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. 2017;6(2):139-164.
doi: 10.21106/ijma.236.

Social Determinants of Health in the United States: Addressing Major Health Inequality Trends for the Nation, 1935-2016

Gopal K Singh  1 , Gem P Daus  1 , Michelle Allender  1 , Christine T Ramey  1 , Elijah K Martin  1 , Chrisp Perry  1 , Andrew A De Los Reyes  1 , Ivy P Vedamuthu  1
Affiliations

Social Determinants of Health in the United States: Addressing Major Health Inequality Trends for the Nation, 1935-2016

Gopal K Singh et al. Int J MCH AIDS. 2017.

Abstract

Objectives: This study describes key population health concepts and examines major empirical trends in US health and healthcare inequalities from 1935 to 2016 according to important social determinants such as race/ethnicity, education, income, poverty, area deprivation, unemployment, housing, rural-urban residence, and geographic location.

Methods: Long-term trend data from the National Vital Statistics System, National Health Interview Survey, National Survey of Children's Health, American Community Survey, and Behavioral Risk Factor Surveillance System were used to examine racial/ethnic, socioeconomic, rural-urban, and geographic inequalities in health and health care. Life tables, age-adjusted rates, prevalence, and risk ratios were used to examine health differentials, which were tested for statistical significance at the 0.05 level.

Results: Life expectancy of Americans increased from 69.7 years in 1950 to 78.8 years in 2015. However, despite the overall improvement, substantial gender and racial/ethnic disparities remained. In 2015, life expectancy was highest for Asian/Pacific Islanders (87.7 years) and lowest for African-Americans (75.7 years). Life expectancy was lower in rural areas and varied from 74.5 years for men in rural areas to 82.4 years for women in large metro areas, with rural-urban disparities increasing during the 1990-2014 time period. Infant mortality rates declined dramatically during the past eight decades. However, racial disparities widened over time; in 2015, black infants had 2.3 times higher mortality than white infants (11.4 vs. 4.9 per 1,000 live births). Infant and child mortality was markedly higher in rural areas and poor communities. Black infants and children in poor, rural communities had nearly three times higher mortality rate compared to those in affluent, rural areas. Racial/ethnic, socioeconomic, and geographic disparities were particularly marked in mortality and/or morbidity from cardiovascular disease, cancer, diabetes, COPD, HIV/AIDS, homicide, psychological distress, hypertension, smoking, obesity, and access to quality health care.

Conclusions and global health implications: Despite the overall health improvement, significant social disparities remain in a number of health indicators, most notably in life expectancy and infant mortality. Marked disparities in various health outcomes indicate the underlying significance of social determinants in disease prevention and health promotion and necessitate systematic and continued monitoring of health inequalities according to social factors. A multi-sectoral approach is needed to tackle persistent and widening health inequalities among Americans.

Keywords: Chronic Disease; Health Care; Health Disparities; Leading Causes Of Death; Life Expectancy; Race/Ethnicity; Social Determinants; Socioeconomic Status.

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Conflict of interest statement

Conflicts of Interest: The authors declare that they have no conflicts of interest. Financial Disclosure: None to report. Ethics Approval: All analyses were conducted using public-use data and were thus exempt from the institutional review board (IRB) approval.

