Module 3: Health Disparities & Social Determinants
Health disparities are the avoidable differences that result from cumulative social disadvantage, including health outcomes, health care access, coverage and quality of care between groups of people, etc. Health disparities are caused by a multitude of systemic factors often referred to as social determinants of health, including access to safe housing, heathy food, access to health services, transportation, public safety, media and technology, etc.
Some system-wide barriers to accessing care for mental health and substance use challenges also need special consideration because the issues are heightened by cultural dynamics. Barriers to mental health and substance use treatment services can occur at three different levels: individual, organizational and systemic. The barriers at the individual level are related to the individual’s characteristics such as demographics, health beliefs and attitudes, personal enabling resources, perceived illness and personal health practices. The barriers at the organizational level are related to provider and organization characteristics such as skills and attitudes. Barriers at the system level are related to the system characteristics in the organization of the health care system, including system-wide policies, cost of care, scope and types of services offered, etc.
- Define health disparities and social determinants.
- Acquire additional resources for their toolbox to address health disparities and social determinants.
- Apply the skills and tools acquired in this module to a case vignette.
Step 1: Let’s Get Started
This step briefly introduces health disparities and social determinants of health and provides specific objectives that will move you closer to your goals.
Step 2: Time to Engage
The information in this step is accessible and provides a general introduction to health equity. You can listen to a podcast on your morning walk, download a resource to help your client or get a short audio summary of an article that caught your eye before fully engaging with the reading.
In the Supporting Trans and Non-binary People’s Resilience in Health care Settings: TRANSnetwork webinar (64 minutes), the authors delineate the common barriers to health care experienced by the trans and non-binary (TNB) communities, coping strategies that lead to resilience within these communities and specific actions that health care practitioners can take toward advocating and disrupting cis-normative oppressive systems within health care settings. The learning objectives for this webinar include:
- Describe the barriers to service commonly experienced by TNB communities.
- Describe how intersecting systems of oppression disproportionately impact TNB Black, Indigenous and people of color in health care access.
- Describe specific factors facilitating the resilience of TNB people in the face of oppression within health care settings
- Describe specific actions you can take to facilitate the resilience of TNB people in the face of oppressive health care settings.
The Health Disparities Podcast from Movement is Life is filled with conversations about health disparities and the people working to eliminate them.
Here are some of their most recent podcast episodes:
- Physical Therapy: Uniquely Positioned to Help Address Chronic Conditions and Health Disparities (42 minutes)
- Latinx Clinical Research Inclusion: How Dr. Fabian Sandoval and Dr. Gustavo Corrales Teamed up to Move the Needle (35 minutes)
- Understanding Mistrust of Flu and COVID-19 Vaccines, featuring Dr. Sandra Crouse Quinn (42 minutes)
- Freda’s Story: Freda Needed Accountability to Help Decrease Her Pain and Reduce Her A1C. Being Part of a Team was the Key (35 minutes)
- Laura’s Story: How Emotional Connection in a Safe Space Helped Address Her Depression (33 minutes)
- Delivering Trusted and Patient-centered Public Health Information is Essential to the Promotion of Wellness in Latinx Communities. Featuring Dr. Elena Rios (35 minutes)
- Maryland’s successful Health Enterprise Zones Previously Led by Congressman Brown Considered for National Adoption (24 minutes)
- Uncomfortable Truths, Inspiring Perspectives: A Round Table Discussion on Diversity, Equity and Inclusion with Young Health Professionals. (76 minutes)
- America Needs More Minority Doctors and Nurses: Why and How. Featuring Dr. Melvyn Harrington. (23 minutes)
- The Culture of Health Blog, Home Is Where Our Health Is by Jessica Mark and Najaf Ahmad address housing stability, equity and health as it affects how long and how well we live.
This blog addresses the following topics:
- Safe, affordable housing
- Housing costs can undermine health
- Housing discrimination
- Ending discriminatory housing policies
- Working toward solutions
- The Steve Fund provides a full report, Ring the Alarm on the crisis of Black youth suicide in America encouraging immediate action to raise awareness in communities of color and make resources available. They also have additional resources for families and professionals.
- The William T. Grant Foundation report, Disparities in Child and Adolescent Mental Health and Mental Health Services in the U.S. by Margarita Alegría; Jennifer Greif, Ph.D.; Katie McLaughlin, Ph.D.; and Stephen Loder, BA, describes four mechanisms responsible for disparities in mental health outcomes among children and adolescents of color who are transitioning into adulthood. The topics addressed include:
- Socio-economic status
- Childhood adversities
- Family structure across development
- Neighborhood level factors
- Youth.gov explores Disparities and Resiliency in Adolescent Health, including:
- Toxic stress and adverse childhood experiences (ACEs)
- Resilience to toxic stress and ACEs
- Socioeconomic status and neighborhoods
- Resiliency in neighborhoods
- Marginalized youth and health disparities
- Resiliency in marginalized youth
- Resources for College Students Quarantining in Unsupportive Environments During COVID-19 was compiled by the University of Florida Spring 2020 Multiculturalism and Diversity in Counseling Psychology class. This infographic also provides a link to the COVID-19: College Students Quarantining in Unsupportive Environments Resource List, a running document that includes multilingual resources that you may find useful when working with college students as well as other communities. The topics highlighted include:
- COVID-19 and college students
- COVID-19 and the queer community
- COVID-19 and folks with disabilities
- COVID-19 and housing and food insecurity
- The American Psychological Association provides the Health Disparities and Stress Fact Sheet that discusses the following topics in greater depth:
- Types of stress
- How stress affects health
- The role of chronic stressors in health disparities among different racial and ethnic groups
- Acculturative stress
- Socioeconomic, daily and family stress
Given the rise in home-based violence, the American Psychological Association has collaborated with other psychological associations across the world to create an evidence-based, action-oriented, multi-language resource that has been translated into 19 languages, World’s Psychological Associations Unite Against Home-based Violence During COVID-19.
