Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, United States.
Division of Rheumatology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, United States.
Front Public Health. 2022 Sep 30;10:980731. doi: 10.3389/fpubh.2022.980731. eCollection 2022.
Chronic diseases are increasingly responsible for the burden of health outcomes across the world. However, there is also increasing recognition that patterns of chronic disease outcomes (e.g., mortality, quality of life, etc.) have inequities across race, gender, and socioeconomic groups that cannot be solely attributed to these determinants. There is a need for an organizing framework which centers fundamental causes of health disparities that may better guide future work in centering these mechanisms and moving beyond acknowledgment of health disparities. In this paper, we synthesize several concepts from health disparities literature into a conceptual framework for understanding the interplay of patients' lived experiences, the health care system and structural determinants. Our framework suggests that (1) structural factors influence the health care system, the patient, the health care provider, and the provider-patient relationship through process of subordination and (2) that structurally competent actions are critical to reducing health inequities. The addition of subordination to theoretical frameworks involving health equity and social determinants of health, along with engagement with concepts of structural competency suggest several systems level changes to improve health outcomes.
慢性病在全球范围内对健康结果的负担负有越来越大的责任。然而，人们也越来越认识到，慢性病结果（例如死亡率、生活质量等）的模式在种族、性别和社会经济群体之间存在不平等，而这些不平等不能仅仅归因于这些决定因素。需要有一个组织框架，将健康差距的根本原因放在中心位置，这可能会更好地指导未来的工作，将这些机制放在中心位置，并超越对健康差距的认识。在本文中，我们将健康差距文献中的几个概念综合到一个理解患者生活体验、医疗保健系统和结构决定因素相互作用的概念框架中。我们的框架表明：(1)结构因素通过从属过程影响医疗保健系统、患者、医疗保健提供者以及提供者-患者关系；(2) 结构能力的行动对于减少健康不平等至关重要。将从属关系加入到涉及健康公平和健康的社会决定因素的理论框架中，并结合结构能力的概念，表明需要进行一些系统层面的改变，以改善健康结果。
