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Health Disparities, Health Equity, and Social Determinants of Health

Presented by:

The Ca-Nv Public Health Training CenterFunded by Grant #UB6HP20202 from the Health Resources and

Services Administration, U.S. Department of Health and Human Services

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California-NevadaPublic Health Training Center

• Collaboration of:– San Diego State Univ., Graduate School of Public Health– Loma Linda U., School of Public Health– California State University Fullerton, Dept. of Health Science– Univ. of Nevada Las Vegas, School of Community Health Sciences

• Goal: – Strengthen performance in the core functions and delivery of essential

services among public health workers in CA and NV

• Website:– http://www.CaNvPHTC.org

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Upcoming Trainings in San DiegoIn-Person Trainings (all 8:30AM-noon)

• 8/29/12: Writing Grant Proposals for Health Programs

Webinars• TBA: Fall Prevention: A Step-by-Step Guide to Reducing

Falls in Older Adults (10-11AM)

• 9/13/12: Health Policy for Program Planning (11:30AM-12:30PM)

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Go to CaNvPHTC.sdsu.edu/Trainings/default.asp to register

Health Disparities, Health Equity, and Social Determinants of Health

August 27, 2012Trainers:

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Hala Madanat, PhDAssociate ProfessorGraduate School of Public HealthSan Diego State UniversitySan Diego Prevention Research Center

Leslie Ray, MPH, MPPH, MASenior EpidemiologistPublic Health ServicesCommunity Health StatisticsEmergency Medical ServicesCounty of San Diego Health and Human Services Agency

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Objectives

This training will help you to:1. Define health disparities and health equity.

2. Identify different determinants of health and describe how they impact health.

3. Identify strategies for improving health equity.

4. Describe the roles and responsibilities of the public health workforce in eliminating disparities and achieving health equity.

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INTERACTIVE AUDIENCE RESPONSE QUESTIONS

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A. JapaneseB. BangladeshisC. CubansD. Algerians living in ParisE. All of the above

African American males in Harlem have a shorter life expectancy from age five than which of the following groups?

Question

A. 3 timesB. 4 timesC. 5 timesD. 7 times

Children living in poverty are how many times more likely to have poor health, compared with children living in high-income households?

Question

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A. Whether or not you smokeB. What you eatC. Whether or not you are wealthyD. Whether or not you have health insuranceE. How often you exercise

On average, which of the following conditions is the strongest predictor of your health?

Question

A. Declined by 12%B. Stayed the sameC. Widened by 60%

Between 1980 and 2000 the gap in life expectancy between the most and least deprived counties in the U.S:

Question

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A. HispanicsB. BlacksC. WhitesD. Chinese

In a national survey conducted by Keickhefer and colleagues, in 1996-2000, it was determined that having a usual source of care is essential for children with chronic illnesses. Which race/ethnicity was determined to do best in this area?

Question

Group Discussion

Why are some people healthier than other people?

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If everyone’s health were the same we wouldn’t

need public health.

Definition of Health Disparities

• According to the National Institutes of Health:

“Health disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.”

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Health Disparities

• Refers to gaps in the quality of health and health care

• Not biological• Socially and politically determined

–Unequal access–Unequal treatment–Unequal outcomes

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Disparities Examples (CDC 2004)

Infant Mortality

Increases as mother’s level of education decreases

Chronic Disease

Native Hawaiians (15.4%), American Indians (13.6%), African Americans (11.3%), and Hispanics (9.8%) are more likely to be diagnosed with diabetes than their white counterparts (7%)

Infectious Disease

African Americans are 9 times more likely to die from HIV/AIDS than their white counterparts 

InjuryAmerican Indian males between 15 and 24 were more likely to be injured and more likely to die in a motor vehicle related crash than white makes of the same age

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Infant Mortality Rates by Race: 1915-1997* (US)

020406080

100120140160180200

1915

1920

1925

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

1997

Year

Infa

nt d

eath

s pe

r 1,0

00 li

ve b

irths

BlacksWhites

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*Note:  For years 1915‐1960, “White” included persons stated to be “White,” “Cuban,” “Mexican,” or “Puerto Rican.” All others during that time period were referred to as “Nonwhite.”

