Structural and health system determinants of health outcomes in systemic lupus erythematosus: Understanding the mechanisms underlying health disparities.

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.