Health equity

Health equity refers to the study of differences in the quality of health and healthcare across different populations. Health equity is different from health equality, as it refers only to the absence of disparities in controllable or remediable aspects of health. It is not possible to work towards complete equality in health, as there are some factors of health that are beyond human influence. Equity implies some kind of social injustice. Thus, if one population dies younger than another because of genetic differences, a non-remediable/controlable factor, we tend to say that there is a health inequality. On the other hand, if a population has a lower life expectancy due to lack of access to medications, the situation would be classified as a health inequity. These inequities may include differences in the "presence of disease, health outcomes, or access to health care" between populations with a different race, ethnicity, sexual orientation or socioeconomic status.

Health equity falls into two major categories: horizontal equity, the equal treatment of individuals or groups in the same circumstances; and vertical equity, the principle that individuals who are unequal should be treated differently according to their level of need. Disparities in the quality of health across populations are well-documented globally in both developed and developing nations. The importance of equitable access to healthcare has been cited as crucial to achieving many of the Millennium Development Goals.

Socioeconomic status
Socioeconomic status is both a strong predictor of health, and a key factor underlying health inequities across populations. Poor socioeconomic status has the capacity to profoundly limit the capabilities of an individual or population, manifesting itself through deficiencies in both financial and social capital. It is clear how a lack of financial capital can compromise the capacity to maintain good health. In the UK, prior to the institution of the NHS reforms in the early 2000s, it was shown that income was an important determinant of access to healthcare resources. Maintenance of good health through the utilization of proper healthcare resources can be quite costly and therefore unaffordable to certain populations.

In China, for instance, the collapse of the Cooperative Medical System left many of the rural poor uninsured and unable to access the resources necessary to maintain good health. Increases in the cost of medical treatment made healthcare increasingly unaffordable for these populations. This issue was further perpetuated by the rising income inequality in the Chinese population. Poor Chinese were often unable to undergo necessary hospitalization and failed to complete treatment regimens, resulting in poorer health outcomes.

Similarly, in Tanzania, it was demonstrated that wealthier families were far more likely to bring their children to a healthcare provider: a significant step towards stronger healthcare. Some scholars have noted that unequal income distribution itself can be a cause of poorer health for a society as a result of "underinvestment in social goods, such as public education and health care; disruption of social cohesion and the erosion of social capital".

The role of socioeconomic status in health equity extends beyond simple monetary restrictions on an individual's purchasing power. In fact, social capital plays a significant role in the health of individuals and their communities. It has been shown that those who are better connected to the resources provided by the individuals and communities around them (those with more social capital) live longer lives. The segregation of communities on the basis of income occurs in nations worldwide and has a significant impact on quality of health as a result of a decrease in social capital for those trapped in poor neighborhoods. Social interventions, which seek to improve healthcare by enhancing the social resources of a community, are therefore an effective component of campaigns to improve a community's health. A 1998 epidemiological study showed that community healthcare approaches fared far better than individual approaches in the prevention of heart disease mortality.

Education
Education is an important factor in healthcare utilization, though it is closely intertwined with economic status. An individual may not go to a medical professional or seek care if they don’t know the ills of their failure to do so, or the value of proper treatment. In Tajikistan, since the nation gained its independence, the likelihood of giving birth at home has increased rapidly among women with lower educational status. Education also has a significant impact on the quality of prenatal and maternal healthcare. Mothers with primary educations consulted a doctor during pregnancy at significantly lower rates (72%) when compared to those with a secondary education (77%), technical training (88%) or a higher education (100%). There is also evidence for a correlation between socioeconomic status and health literacy; one study showed that wealthier Tanzanian families were more likely to recognize disease in their children than those that were poorer.

Spatial disparities in health
See Healthcare reform in China

For some populations, access to healthcare and health resources is physically limited, resulting in health inequities. For instance, an individual might be physically incapable of traveling the distances required to reach healthcare services, or such distances might make seeking regular care unappealing despite the potential benefits. Costa Rica, for example, has demonstrable health spatial inequities with 12-14% of the population living in areas where healthcare is inaccessible. Inequity has decreased in some areas of the nation as a result of the work of healthcare reform programs, however those regions not served by the programs have experienced a slight increase in inequity.

