwide
Greatest proportion of TB per population
Highest maternal and neonatal mortality rates
Child mortality in Sub-Saharan Africa is more than 15 times higher than in developed regions.(1 in 9 children dies before the age of 5)
Illiteracy rate of 40%
Life Expectancy: 55 years
Race and Ethnicity
While race and ethnicity are considered as synonymous, there are subtle distinctions in their definitions

Race: refers to outward characteristics (skin, hair, or eye color)
Ethnicity: refers to cultural factors, including nationality and language
Health Disparities and Race
Biologically, we are all members of the human race, however, there is an unequal burden of morbidity and mortality among racial minorities in the United States. This figure shows that, while stratifying for education levels, there is obvious disparity between race/ethnicity and premature infant mortality rates.
Work Culture and health inequality
Over a billion people, about 15% of the world's population, have some form of disability.
Between 110 million and 190 million adults have significant difficulties in functioning.
Rates of disability are increasing due to population aging and increases in chronic health conditions, among other causes.
People with disabilities have less access to health care services and therefore experience unmet health care needs.
Cultural Backgrounds and Health Inequality
Presented by: Ina Grose, Lori Stevens, Regency Gray, Randi Alexander, Arpana Jaiswal, Jennifer Kunze, Brittany Lawrance, and Afshan M
Mental Disabilities
Physical Disabilities
LaVeist T, Isaac L. Race, Ethnicity, and Health: A Public Health Reader. John Wiley & Sons; 2012.
Racial Differences in Health
In general, African Americans, Native Americans, and Pacific Islanders live shorter lives and have poorer health outcomes compared to Whites and Asian Americans.
lower life expectancy
infant mortality
coronary artery disease
Initially, immigrants have better health outcomes than their peers, but their health deteriorates the longer they live in the United States due to acculturation.
Race and Class
Race and class are closely intertwined; The effects of race cannot be assessed without considering the effects of class.

Socioeconomic status is a major component of the causal pathway by which race affects health.
African Americans
Latino Americans
Health outcomes for Latinos are generally favorable when compared to other racial/ethnic groups
Adults have lower mortality rates than whites and blacks (22% lower than whites; 41% lower than blacks)
infant mortality among Latinos similar to those of whites and 58% lower than blacks
Asian Americans
Asians have exhibited fewer than predicted deaths in some categories compared to white Americans
consistently lower death rates in motor vehicle accidents, suicide, coronary heart disease, stroke, homicide, and cancer

The rate of preventable hospitalizations is lowest among Asian Americans due to high vaccination rates, and proper access to preventative care.
Global Health Inequalities
Global statistics on Religion and Geography according to the CIA World Fact Book:
Health-protective benefits from social networks
In general, poor neighborhoods have fewer parks, fewer safe places to walk, and tend to spend time indoors rather than outside.
This all contributes to higher rates of obesity, diabetes, and cardiovascular disease.
Historically, racism has influenced education, housing, and wealth acquiring opportunities, where certain ethnic groups are ultimately disadvantaged.
This causes certain ethnic/racial groups to fall in lower socioeconomic statuses.

Studies have shown that employers will prefer white applicants with a criminal record over black applicants with no criminal history.
Segregation and Discrimination
However, even when controlling for socioeconomic status, racial health inequalities still persist.

Segregation leads to: a) social isolation, b) lower economic opportunities, and c) less healthy choices since certain ethnic groups are pressured into living in certain neighborhoods.

Victims of racial discrimination on a daily basis have identified racism as a stressor. High-stress environments lead to an increased risk of chronic cardiovascular, respiratory, and pain-related issues. This ultimately contributes to poor health outcomes.
Marital and Parental Status and Health
Developing Countries
- Lower incidence of breast cancer with higher mortality
- Weaker health care systems
- Fewer health care resources
-Advanced stage disease presentation
-Less percentage spent on health care equated to very high mortality
-Higher priority on communicable diseases
Developed Countries
- Higher incidence of breast cancer with lower mortality rates
- Advanced, established health care systems
- Public health care = decreased level of inequality (Sweden)
- Private health care = increased health inequality (US)
Igene H, Global health inequalities and breast cancer: an impending public health problem for developing countries. Breast J. 2008; 14(5): 428-434.
Christian - 32.3%
(North America, Latin America, Caribbean, Europe, Sub-Saharan Africa, Australia)

Muslim - 22.9%
(West Africa, North Africa, Middle East, Central Asia, Indonesia)

Hindu – 13.8%
(India subcontinent, Mongolia)

None-religious – 13.6%
(Europe, China, North America)

