Social Conditions and Self-Management Are More Powerful Determinants of Health Than Access to Care

  1. Theodore Pincus, MD;
  2. Robert Esther, MD;
  3. Darren A. DeWalt, MD; and
  4. Leigh F. Callahan, PhD
  1. From Vanderbilt University School of Medicine, Nashville, Tennessee; and Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. For current author addresses, see end of text. Note: This manuscript emerged from an elective course, “Medicine as a Social Science,” at Vanderbilt University. Grant Support: By the Jack C. Massey Foundation; the Maury County Lupus Fund; Showa Denko KK; The Arthritis Foundation; National Institutes of Health grant 21393 to the Arthritis, Rheumatism and Aging Medical Information System (ARAMIS); and grant AR30701 from the National Institutes of Health. Requests for Reprints: Theodore Pincus, MD, Vanderbilt University School of Medicine, Division of Rheumatology and Immunology, 203 Oxford House, 1313 21st Avenue South, Nashville, TN 37232. Current Author Addresses: Dr. Pincus: Vanderbilt University School of Medicine, Division of Rheumatology and Immunology, 203 Oxford House, 1313 21st Avenue South, Nashville, TN 37232.
     
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    Abstract

    Professional organizations advocate universal access to medical care as a primary approach to improving health in the population.Access to medical services is critical to outcomes of acute processes managed in an inpatient hospital, the setting of most medical education, research, and training, but seems to be limited in its capacity to affect outcomes of outpatient care, the setting of most medical activities. Persistent and widening disparities in health according to socioeconomic status provide evidence of limitations of access to care. First, job classification, a measure of socioeconomic status, was a better predictor of cardiovascular death than cholesterol level, blood pressure, and smoking combined in employed London civil servants with universal access to the National Health Service. Second, disparities in health according to socioeconomic status widened between 1970 and 1980 in the United Kingdom despite universal access (similar trends were seen in the United States). Third, in the United States, noncompletion of high school is a greater risk factor than biological factors for development of many diseases, an association that is explained only in part by age, ethnicity, sex, or smoking status. Fourth, level of formal education predicted cardiovascular mortality better than random assignment to active drug or placebo over 3 years in a clinical trial that provides optimal access to care. Increased recognition of limitations of universal access by physicians and their professional societies may enhance efforts to improve the health of the population.

    Professional medical organizations, including the American College of Physicians and the American Medical Association, have advocated universal access to medical care as a major initiative toward improving the health of the U.S. population [1, 2]. We agree fully with this advocacy but are concerned that improved access to care may have limited effects on improving health. Access to medical services is clearly critical to outcomes in the inpatient hospital, the setting of most traditional medical education, training, and research (and of most public perceptions as the primary arena of medical activities). However, most current medical care occurs in outpatient settings, where the actions and life situations of patients may determine outcomes as much as the actions of health professionals and the health care system do. Access alone does not ensure benefits of available medical services.

    Our concerns about possible limitations of access in improving health in the population are based in large part on evidence of persistent and widening disparities in health according to socioeconomic status. Such disparities have been reported in most developed nations [3-11], including Australia [12], Belgium [13], Denmark [14], Finland [15], Italy [16], Japan [17], the Netherlands [18], New Zealand [19], Norway [20], Russia [21], Spain [22], Sweden [23], the United Kingdom [24, 25], and the United States [3, 6, 26, 27]. Many of these countries have had longstanding universal access to medical care. Low socioeconomic status is associated with poor outcomes in most conditions [3, 4, 26, 28], including cardiovascular [3, 26, 29-31], pulmonary [32], rheumatic [33-36], neoplastic [37], and psychiatric diseases [38].

    Disparities in health according to socioeconomic status are often regarded in the medical literature as “demographic” or “psychosocial” concerns and usually are attributed to limited access to medical care or to biomedical risk factors. Associations of good health with access to insurance and medical care lead some to believe that better health in people of high socioeconomic status is a result of more frequent interactions with the health care system and that improved access to care is the primary approach to improving the health of persons of low socioeconomic status. However, persons of low socioeconomic status currently use many medical services more often than persons of high socioeconomic status [39], perhaps because of ineffective use of services by persons with a greater burden of disease [40]. In most studies that have included a marker of socioeconomic status, such as level of education, occupation, type of housing, or income, these markers often explain health status more effectively than biomedical risk factors do; the primary exception is diseases associated with a single gene [3, 4, 26, 28].

