Secondary Logo

Journal Logo

SARCOIDOSIS: Edited by Daniel A. Culver and Hilario Nunes

Socioeconomic determinants and disparities in sarcoidosis

Sharp, Michellea; Eakin, Michelle N.a; Drent, Marjoleinb,c,d

Author Information
Current Opinion in Pulmonary Medicine: September 2020 - Volume 26 - Issue 5 - p 568-573
doi: 10.1097/MCP.0000000000000704
  • Open



Low socioeconomic status is known to significantly impact health outcomes overall [1]. Social-economic status is defined as ‘an individual's social or economic standing’ and is often measured by income, education level, employment, and location of residence [2]. Socioeconomic status can influence health by multiple pathways including reducing access to care overall and decreasing utilization of specialty services [2], reducing access to food stores [3], and worsening physical environments both at home and work [4]. Low socioeconomic status is also associated with increased stress and chronic stress has been shown to impact immune function and is increased in sarcoidosis [5–7].

Sarcoidosis is systemic disease characterized by granulomatous inflammation [8]. Sarcoidosis is an inflammatory multiorgan disease with a wide variety of clinical manifestations, often affecting people of working age [8]. Patients suffer from a broad spectrum of physical symptoms of varying severity including cognitive impairment and disabling fatigue that impact function [9,10]. The burden and disability of sarcoidosis can result in significant direct and indirect economic consequences including unemployment, workdays lost, and medical bills [11,12▪,13▪]. Sarcoidosis is also associated with worse health-related quality of life (HRQoL) and increased mortality compared with those without sarcoidosis [14]. Studies over several decades indicate that significant disparities exist in sarcoidosis outcomes by socioeconomic status, race, and gender [15].

In this review, we describe the known health disparities that exist among patients with sarcoidosis by socioeconomic status, race, and gender. We review the disease characteristics of sarcoidosis and explore the possible reasons for health disparities in sarcoidosis. We investigate the possible intersectionality among socioeconomic status, race, and gender in sarcoidosis and the role of stress in disparities. Finally, we suggest possible interventions including working with patient societies to create educational programs accessible for low-income patients and caregivers, targeting medication adherence and trust in physicians and the medical system, and ensuring access to high-quality care for all patients that may mitigate some of these disparities. 

Box 1
Box 1:
no caption available


Individuals with low income are more likely to have worse morbidity and a higher mortality compared with their higher income counterparts. The disparities seen in sarcoidosis by income are similar to those seen in other diseases. Low-income individuals with sarcoidosis defined by either income below the poverty level or less than $20 000 a year are reported to have worse dyspnea [16], lower HRQoL [17▪▪], and significantly higher rates of new sarcoidosis related comorbidities [17▪▪]. Additionally, low-income individuals with sarcoidosis have been found to have lower lung function and higher rates of hospitalizations when compared with higher income individuals with sarcoidosis [18,19].

Individuals with sarcoidosis often require long-term treatment to prevent disease progression [20,21]. Glucocorticosteroids are first-line treatment based on consensus guidelines [21–23] but may be associated with significant side-effects and worse HRQoL [24,25]. Given this, treating physicians should develop familiarity with some of the alternative agents. Medications such as methotrexate, azathioprine, mycophenolate, and anti-TNF treatments are recommended as steroid-sparing agents when glucocorticosteroids are not tolerated [21,22,25,26]. However, steroid-sparing agents are not always effective and often require concomitant low-dose glucocorticosteroids treatment and frequent monitoring with blood work for possible toxicities. Steroid-sparing agents are more expensive compared with glucocorticosteroids and may be harder to obtain depending on location in the world and insurance system. Low-income individuals have been found to have more glucocorticosteroid-related comorbidities [17▪▪] and report significant barriers to care including difficulty obtaining medications in the United States [19]. These findings may suggest that low-income individuals are more likely to receive glucocorticosteroids only regimens, which may result in lower HRQoL and more comorbidities. Hence, this may even increase the burden of sarcoidosis, and, furthermore, it might be expected that less improvement will be achieved in those patient with only access to glucocorticosteroids.

