Determinants of Health and Health Disparities: Conceptual Frameworks,

Social, Behavioral and Biological Mechanisms

Eliseo J. Pérez-Stable, MDProfessor of Medicine, Professor of Medicine,

Division of General Internal Medicine, Department of Medicine, Division of General Internal Medicine, Department of Medicine,

Medical Effectiveness Research Center for Diverse PopulationsMedical Effectiveness Research Center for Diverse Populations

April 8, 2010

Types of Diverse Groups

Current health disparities research focuses on differences across race and ethnic groups

Much prior research examined differences by socioeconomic status (SES) or social class:– Low income vs. others– Less formal education vs. others

Both are “vulnerable” populations

Phases of Disparities Research

DetectingDefine health disparitiesDefine vulnerable

populations

UnderstandingIdentify determinants and mechanismsof disparities

ReducingInterveneEvaluateTranslate/disseminateChange policy

Adapted from Kilbourne et al, 2006

Defining Disparities: Worse health than their counterparts

Premature mortality including infant mortality Morbidity

– Chronic disease (heart disease, DM, cancer)– Communicable disease (Tuberculosis, HIV)– Low birth weight

Physiological risk factors related to behavior– Hypertension– Obesity/overweight– Diabetes

Functional limitations, disability Self-rated health

Understanding Race/Ethnic Disparities

What is it about being in a minority group that could lead to poorer health?– What does race/ethnicity “stand for”

Deconstruct “race/ethnic group membership” into underlying variables– Behaviors, attitudes, values, beliefs, ethnic

identity, acculturation, discrimination, educational experiences, literacy, language proficiency, social class, culture, genetics…

Social Class Disparities

What is it about being lower SES that could lead to poorer health?– What does lower SES “stand for”

Deconstruct “being of lower SES” into underlying variables– Behaviors, attitudes, values, beliefs, ethnic

identity, acculturation, discrimination, educational experiences, literacy, language proficiency, culture, genetics…

Understanding Disparities: Role of Conceptual Frameworks

Ground research in theory and knowledge

Help identify and organize key variables addressing global objectives– On the pathway to disparities

Help develop specific research questions

Guide selection of measures

Numerous Frameworks: Determinants of Health

HealthDeterminants

Conceptual Frameworks Need to Depict Determinants of Health Disparities

Race/ethnic and SES health disparities

Determinants

Frameworks cast a broader net of determinants:-- relevant to vulnerable groups-- vary across and within race/ethnic groups-- plausible mechanisms

Three Broad Types of Conceptual Frameworks: Interactions

Population science– Determinants of health in a population: Model– Samples are populations or subgroups

Health services research– How health care affects outcomes– Samples are patients or health plan members