Buddhist – 6.9%
(South-East Asia)
Religious affiliation is a self-identified association with a religion or religious group. Religious affiliation is related to geography and intertwined with ethnicity, economic status, and political systems, making it challenging to determine religion's contribution to health inequalities.
For example, mortality rates among different religious groups could be related to SES, race, or gender differences rather than religious affiliation.
Additionally, health inequalities vary between developed and developing countries. Whereas developing countries are still focused on communicable diseases and developed countries have increased rates of chronic diseases with higher rates of life expectancy.
Belonging to a social network
Source of personal identity and purpose
Religious social networks can encourage healthier behavior patterns.
For example, religions that forbid smoking and drinking or encourage limited alcohol consumption.
No or limited social networks
Those who do not belong to a social support network are more likely to experience: depression, greater risk of pregnancy complications, and higher levels of complications for chronic diseases.
Social support comes from more than just religious affiliation, therefore this is just a possibility of health inequality for those not affiliated with a religion.
Mortality Comparison by Religion in the US
Data from the Health and Retirement Study from 1992-2006 of 18,727 adults > 50 years of age showed that among Catholic, Jewish, Mainline Protestant, Evangelical Protestant, and Black Protestant groups:
There was reduced mortality among those with more frequent attendance at any religious service than no attendance.
This may be explained by improved psychological measures through a sense of meaning and receiving spiritual comfort.
There was reduced mortality among Protestants and Jews, who have a higher proportion of Whites and higher SES distribution than other religions in this study.
Sullivan, AR, Mortality differentials and religion in the US: religious affiliation and attendance. J Sci Study Relig. 2010; 49(4): 740-753.
North America
Latin America
77% Christian
17% Non-Religious
Literacy: 99%
Life Expectancy: 79 yrs
83% Christian
9% Non-Religious
Literacy: 82%
Life Expectancy: 72 yrs
92% Christian
4.2% Non-Religious
Literacy: 90%
Life Expectancy: 74 yrs
Cultural Branches
An integrated pattern of human behavior that includes the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.

Cultural Background and Health Inequality
Health Inequality:
Health inequalities are differences in health that are avoidable, unjust, and unfair".
Equity in health means that all persons have fair opportunities to attain their full health potential, to the extent possible.

26% Muslim
23% Hindu
South-East Asia and Western Pacific account for 56% new TB cases globally
South Asia has the second highest child mortality rate (1 in 16 children dies before the age of 5)
Literacy: 77%
Life expectancy: 69 yrs
In this presentation, we will be considering eight different characteristics of culture:
1. Race and Ethnicity
2. Socioeconomic Status
3. Age
4. Religion and Geography
5. Disabilities and Military Status
6. Work Cultures
7. Parental and Marital Status
8. Gender, Sexual Identity/Expression, and Sexual Orientation

Overall mortality is 28% higher compared to white Americans, particularly in:
Heart disease
Lung cancer
Breast cancer
Risk of infant mortality is 1.5 to 3 times higher in black women compared to women of other races.
71% Christian
21% Non-Religious
Top leading causes of death listed in order are:
heart disease
Literacy rate: 99%
Life expectancy: 76 yrs
Blacks have the highest prevalence of obesity.

One out of every five infants born to a black mother is born premature.

Higher rates of uninsured persons, and lower quality health care.
Recent immigrants in the United States experience better health outcomes initially compared to white Americans and other racial/ethnic groups.
However, as people begin to adapt to the United States, acculturation is associated with negative health behaviors and outcomes:
Illicit drug use
Poor nutrition and dietary patterns
Lower birth rate
Gender, Sexual Identity & Sexual Orientation
Gender inequality at work and health
Biological difference among men and women affect their health differently at work.
A study shows that in general work-related fatigue, repetitive strain injury, infections and mental health problems are more common among women than among men (Östlin, 2002a).
Another study hypothesized that on average women are at greater risk of harm from fat-soluble chemicals because of a higher proportion of fat tissue, thinner skin and slower metabolism (Meding,1998)
Women’s and men’s reproductive systems differ greatly. Women menstruate, become pregnant and nurse children, and these processes may be affected by workplace exposure.
Gender harassment of professional women by higher level men is associated with higher levels of stress and negative mood (O’Connell & Korabik, 2002)
SES at work
SES is often measured as a combination of education, income, and occupation. Low SES is related with poor health.
High stress jobs are linked with higher blood pressure and high cardiovascular disease in workers.
Sleep deprivation and fatigue are correlated with higher work related accidents in blue collar workers.
Smoking prevalence in blue collar workers is double that of white collar workers. (Barbeau, 2004).
Male infertility has been associated with job burnout for persons working in the construction industry (Sheiner, 2002).
Lower wage workers are more likely to work for small businesses or part time, therefore they have limited access to health insurance, sick days and paid vacation time. They are also less likely to be allowed to use paid time off for sick child care (Richman et al., 2006).
Lower wage workers have less job flexibility, less sympathy from employers about their needs and a more challenging work-life balance.
According to the US Bureau of Labor Statistics in 2012:
Whites (80%) made up majority of the labor force, Blacks and Asians added up to another 12% and 5% respectively, and Native Americans less than 1%.
Highest paying major occupational category were management, professional and related occupation; 49% of employed Asians, 39% of employed Whites, 30% of employed Blacks and 21% employed Hispanics work in this category.
US unemployment rates were 8.1%. However, the rate varied across race and ethnicity group, highest for Blacks (13.1%) and lowest for Asians (5.9%) and Whites (7.2%).