    We summarize a few of the many reports on disparities in health according to socioeconomic status and suggest that poor health in socioeconomically disadvantaged populations results more from unfavorable social conditions [41-43] and ineffective self-management [44-47] than from limitations in access to care [7, 28, 48-51]. If this suggestion is correct even in part, it may have important implications concerning priorities for physicians and their professional organizations in health care reform [1, 2, 52]. Investment in education, improvement in social conditions, and research on self-management may improve health in persons of low socioeconomic status more than expanded access to medical care [7, 28, 48-51]. Such investments are unlikely to be made without strong support from physicians. We hope to stimulate further discussion among health professionals and their organizations of possible initiatives beyond universal access to the health care system to improve the health of the U.S. population. We suggest that broadening the approach beyond advocacy for access will increase the capacity of health professionals to influence health favorably.

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    Job Classification Predicted Cardiovascular Mortality in the United Kingdom Better than Blood Pressure, Smoking, and Cholesterol Level Combined

    The cardiovascular mortality rate over 7 years in 17 530 London civil servants (Figure 1) was more than 4% among unskilled workers (“other” in Figure 1, left), compared with 3% among clerical workers, 2% among professionals or executives, and less than 1% among administrators [29, 53]. The presence of identified risk factors, including cholesterol level, blood pressure, and smoking, explained less than half of these differences (Figure 1, right). All of these persons were working at the onset of the observation period and had access to medical care through the National Health Service. Therefore, neither biomedical risk factors nor limited access to medical care can account for most of the differences, and the major component of differences in the risk for cardiovascular death remains “unexplained.” We suggest an explanation based on lifestyle and behavioral considerations.

    Figure 1. Mortality rate over 7.5 years from coronary heart disease (CHD) in 17 530 London civil servants according to type of employment at study entry. Relative risk for death from coronary heart disease according to employment grade explained by blood pressure, cholesterol level, and smoking as recognized risk factors at entry. Reproduced with permission from Marmot and colleagues .
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    Figure 1. Mortality rate over 7.5 years from coronary heart disease (CHD) in 17 530 London civil servants according to type of employment at study entry. Relative risk for death from coronary heart disease according to employment grade explained by blood pressure, cholesterol level, and smoking as recognized risk factors at entry. Reproduced with permission from Marmot and colleagues . Left.Right.[29]
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    Widening Disparities in Health according to Socioeconomic Status Despite the Presence of a National Health Service

    Disparities in health according to socioeconomic status have widened since the 1970s in the Netherlands [18], the United States [54, 55], and the United Kingdom [56]. These trends may in part reflect unequal access to medical care. However, data from the United Kingdom indicate that access to the National Health Service has not eliminated disparities in health according to socioeconomic status. In fact, these disparities have become greater as medical care has become more complex and, presumably, more effective (Figure 2).

    Figure 2. SMR = standardized mortality ratio. White circles = manual workers; black circles = nonmanual workers; dashed line = standard mortality (that is, 100). Reproduced with permission from Marmot and colleagues .
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    Figure 2. SMR = standardized mortality ratio. White circles = manual workers; black circles = nonmanual workers; dashed line = standard mortality (that is, 100). Reproduced with permission from Marmot and colleagues . Mortality rates from all causes, lung cancer, coronary artery disease (CAD), and cerebrovascular disease (Cerebro VD) from 1970 to 1972 and 1979 to 1983 among men 20 to 64 years of age (top) according to occupational status and among married women 20 to 54 years of age (bottom) according to their husbands' occupations.[29]
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    Higher Prevalence of Most Diseases Associated with Low Socioeconomic Status in the United States

