Case Report - (2021) Volume 18, Issue 1
Nicole Downey* and Jennifer DiBenedetto
Nursing Theory, School of Nursing, UNC Greensboro School of Nursing, Eastern, United States
Received Date: December 10, 2020; Accepted Date: December 17, 2020; Published Date: December 24, 2020
A concept analysis is a process that seeks to explore the structure, function, defining characteristics, and other basic elements of a concept [1]. The product of a concept analysis is never fixed, since knowledge is gained and the effects of culture, context, and societal factors alter what is known to be true over time [1]. The purpose of this concept analysis is to explore and solidify the meaning of health disparity so that the product of the analysis may be applied to my future practice as an adult gerontology primary care nurse practitioner. Since I work in an inpatient medicine unit in an urban setting, I interact with many patients who do not have equal access to carein many different contexts. I see firsthand the effects that these inequalities have on overall health, treatment opportunities, experiences, and outcomes of different patients. A more solid foundation of the concept of health disparity can allow for improved identification of the issue within practice, while providing a basis for nurses to promote better advocacy and changes in their workplaces and communities to improve patient outcomes.
There are no dictionary results for the words “health disparity” as a single term, but there are definitions for the words as separate entities. According to the Merrium-Webster dictionary (n.d.) [2], the word “health” has multiple definitions, including the following: the condition of being sound in body, mind, or spirit; freedom from physical disease or pain; the general condition of the body; a condition in which someone or something is thriving or doing well; a general condition or state. The word “disparity” is defined as “a noticeable and usually significant difference or dissimilarity” [2].
The term “health disparity” is frequently used in the literature of multiple disciplines. The Centers for Disease Control and Prevention (CDC) and Healthy People 2020 both describe health disparity as differences in health that are related to certain disadvantages in society [3,4]. The National Institute on Minority Health and Health Disparities & U.S. National Library of Medicine [5] give specific examples of healthy disparities that can occur between these groups, including who gets which diseases, the severity of diseases, complications, mortality, and access to health care, and screening for diseases.
Artiga et al. [6] describes health disparities as differences in health between people of different race/ethnicity, socioeconomic status, age, geographic location, gender identity, sexual orientation, and disability status. The CDC states that health disparities affect “socially disadvantaged populations” [3], while Healthy People 2020 states that it affects people who are socially, economically, and/or environmentally disadvantaged [4]. It has also been stated to affect certain groups who face greater amounts of adversity based on their race or ethnicity, religion, socioeconomic status, gender, age, mental health status or history, disability, sexual orientation or gender identity, geographic location, or any other attribute that has historically been discriminated against [4].
The historical and present inequalities in social, political, financial and environmental resources are attributed to the root of differences that exist as well [3]. For example, inequalities in education, such as dropping out of school, is associated with health problems, while completion of higher levels of education is associated with longer life and increased health literacy. LGBTQ young people are at a higher risk for poorer health outcomes surrounding sexual behaviors, violence, substance use, and suicide [3]. Education, healthy food, clean water, safe and affordable housing and transportation, and health insurance are a few examples of factors that determine health which may be less available to certain populations, which therefore contribute to health disparity [4]. The Centers for Disease Control and Prevention (CDC) describes health disparities as preventable, and recognizes the term as differences in disease burden, injury, violence, or opportunities to achieve the best health status possible [3].
Health disparities in the context of race are discussed frequently in the literature. Koschmann et al. [7] explain the responsibility that nurses have to research health disparities and their causative factors, including the acknowledgement that racism is a root cause of health disparity. The authors state that using race-neutral or culturally competent care strengthens disparities; therefore the nursing profession needs to shift their focus to an antiracist approach in practices, research and education. In addition, nursing research needs to include underrepresented populations and the nursing workforce needs to increase its diversity in order to reduce health disparities [7]. Laurencin and Walker [8] state the impact that racial profiling has on health disparity. The authors identify that violence and injury from police to Black Americans can affect the mental, physical, and emotional health of people and their communities. In addition, stopping certain individuals at a higher rate than others, as seen with “stop and frisk” policies, can cause increases in stress responses and depression in Black Americans, which increases risks for heart disease, diabetes, and cancer. Police mistreatment of Black individuals is associated with decreased mental health such as PTSD and suicidal ideation, and worse mental health is associated with the killings of Black people by police, creating a vicious cycle [8]. The stress of a Black pregnant woman from worrying about the possibility of racial profiling in her unborn child may impact her baby’s birth weight and length of pregnancy. Laurencin and Walker [8] state that because of its numerous impacts on health, racial profiling needs to be acknowledged as a public health issue.