Studies have shown a positive relationship between unemployment and poor health. Unemployment, type of occupation, work condition and low wages are known to affect health adversely.
United States Census Bureau 2014
The graphs above show men and women's marital status from 1950-2014. The graph below shows the average age that both men and women get married for the first time.
The U.S. Department of Health and Human Services in 2007 synthesized several studies examining effects of marriage in 5 different categories of health.
Health Behaviors
Health Care Access, Use, and Costs
Mental Health
Physical Health and Longevity
Inter-generational Health Effects
Health Behaviors
This review focused on the behaviors that have a direct correlation to an individual's health outcomes: alcohol and drug use, smoking, body weight, and exercise
Studies have shown that marriage has positive and negative effects on both men and women when if comes to healthy behaviors.
According to the studies marriage reduces:
Heavy Drinking
Overall Alcohol Consumption
Marijuana use

According to the studies marriage encourages:
Sedentary lifestyle
Reductions in physical activity particularly in men
Weight gain

All behaviors in a marriage are influenced by the support of an individual's partner. If their partner encourages healthy behaviors it is easier to keep active and stay healthy.
Levels and Trends in Child Mortality Report 2013. UNICEF. http://www.unicef.org/mediafiles/2013_IGME_child_mortality_Report.pdf. Published 2013. Accessed March 13, 2015.
The African regional health report: the health of the people. WHO Web site.
http://www.who.int/bulletin/africanhealth/en/ Published March 2015. Accessed March 13, 2015
Top 3 leading causes of death listed in order are heart disease, cerebrovascular disease, and diabetes.
Leading causes of death. Pan American Health Organization Web site. http://www.paho.org/HQ/index.php?option=com_content&view=article&id=3501&Itemid=2391&lang=en. Published 2008. Accessed March 13, 2015.
Leading cause of death fact sheet: Europe. WHO Web site. http://www.euro.who.int/__data/assets/pdf_file/0004/185215/Leading-causes-of-death-in-Europe-Fact-Sheet.pdf. Published 2012. Accessed March 13, 2015.
Mandryk, J.
Operation World
. Colorado Springs, CO: Biblica Publishing, 2010.
Data from the Health Surveys for England in 1999 and 2004 compared health outcomes for Christians, Muslims, Hindus, and those not identifying with religion while adjusting for age, SES, race, and gender. The study portrayed health disadvantage among religious minority groups.
Ethnic minority groups were associated with higher waist-hip ratio.
Non-White groups had higher rates of poor health and diabetes regardless of religion.
Muslims had the highest rates of activity-limiting illness, BMI, waist-hip ratio, and tobacco use.
Christian groups had higher rates of physical activity.
In this study health inequalities were largely explained by SES, as in the Muslim group.
Karlsen, S and Nazroo JY. Religious and ethnic differences in health: evidence from the health surveys for England 1999 and 2004.
Ethnicity & Health.
Health Care Access, Use, and Cost
This review focused on the link between marriage and three main health care outcomes: health insurance status, health care use, and total health care costs.
Health care access-
having the option to cover the individual's spouse on their policy marriage provides a positive relationship with individuals having insurance. This opportunity is more significant for women.
Health care use
- there is a direct link between marriage and health care use. Marriage is associated with shorter hospital stays, less doctors visits, increased preventive care like screenings, and reduced risk of potentially being put into a nursing home.
Health care costs
- marriage has a direct association with lower health care costs. Studies have shown a reduction of:
Reduced nursing home costs
Shortened hospital stays because spouse is care giver.
Note that the lower health care costs do not have a link to a person's marriage and physical health.
Mental Health
This review focus on the effects of marital status on one common form of psychological distress: the presence of depressive symptoms
Socioeconomic Status (SES)
Socioeconomic status (SES) is an economic and sociological combined total measure of a person's work experience and of an individual's or family's economic and social position in relation to others, based on income, education, and occupation.
Opportunities increase with increased education
The more a person is educated, the more knowledge and life skills they have available

Adler, N., & Newman, K. (2002). Socioeconomic Disparities In Health: Pathways And Policies. Health Affairs, 21(2), 60-76.

As income increases:
There is more:
Access to healthcare
Participation in health behaviors
Access to healthier foods
There is less:
Harmful environmental exposure (ex: lead)
Chronic stress
Unwanted pregnancy
Smoking and drug use
Health Disparities Associated with SES
morbidity and
due to
such as:

Lower birth weight
Cardiovascular disease

Gender "refers to the socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for men and women" (1)
Distinct from sex, which "refers to the biological and physiological characteristics that define men and women" (1)
Gender identity refers to one's "innate, deeply felt psychological identification as a man, woman or some other gender, which may or may not correspond to the sex assigned to them at birth (i.e., the sex listed on their birth certificate)" (2).
Sexual Orientation is, simply, what gender someone is sexually attracted to--which may be distinct from romantic attraction (3)
Sexual Identity is the label for the orientation with which one identifies; e.g., "gay," "lesbian," "bisexual," "asexual," and so on.
Sexual Orientation
Egede L. Race, Ethnicity, Culture, and Disparities in Health Care. JGIM. 2006; 21(6): 667-669. doi:10.1111/j,1525-1497.2006.0512.x
LaVeist T, Isaac L. Race, Ethnicity, and Health: A Public Health Reader. John Wiley & Sons; 2012.
Smedley B, Jeffries M, Adelman L, Cheng J. Race, Racial Inequality and Health Inequities: Separating Myth from Fact.
LaVeist T, Isaac L. Race, Ethnicity, and Health: A Public Health Reader. John Wiley & Sons; 2012.
Smedley B, Jeffries M, Adelman L, Cheng J. Race, Racial Inequality and Health Inequities: Separating Myth from Fact.
LaVeist T, Isaac L. Race, Ethnicity, and Health: A Public Health Reader. John Wiley & Sons; 2012.
Studies show that marriage reduces depressive symptoms for both men and women.

While getting married decreases depressive symptoms, getting a divorce increases them, and can be long-lasting years after the marriage is dissolved.