China experienced a serious decrease in spatial health equity following the Chinese economic revolution in the 1980s as a result of the degradation of the Cooperative Medical System (CMS). The CMS provided an infrastructure for the delivery of healthcare to rural locations, as well as a framework to provide funding based upon communal contributions and government subsidies. In its absence, there was a significant decrease in the quantity of healthcare professionals (35.9%), as well as functioning clinics (from 71% to 55% of villages over 14 years) in rural areas, resulting in inequitable healthcare for rural populations. The significant poverty experienced by rural workers (some earning less than 1 USD per day) further limits access to healthcare, and results in malnutrition and poor general hygiene, compounding the loss of healthcare resources. The loss of the CMS has had noticeable impacts on life expectancy, with rural regions such as areas of Western China experiencing significantly lower life expectancies.

Similarly, populations in rural Tajikistan experience spatial health inequities. A study by Jane Falkingham noted that physical access to healthcare was one of the primary factors influencing quality of maternal healthcare. Further, many women in rural areas of the country did not have adequate access to healthcare resources, resulting in poor maternal and neonatal care. These rural women were, for instance, far more likely to give birth in their homes without medical oversight.

Ethnic and racial disparities
See Ethnicity and health and Race and health.

The United States historically had large disparities in health and access to adequate healthcare between races, and current evidence supports the notion that these racially centered disparities continue to exist and are a significant social health issue. The disparities in access to adequate healthcare include differences in the quality of care based on race and overall insurance coverage based on race. The Journal of the American Medical Association identifies race as a significant determinant in the level of quality of care, with ethnic minority groups receiving less intensive and lower quality care. Ethnic minorities also receive less preventative care, are seen less by specialists, and have fewer expensive and technical procedures than non-ethnic minorities. In fact, Hispanic children are almost three times less likely to receive routine health care as white children, and only 16% of white patients lack routine health care, as compared to about 20% of African Americans and 30% of Hispanic patients. There are also considerable racial disparities in access to insurance coverage, with ethnic minorities generally having less insurance coverage than non-ethnic minorities. For example, Hispanic Americans tend to have less insurance coverage than white Americans and as a result receive less regular medical care. The level of insurance coverage is directly correlated with access to healthcare including preventative and ambulatory care. A 2010 study on racial and ethnic disparities in health done by the Institute of Medicine has shown that the aforementioned disparities cannot solely be accounted for in terms of certain demographic characteristics like: insurance status, household income, education, age, geographic location and quality of living conditions. Even when the researchers corrected for these factors, the disparities persist.

Ethnic health inequities also appear in nations across the African continent. A survey of the child mortality of major ethnic groups across 11 African nations (Central African Republic, Côte d'Ivoire, Ghana, Kenya, Mali, Namibia, Niger, Rwanda, Senegal, Uganda, and Zambia) was published in 2000 by the WHO. The study described the presence of significant ethnic parities in the child mortality rates among children younger than 5 years old, as well as in education and vaccine use. In South Africa, the legacy of apartheid still manifests itself as a differential access to social services, including healthcare based upon race and social class, and the resultant health inequities. Further, evidence suggests systematic disregard of indigenous populations in a number of countries. The Pygmys of Congo, for instance, are excluded from government health programs, discriminated against during public health campaigns, and receive poorer overall healthcare.

In a survey of five European countries (Sweden, Switzerland, the UK, Italy, and France), a 1995 survey noted that only Sweden provided access to translators for 100% of those who needed it, while the other countries lacked this service potentially compromising healthcare to non-native populations. Given that non-natives composed a considerable section of these nations (6%, 17%, 3%, 1%, and 6% respectively), this could have significant detrimental effects on the health equity of the nation. In France, an older study noted significant differences in access to healthcare between native French populations, and non-French/migrant populations based upon health expenditure; however this was not fully independent of poorer economic and working conditions experienced by these populations.

A 1996 study of race-based health inequity in Australia revealed that Aborigines experienced higher rates of mortality than non-Aborigine populations. Aborigine populations experienced 10 times greater mortality in the 30-40 age range; 2.5 times greater infant mortality rate, and 3 times greater age standardized mortality rate. Rates of diarrheal diseases and tuberculosis are also significantly greater in this population (16 and 15 times greater respectively), which is indicative of the poor healthcare of this ethnic group. At this point in time, the parities in life expectancy at birth between indigenous and non-indigenous peoples were highest in Australia, when compared to the US, Canada and New Zealand. In South America, indigenous populations faced similarly poor health outcomes with maternal and infant mortality rates that were significantly higher (up to 3 to 4 times greater) than the national average. The same pattern of poor indigenous healthcare continues in India, where indigenous groups were shown to experience greater mortality at most stages of life, even when corrected for environmental effects.