The diagnosis of sarcoidosis is associated with financial strain [12▪] and low-income individuals report more impact of the disease on family finances [17▪▪]. In a longitudinal study within Sweden, individuals diagnosed with sarcoidosis had similar earnings as the general population prior to diagnosis but experienced a 7% less earnings the year of diagnosis and significantly higher work loss days in the five years after diagnosis [27]. Low-income individuals with sarcoidosis are less likely to report normal physical functioning [19] and report higher rates of job loss [17▪▪] suggesting a disproportionate impact of the diagnosis on this population which may result in poorer health outcomes.

Additionally, individuals diagnosed with sarcoidosis face problems with disability claims [13▪]. Sarcoidosis patients may be more severely disabled than current disability claims assessment protocols for sarcoidosis are equipped to measure; a sufficient extent of objective parameters appear to be lacking [13▪]. Hendriks et al.[13▪] showed a high proportion of sarcoidosis patients who had undergone a disability evaluation felt their concerns dismissed with many disagreeing with the assessment outcome. Sarcoidosis-related education is needed to enhance work-related medical examinations supported by guidelines that account for extent of sarcoidosis impact on functionality, and therefore work capacity.

Individuals with higher educational attainment and insurance have overall better health compared with individuals who have lower education and are uninsured [28,29]. In sarcoidosis, similar patterns are seen with lower education being associated with increased physical limitation from the disease, worse HRQoL, and more fatigue [16,24,30]. Additionally, individuals with sarcoidosis who do not have insurance have increased barriers to medication, worse dyspnea, and lower lung function compared with those with insurance [19]. Individuals with heart failure and lower education have been shown to significantly benefit from self-management interventions compared with those of higher education level [31]. Research is needed in sarcoidosis to identify on how clinicians and nurses can help individuals with low education better manage their disease or identify additional supports for their care.


Race has also been shown to be a significant determinant of disparities in general health status with Black individuals having worse outcomes compared with White individuals, especially in the United States [32]. Genetic differences, socioeconomic differences, institutional racism, poor access to medical care, increased stress, and potential environmental exposures have been implicated as possible reasons for the known racial disparities [32,33]. Black individuals with sarcoidosis have higher mortality rates [15] and higher rates of hospitalizations [18,34▪,35] compared with non-Hispanic whites. Although genetic differences among the races have been reported in sarcoidosis and Black individuals have a higher incidence of sarcoidosis [20,36], the socioeconomic contributions to racial health disparities in sarcoidosis are prominent, especially in the United States.

As mentioned above, a study done in Sweden found that individuals who develop sarcoidosis experience significant financial strain especially during the year of diagnosis [27]. In general as patients’ age, they are more likely to successfully withstand financial strain [37]. Older individuals have more time to acquire savings for times of financial strain and in the United States, there are more social safety nets for older individuals compared with younger individuals. As reported by Rybicki et al.[38], Black individuals are affected by sarcoidosis up to a decade earlier in life compared with non-Hispanic white, which may lead to a greater impact of the financial strain for Black individuals. Additionally, especially in the United States, there is an intersectionality between race and income as several studies have reported that Black individuals with sarcoidosis more likely to fall below the poverty line leading to additional disparities described above [18,39].

Sarcoidosis is an inflammatory disease that can lead to irreversible organ damage if left untreated because of a delay in recognition, poor adherence, or medication intolerance or unaffordability. Black individuals have more advanced sarcoidosis and more organs affected by sarcoidosis compared with non-Hispanic whites [18,40]. Blacks also have worse pulmonary function measured by forced vital capacity % predicted around the time of sarcoidosis diagnosis compared with non-Hispanic whites [19]. The fact that Black individuals with sarcoidosis often have more advanced disease [18,40] could be explained at least partly by a decreased access to medical care leading to a delay in diagnosis. Although genetic differences may exist between the races, factors such as access to care and possible difference in occupational exposures may also contribute to the finding that Black individuals are less likely to have clinical recovery from sarcoidosis compared with non-Hispanic whites [41].