Comparing the mentality of individuals in a stable marriage and individuals that are not married; the stably married individuals have fewer depressive symptoms and symptoms increase more slowly as the individuals grow older.
Health inequalities related to sexual orientation may result from a variety of factors including:
Access to care & financial resources
Social stigma & multiple -phobias
These factors may vary depending the orientation or belief system of the patient, the medical practitioners, and other relevant members of a patient's social circle, such as immediate family, intimate friends, or religious community.
National Marriage and Divorce Rates 2010-2012
Access & Financial Resources
1. Blosnich JR, Farmer GW, Lee JGL, Silenzio VMB, Bowen DJ. Health inequalities among sexual minority adults: Evidence from ten U.S. states, 2010. Am J Prev Med. 2014;46(4):337-349.
2. Mustanski B, PhD, Birkett M, PhD, Greene GJ, PhD, Hatzenbuehler ML, PhD, Newcomb ME, PhD. Envisioning an america without sexual orientation inequities in adolescent health. Am J Public Health. 2014;104(2):218-225.
3. Veenstra G. Race, gender, class, and sexual orientation: Intersecting axes of inequality and self-rated health in canada. International Journal for Equity in Health. 2011;10(1):3.

Physical Health and Longevity
This review examines the effect that marriage has on self-rated health and longevity as well as chronic health conditions.
1. Blosnich JR, Farmer GW, Lee JGL, Silenzio VMB, Bowen DJ. Health inequalities among sexual minority adults: Evidence from ten U.S. states, 2010. Am J Prev Med. 2014;46(4):337-349.
2. Veenstra G. Race, gender, class, and sexual orientation: Intersecting axes of inequality and self-rated health in canada. International Journal for Equity in Health. 2011;10(1):3.

Studies have shown that individuals who marry live longer and enjoy better physical health than those who do not marry.
Married men rate their overall physical health status as positive
Married women did not rate their health status as positive, but is shown as positive through low prevalence of specific health conditions and illnesses.
One exception to physical health and marriage is that a recent study found evidence correlating marriage and the risk of cardiovascular disease in women. No correlation was found for men.
Longevity and marriage have a proven strong link through descriptive methods.
However there is concern that these descriptive methods are not entirely reliable do to the fact that they cannot control the possible effect that healthier people might be more commonly selected into marriage versus unhealthier individuals.
Inter-generational Health Effects
This review focus on the effects of a child's health outcomes as an adult due to their parents marital status growing up
1. "Gender, Women and Health." World Health Organization. http://www.who.int/gender/whatisgender/en/
2. Sexual orientation and gender identity definitions. Human Rights Campaign Web site. http://www.hrc.org/resources/entry/sexual-orientation-and-gender-identity-terminology-and-definitions. Accessed 03/20, 2015.
3. Levesque RR. Sexual orientation and identity labels. In: Levesque RR, ed. Springer New York; 2014:2685-2686. http://dx.doi.org/10.1007/978-1-4419-1695-2_603. 10.1007/978-1-4419-1695-2_603.

Studies have shown that children growing up with married parents is associated with better physical health in adulthood and increased longevity.
Effects on children's health come from mostly the role of the childhood family structure. With this it shapes the children's socioeconomic attainment, and also the adult's health risk behaviors such as smoking and heavy drinking.
On average, children that are raised in two-parent households receive more education and demonstrate healthier behaviors as adults than children that come from other types of families.
Researchers feel that the effects of children's health based on their parents marital status has grown weaker over the years due to the fact that single parent households and divorce have become more common in our society.
1. Burrows G. Lesbian, gay, bisexual and transgender health part 1: Sexual orientation. Practice Nurse. 2011;41(3):23-25.
2. Mustanski B, PhD, Birkett M, PhD, Greene GJ, PhD, Hatzenbuehler ML, PhD, Newcomb ME, PhD. Envisioning an america without sexual orientation inequities in adolescent health. Am J Public Health. 2014;104(2):218-225.
3. IMG Source: https://instagram.com/p/xOgIn-SMUs/
4. Intersectionality. U.S. English Dictionary Online. http://www.oxforddictionaries.com/us/definition/american_english/intersectionality
Social Stigma & Multiple -phobias
Sexual Identity
1. Vrangalova Z, Savin-Williams R. Mostly heterosexual and mostly Gay/Lesbian: Evidence for new sexual orientation identities. Arch Sex Behav. 2012;41(1):85-101.
Health inequalities that occur on the basis of gender can be enforced on no less than three levels (3):
United States Birth Statistics 2014
Number of births: 3, 932,181
Birth Rate: 12.4 per 1,000 population
Fertility rate: 62.5 births per 1000 women aged 15-44 years
Percent unmarried: 40.6%
Mean age at first birth: 26.0
1. Blosnich JR, Farmer GW, Lee JGL, Silenzio VMB, Bowen DJ. Health inequalities among sexual minority adults: Evidence from ten U.S. states, 2010. Am J Prev Med. 2014;46(4):337-349.
2. Mustanski B, PhD, Birkett M, PhD, Greene GJ, PhD, Hatzenbuehler ML, PhD, Newcomb ME, PhD. Envisioning an america without sexual orientation inequities in adolescent health. Am J Public Health. 2014;104(2):218-225.
Parents' Health impact on their children
Research has found that parents have an extreme effect on their children's health. Whether it is based on their education level, SES, or their health beliefs; they are impacting their children's health.
The Data Resource Center for Child & Adolescent Health collected data on children's health based on a variety of factors
Percent of children whose mothers are in excellent or very good
physical and emotional health

