Health Disparities Among Older Adults: An Introduction to the Special Issue

Abstract

The problem of health disparities across the lifespan and in older adulthood has gained recent attention by the National Institute on Aging (NIA) and other organizations and researchers. These disparities are of significant interest as they greatly impact health, life span, and quality-of-life for countless individuals and create economic burden on societies. Given the critical nature of this problem, this special issue will focus on health disparities for older adults across the lifespan. This introductory article will lay the groundwork for subsequent works on disparities among older ethnic minorities, women, lesbian, gay, bisexual, and trans, as well as rural elders. Concepts critical to an understanding of the topic such as social determinants of health, marginalization, and intersectionality will also be discussed.

Although health disparities have existed for centuries, the health inequity has only gained significant attention since the 1990s. Whitehead (1992) and the World Health Organization (WHO, n.d.) were some of the first to discuss those differences in health that in addition to being avoidable, are also considered to be “unfair and unjust” (Whitehead, 1992, p. 220). Since that time and in addition to the WHO, it has been addressed by numerous researchers and agencies including the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH). Although research regarding health disparities initially focused on the experiences of African Americans and other ethnic minorities, such disparities have been part of the American experience from before its formation as a separate nation (Hammonds & Reverby, 2019). In addition to a focus on race, research in health disparities and inequity has expanded to include a range of vulnerable groups, including older adults, women, rural residents, and members of the lesbian, gay, bisexual, trans, and questioning (LGBTQ) communities, women, and rural residents. We note that this work is also expanding to include intersecting identities among these vulnerable groups.

In 1990, the US Department of Health and Human Services (DHHR) began an initiative to address health disparities and to improve the health of Americans within the decade. The resulting “Healthy People 2000” set three broad goals, including the goal to reduce such disparities (Mason & McGinnis, 1990, p. 441). Healthy People 2010 expanded the focus on reducing disparities to that of eliminating disparities, including those related to gender, race and ethnicity, education, income, disability, rurality, and sexual orientation (Office of Disease Prevention and Health Promotion, n.d.). The current initiative, Healthy People 2030 moves beyond eliminating disparities to achieving health equity and attaining health literacy for all (Office of Disease Prevention and Health Promotion, n.d.2). The Healthy People objectives are driven by national data and are intended to be used by states, communities, and organizations to improve the health of individuals and groups. Other countries have also identified and set out to diminish or eliminate the problem of health disparities and inequity and on a global scale. The World Health Organization (WHO) works with individual countries and groups of countries to do the same through the equity and health (EQH) unit (WHO, n.d.).

Interestingly, Carter-Pokras and Baquet (2002) pointed out that the term health disparities were used primarily in the United States, while other countries employed the concept of health inequities. The authors assert that there several different definitions of health disparity among U.S. agencies and organizations. Similarly, Braveman et al. (2011) discussed the problematic nature of the many and often broad definitions of the term in the United States and the lack of consensus about whether the definition should be confined to differences in health outcomes or whether it should also include injustice. The authors further stressed that only clear, concrete definitions can drive relevant and measurable objectives and outcomes and inform policies and priorities for public health spending. As such, they created a committee and crafted more explicit definitions in Healthy People 2020. In this document, health disparity was defined as a “health difference that is closely linked with economic, social, and environmental disadvantage” (in Braveman, 2014, p. 6). The committee took a human and ethical rights and social justice stance to the definition and posited that the differences were avoidable and systematic in nature and impacted disadvantaged populations. Health equity was considered a level of optimal health for all people and Braveman (2014) asserts that it is interconnected with health disparities, as disparities are how we determine whether we are reaching health equity.

In addition to health disparities and health inequities, there are a few related and interconnected concepts that should be discussed in this introduction, such as social determinants of health, marginalization, and intersectionality. Healthy People 2030 has a special focus on social determinants of health (SDOH) which incorporate a range of macro-environmental components, such as systems and policies influencing one's health and access to support service, meso-level aspects, such as the places where people live, work, and play, as well as sociodemographic and individual correlates associated with functioning and quality-of-life outcomes and risks (Office of Disease Prevention and Health Promotion, n.d.2; Palmer et al., 2019). SDOH can adversely impact health and include circumstances such as polluted water, lack of recreation opportunities, poor access to nutritious food, and violence. Clearly, limited access to health and mental health services can also be considered SDOH (Office of Disease Prevention and Health Promotion Palmer et al.). Marginalization, a process by which certain groups are pushed aside, stigmatized, discriminated against, and may lack access to needed resources, is also relevant to health inequity and SDOH. Marginalization can be viewed within the context of SDOH as groups that are marginalized are often faced with conditions that compound their risks for poor health outcomes (Baah et al., 2019). Intersectionality is another critical concept related to health disparity and inequality. Coined by critical race theory scholar and law professor, Kimberle Crenshaw, in 1989, the term describes how individuals can be oppressed and marginalized in more than one, intersecting or overlapping identity category (such as race, age, gender, etc.). These identities may place individuals within certain contexts with poor SDOH and put them at risk for a multitude of health disparities.