Health disparities are frequently referenced in the context of social work. According to Unal [9], empowerment of the vulnerable, oppressed, and people in poverty are standards of the social work profession, so decreasing health disparities is therefore a responsibility. Miller et al. [10] state that American policies likely play a role in the health disparities, and social workers need to advocate for policies that raise the voices of the oppressed in order to improve outcomes. “Upstream” social structures that exist in the United States maintain health disparities and should be advocated against by social workers [10].
Miller et al. [10] mention how in the United States, there are significant differences in morbidity and mortality between different socioeconomic, racial/ethnic, and geographic groups. An individual’s opportunities and resources depend on how that person is perceived by their environment, and those who are seen as different are more likely to be discriminated against and have worse outcomes [11]. Both interpersonal and systemic discrimination in healthcare are experienced by groups that are marginalized in society which can manifest in decreased access to health care and promotes health disparities [11]. Unal [9] discusses the health disparities that exist within the American Indian and Alaska Native populations. According to author American Indians and Alaska Natives have significantly higher rates of disease than non-hispanic white people in the United States, and the highest mortality rate of any group in the United States for tuberculosis, alcoholism, diabetes, unintentional injuries, homicides, pneumonia, influenza, and suicide. The author contributes these outcomes to the health disparities that exist within this population that began with their oppression and mistreatment throughout history from European settlers [9].
Miller et al. [10] compare the United States to the United Kingdom, which has less disparities and more policies to prevent poverty and distribute wealth more equally, highlighting the need for the United States to implement better policies to protect all people. Changes in policies in other topics such as finances, education, housing, and family matters should be advocated for by social workers because they affect health and outcomes [10].
Health disparity is a relevant topic in the field of law. Teitelbaum et al. [12] discusses how the laws and regulations at many different levels prevent equal distribution of social and financial opportunities as well as increased punishments for marginalized groups. The authors discuss how laws are a fundamental determinant of health and need to be updated to protect the oppressed in order to decrease these disparities [12]. Policy implementations at the state and local levels can support approaches to decrease health disparities [13].
Laws that discriminate based on race are associated strongly with the differences in health experiences and outcomes that people of color face. The authors contribute these health disparities to the institutional disadvantages that exist stemming from a long history of genocide, slavery, violence, and oppression [12]. According to González et al. [13], children of marginalized populations face a disproportionate amount of discipline, trauma, and adversity, particularly in the school setting. The exclusionary school discipline (ESD) practices that many schools use in these populations contributes to health disparities and further promotes other social, financial, and educational inequalities that already exist [13].
People who are adopted may experience health disparities due to not knowing their family history. In the article written by May and Evans [14], the authors discuss the cost and saving benefits of genetically testing people who are adopted to decrease the health disparities that they may experience. The article addresses the moral obligation to explore targeted screening for potential conditions that are able to be avoided by genetic testing, which could lessen the health disparities that people who are unsure of their family history experience. Organizational standards and policies may be updated to reflect these potential benefits that may improve length and quality of life for adoptees and lessen the health disparities that they may face [14].
The defining attributes of “health disparity” stem from the multiple representations of the concept in the literature. In order for the concept of health disparity to exist, the following must be true:
• Those affected by health disparities are disadvantaged in social, environmental, economic, or educational aspects based on personal attributes or experiences.
• Health disparities may occur due to a number of factors that include, but are not limited to, access to education, healthy food, clean water, safe housing, transportation, and health insurance.
• Health disparities must be related to an unequal distribution of resources and opportunities and would be preventable otherwise.
• Health disparities are manifested by inequitable differences in care and outcomes related to health.
The term “health disparity” describes the preventable difference in healthcare opportunities and outcomes that disadvantaged populations experience due to a number of inequities in interpersonal and systemic contexts. The existance of this concept stems from the many years of mistreatment by society which has decreased the amount of opportunities for marginilized populations to access variables that affect health. If the people who are affected by health disparity were provided the same resources as other populations, they would have better healthcare experiences and outcomes, and no health disparities would occur.
Model case
According to Walker and Avant [1], a model case is defined as the use of the concept in an example that includes all of its defining attributes. The following example illustrates a model case for the term “health disparity.”
Brian is a 45 year old African American male. He grew up poor in a one-bedroom apartment with his father, who was a single parent, and his siblings in a large city. His father often smoked cigarettes inside their apartment. As a child, Brian often sent to the principal’s office and unfairly blamed for things that he did not do. His teachers often did not encourage his potential, and frequently gave him lower scores on assignments. He did not go to college, and instead began working a stressful job with long hours and little pay right out of high school. The closest grocery store to Brian’s apartment is a 25 minute bus ride through the city. Since he cannot afford healthy food and doesn’t usually have time for this bus ride, often he eats at fast food restaurants due to time constraints and a lower price. All of Brian’s managers are white people and he frequently has to deal with racist remarks in his place of work and daily life. Brian has hypertension and type two diabetes.
