Equity and Social Determinants of Health Among Older Adults

By Steven P. Wallace

Attention to the challenges faced by older adults of color in the United States was first highlighted by a report in 1964 from the National Urban League, Double Jeopardy: The Older Negro in America Today (National Urban League, 1964). At the time, it was groundbreaking just to document the gap in health and wealth between older African Americans and whites, a gap that was particularly acute in old age. In the subsequent half-century, we have expended a lot of effort to further specify the existence of health disparities by race and ethnicity.

The 1985 United States Department of Health and Human Services (HHS) Secretary’s Taskforce Report on Black and Minority Health was the first signal of top governmental-level concern with health differences by race, with the clearest documentation being the mortality gap for African Americans. Forty-two percent of cumulative deaths by age 70 among African Americans were shown to have been avoidable if African Americans’ mortality profile matched that of whites (Heckler, 1985). And in 2003, the Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, clearly documented the healthcare system’s under-treatment and poorer treatment of African Americans (Smedley,
Stith, and Nelson, 2003).

We now have the annual National Healthcare Disparities Report, mandated by Congress, that provides snapshots of access and quality inequities by race and ethnicity. The most recent edition shows that African Americans and Latinos receive lower quality healthcare in 40 percent of the indicators measured, American Indians/Alaska Natives in one-third of the indicators, and Asian Americans in one-quarter. There were many more than 100 quality points tracked, such as the receipt of colon cancer screening by those older than age 50 and hospital admissions for uncontrolled diabetes (Agency for Healthcare Research and Quality [AHRQ], 2014).

Reducing Health Inequities with Prevention 

Health inequities are the result of avoidable differences between populations that affect less powerful groups in society. They stem from a pattern of health determinants, outcomes, and resources associated with broader social inequities. When patterns of social exclusion, blocked opportunities, or unequal returns on effort are common to a population, the resulting differences in health status and healthcare are inequitable (Wallace, 2012).

Most attention to the causes of health inequities among older adults has focused on the medical system, which has its greatest impact on health outcomes after a person becomes ill. But preventing illness has the greatest potential for reducing health inequities, as well as for reducing the need for expensive medical care. Because exposures to many risk factors for disease and disability are unequally distributed across groups, it is important to address social and political factors. Heart disease is the leading cause of death in old age for all groups and there are clear differences in cardiovascular disease rates by income and race or ethnicity. Policy efforts to reduce the average sodium content of commonly consumed packaged foods are one cost-effective approach for reducing blood pressure and cardiovascular disease at the population level (Morrison and Ness, 2011). Similarly, policy efforts exist to improve population-level physical activity, promote balanced diets, and reduce smoking, each of which has a salutatory impact on the risks for cardiovascular disease as well as multiple other health conditions.

Efforts to promote health are not adopted evenly across populations, and groups at the highest risk often are the last to benefit from the societal changes and new technologies. Smoking rates are a good example of the trend of more advantaged populations benefitting first from new knowledge and social patterns. Smoking rates peaked in the mid-1960s in the United States, just before the Surgeon General’s report confirming that tobacco smoking led to cancer and other health problems. In 1966, smoking rates were similar by education, with about 43 percent of the adult population smoking. The most educated group (with sixteen or more years of education) was somewhat less likely to smoke, at 35 percent.

By 1987, the smoking rate for the most educated had fallen by half (to 17 percent), while those with the least education (less than high school) had fallen only by a quarter (from 42 percent to 34 percent) (Centers for Disease Control and Prevention [CDC], 1994). The trend continued from 1985 through 2011, with smoking by college graduates falling in half again to 7.5 percent, while those without a high school diploma declined to 27.4 percent, leaving a large inequity in this significant disease risk factor. This highlights the importance of focusing on different groups in society that are often marginalized due to their exclusion from power and resources.

Race as a Social Determinant of Health

The social and political forces that shape health risks often work through race or ethnicity, gender, and class, each of which has a separate dynamic in determining health status, in addition to interacting with each other. Race long has been known to be a social determinant of health status. Older African Americans consistently have higher rates of major health problems (including hypertension, diseases of the circulatory system, and diabetes) than do non-Latino whites. They also have the highest rates of functional limitations. While the gap in disease and disability rates diminishes when studies control for black−white population differences in wealth and other socioeconomic characteristics, most studies continue to find that race has an independent effect on poor health. 