2011/12 National Survey of Children's Health
Nationwide: 56.7% of children met indicator
Range Across States: 49.5% to 67.6%

Parents Health impact on their children
Percent of children whose fathers are in excellent or very good physical and emotional health:
2011/12 National Survey of Children's Health
Nationwide: 62.0% of children met indicator
Range Across States: 54.6% to 72.0%
Percent of children who live in households where someone smokes:
2011/12 National Survey of Children's Health
Nationwide: 24.1% of children met indicator
Range Across States: 12.4% to 41.0%
Stress of Parents
A variety of factors come into play to cause a parent stress in their daily lives. According to a survey conducted by American Psychological Association, parents stress mostly about money, work, economy, family responsibilities, relationships, personal health concerns, housing costs, job stability, health problems affecting their family, and personal safety.
Östlin P (2002a). Gender inequalities in health: the significance of work. In: Wamala, S. and J. Lynch (eds) Gender and socioeconomic inequalities in health. Studentlitteratur, Lund
Meding B (1998). Work-related skin disease. In: Kilbom Å, Messing K, Bildt Thorbjörnsson C, eds. Women’s health at work. Solna: National Institute of Working Life.
O’Connell, C. E., & Korabik, K. (2000). Sexual harassment: The relationship of personal vulnerability, work context, perpetrator status, and type of harassment to outcomes. Journal of Vocational Behavior, 56(3), 299-329.
Parents stress influence on children
Parents do not feel that their stress has any influence on their children. However, 91% of children reported knowing when their parent was stressed because of their multitude of behaviors: yelling, arguing, and complaining. The graph below shows how children feel when their parent is stressed.
Barbeau, E. M., Krieger, N., & Soobader, M. (2004). Working class matters: Socioeconomic disadvantage, race/ethnicity, gender, and smoking in NHIS 2000, American Journal of Public Health, 94, 269-278.
Sheiner, E. K., Sheiner, E., Carel, R., Potashnik, G., & Shoham-Vardi, I. (2002). Potential association between male infertility and occupational psychological stress. Journal of Occupational & Environmental Medicine, 44(12), 1093-1099.
Richman, A., Johnson, A., & Buxham, L. (2006). Workplace flexibility for lower wage workers: Washington, DC: Corporate Voices for Working Families’ Workplace Flexibility Project.
Parental Health
Parent's health have many different factors and influences. This section is going to focus on two main parts:
Parent's Health impact on their children
Stress of Parents and its influence on their children
US Bureau of Labor Statistics Report no. 1044. http://www.bls.gov/cps/cpsrace2012.pdf
Reference: Anderson, N., Nordal, K., Breckler, S., Ballard, D., Bufka, L., Bossolo, L., ... Kelly, K. (2010). Stress in America 2010:Key Findings. In Stress in America Findings (pp. 8-9). Washington D.C., Virginia.
Reference: Anderson, N., Nordal, K., Breckler, S., Ballard, D., Bufka, L., Bossolo, L., ... Kelly, K. (2010). Stress in America 2010:Key Findings. In Stress in America Findings (pp. 8-9). Washington D.C., Virginia.
Reference: Health Disparities Among Children. (2007). In Reducing health disparities among children: Strategies and programs for health plans. (p. 2). Washington, D.C., Virginia: National Institute for Health Care Management, Research and Educational Foundation.

Mother's Health. (2012, January 1). Retrieved March 14, 2015, from http://www.childhealthdata.org/browse/rankings/maps?s=104
Reference: Father's Health. (2012, January 1). Retrieved March 14, 2015, from http://www.childhealthdata.org/browse/rankings/maps?s=105

Smoking in the Household. (2012, January 1). Retrieved March 15, 2015, from http://www.childhealthdata.org/browse/rankings/maps?s=86
Reference: Births and Natality. (2015, February 6). Retrieved March 14, 2015, from http://www.cdc.gov/nchs/fastats/births.htm
Reference: United States Census Bureau. (2014, October 30). Retrieved March 14, 2015, from http://www.census.gov/hhes/families/data/marital.html
Reference: National Marriage and Divorce Rate Trends. (2015, February 19). Retrieved March 14, 2015, from http://www.cdc.gov/nchs/nvss/marriage_divorce_tables.htm
Reference for Slides 43-48:
Wood, R., Goesling, B., & Avellar, S. (2007). The Effects of Marriage on Health, 1-6. Retrieved March 9, 2015, from http://aspe.hhs.gov/hsp/07/marriageonhealth/rb.pdf
1. Burrows G. Lesbian, gay, bisexual and transgender health part 1: Sexual orientation. Practice Nurse. 2011;41(3):23-25.
2. Mustanski B, PhD, Birkett M, PhD, Greene GJ, PhD, Hatzenbuehler ML, PhD, Newcomb ME, PhD. Envisioning an america without sexual orientation inequities in adolescent health. Am J Public Health. 2014;104(2):218-225.
3. Veenstra G. Race, gender, class, and sexual orientation: Intersecting axes of inequality and self-rated health in canada. International Journal for Equity in Health. 2011;10(1):3.
Individuals whose gender identity does not match the gender assigned to them at birth or who do not conform to the accepted gender constraints of their culture may hesitate to seek medical or psychological advice, care, or treatment out of fear of discrimination, violence, or even "outing." Because being "outed" or revealed as non-gender conforming can lead to job loss, social isolation or even threats to life and limb, it is not uncommon for non-gender-conforming individuals to seek alternative avenues to treat their ailments, such as self-medication or patronizing unlicensed practitioners (2)
Gender is a personal construct as much as a social one and much like society, it can be complicated to navigate. When individuals lack the appropriate language to label their gender, it can be difficult to articulate it to anyone else. And sometimes explanation is insufficient in the face of ignorance or indifference. As in the case of sexual orientation, this leads many to self-treat rather than risk recrimination, discrimination, or mistreatment at the hands of medical practitioners or others who are not necessarily trained in dealing with patients of non-binary gendered states, as well as non-heterosexual orientations (1,2).
World Health Organization [Internet]. Geneva Switzerland: World Health Organization; 2014 [cited 2015 March 16]. Available from http://www.who.int/mediacentre/factsheets/fs352/en/
Mental disorders account for an enormous global burden of disease that is largely underestimated and under appreciated.
Common mental disorders include depression, anxiety, and substance related disorders
These mental disorders disable more people than complications from AIDS, heart disease, traffic accidents and wars.
14% of the global disease burden is attributed to neuropsychiatric disorders like depression and alcohol-substance abuse.