Diabetes Prevalence

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Who is at Risk for Health Disparities?

• An apple a day keeps the doctor away –• if you can buy an apple

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Health Disparities• Health disparities can be defined as

preventable population-specific differences in disease risk, presence of disease, health outcomes, or access to health care.

• Disparities are preventable

• Racial and ethnic minorities are the current focus of most health disparities research.

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Why the focus on race and ethnicity?

Strong relationship between race, SES, health status and poor health outcomes

Racial and ethnic minorities • Report poorer health• Have higher disease morbidity• Have higher mortality rates• Receive less preventive care• Receive fewer treatment options• Link between discrimination, stress

and poor health

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Healthcare Systems Level Factors• Institutionalized System Bias

– Organization and financing– Lack of resources, knowledge, or institutional

priorities for interpretation services and culturally responsive services

– Time pressures on physicians– Geographic availability of health care institutions,

medications, interventions

• Managed care systems replacing community based care systems

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Strategies for Eliminating Disparities

• Assessment – Assess health outcomes– preventive services – invest in Health research and surveillance– participation and inclusion, ownership

• Assurance - Diversify the health workforce– providers, competencies, equal representation

• Policy Development – Monitor health services– system bias, access to care, appropriate care

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HEALTH STATUS AND HEALTH DISPARITIES IN SAN DIEGO

Key Health Indicators for San Diego County

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• 3 million people

• Racial/Ethnic groups from around the world.

• Over 100 languages

Source: SANDAG, San Diego County 2010 Population Estimates

Asian 9.4%N=292,251

White 51.6%N=1,597,847

Black 5.4%N=166,486 Hispanic 29.3%

N=906,898

Hawaiian/Pacific Islander 0.4%N=13,144American Indian

0.5 %N=15,946

San Diego County PopulationBy Race/Ethnicity, 2010

San Diego County Population 2010,by race and ethnicity

Cancer Deaths by Race/Ethnicity San Diego County, 2003-2009

Age-Adjusted Rates

Resource: County of San Diego, HHSA

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Heart Disease Deaths by Race/Ethnicity San Diego County, 2003-2009

Age-Adjusted Rates

Resource: County of San Diego, HHSA

Stroke Deaths by Race/Ethnicity San Diego County, 2003-2009

Age-Adjusted Rates

Resource: County of San Diego, HHSA

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Diabetes Deaths by Race/Ethnicity San Diego County, 2003-2009

Age-Adjusted Rates

Resource: County of San Diego, HHSA

Percent of Adults Overweight and Obesity (BMI >25) by Race/Ethnicity

San Diego County, 2001, 2003, 2005, 2007

Source: California Health Interview Survey (CHIS)

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Percent of Adults Obesity (BMI > 30) by Race/Ethnicity

San Diego County, 2001, 2003, 2005, 2007

Source: California Health Interview Survey (CHIS)

Percentage of Overweight* Studentsby Race/Ethnicity, 1999, 2003, 2005, 2007

* Students who were at or above the 95th percentile for BMI by age and sex based on reference data from NHANES I.Source: 1999, 2003, 2005, 2007 Youth Risk Behavior Survey, San Diego City High Schools.

A significantly higher percentage of Hispanic students were overweight.

Overall Percentage of Overweight Students, San Diego, 2007: 12.3%

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•Source: AIDS Epidemiology Program

Number of New AIDS Cases Diagnosed, by Year, San Diego County

Infant Mortality San Diego County, 2002-2007

Infant Mortality Rates

Resource: County of San Diego, HHSA

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Asthma Deaths by Race/Ethnicity San Diego County, 2000-2009

3-Year Average Age-Adjusted Rates

San Diego Health Status— A Few Summary Points of Interest

• For blacks, death rates for stroke has equalized with all other racial and ethnic groups.

• For blacks, infant mortality has decreased but more data points are need to determine if trend will hold; infant mortality is still highest in blacks.

• Blacks and Hispanics show the highest prevalence of obesity. Obesity correlates with an array of chronic health conditions.

• While AIDS overall is decreasing, rates are increasing in people of color and are greatest in blacks.