Although Black individuals with sarcoidosis require long term treatment more often compared with non-Hispanic whites [42], they are generally underrepresented in the clinical trials investigating treatment efficacy in sarcoidosis [43,44,45]. In individuals with unremitting pulmonary sarcoidosis who require treatment, continuous treatment has been shown to be superior to intermittent treatment in terms of modifying lung function [45]. In addition to the barriers that may exist to obtaining steroid-sparing medications described above for low-income individuals, Black individuals with sarcoidosis have been reported to be less adherent to medications for sarcoidosis in general compared with non-Hispanic whites [46▪], which may also contribute to health disparities. Research in other diseases such as hypertension has shown that racial discrimination has been shown to lead to poorer medication adherence and worse trust among Black individuals [47] but needs to be considered in sarcoidosis, especially in the United States.


Sarcoidosis is probably more common amongst women, although this also appears to vary from country to country [21]. The peak incidence of sarcoidosis occurs between the ages 20 and 40 in both men and women, with a second lower and broader peak in women between 45 and 65 years of age. With regard to gender differences, female patients showed more emotional problems as well as body care, sleep, and movement problems than males [48].

In sarcoidosis, females were reported to have higher rates of hospitalizations [35], lower lung function based on Forced Vital Capacity % predicted [19], higher rates of depressive symptoms [39], higher amounts of work loss [27], and worse HRQoL compared with males [49]. In a study by De Vries et al.[48] female patients reported the presence of more symptoms more often and the nature of these symptoms also differed from those of male patients. In addition, female patients had a lower QOL in the areas of physical and psychological health, particularly with regard to pain, sleep, positive feelings, self-esteem, bodily image, mobility, and daily life activities [48]. Medication also differed between female and male patients. In patients with current symptoms, females were prescribed more eye drops, pain killers, and nonsteroidal anti-inflammatory drugs, while males received more frequently corticosteroids. Studies are needed to evaluate whether the differences in the present study between male and female sarcoidosis patients are caused by a subject selection bias or lifestyle differences; have a genetic, hormonal, or biological base; or just are an epiphenomenon.

Intersectionality between gender and race

An intersectionality, overlap of various social identities experienced by an individual or group, between gender and race has been described with Black females experiencing worse HRQoL in comparison to Black males with higher perceived discrimination among females [48,50]. Sarcoidosis is model disease to further investigate the intersectionality between gender and race as it is more common among females in all races compared with males with black females having the highest incidence overall [15]. The disparities in hospitalizations rates and lung function exist for both Black and female individuals with sarcoidosis. Further investigation should be done to understand sex as a biological variable across the research spectrum and the possible intersectionality with race.


Financial strain, systemic racism, and gender biases have all been linked to increased levels of psychosocial stress. Stress has been identified as a top determinant of health disparities by the WHO [51]. Perceived stress is significantly elevated among individuals with sarcoidosis [7]. Stress occurs when an individual perceives that environmental demands are too taxing or threatening or that their ability to cope is limited [52]. Low-income and minority individuals are more likely to report severe stress over their lifetime [5] and stress has been identified as a causal pathway linking socioeconomic status to adverse health outcomes [53]. High levels of stress are linked with increased mortality [54], higher chronic disease prevalence [55], and lower Quality of life [53]. Studies demonstrate biologic plausibility; mechanistic pathways include neurobiological pathways [56] and epigenetic changes [57] collectively leading to upregulation of inflammatory pathways and thereby health decline. Given that stress is reported to be high among patients with sarcoidosis [7], it is important to understand the potential contributions of social-environmental stress on immune function and health outcomes in sarcoidosis.


The clinical presentation and course of sarcoidosis can be very different among patients. The data presented in this review highlights the need to improve access to high-quality medical care for all patients with sarcoidosis regardless of age, gender, race, or socioeconomic status as an important avenue to address disparities.