SES is a greater predictor of health disparities than any other factor.
Compared to heterosexuals, LGBT+ persons endure higher smoking prevalence, poorer mental health, more frequent asthma diagnoses, and a greater incidence of "self-directed violence" (1).
Compared to gay men, bisexual men were 60% less likely to have had an HIV test (1).
Mental health inequalities are strongly associated with social and economic context.
Most poor nations are at higher risk of developing mental disorders compared to non-poor nations.
Mental disorders increase the likelihood of living in poverty.
Due to the influence on functionality and ability to get and sustain employment.
Health Inequalities
Non-heterosexual adolescent girls are less likely to pursue or be offered reproductive or sexual health care than heterosexual adolescent girls, but are at equal or greater risk for pregnancy or contraction of STIs (3).
Bisexual persons face reduced healthcare access compared to heterosexual persons and lesbian/gay persons (2).
Lesbian women and bisexual people tend to have less insurance coverage (2).
Bisexual women report more activity limitations due to physical, mental, or emotional problems (2).
Consequences of mental health inequalities:
Unnecessary suffering
Premature deaths
Increased stigma
Lack of investment in mental health workforce and infrastructure
Limited or lack of treatment for people suffering from mental health disorders. (Developing countries often lack policies to address the basic needs and rights of individuals with mental illness)
Mental Disabilities (cont)
Much like gender, sexual identity or the labels people use to describe sexual orientation can vary depending on culture. "Gay" as a synonym for "homosexual" is not universal, nor is the use of "queer." Further, these labels also may be at odds with (some) the sexual behavior of those who use them due to a variety of social pressures (1). For these reasons, it can be difficult to distinguish studies which focus on the role of sexual identity and health inequality from studies which assess the relationship between sexual orientation and health inequality.

For the purposes of this presentation, discussion will be contained to the relationship between sexual orientation and health inequality.
The burden of mental disorders is compounded of high rates of stigma and discrimination.
Clinicians and family members often inaccurately judge what patients value.
Limited knowledge of causes, symptoms and treatment of mental illness often leads to erroneous beliefs that the conditions are caused by individuals themselves or by supernatural forces, possession by evil spirits, curse or punishment following the individual's family or part of family lineage.
Stigmas associated with mental disorders also influence career choices to choosing to work in the mental health field.
Students who express needed psychiatry help is often seen as odd, peculiar or neurotic.
These factors result in unnecessary restrictions in rights to work, education, marriage and participation in community or family functions.
The effects of mental disorders is strongly related to many economic development sectors such as education, employment, law enforcement and incarceration.
Indirect cost associated with these disorders in the U.S is about $79 billion
In the U.S 3% of men and 4.5% of women cannot work or engage in regular activities because of mental or emotional problems.
Unmet mental health needs can also create social problems that may increase crime and political instability.
Globally about 2% of national budgets are devoted to mental health.

Health reform agendas in developed and developing countires need to provide legal protection, services, and human rights to people living with mental disorders. The policies must protect people with mental illness from abuse, neglect, and discrimination and also provide them with the care they need.
Ngui, E.M., Khasakhala, L., Ndetei, D., Roberts, L.W. Mental disorders, health inequalities and ethics: A global perspective. NIH Public Access Author Manuscript. 2011 January 1. 22(3): 235-244
Ngui, E.M., Khasakhala, L., Ndetei, D., Roberts, L.W. Mental disorders, health inequalities and ethics: A global perspective. NIH Public Access Author Manuscript. 2011 January 1. 22(3): 235-244
Health Inequalities
1. Birkett M, Russell S, T., Corliss H, L. Sexual-orientation disparities in school: The mediational role of indicators of victimization in achievement and truancy because of feeling unsafe. Am J Public Health. 2014;104(6):1124-1128.
2. Blosnich JR, Farmer GW, Lee JGL, Silenzio VMB, Bowen DJ. Health inequalities among sexual minority adults: Evidence from ten U.S. states, 2010. Am J Prev Med. 2014;46(4):337-349.
3. Riskind R, G., Tornello S, L., Younger B, C., Patterson C, J. Sexual identity, partner gender, and sexual health among adolescent girls in the united states. Am J Public Health. 2014;104(10):1957-1963.
Longer life expectancies: 80.4 years*
More nonfatal, chronic illnesses: arthritis & disability
More chronic stressors, less perceived control, lower self-esteem
leading causes of death: heart disease, cancer
Shorter life expectancies: 75.2 years*
More likely to engage is health-damaging behavior in youth leading to accidents or homicide
leading causes of death: heart disease, cancer