LGBT minority group health disparities
See also LGBT issues in medicine.

Sexuality has become a major source of discrimination and inequity in health. Homosexual, bisexual, and transgender populations experience a wide range of health problems related to their sexuality and gender identity. One of the egregious inequities that faces LGBT individuals is discrimination from healthcare workers or institutions. In a study of the quality of healthcare for South African MSM (Men who have Sex with Men), a cohort of individuals were interviewed about their health experiences. The researchers found that homosexually identified MSM felt that their access to healthcare was limited by their inability to find clinics that employed healthcare workers who did not discriminate based upon their sexuality. They often faced "homophobic verbal harassment from healthcare workers when presenting for STI treatment." Further, those MSM who did not identify as homosexuals did not feel comfortable discussing - and did not disclose - their sexual activity with healthcare workers, limiting the quality of their sexual healthcare. Similarly, a survey of the United States revealed that transgender individuals faced a significant level of discrimination with 19% of individuals having experienced a healthcare worker refuse care because of their gender, 28% having faced harassment from a healthcare worker, 2% having faced violence, and 50% having a doctor who was not able or qualified to provide transgender care.

Furthermore, healthcare for LGBT populations is hindered by a lack of medical research on such groups. Without the appropriate studies, it is difficult to assess what the proper strategies are for treatment of these groups. For instance, a review of medical literature regarding LGBT patients revealed that there is a significant gap in our understanding of breast cancer, which is more prevalent among lesbian and bisexual women. It is unclear whether this is a result of probability or another preventable cause. Similarly, the review notes that it is generally assumed that these groups of women have a lower incidence of cervical cancer than their heterosexual counterparts, and as a result they have low rates of screening, despite the fact that it is unclear whether they are actually at a decreased risk for the disease. In addition, it is difficult to conduct retrospective epidemiological studies on LGBT populations as a result of the practice that sexual orientation is not noted on death certificates.

Healthcare equity and sex
In the United States, women have better access to healthcare than many other places in the world, in part because they have higher rates of health insurance. In one study of a population group in Harlem, 86% of women reported having health insurance (privatized or publicly assisted), while only 74% of men reported having any health insurance. This trend in women reporting higher rates of insurance coverage is not unique to this population and is representative of the general population of the US. In China, gender is a significant determining factor in health, though disparities have lessened in recent years as females start receiving higher quality care. In India, gender inequities in health start in early childhood, as many families provide better nutrition for boys than girls in the interest of maximizing future productivity (as boys are generally seen as breadwinners). In addition, boys receive better care, and are hospitalized when seriously ill at a greater rate than girls. The magnitude of these disparities increased with the severity of poverty in a given population. In general the 2012 WDR noted that women in developing nations experienced greater mortality rates than men when comparing developing nations to more developed nations. That said, men do face greater mortality than females in a number of countries as a result of behavior or violence.

Health inequality and environmental influence
Minority populations have increase exposure to environmental hazards that include lack of neighborhood resources, structural and community factors as well as residential segregation that result in a cycle of disease and stress. The environment that surrounds us can influence individual behaviors and lead to poor health choices and therefore outcomes. Minority neighborhoods have been continuously noted to have more fast food chains and fewer grocery stores than predominantly white neighborhoods. These food deserts affect a family’s ability to have easy access to nutritious food for their children. This lack of nutritious food extends beyond the household into the schools that have a variety of vending machines and deliver over processed foods. These environmental condition have social ramifications and in the first time in US history is it projected that the current generation will live shorter lives than their predecessors will.

In addition, minority neighborhoods have various health hazards that result from living close to highways and toxic waste factories or general dilapidated structures and streets. These environmental conditions create varying degrees of health risk from noise pollution, to carcinogenic toxic exposures from asbestos and radon that result in increase chronic disease, morbidity, and mortality. The quality of residential environment such as damaged housing has been shown to increase the risk of adverse birth outcomes, which is reflective of a communities health. Housing conditions can create varying degrees of health risk that lead to complications of birth and long-term consequences in the aging population. In addition, occupational hazards can add to the detrimental effects of poor housing conditions. It has been reported that a greater number of minorities work in jobs that have higher rates of exposure to toxic chemical, dust and fumes.