Race affects the health of minorities throughout their life course through both perceived and structural mechanisms. Experiences of discrimination and bias lead to increased stress and unhealthy adaptive behaviors across all socioeconomic statuses (Zarit and Pearlin, 2005). Structural discrimination creates patterns in life chances through “neutral” policies and practices that impact groups differently. Social Security, for example, has a gender-neutral set of criteria for earning service benefits that has the effect of leaving an inequitable number of older women struggling economically in old age.

The pattern of racial inequities for Latino older adults is more complex because their disease rates do not reflect their low economic position as clearly as do the disease rates of African Americans. Most evidence suggests that Latino men have a lower prevalence of heart disease and major cancers than whites, but it is not clear why. Older Latinos clearly are disadvantaged socioeconomically, have very high rates of diabetes and obesity, and engage less in exercise than non-Latino whites. In addition, hypertension is at least as prevalent among Mexican American older adults as it is among the general older adult population. Smoking and alcohol consumption rates among Latino males also are high. Any advantages in diseases of the heart and cancer among Latino males cannot be explained by known risk factors.

The most likely explanation is that immigration to the United States selects for the healthiest persons, while some of those who fall ill or face the worst settlement experiences return to their homeland (Markides, Rudkin, and Wallace, 2007). This suggests that immigrants arrive with a “health capital” that is important to protect and promote so that they can remain healthy. As future generations of Latino elders who are mostly U.S.-born may not benefit from that health capital, making investments in the health of younger Latinos is particularly important so that they will be less affected by a cumulative disadvantage when they reach old age.

Economic Resources as a Social Determinant of Health

Economic resources are a well-documented social determinant of health (Hajat et al., 2011). Mortality rates increase as poverty increases, with the effect being most dramatic in ages 24 to 44 and ages 45 to 64. A similar, but smaller, increase in mortality rates occurs for older adults living in neighborhoods with high poverty rates (Rehkopf et al., 2006).

It is likely that the higher total mortality in older ages washes out some income effects, in addition to those most vulnerable to the disadvantages of low incomes having died at younger ages. Disability rates also vary among older adults by income, even after controlling for age, gender, education, and race (Schoeni et al., 2005). Self-reported health also is related to income, and those with low incomes experience health declines at earlier ages than wealthier individuals (Crimmins, Kim, and Seeman, 2009). The association between poverty and poor health in old age is reciprocal—poverty causes poor health (social causation) and poor health causes low incomes (social selection)—but social causation is the dominant direction.

Economic resources are considered a “fundamental” cause of health because they are necessary to obtain all goods and services needed in a healthy life. In addition to individual resources, collective resources impact access to the conditions that promote a healthy life course. Residential neighborhoods are strongly segregated by income (and race), limiting access of the poor to healthy housing. Higher income neighborhoods are more likely to be away from the pollution of freeways and factories, are convenient to affordable and healthy food, have access to quality medical and other services, and promote physical activity by being safe and attractive for walking.Those with lower incomes also are subject to social exclusion by having less access to steady employment, suffering from inferior public services, and having little voice in public policy decisions. This suggests that reducing poverty is an effective way to reduce health declines and improve health equity in old age.

Residential neighborhoods are an important life space for older adults because they spend more time in their neighborhoods than do employed younger adults. Neighborhoods are highly segregated by race and socioeconomic status, and neighborhood socioeconomic status is associated with mortality, disability, and self-assessed health. The conditions that are likely to affect older adults in lower income neighborhoods include determinants of health such as fewer grocery stores and alternatives to fast food. Low-income communities also have fewer and lower quality sources of medical care, higher crime rates, lower quality housing, and weaker social support networks (Wallace, 2012).

Improvements in life expectancy at the national level are driven by broad-based economic growth when growth works to reduce poverty (e.g., in South Korea), or by the expansion of supports even without economic growth, as in when basic health-enhancing services reach all residents (e.g., in Costa Rica) (Sen, 1998). In contrast, when economic growth goes largely to people who are already well off, and where public services for individuals with low incomes are inadequate, economic growth has a marginal impact on national health outcomes. Within countries, inequality influences both mortality and self-assessed health after a threshold level of income is reached, especially at the highest levels of inequality. The inequality effect for mortality is most apparent for people younger than age 65, where the leading causes of death include unintentional injury, suicide, homicide, and HIV—all conditions that are particularly sensitive to social conditions (Backlund et al., 2007).

Steps for Improving Health Literacy

Education is a powerful determinant of social and economic position. People with higher education have longer life expectancies, lower rates of most health conditions, and lower levels of disability—independent of their income and health insurance. The health status gap between those with the highest and lowest educational levels has been increasing for the past several years, indicating that the advantages of more education (and disadvantages of less education) are of growing importance in health inequities. The educational gap in mortality rates increased between 1990 and 2000 for older adults. Mortality rates during that period changed little for those with a high school education or less, while death rates declined among those with more than a high school education. The educational disparity in smoking rates and other protective health behaviors, such as larger social networks, is a likely contributor to these widening mortality differences (Meara, Richards, and Cutler, 2008).