Figures

Figure 1
Figure 1
Poverty, Unemployment, and Health Uninsurance Rates (%) by Race/Ethnicity, United States, 2015 Source: US Census Bureau. 2015 American Community Survey.
Figure 2
Figure 2
Percentage of Population aged ≥25 Years with a College Degree, United States, 2000 and 2011-2015 (3,143 Counties) Source: Data derived from the 2000 Census and 2011-2015 American Community Survey.
Figure 3
Figure 3
Percentage of Population Below the Federal Poverty Level, United States, 2000 and 2011-2015 (3,143 Counties) Source: Data derived from the 2000 Census and 2011-2015 American Community Survey.
Figure 4
Figure 4
Unemployment Rate (Percentage of Civilian Labor Force that is Unemployed), United States, 2011-2015 (3,143 Counties) Source: Data derived from the 2011-2015 American Community Survey.
Figure 5
Figure 5
Population Lacking English Language Proficiency (Percentage of Population Aged 5 Years and Older Speaking English Not Well or Not At All), United States, 2011-2015 (3,143 Counties) Source: Data derived from the 2011-2015 American Community Survey.
Figure 6
Figure 6
Life Expectancy at Birth (in Years) by Race and Sex, United States, 1950-2015 Source: CDC/NCHS. National Vital Statistics System.
Figure 7
Figure 7
Life Expectancy at Birth (Years) by Race/Ethnicity and Sex, United States, 2015 Source: Data dervied from the National Vital Statistics System.
Figure 8
Figure 8
Life Expectancy at Birth (Years) by Levels of Urbanization, United States, 1990-1992 and 2010-2014 Source: Singh GK, Siahpush M. American Journal of Preventive Medicine. 2014; 46(2):e19-e29 (updated data). Data derived from the US National Vital Statistics System.
Figure 9
Figure 9
Infant Mortality Rate by Race, United States, 1935-2015 Source: Singh GK, van Dyck PC. Infant Mortality in the United States. A 75th Anniversary title V Publication. HRSA. 2010 (updated data) and CDC/NCHS.
Figure 10
Figure 10
Infant Mortality Rate by County-Level Family Poverty Rate, United States, 1999-2001 and 2010-2014 Source: Data derived from the National Vital Statistics System.
Figure 11
Figure 11
Child and Adolescent (1-19) Mortality Rates by County-Level Family Poverty Rate, United States, 1999-2001 and 2010-2014 Source: Data derived from the National Vital Statistics System.
Figure 12
Figure 12
State Variation in Prevalence of Current Asthma among US Children and Adolescents Aged Under 18 Years, 2011-2012 National Survey of Children’s Health.
Figure 13
Figure 13
Trends in CVD Mortality by Race/Ethnicity and Sex, United States, 1969-2015 Source: Singh GK, Siahpush M, Azuine RE, Williams SD. Widening Socioeconomic and Racial Disparities in Cardiovascular Disease Mortality in the United States, 1969-2013. International Journal of MCH and AIDS. 2015; 3(2)106-118 (updated data).
Figure 14
Figure 14
Age-Adjusted All-Cause Mortality Rates per 100,000 Population for the United States (3,143 Counties), 1999-2003 and 2011-2015 Source: Derived from the 1999-2015 National Vital Statistics System.
Figure 15
Figure 15
Age-Adjusted Cardiovascular Disease (CVD) Mortality Rates per 100,000 Population for the United States (3,143 Counties), 1999-2003 and 2011-2015 Source: Derived from the 1999-2015 National Vital Statistics System.
Figure 16
Figure 16
Age-Adjusted All-Cancer Mortality Rates per 100,000 Population for the United States (3,143 Counties), 1998-2002 and 2010-2014 Source: Derived from the 1998-2014 National Vital Statistics System.
Figure 17
Figure 17
Age-Adjusted COPD Mortality Rates per 100,000 Population for the United States (3,143 Counties), 1998-2002 and 2010-2014 Source: Derived from the 1998-2014 National Vital Statistics System.
Figure 18
Figure 18
Age-Adjusted Diabetes Mortality Rates per 100,000 Population for the United States (3,143 Counties), 1998-2002 and 2010-2014 Source: Derived from the 1998-2014 National Vital Statistics System.
Figure 19
Figure 19
Age-Adjusted Unintentional Injury Mortality Rates per 100,000 Population for the United States (3,143 Counties), 1998-2002 and 2010-2014 Source: Derived from the 1998-2014 National Vital Statistics System.
Figure 20
Figure 20
Age-adjusted Suicide Mortality Rates per 100,000 Population, United States, 1999-2015 (3,143 Counties) Source: Data derived from the US National Vital Statistics System.
Figure 21
Figure 21
Age-Adjusted Homicide Rates per 100,000 Population for the United States (3,143 Counties), 1998-2002 and 2010-2014 Source: Derived from the 1998-2014 National Vital Statistics System.
Figure 22
Figure 22
Estimated Age-Adjusted Drug Overdose Mortality Rates per 100,000 Population by County, United States, 2000 and 2015 Source: CDC/NCHS, National Vital Statistics System.
Figure 23
Figure 23
Age-adjusted Drug Overdose Mortality Rate per 100,000 Population by Urbanization Level, United States, 2000 and 2015 Source: CDC/NCHS. Data derived from the National Vital Statistics System.
Figure 24
Figure 24
Trends in HIV/AIDS Mortality by County Socioeconomic Status, Both Sexes Combined, United States, 1987-2014 Source: Singh GK, Azuine RE, Siahpush M. Widening Socioeconomic, Racial, and Geographic Disparities in HIV/AIDS Mortality in the United States, 1987-2011. Advances in Preventive Medicine. 2013. DOI: 10.1155/2013/657961. Updated data derived from the US National Vital Statistics System.
Figure 25
Figure 25
Age-adjusted HIV/AIDS Mortality Rates per 100,000 Population, United States, 1992-2014 (3,143 Counties) Source: Singh GK, Azuine RE, Siahpush M. Widening Socioeconomic, Racial, and Geographic Disparities in HIV/AIDS Mortality in the United States, 1987-2011. Advances in Preventive Medicine. 2013. DOI: 10.1155/2013/657961. Updated data derived from the US National Vital Statistics System.
Figure 26
Figure 26
Age-adjusted Prevalence of Diagnosed Diabetes among Adults Aged ≥18 years, by State, United States, 2000 and 2016 Source: CDC. Behavioral Risk Factor Surveillance System. https://www.cdc.gov/brfss/index.html.
Figure 27
Figure 27
Age-Adjusted Prevalence (%) of Current Smoking, Obesity, and Hypertension by Family Income, US Adults Aged 18 Years and Older, 2015 Source: CDC/NCHS. 2015 National Health Interview Survey.
Figure 28
Figure 28
Emergency Room (ER) Visits by Sociodemographic Factors, Children <18 Years of Age, United States, 2015 National Health Interview Survey
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