The National Heart, Lung, and Blood Institute completed a workshop to define priorities to improve clinical care in sarcoidosis and cited addressing disparities as an avenue to improve clinical outcomes [58]. Health disparities in sarcoidosis by socioeconomic status, race, and gender have been described for decades. Having low income and no or other public insurance may cumulatively discourage seeking medical care. However, little work has been done to identify the major causes of these disparities, identify potential mechanisms, and develop interventions to mitigate the socioeconomic, racial, and gender disparities that are widely prevalent. In fact, Black individuals are often underrepresented in the current research being done in sarcoidosis. As clinicians and researchers, we owe it to our patients to not only describe the disparities but to design interventions that may improve the disparities seen in sarcoidosis and be aware of the differences per country and in access to healthcare systems. As recently stated by Cozier et al.[59], ‘It is clear that sarcoidosis is a diagnosis that patients and their families can ill afford.’

Possible avenues for patient-level interventions that may improve the socioeconomic disparities in sarcoidosis include interventions promoting self-management and education around symptom recognition, treatment side-effect management, and treatment options, creating patient educational programs that are accessible for low-income patients. Cooperation with patient societies is an avenue which should be explored to improve and develop educational programs for both patients and caregivers and make them more accessible. Interventions addressing racial disparities in sarcoidosis may include those targeted at improving medication adherence and trust in physicians and the medical system. Furthermore, given the association between stress and the immune system and high levels of perceived stress in sarcoidosis, integrating screening and addressing social determinants of health may be necessary to reduce overall stress and improve health. There is a need for targeted research to identify additional causes and mechanisms for disparities, including the role of stress and occupational exposures. Increasing awareness and innovative ways to increase access to high-quality care for all, but especially for vulnerable populations are essential. Additionally, advocating for national policies to improve access to medical care and treatment for all sarcoidosis patients in general may be an important avenue to addressing the disparities in sarcoidosis in countries in which these policies do not exist.


We would like to thank Taylor Brown for assistance with this review.

Financial support and sponsorship

M.S. was supported by the Pearl M. Stetler Fellowship Award during time of this manuscript development.

Conflicts of interest

There are no conflicts of interest.


Papers of particular interest, published within the annual period of review, have been highlighted as:


1. Anderson NB, Armstead CA. Toward understanding the association of socioeconomic status and health: a new challenge for the biopsychosocial approach. Psychosom Med 1995; 57:213–225.
2. Sahni S, Talwar A, Khanijo S, et al. Socioeconomic status and its relationship to chronic respiratory disease. Adv Respir Med 2017; 85:97–108.
3. Morland K, Wing S, Diez Roux A, et al. Neighborhood characteristics associated with the location of food stores and food service places. Am J Prev Med 2002; 22:23–29.
4. Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Affairs 2002; 21:60–76.
5. Cohen S, Doyle WJ, Baum A. Socioeconomic status is associated with stress hormones. Psychosom Med 2006; 68:414–420.
6. Dhabhar FS. Effects of stress on immune function: the good, the bad, and the beautiful. Immunol Res 2014; 58:193–210.
7. De Vries J, Drent M. Relationship between perceived stress and sarcoidosis in a Dutch patient population. Sarcoidosis Vasc Diffuse Lung Dis 2004; 21:57–63.
8. Schupp JC, Freitag-Wolf S, Bargagli E, et al. Phenotypes of organ involvement in sarcoidosis. Eur Respir J 2018; 51:1700991.
9. Voortman M, Hendriks CM, Elfferich MD, et al. The burden of sarcoidosis symptoms from a patient perspective. Lung 2019; 197:155–161.
10. Drent M, Strookappe B, Hoitsma E, et al. Consequences of sarcoidosis. Clin Chest Med 2015; 36:727–737.
11. Rice JB, White A, Lopez A, et al. Economic burden of sarcoidosis in a commercially-insured population in the United States. J Med Econ 2017; 20:1048–1055.
12▪. Gade Sikjær M, Hilberg O, Ibsen R, et al. Direct and indirect economic and health consequences related to sarcoidosis in Denmark: a national register-based study. Respir Med 2019; 152:7–13.
13▪. Hendriks CM, Saketkoo LA, Elfferich MD, et al. Sarcoidosis and work participation: the need to develop a disease-specific core set for assessment of work ability. Lung 2019; 197:407–413.
14. Tukey MH, Berman JS, Boggs DA, et al. Mortality among African American women with sarcoidosis: data from the Black Women's Health Study. Sarcoidosis Vasc Diffuse Lung Dis 2013; 30:128–133.
15. Gerke AK, Judson MA, Cozier YC, et al. Disease burden and variability in sarcoidosis. Ann ATS 2017; 14: (Suppl 6): S421–428.
16. Rabin DL, Richardson MS, Stein SR, et al. Sarcoidosis severity and socioeconomic status. Eur Respir J 2001; 18:499–506.
17▪▪. Harper LJ, Gerke AK, Wang XF, et al. Income and other contributors to poor outcomes in U.S. patients with sarcoidosis. Am J Respir Crit Care Med 2020; 201:955–964.
18. Kajdasz DK, Judson MA, Mohr LC, et al. Geographic variation in sarcoidosis in South Carolina: its relation to socioeconomic status and healthcare indicators. Am J Epidemiol 1999; 150:271–278.
19. Rabin DL. Sarcoidosis: social predictors of severity at presentation. Eur Respir J 2004; 24:601–608.
20. Chen ES, Moller DR. Sarcoidosis—scientific progress and clinical challenges. Nat Rev Rheumatol 2011; 7:457–467.
21. Grunewald J, Grutters JC, Arkema EV, et al. Sarcoidosis. Nat Rev Dis Primers 2019; 5:45.
22. Bradley B, Branley HM, Egan JJ, et al. Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society. Thorax 2008; 63: (Suppl 5): v1–v58.
23. Drent M, Cremers JP, Jansen TL. Pulmonology meets rheumatology in sarcoidosis: a review on the therapeutic approach. Curr Opin Rheumatol 2014; 26:276–284.
24. Cox CE, Donohue JF, Brown CD, et al. Health-related quality of life of persons with sarcoidosis. Chest 2004; 125:997–1004.
25. Drent M, Proesmans VL, Elfferich MD, et al. Ranking self-reported gastrointestinal side effects of pharmacotherapy in sarcoidosis. Lung 2020; 198:395–403.
26. Drent M, Cremers JP, Jansen TL, et al. Practical eminence and experience-based recommendations for use of TNF-α inhibitors in sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 2014; 31:91–107.
27. Arkema EV, Eklund A, Grunewald J, et al. Work ability before and after sarcoidosis diagnosis in Sweden. Respir Med 2018; 144:S7–12.
28. Ross CE, Wu C. The links between education and health. Am Sociol Rev 1995; 60:719–745.
29. Pan J, Lei X, Liu GG. Health insurance and health status: exploring the causal effect from a policy intervention. Health Econ 2016; 25:1389–1402.
30. Michielsen HJ, De Vries J, Drent M, et al. Psychometric qualities of the fatigue assessment scale in Croatian sarcoidosis patients. Sarcoidosis Vasc Diffuse Lung Dis 2005; 22:133–138.
31. Smeulders ES, van Haastregt JC, Ambergen T, et al. Heart failure patients with a lower educational level and better cognitive status benefit most from a self-management group programme. Patient Educ Couns 2010; 81:214–221.