Racial segregation is another environmental factor that occurs through the discriminatory action of those organizations and working individuals within the real estate industry, whether in the housing markets or rentals. Even though residential segregation is noted in all minority groups, blacks tend to be segregated regardless of income level when compared to Latinos and Asians. Thus, segregation results in minorities clustering in poor neighborhoods that have limited employment, medical care, and educational resources, which is associated with high rates of criminal behavior. In addition, segregation affects the health of individual residents because the environment is not conducive to physical exercise due to unsafe neighborhoods that lack recreational facilities and have nonexistent park space. Racial and ethnic discrimination adds an additional element to the environment that individuals have to interact with daily. Individuals that reported discrimination have been shown to have an increase risk of hypertension in addition to other physiological stress related affects. The high magnitude of environmental, structural, socioeconomic stressors leads to further compromise on the psychological and physical being, which leads to poor health and disease.

Individuals living in rural areas, especially poor rural areas, have access to fewer health care resources. Although 20 percent of the U.S. population lives in rural areas, only 9 percent of physicians practice in rural settings. Individuals in rural areas typically must travel longer distances for care, experience long waiting times at clinics, or are unable to obtain the necessary health care they need in a timely manner. Rural areas characterized by a largely Hispanic population average 5.3 physicians per 10,000 residents compared with 8.7 physicians per 10,000 residents in nonrural areas. Financial barriers to access, including lack of health insurance, are also common among the urban poor.

Disparities in access to health care
Reasons for disparities in access to health care are many, but can include the following:


 * Lack of insurance coverage. Without health insurance, patients are more likely to postpone medical care, more likely to go without needed medical care, and more likely to go without prescription medicines. Minority groups in the United States lack insurance coverage at higher rates than whites. This problem does not exist in countries with fully funded public health systems, such as the examplar of the NHS.
 * Lack of a regular source of care. Without access to a regular source of care, patients have greater difficulty obtaining care, fewer doctor visits, and more difficulty obtaining prescription drugs. Compared to whites, minority groups in the United States are less likely to have a doctor they go to on a regular basis and are more likely to use emergency rooms and clinics as their regular source of care. In the United Kingdom, which is much more racially harmonious, this issue arises for a different reason; since 2004, NHS GPs have not been responsible for care out of normal GP surgery opening hours, leading to significantly higher attendances in A+E
 * Lack of financial resources. Although the lack of financial resources is a barrier to health care access for many Americans, the impact on access appears to be greater for minority populations.
 * Legal barriers. Access to medical care by low-income immigrant minorities can be hindered by legal barriers to public insurance programs. For example, in the United States federal law bars states from providing Medicaid coverage to immigrants who have been in the country fewer than five years.
 * Structural barriers. These barriers include poor transportation, an inability to schedule appointments quickly or during convenient hours, and excessive time spent in the waiting room, all of which affect a person's ability and willingness to obtain needed care.
 * The health care financing system. The Institute of Medicine in the United States says fragmentation of the U.S. health care delivery and financing system is a barrier to accessing care. Racial and ethnic minorities are more likely to be enrolled in health insurance plans which place limits on covered services and offer a limited number of health care providers.
 * Scarcity of providers. In inner cities, rural areas, and communities with high concentrations of minority populations, access to medical care can be limited due to the scarcity of primary care practitioners, specialists, and diagnostic facilities. In the UK, Monitor (a quango) has a legal obligation to ensure that sufficient provision exists in all parts of the nation.
 * Linguistic barriers. Language differences restrict access to medical care for minorities in the United States who are not English-proficient.
 * Health literacy. This is where patients have problems obtaining, processing, and understanding basic health information. For example, patients with a poor understanding of good health may not know when it is necessary to seek care for certain symptoms. While problems with health literacy are not limited to minority groups, the problem can be more pronounced in these groups than in whites due to socioeconomic and educational factors.
 * Lack of diversity in the health care workforce. A major reason for disparities in access to care are the cultural differences between predominantly white health care providers and minority patients. Only 4% of physicians in the United States are African American, and Hispanics represent just 5%, even though these percentages are much less than their groups' proportion of the United States population.
 * Age. Age can also be a factor in health disparities for a number of reasons. As many older Americans exist on fixed incomes which may make paying for health care expenses difficult.  Additionally, they may face other barriers such as impaired mobility or lack of transportation which make accessing health care services challenging for them physically.  Also, they may not have the opportunity to access health information via the internet as less than 15% of Americans over the age of 65 have access to the internet. This could put older individuals at a disadvantage in terms of accessing valuable information about their health and how to protect it. On the other hand, older individuals in the US (65 or above) are provided with medical care via Medicare.

