CENTER ON SOCIAL DISPARITIES IN HEALTH
Transcript of CENTER ON SOCIAL DISPARITIES IN HEALTH
CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco
Where health disparities begin: the role of social and economic determinants
March 20 9th Annual Health Disparities Symposium University of Alabama, Birmingham Paula Braveman, MD, MPH Professor of Family & Community Medicine Director, Center on Social Disparities in Health University of California, San Francisco
A few definitions
Health disparities: health differences closely linked with social & economic disadvantage adversely affect groups who are at an underlying social disadvantage– e.g., based on race, wealth, gender, disability, LGBT – because of historical discrimination or exclusion
Health equity : the principle underlying a commitment to eliminate disparities. implies addressing social (including economic) determinants of health, as well as health care Justice
Social determinants: non-medical factors that influence health and can be shaped by policies; includes economic factors
Infant mortality rate: England and Wales
0
20
40
60
80
100
120
140
160
1842 1860 1873 1888 1903 1915 1932 1946 1962
Source: T. McKeown, 1974.
NICU’s
Penicillin
Age-adjusted mortality by occupation, UK civil servants aged 40-64, Whitehall Study
Source: Marmot, M. G., et al (1984). "Inequalities in death--specific explanations of a general pattern?" Lancet 1(8384): 1003-1006.
Life expectancy in US varies by income in a stepwise gradient pattern
45.5
51.5
47.7
54.5
51.1
56.5
53.5
58.2
40
45
50
55
60
Men Women
Life
exp
ecta
ncy
at a
ge 2
5 ≤100% FPL 101-200% FPL201-400% FPL401%+ FPL
Family Income: Percent of Federal Poverty Level
Source: National Longitudinal Mortality Study, 1988-98.
Child health varies by parents’ income (& education): Poor/fair child health reported by parent
4.3
2.4
1.4
1.0
0.6
0
1
2
3
4
5
6
% o
f chi
ldre
n ag
e 0-1
7 yea
rs
with
poo
r/fai
r hea
lth
<100% FPL100%-199% FPL200-299% FPL300-399% FPL≥400% FPL
Source: National Health Interview Survey (NHIS) 2001-2005. Age-Adjusted.
Family Income (% of Federal Poverty Level)
Family Income (Percent of Federal
Poverty Level)
Racial/ethnic differences do not explain differences in adult health by income
23.9
19.2 20.9
18.3
15.6 14.8
11.2 10.3
7.7 6.8 6.4
4.0
0
5
10
15
20
25
Black, Non-Hispanic Hispanic White, Non-Hispanic
Perc
ent o
f per
sons
with
poo
r/fa
ir he
alth
<100%
100%-199%
200%-399%
≥400%
Family Income: Percent of Federal Poverty Level
Source: CDC/NCHS, National Health Interview Survey 2010. Age adjusted.
How could income affect health? A body of literature supports:
Income can shape options for: • Housing • Neighborhood conditions • Diet • Exercise • Services (e.g., childcare,
transportation, repairs, medical care…) that can alleviate stress
• Most of above can affect stress and thus family stability
Parents’ income shapes the next generation’s: • Education • Work • Income
Income shapes neighborhood options. How could a neighborhood affect health?
Safe places to exercise Access to healthy food Ads for harmful substances Social networks & support Norms, role models, peer
pressure Fear, anxiety, despair, stress Quality of schools Racial segregation tracks
Blacks & Latinos into poorer neighborhoods than Whites of similar income
Image: http://www.seattlemet.com/news-and-profiles/publicola/ articles/some-rich-architects-mansion.
CENTER ON SOCIAL DISPARITIES IN HEALTH University of Cali fornia, San Francisco
The stress-health link: biologically plausible?
• Advances in neuroscience help elucidate how social factors “get into the body”
• HPA axis, sympathetic nervous system, and immune/inflammatory mechanisms have been demonstrated as responses to stress – Mediators include cortisol, other stress hormones,
cytokines, telomerase
• Chronic stress is a plausible and likely major contributor to both socioeconomic and racial/ethnic inequalities in health
CRH
DAMAGE TO MULTIPLE ORGANS & SYSTEMS
chronic disease, immune suppression, inflammation
STRESSOR
CORTISOL
Hypothalamus
Pituitary Gland
Adrenal Glands
ACTH
Source: Center on Social Disparities in Health, UCSF.
How could stress affect health?
Less income, more stressors Separation or divorce during pregnancy (similar patterns for 11 major stressors)
12.7
7.0
3.63.0
1.2
0
3
6
9
12
15
% o
f wom
en s
epar
ated
or d
ivor
ced
durin
g pr
egna
ncy
Family Income (% of Federal Povery Level)
≤100%
101-200%
201-300%
301-400%
>400%
Family Income:Percent of Federal Poverty Level
Source: CA Maternal & Infant Health Assessment 2003-2006.
More education, longer life
47.1
51.7 51.4
57.0
52.3
58.1 56.4
60.3
40
45
50
55
60
65
Men Women
Life
Exp
ecta
ncy
at a
ge 2
5
Less than high schoolHigh-school graduateSome collegeCollege graduate
Educational Attainment:
Source: CDC/NCHS, National Health Interview Survey Linked Mortality File, 2006.