32. Dovidio JF, Penner LA, Albrecht TL, et al. Disparities and distrust: the implications of psychological processes for understanding racial disparities in health and healthcare. Soc Sci Med 2008; 67:478–486.
33. Paradies Y, Ben J, Denson N, et al. Racism as a determinant of health: a systematic review and meta-analysis. PLoS ONE 2015; 10:e0138511.
34▪. Ogundipe F, Mehari A, Gillum R. Disparities in sarcoidosis mortality by region, urbanization, and race in the United States: a multiple cause of death analysis. Am J Med 2019; 132:1062–1068.e3.
35. Gerke AK, Yang M, Tang F, et al. Increased hospitalizations among sarcoidosis patients from 1998 to 2008: a population-based cohort study. BMC Pulm Med 2012; 12:19.
36. Rybicki BA, Walewski JL, Maliarik MJ, et al. The BTNL2 gene and sarcoidosis susceptibility in African Americans and Whites. Am J Hum Genet 2005; 77:491–499.
37. Francoeur RB. Use of an income-equivalence scale to understand age-related changes in financial strain. Res Aging 2002; 24:445–472.
38. Rybicki BA, Maliarik MJ, Major M, et al. Epidemiology, demographics, and genetics of sarcoidosis. Semin Respir Infect 1998; 13:166–173.
39. Chang B, Steimel J, Moller DR, et al. Depression in sarcoidosis. Am J Respir Crit Care Med 2001; 163:329–334.
40. Thillai M, Potiphar L, Eberhardt C, et al. Obstructive lung function in sarcoidosis may be missed, especially in older white patients. Eur Respir J 2012; 39:775–777.
41. Israel HL, Karlin P, Menduke H, et al. Factors affecting outcome of sarcoidosis: influence of race, extrathoracic involvement, and initial radiologic lung lesions. Ann NY Acad Sci 1986; 465 (1 Tenth Int):609–618.
42. Judson MA, Boan AD, Lackland DT. The clinical course of sarcoidosis: presentation, diagnosis, and treatment in a large white and black cohort in the United States. Sarcoidosis Vasc Diffuse Lung Dis 2012; 29:119–127.
43. Judson MA, Baughman RP, Costabel U, et al. Efficacy of infliximab in extrapulmonary sarcoidosis: results from a randomised trial. Eur Respir J 2008; 31:1189–1196.
44. Judson MA, Baughman RP, Costabel U, et al. Safety and efficacy of ustekinumab or golimumab in patients with chronic sarcoidosis. Eur Respir J 2014; 44:1296–1307.
45. Gibson G, Prescott R, Muers W, et al. British Thoracic Society Sarcoidosis Study: British Thoracic Society sarcoidosis study: effects of long term corticosteroid treatment. Thorax 1996; 51:238–247.
46▪. Sharp M, Brown T, Chen ES, et al. Association of medication adherence and clinical outcomes in sarcoidosis. Chest 2020; 158:226–233.
47. Cuffee YL, Hargraves JL, Rosal M, et al. Reported racial discrimination, trust in physicians, and medication adherence among inner-city African Americans with hypertension. Am J Public Health 2013; 103:e55–e62.
48. De Vries J, Van Heck GL, Drent M. Gender differences in sarcoidosis: symptoms, quality of life, and medical consumption. Women Health 2000; 30:99–114.
49. Michielsen HJ, Peros-Golubicic T, Drent M, et al. Relationship between symptoms and quality of life in a sarcoidosis population. Respiration 2007; 74:401–405.
50. Coley SL, Mendes de Leon CF, Ward EC, et al. Perceived discrimination and health-related quality-of-life: gender differences among older African Americans. Qual Life Res 2017; 26:3449–3458.
51. WHO. Social determinants of health [Internet]. WHO (World Health Organization); Available from: [cited May 8, 2020]
52. Lazarus RS, Folkman S. Stress, appraisal, and coping. 1984; New York: Springer Publishing Company, 460 p.
53. Baum A, Garofalo JP, Yali AM. Socioeconomic status and chronic stress: does stress account for SES effects on health? Ann NY Acad Sci 1999; 896:131–144.
54. Prior A, Fenger-Grøn M, Larsen KK, et al. The association between perceived stress and mortality among people with multimorbidity: a prospective population-based cohort study. Am J Epidemiol 2016; 184:199–210.
55. Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA 2007; 298:1685–1687.
56. Tawakol A, Osborne MT, Wang Y, et al. Stress-associated neurobiological pathway linking socioeconomic disparities to cardiovascular disease. J Am Coll Cardiol 2019; 73:3243–3255.
57. Zannas AS, Jia M, Hafner K, et al. Epigenetic upregulation of FKBP5 by aging and stress contributes to NF-κB-driven inflammation and cardiovascular risk. Proc Natl Acad Sci USA 2019; 116:11370–11379.
58. Maier LA, Crouser ED, Martin WJ, et al. Executive summary of the NHLBI workshop report: leveraging current scientific advancements to understand sarcoidosis variability and improve outcomes. Ann ATS 2017; 14: (Suppl 6): S415–S420.
59. Cozier YC, Govender P. Sarcoidosis: an ill-afforded disease. Am J Respir Crit Care Med 2020; 201:890–891.

gender; health disparities; race; sarcoidosis; socioeconomic

Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.