Determinants of MSK health and disability--social determinants of inequities in MSK health.

Even in most egalitarian societies, disparities in care exist to the disadvantage of some people with chronic musculoskeletal (MSK) disorders and related disability. These situations translate into inequality in health and health outcomes. The goal of this chapter is to review concepts and determinants associated with health inequity, and the effect of interventions to minimize their impact. Health inequities are avoidable, unnecessary, unfair and unjust. Inequities can occur across the health care continuum, from primary and secondary prevention to diagnosis and treatment. There are many ways to define and identify inequities, according for instance to ethical, philosophical, epidemiological, sociological, economic, or public health points of view. These complementary views can be applied to set a framework of analysis, identify determinants and suggest targets of action against inequity. Most determinants of inequity in MSK disorders are similar to those in the general population and other chronic diseases. People may be exposed to inequity as a result of policies and rules set by the health care system, individuals' demographic characteristics (e.g., education level), or some behavior of health professionals and of patients. Osteoarthritis (OA) represents a typical chronic MSK condition. The PROGRESS-Plus framework is useful for identifying the important role that place of residence, race and ethnicity, occupation, gender, education, socioeconomic status, social capital and networks, age, disability and sexual orientation may have in creating or maintaining inequities in this disease. In rheumatoid arthritis (RA), a consideration of international data led to the conclusion that not all RA patients who needed biologic therapy had access to it. The disparity in care was due partly to policies of a country and a health care system, or economic conditions. We conclude this chapter by discussing examples of interventions designed for reducing health inequity.