Disparities in quality of health care
Health disparities in the quality of care exist and are based on language and ethnicity/race which includes:

Problems with patient-provider communication
Communication is critical for the delivery of appropriate and effective treatment and care, regardless of a patient’s race, and miscommunication can lead to incorrect diagnosis, improper use of medications, and failure to receive follow-up care. The patient provider relationship is dependent on the ability of both individuals to effectively communicate. Language and culture both play a significant role in communication during a medical visit. Among the patient population, minorities face greater difficulty in communicating with their physicians. Patients when surveyed responded that 19% of the time they have problems communicating with their providers which included understanding doctor, feeling doctor listened, and had questions but did not ask. In contrast, the Hispanic population had the largest problem communicating with their provider, 33% of the time. Communication has been linked to health outcomes, as communication improves so does patient satisfaction which leads to improved compliance and then to improved health outcomes. Quality of care is impacted as a result of an inability to communicate with health care providers. Language plays a pivotal role in communication and efforts need to be taken to ensure excellent communication between patient and provider. Among limited English proficient patients in the United States, the linguistic barrier is even greater. Less than half of non-English speakers who say they need an interpreter during clinical visits report having one. The absence of interpreters during a clinical visit adds to the communication barrier. Furthermore, inability of providers to communicate with limited English proficient patients leads to more diagnostic procedures, more invasive procedures, and over prescribing of medications. Poor communication contributes to poor medical compliance and health outcomes. Many health-related settings provide interpreter services for their limited English proficient patients. This has been helpful when providers do not speak the same language as the patient. However, there is mounting evidence that patients need to communicate with a language concordant physician (not simply an interpreter) to receive the best medical care, bond with the physician, and be satisfied with the care experience. Having patient-physician language discordant pairs (i.e. Spanish-speaking patient with an English-speaking physician) may also lead to greater medical expenditures and thus higher costs to the organization. Additional communication problems result from a decrease or lack of cultural competence by providers. It is important for providers to be cognizant of patients’ health beliefs and practices without being judgmental or reacting. Understanding a patients’ view of health and disease is important for diagnosis and treatment. So providers need to assess patients’ health beliefs and practices to improve quality of care. Patient health decisions can be influenced by religious beliefs, mistrust of Western medicine, and familial and hierarchical roles, all of which a white provider may not be familiar with. Other type of communication problems are seen in LGBT health care with the spoken heterosexist (conscious or unconscious) attitude on LGBT patients, lack of understanding on issues like having no sex with men (lesbians, gynecologic examinations) and other issues.

Provider discrimination
Provider discrimination occurs when health care providers either unconsciously or consciously treat certain racial and ethnic patients differently from other patients. This may be due to stereotypes that providers may have towards ethnic/racial groups. Doctors are more likely to ascribe negative racial stereotypes to their minority patients. This may occur regardless of consideration for education, income, and personality characteristics. Two types of stereotypes may be involved, automatic stereotypes or goal modified stereotypes. Automated stereotyping is when stereotypes are automatically activated and influence judgments/behaviors outside of consciousness. Goal modified stereotype is a more conscious process, done when specific needs of clinician arise (time constraints, filling in gaps in information needed) to make a complex decisions. Physicians are unaware of their implicit biases. Some research suggests that ethnic minorities are less likely than whites to receive a kidney transplant once on dialysis or to receive pain medication for bone fractures. Critics question this research and say further studies are needed to determine how doctors and patients make their treatment decisions. Others argue that certain diseases cluster by ethnicity and that clinical decision making does not always reflect these differences.

Lack of preventive care
According to the 2009 National Healthcare Disparities Report, uninsured Americans are less likely to receive preventive services in health care. For example, minorities are not regularly screened for colon cancer and the death rate for colon cancer has increased among African Americans and Hispanic populations. Furthermore, limited English proficient patients are also less likely to receive preventive health services such as mammograms. Studies have shown that use of professional interpreters have significantly reduced disparities in the rates of fecal occult testing, flu immunizations and pap smears. In the UK, Public Health England, a universal service free at the point of use, which forms part of the NHS, offers regular screening to any member of the population considered to be in an at-risk group (such as individuals over 45) for major disease (such as colon cancer, or diabetic-retinopathy).