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Group Activity• Health Disparities Brainstorm

– What are some of the population level health differences you see in your work?

– What do you think helps to explain those differences?

– What are the roles and responsibilities of the public health workforce in eliminating disparities?

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WHAT WILL YOU DO DIFFERENTLY TO HELP ADDRESS HEALTH DISPARITIES?

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Questions?

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Social Determinants of Health

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Case Study

• Marisela is a mother in San Ysidro. Her 2 year old daughter Alyssa has diarrhea and is getting worse. The community health worker happens to stop by, notices that Alyssa is sick and is perplexed by the fact that Marisela hasn't done much to help Alyssa.

Health Behavior Approach1. Don’t smoke. If you do stop or cut back.2. Eat a balanced diet, include fruits/vegetables.3. Keep physically active.4. If you drink, do so in moderation.5. Cover up in the sun.6. Practice safe sex.7. Participate in appropriate health screening.8. Drive defensively; don’t drink and drive.9. Manage your stress.10. Maintain social ties

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Social Determinants Approach

1. Don’t have poor parents or live in a poor neighborhood.

2. Don’t be poor. If you are, stop. If you can’t, try not to be poor for too long.

3. Get a job and practice not losing it.4. Own a car – but use it only for weekend

outings. Walk to work.5. Make sure you have health insurance.6. Don’t be illiterate. 7. Avoid social isolation.

Health Determinants“ The fundamental conditions and resources for

health are peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity. Improvement in health requires a secure foundation in these basic prerequisites.”

Ottawa Charter for Health Promotion

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Men Women Children Total

Class 1 (folks well off)

67% 3% 0% 38%

Class 2 92% 14% 0% 59%

Class 3(the under class)

84% 54% 66% 62%

Total 82% 26% 46% 62%

Mortality by Social Class among 1,316 People

Survival status of females by class

Died Lived Total % Died % Lived

1St class 4 139 143 2.8% 97.2%2nd class 15 78 93 16.1% 83.9%3rd class 81 98 179 45.3% 54.7%Total 100 318 415 24.1% 76.6%Source: Walter Lord (1955)

What was the cause of death in the last two slides?

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The Titanic: A Health Inequalities Metaphor

Inequalities continue

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The Root Causes: The Iceberg Metaphor

Tip of the Iceberg

Drug Abuse

PovertyHopelessness

EducationLow self-esteem

Societal indifferenceParenting practices

Social support

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WHO Commission on Social Determinants of Health

Health care is only one factor

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Individual Health Behaviors Matter but….

Healthy People 2020

Source: http://www.healthypeople.gov/HP2020/

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Healthy People 2020- Goals

• Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.

• Achieve health equity, eliminate disparities, and improve the health of all groups.

• Create social and physical environments that promote good health for all.

• Promote quality of life, healthy development, and healthy behaviors across all life stages.

Socio-ecological Model

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A population perspective is an ecological perspective

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The Built Environment

There is growing recognition that the built environment

—the man-made physical structures and infrastructure of communities—

has an impact on our health.

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Disparities in Built Environment:• access to food• access to parks, green

spaces• Housing• transportation

Frumkin, Howard. Env. Health Persp.,2005; 113(5), A290‐91.

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Example: Access to Food

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• In NYC, only 18% of grocery stores in East Harlem stocked diabetes-friendly foods, vs. 50% in the more affluent Upper East neighborhood.

• This may explain why diabetes rates in East Harlem are 2 times that of the state of New York.

• Horowitz et al., Am. J of Pub. Health, 2004; 94(9), 1549-54.

Example: Physical Activity and Space

• Direct relation between the convenience of the walking place and the proportion of respondents meeting current activity recommendations.”Powell et al. Am. J. of Pub. Health, 2003; 93(9), 1519-21.

• Walking at recommended levels was associated with having good access to attractive open spaces Giles-Corti et al. Am. J. of Pub. Health, 2003; 93(9), 1583-89.

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Moving Further Upstream to Improve Health

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RWJF: A New Way to Talk about the Social Determinants of Health

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What Does a Comprehensive Action Plan Look Like?

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