In this case, many things may have contributed to his hypertension and diabetes from the time that Brian was a child. For example, the small living conditions in a city with his exposure to secondhand smoke could have played a role in these conditions. Because of his stressful home situation living in poverty and the fact that his school did not support him, he was unable to go to college and frequently missed out on opportunities that could have allowed him to continue his education or succeed in the academic setting. Therefore, he was unable to get a neither adequately paying job nor health insurance. Because he often was forced to work overtime in order to pay the bills, he frequently would eat at fast food restaurants to save time and money. The lack of a healthy diet and high stress both may have contributed to these comorbidities. In multiple ways, society failed Brian and caused him to have higher amounts of stress and less opportunity for personal health promotion. If he had more equitable opportunities, he may have been able to prevent these conditions from occurring.
Borderline case
Walker and Avant [1] define a borderline case as an example that contains most but not all of the defining attributes of a concept. The following scenario is an example of a borderline case, which may assist in clarifying the defining features by noting the contrasts from the model case.
Alexis is a 16 year old female whose parents both immigrated to the United States from Mexico. Her father travels frequently as a truck driver and her mother works two jobs to pay the bills. Her family’s home is in a rural community, where Alexis must take a 45 minute bus drive to get to school, and the closest hospital is 60 minutes away. After a few weeks of symptoms that had gotten more severe, Alexis was diagnosed with type one diabetes. Although Alexis is experiencing many factors that contribute to inequalities in her health, her type one diabetes could not have been prevented if these factors were removed. Therefore, this case represents most but not all of the defining features of health disparity in terms of her type one diabetes diagnosis. However, it should be noted that Alexis may be experiencing other forms of health disparity, but they are not presented in this case.
Related case
Related cases are similar to the concept at hand, but do not contain all of the defining attributes. These cases have concepts of their own that are not the same as the main concept [1].
Sarah is a 26 year old caucasion female who grew up in the suburbs outside of a large city. She is a stay at home mom with two young children and her husband is a lawyer. When she started to experience severe pain in her back that progressively worsened and one day became unbearable, her husband took the rest of the day off of work and drove her to the hospital. Upon arriving at the emergency department, her husband was recognized by an employee from his job, and Sarah was then seen right away. She received pain medication and testing was done which revealed she had an extremely advanced form of bone cancer. She was referred to a highly rated oncology team in the area, but unfortunately Sarah passed away after three months. This is an example of a related case, because although Sarah’s outcome was not positive, it was not due to her lack of access or resources. The concept in this case could be called illness. Her privilege of having a husband who could take off of work, transportation, and her social status assisted her in getting the most effective health care rather than hindering it, so her death cannot be attributed to her disadvantage in any of these factors.
Contrary case
Contrary cases are examples that are clearly not related to the concept and do not contain any of the defining features. They assist in determining the defining attributes of a concept because any that occur in the model case that also can happen in a contrary case should not be included as defining attributes [1].
Chad is a 35 year old white male who lives in a large home with his wife and two children. He graduated with his Masters Degree in Business and is the CEO of a large company. He drives his car fifteen minutes each day to work and he has no health conditions.
This is clearly a contrary case because Chad’s experiences have not led him to be socially, environmentally, economically, or educationally disadvantaged in any way, and he has not experienced any poor health outcomes.
Illegitimate case
An illegitimate case is an example of the term used out of context or in a way that is used inappropriately [1]. While “health disparity” as a single concept does not have an example of an illegitimate case, both words used separately do. For example, the word “health” used in the following sentence is an example of an illegitimate case: “Bill wanted to assess the company’s financial health prior to accepting the position.” The use of this term is different from the meaning in the context of physical health, therefore making it an illegitimate case.
The word “disparity” also has an example of an illegitimate case. Consider the following statement: “The disparity in size between an insect and a human is large.” This can be seen as an illegitimate case because the defining attributes of this term differ from that in the context of disparities associated with health.
Invented case
According to Walker and Avant [1], invented cases are often comparable to science fiction and occur outside of the human experience. Consider the following scenario as an example of an invented case for the term “health disparity.”