Biology/physiology– Biological and genetic pathways to disease

Population-Based Determinants: Multiple Levels of Influence on Health

Individual– biological, behaviors, attitudes, age,

education, occupation Family and Social Network

– size, structure, support, beliefs Neighborhood or community

– resources, toxins, aesthetics, crime/poverty, housing, transportation

Population-Based Determinants: Multiple Levels of Influence on Health

Cultural group, ethnic identity– shared beliefs, values, behaviors

Occupation or workplace – toxins, safety, working conditions

Organizational/institutional structures– educational system, health care, parks

Societal, political

Individual Embedded in Ecological Context

FamilyIndividual

Family

CommunityCommunity

Society

One Ecological Model of Determinants of Health

Bio-behavioralmechanisms,

genetics

Individual behavior

Macro social, environmental conditions and policy

Living and working conditions

Social, family, community networks

Over the lifespan

NationalAcademy ofSciences, 2002

An Alternative Depiction of Multi-level Determinants of Health Disparities

Psychosocial - beliefs, attitudes, adherence, coping, personality

Lifestyle - exercise, diet, alcohol, smoking, sexual behavior, illicit drug use

Health care

Sociodemographics - age, race, ethnicity, education, income

Physical environment

Social environment

Healthdisparities

Biological - genetics,stress, allostatic load, opiate receptors, metabolism

Contextual Individual-level

Organizational,institutional

Economic resources

Societal, political

Ecological/Multi-level Determinants

Psychosocial - adherence, coping

Lifestyle - exercise, diet, alcohol, smoking, sexual behavior

Health care

Sociodemographics - age, race, ethnicity, education

Physical environment

Social environment

Biological - genetics,stress, allostatic load, opiate receptors, metabolism

Context Individual-level

Organizational,institutional

Economic resources

Societal, political

Psychological -beliefs, attitudes, personality

Healthdisparities

Physical Environment

Neighborhood safety, appearance

Housing quality Transportation Segregation Hazardous materials Occupational

hazards

# of liquor stores # of full service

grocery stores Availability of fresh

fruits and vegetables # of areas for walking

(sidewalks) Bicycling paths, parks

Ecological/Multi-level Determinants

Psychosocial - adherence, coping

Lifestyle - exercise, diet, alcohol, smoking, sexual behavior

Health care

Sociodemographics - age, race, ethnicity, education

Physical environment

Social environment

Biological - genetics,stress, allostatic load, opiate receptors, metabolism

Context Individual-level

Organizational,institutional

Economic resources

Societal, political

Psychological -beliefs, attitudes, personality

Healthdisparities

Social Environment

Social opportunities Family environment Social support Discrimination or racism Neighborhood cohesiveness Community meeting places

Conceptual Frameworks of Determinants: Social Environment

Berkman LF and Glass T, Social integration, social networks, social support, and health, in Social Epidemiology, chapter 7, p 143.

Socialstructuralconditions

(macro)

Social networks (mezzo)

Psycho-social

mechanisms (micro)

Pathways

•Culture•Socio economic factors

•Network structure•Frequency of contact

•Social support•Social influence•Access to resources

•Health behaviors•Psychological•Physiologic

Ecological/Multi-level Determinants

Psychosocial - adherence, coping

Lifestyle - exercise, diet, alcohol, smoking, sexual behavior

Health care

Sociodemographics - age, race, ethnicity, education, SES

Physical environment

Social environment

Biological - genetics,stress, allostatic load, opiate receptors, metabolism

Context Individual-level

Organizational,institutional

Economic resources

Societal, political

Psychological -beliefs, attitudes, personality

Healthdisparities

Societal Approaches to Health Improvement-Structural Interventions

Prevention strategies that target population health by changing social and community environments– “No indoor smoking” ordinances– Taxation policies– Smog control legislation (lead in gas)– Food labeling (nutrients)– Signage to use stairs (not elevators)

Singer BH et al. New Horizons in Health, 2001

Societal Approaches

“New York bans most trans fats in restaurants” (NY Times, Dec 6, 2006)– First municipal ban on use of all but tiny

amounts of trans fat NY Board of Health

– Also approved a measure to require some restaurants (mostly fast food) to prominently display caloric content of menu items

Lifestyle as a Pathway

Psychosocial - compliance, coping

Lifestyle - exercise, diet, alcohol, smoking, sexual behavior, other substance use

Health care

Sociodemographics - age, race, ethnicity, education, income

Physical environment

Social environment

Biological - genetics,metabolism, allostatic load, opiate receptors

Contextual Individual-level

Organizational,institutional

Economic resources

Societal, political

Healthdisparities

Cigarette Smoking in the U.S. – 2006National Health Interview Survey

% Men % Women

White African Am Latino Asian Am Indian

24.3 27.6 20.1 16.8 35.6

19.7 19.2 10.1 4.6 29.0

MMWR 2007;56:1157-1161

Nicotine Metabolism and Intake in African Americans

African Americans have 50% more lung cancer and higher cotinine levels per cigarette despite fewer cigarettes/day

Total and renal clearance of cotinine were 20% lower in African Americans

Nicotine intake per cigarette was 30% greater in African Americans

JAMA 1999;280:152-56

Nicotine Metabolism in Chinese and Latinos

Metabolic clearance of nicotine and cotinine in Latinos was similar to Whites and lower among Chinese

Intake of nicotine per cigarette:– Chinese: 0.73 mg (0.53 to 0.94)– Latinos: 1.05 mg (0.85 to 1.25)– Whites 1.10 (0.91 to 1.30)