    In addition to significant associations of low socioeconomic status with morbidity and mortality after the development of many diseases, noncompletion of high school in the United States is associated with a considerably higher likelihood of developing many chronic diseases before the age of 65 years. This association is explained only in part by age, ethnicity, sex, and smoking status [6] (Table 1). Among persons younger than 65 years of age, arthritis and hypertension occur in about 25% of persons with less than 8 years of education (about 10% of the 1978 total U.S. population), in 13% to 15% of those with 9 to 11 years of education (about 15% of the 1978 total U.S. population), in 9% to 11% of those with 12 years of education (about 38% of the 1978 total U.S. population), and in 6% to 7% of those with more than 12 years of formal education (about 37% of the population). Similar patterns are evident for back pain, heart attack, peptic ulcer, diabetes, chronic bronchitis, renal disease, epilepsy, stroke, and tuberculosis.

    View this table:
    Table 1. Persons in the 1978 U.S. Population 18 to 64 Years of Age Reporting Health Conditions, according to Level of Formal Education*

    Several exceptions are notable. The prevalence of asthma, allergies, and thyroid disease is similar in all groups, and the prevalence of multiple sclerosis is greater in those with education. Disparities in the prevalence of neoplastic diseases according to level of education were explained by age and smoking status [6]. Nonetheless, the odds of developing musculoskeletal, cardiovascular, gastrointestinal, renal, pulmonary, or psychiatric disease before the age of 65 years were two to three times greater for persons who did not complete high school than for those who completed high school [10]. These odds are considerably higher than the odds of developing these diseases according to most recognized biomedical risk factors other than a single gene. Again, this finding is explained only in small part by age, sex, ethnicity, and smoking status [6] or by limited access to medical care.

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    Mortality according to Level of Education in the β-Blocker Heart Attack Trial Unexplained by Extensive Cardiovascular Measures

    In the β-Blocker Heart Attack Trial to prevent death in patients who had recovered from myocardial infarction [30], the subsequent 3-year mortality rate was lower in patients who took propranolol (8%) than in men who took placebo (13%). However, these differences were considerably less marked than differences according to level of formal education in both the β-blocker and the placebo groups (Figure 3). Life stress or social isolation rather than extensive physiologic measures explained differences according to educational level. Other studies have identified these psychosocial variables as important predictors of death [57, 58]. Even in the setting of a clinical trial with extensive access to medical care, biomedical risk factors explain only a small component of associations between socioeconomic status and mortality.

    Figure 3. Numbers in parentheses are numbers of patients. Solid lines = least favorable values for prognostic variable; dashed lines = intermediate values for prognostic variable; dotted lines = most favorable values for prognostic variable. Reproduced with permission from Ruberman and colleagues .
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    Figure 3. Numbers in parentheses are numbers of patients. Solid lines = least favorable values for prognostic variable; dashed lines = intermediate values for prognostic variable; dotted lines = most favorable values for prognostic variable. Reproduced with permission from Ruberman and colleagues . Comparison of mortality rates in the β-Blocker Heart Attack Trial according to random assignment to placebo or drug, level of formal education, life stress, and social isolation.[30]
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    Discussion

    The data presented above and considerable additional data [28, 33-35, 59-63] suggest that limited access to medical services is not the primary basis for socioeconomic disparities in health. Emphasis on access emerges in part from the spectacular success of the biomedical model [28, 64], the dominant paradigm of 20th-century medicine, in acute inpatient medical activities. Clearly, access is required for good outcomes in acute medical events. In outpatient care [28, 35, 45, 46, 52, 64], however, the biomedical model is not so effective. Less than 20% of symptoms reported at physician visits are explained by detectable organic pathology [65], and patients successfully self-manage 70% to 90% of symptoms [46].

    A focus on access to health care professionals ignores the most important determinant of health: the patient himself or herself in a sociocultural context [41-47, 66]. Experienced clinicians recognize that certain patients can be helped minimally by even the most expert professional services, whereas other patients can be expected to do well with minimal professional intervention. Similar access will not necessarily lead to similar use of services among people of all socioeconomic groups [25]. Such issues as the cost of a visit to a physician, travel time, transportation, and cultural beliefs influence the use of medical services. If disparities in health according to socioeconomic status are increasing and are likely to increase further despite universal access [18, 54-56], we must do more to address them than to advocate universal access to care.