Health Disparities Across the Lifespan

The COVID-19 pandemic has left little doubt that health disparities have and continue to exist in the United States and in other countries. Prior to the pandemic, ethnic minorities, and persons with lower incomes of all ages in the United States suffered disproportionately more from health and mental conditions compared to their White counterparts. Not surprisingly, by May 2021 of the pandemic, American Indian and Alaska Native, Hispanic, and African American's had higher rates of infection, hospitalizations, and death due to COVID-19 (Ndugga & Artiga, 2021). On a global scale, the virus also impacted marginalized populations more severely, especially those from poorer backgrounds and countries. In addition, there was great inequity in terms of countries having access to vaccines to supply to their citizens (WHO, 2022a, 2022b). Increased age has also been a significant risk factor for becoming seriously ill, becoming hospitalized, and dying from the virus (Mueller et al., 2020). Health inequities have continued past the pandemic. Although overall improvement has been seen in life expectancy on a global scale, the WHO (2022a, 2022b) still reports a life expectancy difference of 10 years between what they identify as high-income countries (HIC) and low-income countries (LIC). Similarly, the healthy life expectancy (HALE) is the average age that an individual can expect to live in good health and the difference between high- and low-income countries was also 10 years on this measure.

For older adults, health disparities are complex, as inequities often begin early in life and persist throughout the life course. The life course perspective is helpful to understanding this trajectory and that biological factors as well as physical and psychosocial environments from previous life stages can impact health in later adulthood. In fact, risk factors accumulated by an individual can be transferred to and impact other generations. Marginalized groups often have prolonged exposure to stressful environments and risk factors across the life course, resulting in greater vulnerability to illness in later life stages (Jones et al., 2019). Although health disparities and inequity affect individuals at all stages of life, older adults from marginalized groups are at risk of having a cumulative impact of health disparities across the life course. This will become an even larger scale problem as individuals are living longer in almost every nation in the world. In fact, in the next ten years, one in six people will be 60 years of age or older (UN, 2019). As advancing age often increases the likelihood of chronic illnesses, the global aging trend will surely strain the health care and long-term care delivery systems of many countries. Similarly, if left on its current path, the crisis of health disparity and health inequity faced by many nations will compound this predicament.

Articles in the Special Issue

Having provided a definition of health disparities and other relevant concepts as well as background on disparities across the life course, it should be clear that it is critical to address this issue. The most important reason is that health disparities cause poor health outcomes for individuals and groups of individuals which can cause suffering throughout their lives as well as shorten their lives. This is a social justice issue on a national and global scale. Health disparities are also an economic issue, as they cause an undue economic burden on societies. For example, if current trends continue in the United States, healthcare costs from disparities will rise from $320 billion to $1 trillion by 2040, based on an analysis considering biases and systematic inequities related to race, gender, and socioeconomic status (Gordon, 2022). Health disparities are a global phenomenon, with numerous countries and organizations launching initiatives to combat this crisis for all ages and a few specifically targeting older adults. For example, the National Institute on Aging (NIA) Strategic Directions for Research includes understanding health disparities as they relate to older adults and improving the health of diverse elders (NIA, n.d.) and at the global level the United Nations (UN) and the WHO (WHO, 2022a, 2022b) have implemented the Decade of Healthy Ageing, dedicated to healthy aging which includes reducing health inequities. In the spirit of these efforts, this special issue will address health disparities and inequity for older adults and across the life course.

This special issue begins with a discussion of the health disparities among older, Black men by Baxter, Zare, and Thorpe. They examine healthy aging, as well as health disparities, across the life course for Black men. The authors offer a special focus on cardiovascular disease and related diseases and functional impairments and the SDOH that increase poor health outcomes for this population. The life course perspective and the importance of health promotion and disease prevention in earlier adult years are also discussed. Next, Hand and Ihara offer an overview of ageism, sexism, and other forms of structural discrimination and their links with disparities in physical and mental health. In it, a case is made for a more intersectional approach to healthcare and social service delivery, particularly for older women, in efforts to attend to UN Global goals of promoting health and wellness, gender equality, fewer disparities, and as such, social justice. In the third article, Lampe, Barbee, Tran, Bastow, and McKay highlight a largely overlooked group: adults identifying as members of the LGBTQ+ community. The unique health and mental health needs and disparities of this population and the cumulative disadvantages they may encounter throughout the life span are addressed. Hash, Schreurs, Tolley, and Fiske round out the special issue with their focus on rural older adults. This article begins by defining what is meant by “rural” and proceeds to specify the health, mental health, and economic disparities for rural residents across the life course. Best practices and future directions related to policies, programs, and interventions to combat health disparities among rural residents and elders are also discussed. A unique program and data focused on the Appalachian region of the United States will be highlighted. We also include a brief post-script note from our editorial assistant, providing important insights into inviting young scholars into the publication process and how doing so might be an “easy” step to beginning to reduce disparities within the sciences.

The foundation provided in this special issue and the more specific data and information on the unjust and avoidable health disparities detailed in those that follow are critical readings for professionals, researchers, educators, and students in the health and social services as well as other disciplines that could have an impact on the health and well-being of older adults. This subject is even more pertinent in the context of recent illumination of and call to action on health and economic disparities, discrimination, and inequality among minority and at-risk populations in the United States. As such, the editors and authors invite readers to expand their knowledge and join research, policy, program, and practice efforts to eliminate health disparities for older adults and across the life course.