Step 3: Creating a Stronger Foundation
This list of materials and resources provides a more detailed description of how to apply the tools introduced in Step 2. This step requires you to engage in deeper analysis of the topic through documentaries, research articles, trainings and books. Some of the tools, like research articles and books, may have a cost attached and we recommend that your organization provide them and that share them with other team members. Tools like trainings may require you to engage for longer periods of time than the initial resources.
For more resources that focus on health disparities among LGBTQ+ communities and communities of color, review the following articles.
- Guidelines for Psychological Practice with Transgender and Gender Nonconforming People
- Singh, A. A., & Dickey, L. M., (2016). Implementing the APA guidelines on psychological practice with transgender and gender nonconforming people: A call to action to the field of psychology. Psychology of Sexual Orientation and Gender Diversity, 3(2), 195–200. https://doi-org.proxy-remote.galib.uga.edu/10.1037/sgd0000179
- Abreu, R. L., Gonzalez, K.A., Mosley, D.V., Pulice-Farrow, L., Adam, A., & Duberli, F., (2020). “They feel empowered to discriminate against las chicas”: Latina transgender women’s experiences navigating the health care system. International Journal of Transgender Health. DOI: 1080/26895269.2020.1767752
- Braveman P. (2014). What are health disparities and health equity? We need to be clear. Public health reports (Washington, D.C. : 1974), 129 Suppl 2(Suppl 2), 5–8. https://doi.org/10.1177/00333549141291S203
- Sanchez, K. (2016). Eliminating Behavioral Health Disparities and Improving Outcomes for Racial and Ethnic Minority Populations. Psychiatric Services, 1, 13.
After reviewing the previous resources and tools that focus heavily on the racial and ethnic health disparities that have been exacerbated during COVID-19it is vital to understand that health disparities are a longstanding issue that has existed across and within systems.
Health disparities are impacting Black, Indigenous and people of color (BIPOC) at higher rates and the cumulative social disadvantages are magnified. To get started, watch Bettina Love, Ph.D., M.Ed., talk about her book, We Want to Do More Than Survive (start at 7:25) (95 minutes) where she shares her thoughts on how educators, parents and community leaders can advocate for “education freedom” for students through civic engagement and activism. Yolanda Sealey-Ruiz, MA, Ph.D., discusses the need to start deep self-work within oneself and Genevieve DeBose Akinnagbe, MA, speaks about the importance of telling students early on that they matter. Some of the key topics discussed include:
- System justification
- Educational survival complex
- Spirit murdering
- Health disparities among children
- Critical race theory
- White supremacy
- The power of language
Step 4: Your Turn
This step encourages you to apply what you have learned through a case vignette. We recommend that you explore the gaps present within the vignette and implement any new skills acquired through this module. Consult with others on your team to explore the multiple ways to address the issues, especially as you take your role within your organization and your experience, skills and worldview into account. We provide reflection questions from the following perspectives: individual learning and beliefs, organizational learning and systemic. You can use the questions to have discussions with others and think through all the facets that are relevant to your work.
Rob is an experienced therapist, but Carolina’s referral from Luz, a nurse practitioner, made him pause. As Rob read over her chart, he felt overwhelmed by her long history of trauma. Initially, Carolina had been seen for somatic symptoms consistent with panic attacks, but a cursory history revealed indications of a possible psychotic disorder, depression and sexual trauma. Carolina was an immigrant from Nicaragua and was in a series of relationships where there was serious interpersonal violence. Rob set the chart down. He wondered what he could possibly do to help someone who experienced this kind of extensive depravation and poverty. As much as he hated to admit it, Rob felt pessimistic about his ability to help, which was a rare feeling.
He thought about a continuing education seminar he had attended at his most recent national conference about understanding health disparities and the complex web of social determinants of health. Rob remembered that that presenters emphasized that getting bogged down in the cumulative effect of disadvantage was not helpful to the client. Rob remembered that Luz mentioned how much she liked Carolina and admired her for her positive outlook. Rob remembered concepts he had learned about such as resilience and cultural strengths.
Rob drummed his fingers on the file and reminded himself why he wanted to be a therapist. He couldn’t ignore the cumulative effects of health disparities, but he also couldn’t simply focus on pathology. Rob decided to try to understand how Carolina navigated her personal history and the U.S. medical system to help bolster her coping skills, maintain her health and access resources that could be helpful. Rob chuckled as he recognized that he was nervous. A deep breathing exercise helped him center himself before he walked to meet Carolina to begin their therapy relationship.
- In the vignette, Luz, the nurse practitioner, helps humanize the client. What are some ways to keep the person front and center, rather than her history? (individual learning and change)
- How can you ensure your organization sponsors and offers training that emphasizes resilience and cultural strengths? (organizational learning and change)
- A client experiencing health disparities due to inequities in the social determinants of health may not get help right away and present with highly acute symptoms. How might new client intake sessions be structured to take acuity as a result of inequity into account, rather than an individual factor? (systemic change)