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Determinants of MSK health and disability – Social determinants of inequities in MSK health

https://doi.org/10.1016/j.berh.2014.08.001Get rights and content

Abstract

Even in most egalitarian societies, disparities in care exist to the disadvantage of some people with chronic musculoskeletal (MSK) disorders and related disability. These situations translate into inequality in health and health outcomes. The goal of this chapter is to review concepts and determinants associated with health inequity, and the effect of interventions to minimize their impact.

Health inequities are avoidable, unnecessary, unfair and unjust. Inequities can occur across the health care continuum, from primary and secondary prevention to diagnosis and treatment. There are many ways to define and identify inequities, according for instance to ethical, philosophical, epidemiological, sociological, economic, or public health points of view. These complementary views can be applied to set a framework of analysis, identify determinants and suggest targets of action against inequity.

Most determinants of inequity in MSK disorders are similar to those in the general population and other chronic diseases. People may be exposed to inequity as a result of policies and rules set by the health care system, individuals' demographic characteristics (e.g., education level), or some behavior of health professionals and of patients.

Osteoarthritis (OA) represents a typical chronic MSK condition. The PROGRESS-Plus framework is useful for identifying the important role that place of residence, race and ethnicity, occupation, gender, education, socioeconomic status, social capital and networks, age, disability and sexual orientation may have in creating or maintaining inequities in this disease. In rheumatoid arthritis (RA), a consideration of international data led to the conclusion that not all RA patients who needed biologic therapy had access to it. The disparity in care was due partly to policies of a country and a health care system, or economic conditions. We conclude this chapter by discussing examples of interventions designed for reducing health inequity.

Introduction

Even in most egalitarian societies, disparities in care exist and may affect people with chronic musculoskeletal (MSK) disorders and related disability. These may translate into inequality in health and health outcomes. Access to appropriate prevention and care for chronic MSK disorders is not only necessary, but is a basic human right. The insufficient integration of this concept in research on determinants of disease progression and prevention underlines the need for research. To measure inequity and its determinants, it is essential to have indicators of inequity. In the past 10 years, there has been an increase in initiatives to promote awareness about inequity in health and health care. The Cochrane methodology group introduced a framework to detect and report determinants of health inequity in all systematic reviews [1], *[2]. A developing area of measurement is Patient Reported Outcome (PRO). The Outcome Measures in Rheumatology (OMERACT) initiative introduced health equity considerations in development of such instruments in 2012 [3]. This includes a specific attention dedicated to measuring health literacy and ensuring cross-cultural equivalence of PRO, irrespective of socioeconomic status and language. The goal of this chapter is to review concepts and determinants associated with health inequity, and the effect of interventions to minimize their impact.

Section snippets

Inequality versus inequity

Whitehead [4] asserted that health inequalities are inequity if they are avoidable, unnecessary, unfair and unjust. In 2003, Braveman [5] proposed that health equity was a state of absence of systematic disparities in health (or its social determinants) between the advantaged and disadvantaged social groups. As such, health equity is a fundamental ethical principle of social justice. Norheim [6] pointed out in 2009 that health inequalities that are amenable to human intervention were unfair and

Points of view

There are many ways to define and identify inequities according to ethical, philosophical, sociological, epidemiological, economic, or public health points of view. Researchers with ethical and philosophical points of view differentiate between inequality, which identifies difference in care provision based on needs, and inequity, which focuses on justice in care provision. On the other hand, sociologists focus on identifying inequities and developing hypotheses for studying relevant

Determinants

Most determinants of inequity in MSK disorders are similar to those in the general population and other chronic diseases. In this chapter, we will focus on osteoarthritis (OA), a model of chronic MSK disease, and rheumatoid arthritis (RA), a common chronic inflammatory disorder, in which access to expensive biological therapies is crucial to some patients.

Intervention by determinants

Acknowledging the role of these determinants leads to promotion of specific actions to reduce their impact (socioeconomic factors), or to have direct action if they are modifiable (lifestyle factors). Some examples illustrate these interventions.

Target actions against inequity

Knowledge of determinants does not imply direct action against determinants to reduce inequity. To this end, several initiatives have been proposed and tested in different conceptual frameworks. These frameworks are reviewed to help define future actions.

Conclusion

There are major challenges to improving care for disadvantaged populations. Although some of the factors are not modifiable, health professionals and society should be aware of them and their impact on patients' ability to access the best available and the most appropriate care. We have summarized several interventions that were designed to mitigate the effect of health inequity for people with chronic MSK conditions; however, significant action is still needed to reduce these inequalities,

Conflict of interest statement

The authors declare no conflict of interest.

Acknowledgment

We wish to thank Dr Sherine Gabriel whose previous thoughts and exchanges have been inspirational to this work.

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