Plans for achieving health equity
There are a multitude of strategies for achieving health equity and reducing disparities outlined in scholarly texts, some examples include:


 * Provider based incentives to improve healthcare for ethnic populations. One source of health inequity stems from unequal treatment of non-white patients in comparison with white patients. Creating provider based incentives to create greater parity between treatment of white and non-white patients is one proposed solution to eliminate provider bias. These incentives typically are monetary because of its effectiveness in influencing physician behavior.
 * Using Evidence Based Medicine (EBM). Evidence Based Medicine (EBM) shows promise in reducing healthcare provider bias in turn promoting health equity. In theory EBM can reduce disparities however other research suggests that it might exacerbate them instead. Some cited shortcomings include EBM’s injection of clinical inflexibility in decision making and its origins as a purely cost driven measure.
 * Increasing awareness. The most cited measure to improving health equity relates to increasing public awareness. A lack of public awareness is a key reason why there has not been significant gains in reducing health disparities in ethnic and minority populations. Increased public awareness would lead to increased congressional awareness, greater availability of disparity data, and further research into the issue of health disparities.

Health inequalities
Health inequality is the term used in a number of countries to refer to those instances whereby the health of two demographic groups (not necessarily ethnic or racial groups) differs despite comparative access to health care services. Such examples include higher rates of morbidity and mortality for those in lower occupational classes than those in higher occupational classes, and the increased likelihood of those from ethnic minorities being diagnosed with a mental health disorder. In Canada, the issue was brought to public attention by the LaLonde report.

In UK, the Black Report was produced in 1980 to highlight inequalities. On 11 February 2010, Sir Michael Marmot, an epidemiologist at University College London, published the Fair Society, Healthy Lives report on the relationship between health and poverty. Marmot described his findings as illustrating a "social gradient in health": the life expectancy for the poorest is seven years shorter than for the most wealthy, and the poor are more likely to have a disability. In its report on this study, The Economist argued that the material causes of this contextual health inequality include unhealthful lifestyles - smoking remains more common, and obesity is increasing fastest, amongst the poor in Britain.

Poor health and economic inequality
Poor health outcomes appear to be an effect of economic inequality across a population. Nations and regions with greater economic inequality show poorer outcomes in life expectancy, mental health, drug abuse, obesity, educational performance, teenage birthrates, and ill health due to violence. On an international level, there is a positive correlation between developed countries with high economic equality and longevity. This is unrelated to average income per capita in wealthy nations. Economic gain only impacts life expectancy to a great degree in countries in which the mean per capita annual income is less than approximately $25,000. The United States shows exceptionally low health outcomes for a developed country, despite having the highest national healthcare expenditure in the world. The US ranks 31st in life expectancy. Americans have a lower life expectancy than their European counterparts, even when factors such as race, income, diet, smoking, and education are controlled for.

Relative inequality negatively affects health on an international, national, and institutional levels. The patterns seen internationally hold true between more and less economically equal states in the United States. The patterns seen internationally hold true between more and less economically equal states in the United States, that is, more equal states show more desirable health outcomes. Importantly, inequality can have a negative health impact on members of lower echelons of institutions. The Whitehall I and II studies looked at the rates of cardiovascular disease and other health risks in British civil servants and found that, even when lifestyle factors were controlled for, members of lower status in the institution showed increased mortality and morbidity on a sliding downward scale from their higher status counterparts. The negative aspects of inequality are spread across the population. For example, when comparing the United States (a more unequal nation) to England (a less unequal nation), the US shows higher rates of diabetes, hypertension, cancer, lung disease, and heart disease across all income levels. This is also true of the difference between mortality across all occupational classes in highly equal Sweden as compared to less-equal England

Further Notes

 * Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004).
 * McDonough, J., Gibbs, B., Scott-Harris, J., Kronebusch, K., Navarro, A., and Taylor, K. A. "State Policy Agenda to Eliminate Racial and Ethnic Health Disparities," Commonwealth Fund (June 2004).
 * Smedley, B., Stith, A., and Nelson, A. "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care." Institute of Medicine (2002).
 * McDonough, J., Gibbs, B., Scott-Harris, J., Kronebusch, K., Navarro, A., and Taylor, K. A. "State Policy Agenda to Eliminate Racial and Ethnic Health Disparities," Commonwealth Fund (June 2004).
 * Smedley, B., Stith, A., and Nelson, A. "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care." Institute of Medicine (2002).