Nicotine intake = tobacco smoke

Lifestyle as a Pathway 2

Psychosocial - compliance, coping

Health care

Sociodemographics - age, race, ethnicity, education, income

Physical environment

Social environment

Psychological - beliefs, attitudes

Contextual Individual-level

Organizational,institutional

Economic resources

Community resources

Emmons, K Health behavior in a social context, in Social Epidemiology, 2000, ch. 11.Policy

Health

Lifestyle, health behavior

The Role of Socioeconomic Status

Minority groups on average have lower socioeconomic status than Whites

Lower SES is thus a key hypothesis for observed race/ethnic health disparities

But SES is it’s own major determinant May vary by race/ethnic group

Ecological/Multi-level Determinants

Psychosocial - compliance, coping

Lifestyle - exercise, diet, alcohol, smoking, sexual behavior

Health care

Sociodemographics - age, race, ethnicity, education, SES

Physical environment

Social environment

Biological - genetics,allostatic load, opiate receptors

Low SES context Low individual-level SES

Organizational,institutional

Economic resources

Societal, political

Psychological -beliefs, attitudes, personality

Healthdisparities

Living in Poor Neighborhoods Increases Health Risk

Contextual analysis– Examine whether neighborhood-level

factors contribute to risk controlling for individual-level factors

Metaanalysis of 25 studies– All but 2 reported significant effect of

social environment (neighborhood) and health, controlling for individual factors

KE Pickett, J Epidemiol Comm Health 2001;55:111.

Access to Markets with Healthy Foods for Diabetics in New York City

Food targets: Fruit, vegetables, 1% fat milk, diet Food targets: Fruit, vegetables, 1% fat milk, diet drinks, high fiber breaddrinks, high fiber bread

173 stores in East Harlem and 152 stores in Upper 173 stores in East Harlem and 152 stores in Upper East SideEast Side

Had all 5 categories: 9% vs. 48%Had all 5 categories: 9% vs. 48% More likely to live on a block with no store selling More likely to live on a block with no store selling

foods in E Harlem–50% vs. 24%foods in E Harlem–50% vs. 24% Example of disparities in environmental justice Example of disparities in environmental justice

issues complicating behaviorissues complicating behavior

AJPH 2004; 94: 1549-54AJPH 2004; 94: 1549-54

Access to Healthy Foods and Health

Lifestyle behaviors- shop at stores with healthy food- buy healthy food- eat healthy food

Physical Access toHealthy Food:TransportationNumber of grocery storesDistance to nearest grocery store

Obesity,diabetes

Context Individual-level

Financial Resources:Income/economic strain

Food insecurity- not enough money to buy food

Cumulative Pathways or Lifecourse Issues

Health disparities due to lifetime of adverse conditions––Specific research:

Childhood levels of SES and cumulative disadvantageous economic circumstances are associated with poor health in mid-life

Lifetime experiences of discrimination due to race/ethnicity adversely affect health

Cumulative exposure is critical

Framework: Socioeconomic Status Over the Lifecourse and Health

Lynch J and Kaplan G, Social Epidemiology, Oxford, 2000 (Ch 2, p. 28)

Socioeconomic Position

Birth Childhood Adulthood Old Age

Low birth weightGrowth retardation

Smoking,diet, exercise

Job stressInadequate

medical care

Intrauterineconditions

Education,environment

Work conditions,income

Income,assets

Atherosclerosis CVD Reducedfunction

Racism/Discrimination: a Plausible Lifecourse Hypothesis

Health outcomes associated with racism (mechanism through stress?):

Hypertension Psychological distress Poorer self-rated health

… all are independent of effects of SES

Nazroo JY, AJPH, 93: 277Williams DR, Ethn Dis, 2001;11:800

Biopsychosocial Effects of Perceived Racism on Health

Environmental stimulus

Perception

Perception of racism

Perception of different

stressor

No perception of racism or other stressor

Coping responses

Psychological and physiological stress responses

Health outcomes

Blunted psychological and physiological stress

responses

Sociodemographic,Psychological, Behavioral factors

Three Broad Types of Conceptual Frameworks

Population science– Determinants of health in a population– Samples are populations or population

subgroups Health services research

– How health care affects outcomes– Samples are patients or health plan

members Biology/physiology

– Biological and genetic pathways to disease

Structure-Process-Outcome Paradigm

Patient outcomes

Structure of care

•Structure - system of care•Technical process - knowledge and judgment skills •Interpersonal process - the way care is provided