Samis an alien living in a beautiful town on Mars. The town’s air is incredibly clear, healthy, and frees from pollution and the may or of the town ensures that healthy food is near by at all times. Sam has no health concerns. However, another alien named Theresa lives just off the coast on the other side of Mars. The water near Theresa’s home and the air in her town is much polluted. There is not much food, and there is a large amount of violence in the area near her home. Theresa has developed chronic asthma and cancer from the pollution. Theresa gets nervous to leave her home to go to her health care appointments because she is worried about travelling through the violence, and she cannot afford a vehicle to get there faster. Theresa ends up getting very sick and dies due from an asthma exacerbation. The difference in experiences and outcomes of these aliens can be similarly compared to what some humans face in terms of health disparities, which qualifies this as an invented case.
Antecedents are events that must be in place before the concept can occur, and cannot be the same as any of the defining attributes. They assist in identifying assumptions about the main concept and clarifying the defining attributes [1]. Discrimination against particular groups of people, a history of unjust treatment by society, and a lack of equal access to resources must occur for the defining attributes of health disparity to exist, and therefore are considered antecedents. When a certain population is marginilized in society, their group as a whole has often been historically deprived of access to the same resources that other groups have. These groups may be identified based on factors such as race, ethnicity, religion, fincancial status, gender, age, disability, and others [4]. Some examples of these resources include education, healthy food, clean water, safe and affordable housing and transportation, and health insurance, which are all necessary to foster health [4]. Therefore, individuals in these groups are unable to adequately promote their own health as well as the health of their family members, which causes and maintains health disparities.
Consequences are occurrences that happen as a result of the concept [1]. The higher number of negative health-related outcomes in marginalized populations is a consequence of health disparity. According to Duran et al. [15], increased or premature mortality, faster disease progression, greater disease burdon or poorer self-reported daily functioning or symptoms, and a higher incidence or prevalence of disease occur because of health disparity. In addition, a higher financial burden of disadvantaged individuals occurs as their decreased health causes them to spend more money out-of-pocket on healthcare. A cycle of inadequate opportunities in populations affected by health disparities occurs as a result of this concept because as people are increasingly sicker, their ability to improve their financial status, education, and other factors that may improve their access to care, decreases.
Empirical referents are categories of phenomena of a concept that make it measureable and prove its existence [1]. While much of the literature involving health disparities discusses research in qualitative terms, quantitative measures may be beneficial to evaluate its existence and resulting outcomes. However, there is a gap in the literature regarding a tool that is proven reliable and effective to measure health disparities. While we know that disparities exist due statistics and differences in outcomes between certain groups, further research is needed to develop a scalable tool that may appropriately measure this concept.
The way in which data is collected and analyzed can affect the results, so it is important to use accurate measurement techniques to appropriately measure health disparities [16]. Penman-Aguilar et al. [16] identify beneficial practices when measuring health disparities, such as identifying groups that have less societal power and more disadvantages compared with those who do not and placing these results next to each other to compare. In addition, measuring disparities at multiple levels such as individual and structural may improve the accuracy and analysis of data obtained [16].
The National Institute on Minority Health and Health Disparities created recommendations to standardize the measurement of health disparities in order to harmonize research and allow for reproducible studies [15]. Some example of the recommendations include the following: clearly differentiate the indicators of health outcomes and health determinants studies, develop common early warning indicators of health disparities, and establish criteria for population characteristics to include in health disparity research [15].
The Office of Disease Prevention and Health Promotion (ODPHP), the National Center for Health Statistics (NCHS), and the Office of Minority Health (OMH) joined forces to create a tool to measure health disparities in terms of the Healthy People 2020 objectives. This tool may be applied to any of the Healthy People 2020 objectives by online users, and the disparities are color coded in terms of statistical significance. The tool highlights differences in outcomes in terms of sex, race/ethnicity, educational attainment, and family income [17].
The Centers for Medicare & Medicaid Services (CMS) Office of Minority Health (OMH) (n.d.) created a “Mapping Medicare Disparities (MMD) Tool” which highlights disparities between different populations in terms of health outcomes, cost, and utilization. This tool is depicted as an interactive map that enables disparities to be analyzed by identifying how a geographic area or population differs from the state or national average. This resource may assist in making policy decisions and improved interventions to reduce disparities by identifying where they occur [18].
Health disparity is a concept that has many implications for healthcare and the advanced practictioner nursing profession. Since health disparities can be prevented, stakeholders at the structural, organizational, and intrapersonal levels in society must address the contributing factors in order to decrease the negative outcomes that result from this concept. By decreasing health disparity, all people, regardless of societal factors, will have more equitable access and quality of healthcare, which has the potential to result in improved outcomes for marginilized populations.