*not adjusted for race or socioeconomic status (SES) (1)
1. Read JG, Gorman BK. Gender and health inequality. Annu Rev Sociol. 2010;36(1):371-386.
2. Veenstra G. Race, gender, class, and sexual orientation: Intersecting axes of inequality and self-rated health in canada. International Journal for Equity in Health. 2011;10(1):3.
3. What plans cover birth control benefits. Healthcare.gov Web site. https://www.healthcare.gov/coverage/birth-control-benefits/
Accessed 3/20/2015
4. Suddath C. Can the U.S. ever fix its messed-up maternity leave system? Bloomsberg Businessweek. 2015:20 March 2015.
Age can be associated with being disabled.
Developing country households with older residents tend to be poorer than other households.
With older age people become less able to work and receive fewer employment opportunities.
Between 15 and 20 percent of the population worldwide have some form of disability.
2 to 4 percent of people have a severe disability
Also many household members have to quit their jobs in order to care for disabled members.
Disabled members typically have higher health care costs, and they may also face social and political marginalization.

The relationship between disability and poverty varies at a national level according to the availability of health care, nutrition programs, disability benefits and accessible schooling.
Intersectionality: Income & Gender
Intersectionality: Sexual orientation & Income
The odds of bisexual women avoiding seeking medical care due to cost are 2.5 times the odds of heterosexual women not seeking medical care due to cost (1).
In Veenstra's study, bisexuals more likely than heterosexuals to self-rate health status as "poor" (3).
Economically poor homosexuals subject to multiple avenues of inequality leading to "poor" self-rated health (3)
LGBT+ persons suffer mentally, emotionally and physically as a result discrimination, victimization, and exclusion at the individual, interpersonal, and institutional and/or societal level (2).
Samman, E., Rodriguez-Takeuchi, L. Inequalities relating to health and the life course: Disability, mental illness and older age. Addressing Inequalities: The Heart of the Post-2015 Development Agenda and the Future We Want for All. 2012 November.[cited 2015 March 16]. Available from: http://www.beyond2015.org/sites/default/files/Inequalities%20Agedisabilitymentalhealth.pdf
Military personnel are a small unique group of individuals that usually have access to full healthcare benefits for not only themselves but their children as well.

In order to join the military, one must fulfill certain physical, health and education requirements.

Retirees must complete 20 years of good service and maintain physical, health and educational requirements.

Physicians and nurses within the military treatment facility (MTF) conduct duties and responsibilities differently than their civilian counterparts due to military protocol and rank structure.
Factors military personnel may be subject to and possible effects on health inequalities:
Combat experience: can affect psychological well-being and characteristics in life and is independently associated with decreased educational attainment, labor force participation and earnings.
Rigid command structure: encourages compliance with instructions and respect for authority. Could improve delivery of medical care throughout life.
Post-service income (Retired bonuses)
Access to healthcare via military treatment facilities

Military service can also promote unhealthy behaviors like drinking and smoking. Cigarettes are sold on military installations tax free

Edwards, R. Widening Health Inequalities Among U.S. Military Retirees Sine 1974. NIH Public Access Author Manuscript. 2008 December. 67(11): 1657-1668
Age and Health Inequality
Age-related health disparities pertain to health challenges associated with a particular age group.
A notable shift has occurred in all age groups towards chronic diseases and degenerative health conditions as leading causes of death.
Persons aged 50 years or older face the greatest difficulties against health disparities in terms of screening interventions and treatment outcomes.
This characteristic has received little attention from researchers in comparison to other disparities such as race/ethnicity, SES, and gender-related.
Centers for Disease Control and Prevention. The State of Aging and Health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2013. Available at: http://www.cdc.gov/aging/pdf/state-aging-health-in-america-2013. Accessed March 13, 2015.

Jerant, Anthony F., Peter Franks, J. Elizabeth Jackson, and Mark P. Doescher. "Age-related disparities in cancer screening: analysis of 2001 Behavioral Risk Factor Surveillance System data." The Annals of Family Medicine. 2004;2(5):481-487. doi: 10.1370/afm.118.
Generational Health Disparities
Age-related health inequities can also be found between different generations of the U.S. population.
Four Main Generations
1. Silent Generation (born 1926 – 1945)
Veterans of the Korean War and Vietnam War
2. Baby Boomers (born 1946 – 1964)
Post-World War II
3. Generation X (born 1965 – 1983)
Part of the era of cultural and social change in the U.S.
4. The Millennials (born 1984 – early 2000s)
Also known as Generation Y
Howe, N, Strauss, W. Millennials Rising: The Next Great Generation. Available at: http://books.google.com?id=To_Eu9HCNqIC. Accessed March 13, 2015.
Comparison of U.S. Birth Rates Between Generations
Howe, N, Strauss, W. Millennials Rising: The Next Great Generation. Available at: http://books.google.com?id=To_Eu9HCNqIC. Accessed March 13, 2015.
Comparison of Teen Mortality Rate:
Generation X vs. The Millennials
Howe, N, Strauss, W. Millennials Rising: The Next Great Generation. Available at: http://books.google.com?id=To_Eu9HCNqIC. Accessed March 14, 2015.
Baby Boomers vs. Silent Generation
Generation X vs. The Millennials
In comparison to other generations, Baby Boomers had a lower overall health status.
Positive characteristics
Benefited from medical advancements
Increased life expectancy
Fewer current smokers than previous generation
Negative characteristics
Higher portion were obese and developed obesity at an earlier age
Little or no regular physical activity
Greater risk for diabetes and hypertension
Baby Boomers still have higher rates of chronic diseases and disability resulting in growing health care costs in comparison to the previous generation.
The teenage death rate increased by 20 percent for Generation X and decreased 15 percent during the “Millennial” generation.
The Millennials benefit from significant improvements in prenatal care
When considering race and ethnicity, Asian immigrants mothers gave birth to the healthiest “Millennial” babies.
Exposure to environmental toxins has decreased for “Millennial” kids due to regulations from the U.S. Environmental Protection Agency.