Donabedian A. Quality Review Bulletin, 1992, p. 356

Process of care:-technical care-interpersonal

care

Research on How Structure of Care Affects Disparities

If systems provide medical interpreters, do patients with limited English proficiency have better health outcomes?

If systems offer a broad choice of minority clinicians, do minority patients have better health outcomes?

Research Questions on How Technical Processes Affect Disparities

Are treatments less effective for racial/ethnic minorities than for Whites?

Are appropriate diagnostic procedures used less often for minorities than for Whites?

Are optimal treatments provided less often for racial/ethnic minorities than for Whites?

Research Questions on How Interpersonal Processes Affect Disparities

What are the effects on health of differences in:– Communication

– Elicitation of patient concerns

– Respectfulness

– Perceived discrimination

– Participatory decision making

Ethnicity in Patient-Doctor Relationship

Refusal: whose issue? DNR discussions–Race of clinician is

an independent predictor Cultural competence or humility Language factors Racism may affect behavior:

– Fewer cardiology referrals in Blacks

Ethnicity and Attitudes toward Patient Autonomy among Persons ≥ 65 yrs

Tell Dx %

Tell prognosis

%

Life support %

European Am 87 69 65

Mexican Am 65 48 41

African Am 89 63 60

Korean Am 47 35 28

JAMA 1995; 274:820

Structure-Process-Outcome Paradigm

Ultimate patient outcomes

- health

Structure of care

Process of care:-technical care-interpersonal

care

Intermediatepatient outcomes:

- compliance- knowledge

Another Type of Intermediate Outcome

Ultimate patient outcomes

-mortality-morbidity

Structure of care

Process of care:-technical care-interpersonal

care

Intermediatepatient outcomes:

-blood pressure-weight-HbA1c

Structure-Process-Outcome Paradigm

Ultimate outcomes

- health status

Structure of care

Process of care:-technical care-interpersonal

care

Intermediateoutcomes-adherence-knowledge

Cliniciancharacteristics

Structure-Process-Outcome Paradigm

Ultimate outcomes

- health status

Structure of care

Process of care:-technical care-interpersonal

care

Intermediateoutcomes-adherence-knowledge

Cliniciancharacteristics

Cultural competence:System and clinicians offer highest quality care to all patients regardless of ethnicity,

culture, or language proficiency

Conceptual Framework for National

Healthcare Disparities Reports (AHRQ) Components of Health Care Quality

Consumer Perspectives on health care needs:

Safety Effectiveness Patient centered

Timeliness

Staying healthy

Getting better

Living with illness or disability

Coping with the end of life

Equity

Structure-Process-Outcome Paradigm

Ultimate outcomes

- health status

Structure of care

Process of care:-technical care-interpersonal

care

Intermediateoutcomes-adherence

- knowledge

Patient characteristics

Cliniciancharacteristics

Blending Population and Health Services Frameworks

Ultimate outcomes

- health status

Structure of care

Process of care:-technical care-interpersonal

care

Intermediateoutcomes-adherence

- knowledge

Patient characteristics

Cliniciancharacteristics

Environment

Neighborhood resourcesFamily support

Alternative Health Services Research Framework for Health Disparities

Patientfactors

Clinician factors

Health care system factors

Interpersonal relationship

Adapted from Kilbourne et al., 2006

Alternative Health Services Research Framework for Health Disparities

Patientfactors

Clinician factors

Health care system factors

Interpersonal relationship

Saba et al. J Fam Med., 2006

Visit

Summary: Conceptual Frameworks

Numerous frameworks – Health services– Population science– Biological/physiological

Reflect theories and research from many disciplines

Frameworks can integrate population, health services, and biological approaches

Worth reviewing in designing all research