Related to education is the issue of health literacy. There is a growing concern that many older adults do not have sufficient knowledge—or the skills to use knowledge—to make healthy decisions and to be active participants in their healthcare. Typically, people with more years of education have both better cognitive processing skills to use new complex information effectively, as well as more baseline knowledge relevant to health. To the extent that we provide people with useable knowledge about how their behavior affects their health (e.g., how physical activity can reduce the risk of falls), and how to assess medical advice (e.g., benefits and risks of particular medications), we are improving the conditions under which they can be healthy.

But we too often stop with trying to assess and improve the health literacy of older adults and their caregivers, and forget that public officials and service providers also have constraints on their health literacy. When transportation planners only consider the least expensive options in designing regional transportation, they are demonstrating low levels of health literacy because they also are not factoring in the health benefits of lowered pollution, greater physical activity, and increased access to services by older adults that might come from alternative designs.

The Age-Friendly Cities effort, led by the World Health Organization (WHO) and embodied in a number of U.S. initiatives, provides a series of policy-level analyses for how communities can provide a context that promotes healthy aging through policies across multiple sectors (AARP, 2014; WHO, 2007). In the United States, this has been discussed as prioritizing “health in all policies.” These efforts show how policy makers and others who shape the lifespaces of older adults need to improve their health literacy to promote health equity for older adults. A new initiative by the Robert Wood Johnson Foundation to foster a “culture of health” in communities and institutions is one means for improving the health literacy of policy makers (Lavizzo-Mourey, 2014).

Given the earlier discussion of the key role of economic resources in shaping the health of older adults, improving health literacy among policy makers will involve improving their understanding of the basic resource needs of the older population. Currently, when policy makers and other key stakeholders consider the economic status of older adults, the most common indicator of economic need that they use is the Federal Poverty Level or FPL (officially called the federal poverty guideline or threshold). Many public programs are linked to the FPL, such as food stamps, housing subsidies, Medicaid, and assistance with Medicare costs. For policy makers to be fully health literate, they need to understand that the FPL does not provide an adequate measure of the resources needed for older adults to maintain the minimum decent standard of living required for health.

The FPL was designed in the 1960s and based upon an average national 1950s standard of living for young families, not older adults. It is the same amount everywhere in the country (Wallace, Padilla-Frausto, and Smith, 2013). As such, it does not account for the wide variation in housing costs by state and county, is insensitive to the costs of medical care faced especially by older adults, and has not kept up with the standard of living. To provide adequate resources for older adults requires a measure of need based on 21st century regional costs, such as the Elder Economic Security Standard Index (Elder Index). Based upon the actual cost for older adults for basic housing, healthcare, food, transportation, and other needed spending at the county level, it incorporates the characteristics of a measure most wanted by state policy makers, but is not often used because of institutional barriers (Padilla-Frausto and Wallace, 2012). This suggests that cultural competency to promote the health of low-income and minority older adults by key stakeholders involves not only knowledge, but also the ability and incentives to act on that knowledge.

As we work to reduce health inequalities in our country, it is important to remember that while linguistic and cultural competence are crucial for working with older adults, broader societal patterns that disadvantage elders of color, those with low incomes, and women create conditions that make it difficult for them to enjoy a healthy old age. To reduce health inequities among older adults we need to create supportive institutions and laws that create healthy environments for older adults, and make the healthy choice the easy choice for health behaviors. From a life-course perspective (Ferraro and Shi, 2009), diverse elders will be emotionally and physically healthier when they and their families make a living wage, have decent and affordable housing, and reside in safe and health-promoting neighborhoods in a society that values diversity.

Steven P. Wallace, Ph.D., is the chair of and professor in the Department of Community Health Sciences at the UCLA Fielding School of Public Health, and associate director at the UCLA Center for Health Policy Research in Los Angeles, California.

Editor’s Note: This article is taken from the winter 2014/15 issue of ASA’s quarterly journal, Generations, an issue devoted to the topic “Social and Health Disparities in America's Aging Population” ASA members receive Generations as a membership benefit; non-members may purchase subscriptions or single copies of issues at our online storeFull digital access to current and back issues of Generations is also available to ASA members and Generations subscribers at Ingenta Connect. For details, click here.

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