Howe, N, Strauss, W. Millennials Rising: The Next Great Generation. Available at: http://books.google.com?id=To_Eu9HCNqIC. Accessed March 14, 2015.
King DE, Matheson E, Chirina S, Shankar A, Broman-fulks J. The status of baby boomers' health in the United States: the healthiest generation?. JAMA Intern Med. 2013;173(5):385-6. doi:10.1001/jamainternmed.

Leveille SG, Wee CC, Iezzoni LI. Trends in Obesity and Arthritis Among Baby Boomers and Their Predecessors, 1971–2002. American Journal of Public Health. 2005;95(9):1607-1613. doi:10.2105/AJPH.2004.060418.

1. Gebrekristos HT. Health inequalities among sexual minority youth: A need for sexual orientation and gender expression sensitive school environment. Sex Transm Infect. 2012;88(4):236-237.
2. Mustanski B, PhD, Birkett M, PhD, Greene GJ, PhD, Hatzenbuehler ML, PhD, Newcomb ME, PhD. Envisioning an america without sexual orientation inequities in adolescent health. Am J Public Health. 2014;104(2):218-225.

Income difference between Male and female full-time workers
Predicted probabilities of self-rated fair/poor by income and sexual orientation (3)
Predicted probabilities of self-rated fair/poor health by income and gender (2)
Intersectionality: Race & Gender
Predicted probabilities of self-rated fair/poor health by race & gender (3)
Compared to white men in the study by Veenstra, white women, and South Asian men & women are more likely to self-rate as having fair or poor health, with South Asians persons of both genders faring worse than white respondents of either gender (3).
South Asian women were also at "multiple jeopardy" due to the interaction of multiple inequalities: race, gender, and income (3).
The gender wage gap: women's median earnings are lower than men's in almost all occupations
Source: Institute for Women's Policy Research
Religion and Geography
Gender is a social construct defined by the culture in which it is being utilized. Western cultures tend to define gender in terms of being male or female, a gender binary, but this is not universal. In fact, it is not uncommon for non-Western cultures to include three or more genders within their social structures (1, 2, 3).
Those who make more money tend to experience better health and, as women tend to earn less money than men, they tend to have more limited access to adequate healthcare and experience more negative health overall (1,2).

Health disparities negatively impacting women can result from:

No insurance coverage for birth control from "religious exemptor companies" (3)
No equal pay between the two genders (1)
No government-backed paid maternity/paternity leave for men or women (4)
As shown (to left):

The poorest homosexuals demonstrate highest predicted probabilities of fair/poor health
The poorest heterosexuals have second highest probability of fair/poor health

Conclusion: Income is a promising predictor of fair/poor health regardless of sexual orientation (3)
According to Blosnich
et al (2014):

Bisexual women bear a very high burden of health inequalities
Lesbians undergo 30% fewer routine medical exams than heterosexual women
Lesbian and bisexual women report a greater amount of risky behaviors & asthma
According to Blosnich
et al
Gay men were less likely to be over weight or obese than heterosexual men
Bisexual men were more likely to be diagnosed as asthmatic
Gay & bisexual men had higher odds of mental distress and life dissatisfaction
Social actions that cause negative LGBT+ health impacts (2):
Laws that prohibit same-sex marriage
Laws that do or do not ban discrimination on the basis of sexual orientation or gender identity
Laws that do or do not criminalize hate crimes on the basis of sexual orientation or gender identity
Religious organization that exclude or castigate LGBT+ individuals
Impacts include (2):
Increased mortality among LGBT+ adults compared to non-LGBT+ adults
Higher prevalence of psychiatric disorders among LGBT+ adults
Greater likelihood of suicide attempts due to bullying
Increased tobacco use
Bisexuals experience increased stress due to "double closet" (1, p. 344)
Military Aspects
A coinciding factor crucial to the study of health inequality is intersectionality. Intersectionality is "the interconnected nature of social categorizations such as race, class, and gender [and sexual orientation] as they apply to a given individual or group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage" (1).
Gender-based health inequality may result at an interpersonal level when doctors of a given gender, usually women, are discouraged from entering specialties that serve patients of the same gender. This may lead to a shortage of medical practitioners with whom patients feel they can comfortably discuss their health concerns and be reasonably assured that they will be understood and that their concerns will be taken seriously (1).
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