Health Disparities: Where to Start?

Carrie L. Nieman, MD, MPH, on behalf of the Otology and Neurotology Education Committee 

Health disparities are pervasive. Differential health outcomes based on social and structural factors are well-documented throughout otolaryngology-head and neck surgery, and healthcare more broadly.¹ As practicing clinicians, these differences in care can seem a matter of academics, disconnected from the daily care we provide our patients, where we aim to deliver the highest level of care to every patient. We can struggle to connect the dots between how we move from our daily efforts in the clinic and the OR to the resulting gaps in care and outcomes we know to exist. Public health approaches, specifically social epidemiology, can provide the necessary perspective and tools to help us understand what contributes to health disparities and our role in addressing these differences. 

The first step is to recognize that there are two complementary, but fundamentally different, perspectives we adopt when viewing our world as a clinician versus a public health practitioner. As clinicians, our perspective is often focused on the individual level, reflecting efforts to influence an individual’s behaviors, decisions, and outcomes. Through a public health lens, we zoom out and the focus is no longer on the individual alone but on understanding the scale of a community- or population-level problem, its drivers, and avenues for intervention. Epidemiology provides the foundation to understand and address differences in disease prevalence and health outcomes at a collective level. 

Disparities are differences in health outcomes and their determinants between populations based on attributes that relate to demographic, social, geographic, environmental, or other factors.² Within epidemiology, social epidemiology explicitly acknowledges that one’s social context influences individual, community, and societal health. Social epidemiology has its origins in work led, in part, by W.E.B. Du Bois, PhD.^3,4 The starting point in social epidemiology is that the distribution of risk factors and subsequent disease in a community is associated with (if not caused by) the distribution of disadvantage.⁵ How we identify and quantify these sociocultural factors and their effect on the health of a population is the focus of social epidemiology.⁵

As clinicians, we are trained to view disease as a fundamentally biological phenomena, where individual-level behaviors via biological mechanisms cause disease.⁶ Social epidemiology puts forth that disease is the product of biological factors as well as social and individual factors.⁷ More specifically, social factors include structural conditions, such as public policies, poverty, discrimination, racism, sexism, among others, as well as interpersonal conditions, such as social support and social engagements.⁸ Social determinants of health, a likely more familiar term, are those social, economic, and political conditions that influence health.⁹ Social epidemiology also provides the guiding theories and frameworks that help use measure, model, and interpret the effects of social structural factors on health outcomes, beyond biological factors alone, which is necessary to know when, where, and how to intervene and address health disparities. 

We do not all need to be social epidemiologists to make a difference. However, we can each act and contribute to eliminating health disparities. Education and awareness are core public health strategies, which includes our own education and awareness of the diverse factors that influence the health of our patients and communities. We must consider the health of our patients and communities in the broadest context possible, beyond biological factors alone. How broadly we conceptualize the health of our patients, and our communities, influences how we see our role in addressing disparities and what levers we perceive available to augment the distribution of disease and its risk factors in our communities. As readers of literature, our job is to require authors to employ rigorous and reasoned approaches to their work—how they developed their research question, what guiding theoretical frameworks they employed, the hypothesized mechanism underlying the expected association, the rationale for included variables and outcomes, their recognition of the influence of frequently unmeasured social and contextual factors, along with questions that are relevant to the communities in which you practice.¹⁰ For those of us who engage in disparities-related work, we should strive to capture the multilevel factors that influence health and health disparities and the multilevel interventions needed to make a substantive difference.¹¹ We should look to fields like social epidemiology for guidance and seek cross-disciplinary collaborations to strengthen our science and, ultimately, our impact.

Finally, as clinicians, we should help document demographic and relevant social determinants of health within our electronic health record system. Our institutions and communities exist within a context, and we should seek to learn about the history and position of our practice within our communities. We should examine and monitor care outcomes, including patient satisfaction, based on social factors to ensure equitable care and identify when intervention is needed.¹⁰ Finally, we can regularly review our practice environment to examine operational processes and ensure they are welcoming and accessible to patients from a range of backgrounds and abilities. 

We all share in the work that is needed to ensure our patients and all members of our communities have the opportunity to realize their right to health. The good news is that: 

• We do not need to do this alone.
• We do not need to do this without guidance. 
• High-quality, person-centered care is already at the heart of what we do. 

References

1. Bowe SN, Faucett EA. Healthcare Disparities in Otolaryngology. Elsevier Health Sciences; 2023. 
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3. Krieger N. A glossary for social epidemiology. J Epidemiol Community Health. 2001;55(10):693-700. doi:10.1136/jech.55.10.693
4. Jones-Eversley SD, Dean LT. After 121 Years, It’s Time to Recognize W.E.B. Du Bois as a Founding Father of Social Epidemiology. J Negro Educ. 2018;87(3):230-245. doi:10.7709/jnegroeducation.87.3.0230
5. Petteway R, Mujahid M, Allen A, Morello-Frosch R. Towards a People’s Social Epidemiology: Envisioning a More Inclusive and Equitable Future for Social Epi Research and Practice in the 21st Century. Int J Environ Res Public Health. 2019;16(20):3983. doi:10.3390/ijerph16203983
6. Susser M, Susser E. Choosing a future for epidemiology: I. Eras and paradigms. Am J Public Health. 1996;86(5):668-673. doi:10.2105/AJPH.86.5.668
7. Honjo K. Social epidemiology: Definition, history, and research examples. Environ Health Prev Med. 2004;9(5):193-199. doi:10.1007/BF02898100
8. Berkman LF, Glass T, Brissette I, Seeman TE. From social integration to health: Durkheim in the new millennium☆. Soc Sci Med. 2000;51(6):843-857. doi:10.1016/S0277-9536(00)00065-4
9. Health WC on SD of, Organization WH. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health : Commission on Social Determinants of Health Final Report. World Health Organization; 2008.
10. Nieman CL, Suen JJ, Dean LT, Chandran A. Foundational Approaches to Advancing Hearing Health Equity: A Primer in Social Epidemiology. Ear Hear. 2022;43(Supplement 1):5S. doi:10.1097/AUD.0000000000001149
11. Alvidrez J, Castille D, Laude-Sharp M, Rosario A, Tabor D. The National Institute on Minority Health and Health Disparities Research Framework. Am J Public Health. 2019;109(S1):S16-S20. doi:10.2105/AJPH.2018.304883