文章基本信息

标题：Socioeconomic Disparities in Health in the United States: What the Patterns Tell Us
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作者：Paula A. Braveman ; Catherine Cubbin ; Susan Egerter 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2010
卷号：100
期号：Suppl 1
页码：S186-S196
DOI：10.2105/AJPH.2009.166082
语种：English
出版社：American Public Health Association
摘要：Objectives. We aimed to describe socioeconomic disparities in the United States across multiple health indicators and socioeconomic groups. Methods. Using recent national data on 5 child (infant mortality, health status, activity limitation, healthy eating, sedentary adolescents) and 6 adult (life expectancy, health status, activity limitation, heart disease, diabetes, obesity) health indicators, we examined indicator rates across multiple income or education categories, overall and within racial/ethnic groups. Results. Those with the lowest income and who were least educated were consistently least healthy, but for most indicators, even groups with intermediate income and education levels were less healthy than the wealthiest and most educated. Gradient patterns were seen often among non-Hispanic Blacks and Whites but less consistently among Hispanics. Conclusions. Health in the United States is often, though not invariably, patterned strongly along both socioeconomic and racial/ethnic lines, suggesting links between hierarchies of social advantage and health. Worse health among the most socially disadvantaged argues for policies prioritizing those groups, but pervasive gradient patterns also indicate a need to address a wider socioeconomic spectrum—which may help garner political support. Routine health reporting should examine socioeconomic and racial/ethnic disparity patterns, jointly and separately. For years, public health statistics in several European countries have been routinely collected and reported for groups defined by social class, generally measured by ranking according to occupational hierarchies reflecting differences in social standing^{1 – 4}; in the United Kingdom and France, for example, this has been the case for close to a century. At least 5 social classes have routinely been examined in the United Kingdom since 1913,⁵ and several European countries have used 6 or more social class groups in their routine health statistics.^{6 , 7} The presence of detailed socioeconomic information in routine health data in Europe has facilitated the monitoring of socioeconomic patterns in diverse health indicators, with the ability not only to compare the health of socioeconomically disadvantaged persons with that of all others but also to examine health differences among middle-class subgroups and, potentially, comparisons with the wealthy. In contrast, routine public health statistics in the United States historically have been reported by racial or ethnic group,⁸ but health differences across groups defined by socioeconomic factors (typically, income or educational attainment) have been examined less frequently.² When differences in income and education have been reported, the number of groups being compared has often been limited to two or at most three. A review of more than 20 National Center for Health Statistics (NCHS) publications^{9 – 32} on health status or health-related behaviors, released in 2009 and available on the NCHS Web site, revealed that although most examined differences in health by race or ethnicity, fewer than half examined differences by income or education, and most of those considered no more than 3 categories. For example, in the most recent edition of Health, United States ,²⁸ the US Department of Health and Human Services's annual health statistics report, 93 of its 151 tables report health differences by race or Hispanic origin, compared with 34 and 16 tables reporting differences by income (as a percentage of poverty) and education, respectively. With the exception of the Socioeconomic Status and Health Chartbook ,³³ part of the 1998 edition, Health, United States usually compares at most 3 income groups (the “poor,” with incomes below 100% of poverty; “near poor,” with incomes from 100% up to 200% of poverty; and all higher-income persons combined) and 3 education groups (persons who have not completed high school, high school graduates, and those with at least some postsecondary education). The Socioeconomic Status and Health Chartbook , the National Health Interview Survey (NHIS) Series 10 reports,³⁴ and the Agency for Healthcare Research and Quality (AHRQ) National Healthcare Disparities Reports³⁵ are notable exceptions of reports based on routine public health data in which differences are examined across 4 or 5 socioeconomic groups; however, the NHIS reports do not examine differences by race and socioeconomic factors considered jointly, the AHRQ reports focus primarily on health care, and the Socioeconomic Status and Health Chartbook is now more than a decade old. The general lack of routinely reported information on social and economic differences in health in this country has public health implications. The ways that health disparities are patterned socially may help us understand their nature and how best to address them.^{36 , 37} Differences in health that suggest a socioeconomic threshold at or near the poverty line (e.g., a high rate of a particular illness among the poor, contrasted with more favorable and similar rates for all other income groups) would support targeted policies to address aspects of deprivation (e.g., substandard housing, hazardous work) uniquely experienced by the most disadvantaged. In contrast, differences in health that follow a gradient pattern (e.g., with worse outcomes not just among the poor but in “middle-class” subgroups as well, compared with higher-income groups) would suggest the need to consider policies that address factors such as relative deprivation or relative standing,³⁸ degree of control over one's work,³⁹ or levels of chronic stress associated with ongoing logistical challenges (e.g., child care or transportation needs) that may become progressively easier to address with additional economic and social resources,^{40 , 41} at least up to a threshold well above the poverty or near-poverty line. Furthermore, examining racial and socioeconomic patterns in health jointly can inform policies to address inequalities in both dimensions. We aimed to describe patterns of socioeconomic differences in a wide array of important health indicators in the United States, among children and adults overall and within different racial or ethnic groups. A number of US studies have revealed gradient patterns in adult health indicators,^{42 – 45} but we are unaware of US studies or routine reports since Health, United States, 1998 that (1) have looked at socioeconomic patterns in health across a wide range of both child and adult health status and health-related behavior indicators, (2) have examined a sufficient number of income or education categories to be able to distinguish health differences among subgroups of the nonpoor (or those with at least a high school education), and (3) have jointly examined both socioeconomic and racial or ethnic differences in health.