    This perspective may initially seem to “blame the victim,” the person of low socioeconomic status who is more likely to be in poor health, or to blame physicians for having little to offer many of these patients. On the contrary, we believe that recognizing the limitations of access to care will provide intellectual and ethical imperatives to develop additional approaches toward correcting socioeconomic disparities in health. The success of the biomedical model in inpatient medicine has narrowed the meaning of “health care” at this time largely to “professional services.” This view allows private and government payers to classify these services into quantifiable units for reimbursement. For example, payments to physicians may be calculated on the basis of the number of organs examined rather than whether thoughtful care was provided or whether any healing resulted. Physicians whose services include education and counseling for patient self-management, primarily generalists, internists, and pediatricians, have seen their relative reimbursement diminish through this view of medical services.

    Emphasis on the predominant role of health professionals rather than patient actions in health outcomes may also distract from powerful health-promoting activities. For example, in patients with rheumatoid arthritis, a self-help course led to a reduction in pain and physician visits, resulting in savings that were 10 times the cost of the course [67, 68]. The patients' improved sense of control over their illness through self-management rather than knowledge or changes in behavior [69] explains the improved outcomes. Patient education programs directed at reduction of feelings of helplessness [70, 71] and improved self-efficacy [67, 72] may result in considerably greater cost containment and better outcomes in chronic diseases than do current efforts to restrict medications and visits to specialists [46, 69, 73].

    These observations highlight a broader issue: Medicine and health exist in a social context. More than 150 years ago, Rudolf Virchow, an architect of the biomedical model, observed that “medicine is a social science” and that “physicians are the natural attorneys of the poor, and the social problems should largely be solved by them” [74]. Several lines of evidence suggest that social issues influence health at least as much as medical issues do.

    First, social support and simple geographic differences may affect health more than recognized biomedical risk factors [41-43]. These associations may be explained in part by the associations of social circumstances on stress, self-esteem, and social relations [75]. Second, expenditures on health care and education each consumed 6% of the U.S. gross national product in 1965. By 1995, expenditures on health care increased to 14% while expenditures on education remained at 6% [76]. During this period, disparities in health according to socioeconomic status increased [54, 55]. Third, countries with the most equitable distribution of wealth have the highest life expectancy [75], independent of the average income of that society. In the United States, higher mortality rates in individual states are correlated with the degree of income inequality within each state [77, 78].

    Investment in education may therefore improve health in the population more effectively than investment in health services [79]. Wealthy persons may be convinced of the importance of promoting social equality on the basis of enlightened self-interest-greater longevity for themselves as well as for others [80]. However, these messages are unlikely to gain credibility with politicians and the general public without the advocacy of health professionals and their organizations.

    These considerations lead us to suggest that to improve health in the population, physicians must serve as advocates for improved social conditions, public health initiatives, general and health education, and behavioral interventions. Nonetheless, individual physicians can have the most influence in one-on-one encounters with individual patients. In this context, we suggest that health professionals assume considerably more active advocacy for patient self-management. We encourage physicians to explore the multifactorial basis of socioeconomic health disparities in health beyond the reductionist perspective of the biomedical model. Of course, it may be at least as difficult to expand self-management as it is to improve access to care for certain patients, particularly under the time constraints of the present “managed” system.

    We hope that this essay will expose practicing physicians to a few seminal studies on the socioeconomic basis of health. In an age in which great emphasis is given to evidence-based medicine, we hope that the volume of evidence supporting a multidimensional approach to health leads physicians to view this broader approach as valid, intellectually sound, and scientifically grounded. Health professionals should recognize the limitations of access to care as a means of improving health and be leaders in advocating broader approaches toward improving health for all persons.

    Dr. Esther: Department of Orthopedics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599.

    Dr. DeWalt: Departments of Medicine and Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599.

    Dr. Callahan: Departments of Medicine and Epidemiology, Thurston Arthritis Research Center, Sheps Center for Health Services, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599.

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    1. Ann Intern Med September 1, 1998 vol. 129 no. 5 406-411
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