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INTRODUCTION

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Health disparities are the result of population differences that lead to preventable and unfair or unjust barriers to health equity. Health disparities research has demonstrated significant racial gaps in health outcomes. For example, in the United States, infants born to black mothers are more than twice as likely to die before their first birthday as infants born to white mothers. However, health disparities go beyond race and ethnicity as other vulnerable populations can also experience obstacles to health, based on religion, socioeconomic status, gender, age, mental health, disability, sexual orientation or gender identity, geographic location, or other characteristics linked to discrimination or exclusion. For example, children in poor families are twice as likely not to receive preventive medical and dental care as children in families earning 400% or more of the federal poverty level. There is a complex interaction of biological, behavioral, social, and physical environmental factors contributing to health disparities and addressing these gaps requires interventions at the patient, provider, and system level. This chapter will enhance the clinicians’ ability to care for diverse patient populations.

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APPROACHING HEALTH DISPARITIES

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Medicine has traditionally emphasized the role of individual behavior on health. While personal responsibility is important to health, the picture is more complicated when we are trying to examine health disparities. Race, ethnicity, and culture are part of social context, which contributes to an individual’s social position and stratification. Based on this stratification, individuals or groups are differentially exposed to health-damaging conditions and experience differential vulnerability based on the availability of and access to resources. Children’s health deserves special attention because of children’s dependency on adults, demographic differences, epidemiology, and separate system of healthcare financing. Additionally, developmentally, the circumstances a child is born into, including biological, social, and environmental factors, have ongoing and long-lasting effects on their health outcomes. Through circumstances beyond their control, certain disadvantaged children and adults are more vulnerable to poor health outcomes and health inequities than more advantaged groups.

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The life course model emphasizes the cumulative effects of these early-life adversities on adult health. In the Adverse Childhood Experiences (ACE) Study, a graded relationship was observed between ACE scores (based on self-reported abuse and household dysfunction in childhood) and adverse health outcomes measured by depression, anxiety, substance abuse, and sexual risk behaviors in adulthood. ACEs were also associated with increased risk of chronic conditions and premature death. The ACE risk factors are hypothesized to produce a toxic stress response, the result of significant, repetitive or prolonged activation of the body’s stress response systems and stress hormones without the buffering protection of a supportive relationship. This response may cause a cumulative stress-induced burden called allostatic load on overall brain and body functioning that results in physical and mental illnesses.

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Toxic stress is one of the mechanisms postulated to lead to persistent racial disparities in health. There is a long-standing and persistent difference with increased infant mortality, ...

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