Racial/ethnic differences do not explain adult health differences by education
Source: Braveman, Cubbin et al., analyses of BRFSS 2008-2010. Age-Adjusted.
0
10
20
30
40
50
60
Black, Non-Hispanic Hispanic Asian American Indian orAlaska Native
White, Non-Hispanic
Perc
ent o
f adu
lts, a
ges 2
5-74
yea
rs,
in p
oor/
fair
heal
th
Less than high school
High-school graduate
Some college
College graduate
Educational Attainment:
Braveman et al. analyses of NHIS 2001-2005. Age-Adjusted.
0
5
10
15
20
25
30
35
40
<100% 100%-199% 200-299% 300-399% ≥400%
% o
f adu
lts a
ge ≥
25 y
ears
w
ith se
lf-re
port
ed p
oor/
fair
heal
th
Family Income (% of Federal Poverty Level)
Black, Non-HispanicHispanicWhite, Non-Hispanic
Both race and socioeconomic factors matter
•Diet
•Exercise •Smoking
•Health/disease management
Education can shape health behaviors by determining knowledge and skills
•Health knowledge •Literacy
•Problem-solving
• Coping skills
Educational attainment
Other plausible pathways from education to health, e.g., via work & income
HEALTH Educational attainment
Health insurance Sick leave Stress
Neighborhood/ school environment Diet & exercise
options Stress
Working conditions
Work-related
resources
Income
Work
Control / demand imbalance Stress
Psychosocial pathways from education to health
Educational attainment
Social & economic resources Norms
Social support Stress
HEALTH
Social & economic resources
Perceived status Stress
Control beliefs (powerlessness, sense/locus of
control, fatalism, mastery)
Social standing
Social networks
Coping Response to
stressors
Educational attainment
HEALTH
Exposure to hazards Control / demand imbalance Stress
Work-related resources
Housing Neighborhood environment Diet & exercise options Stress
Work Health insurance Sick leave Stress
Working conditions
Income
HEALTH
HEALTH
How could education affect health? Diet Exercise Smoking Health/disease management
Educational attainment
Control beliefs Coping & problem solving Response to stressors Health-related behaviors
Social standing
Social networks
Social & economic resources Perceived status Stress
Social & economic resources Social Support Norms for healthy behavior Stress
HEALTH
Health knowledge, literacy, coping & problem solving
Educational attainment
Social position, e.g. by race & class
Social consequences
of ill health
Disease
1. Social stratification
SOCIETY INDIVIDUAL
Specific exposure
5. Further social stratification
3. Differential vulnerability
2. Differential exposure
4. Differential consequences
Social Context
Policy Context
Understanding health disparities across the life course and across generations
Adapted from Finn Diderichsen, U. Copenhagen 20
Preventing unequal consequences
Decreasing exposures
Decreasing vulnerability
Influencing social stratification
CENTER ON SOCIAL DISPARITIES IN HEALTH University of Cali fornia, San Francisco
Childhood social/economic conditions shape adult health
Adult health is shaped by early experiences Lasting effects of in utero/early childhood deprivation, e.g.,
– Low SES in adulthood (by limiting education) – Neuro-endocrine or immune dysregulation – May not be erased by later circumstances
Chronic stress/deprivation in childhood chronic disease in childhood and adulthood Critical or sensitive periods
Cumulative effects of disadvantage
CENTER ON SOCIAL DISPARITIES IN HEALTH University of Cali fornia, San Francisco
Epigenetics: “Genetics loads the gun. The environment pulls the trigger” (J. Stern)
Features of social and physical environments can interact with an individual’s genome to influence whether a gene is expressed Experience can become biologically embedded --Some alterations in gene expression are heritable! May be important in intergenerational transfer of health risk and social disadvantage Policies can alter the social/physical environmental exposures that trigger/suppress gene expression
Social environment
Physical, chemical,
& built environments
Nutrition
Gene- environment interaction
Physiological adaptations
& disruptions
Health-related behaviors
Educational achievement & economic productivity Physical &
mental health
Biological embedding during sensitive periods
Cumulative effects over time
Foundations of healthy development and sources of early adversity
Lifelong outcomes
How early experiences get into the body
Adapted from Harvard Center on the Developing Child
CENTER ON SOCIAL DISPARITIES IN HEALTH University of Cali fornia, San Francisco
Residual confounding of observed racial/ethnic differences in health by unmeasured
socioeconomic factors & racism-related stress
At the same education level, whites have more income At the same income, whites have more wealth and live in
better-off neighborhoods At same current SES, whites had higher SES in childhood Residual confounding by unmeasured SES -- direct and
indirect effects And: unmeasured stressors related to racial
discrimination
CENTER ON SOCIAL DISPARITIES IN HEALTH University of Cali fornia, San Francisco
Structural racial bias transmits socioeconomic disadvantage across generations The legacy of (once-legal) discrimination: Lower incomes, wealth, education, occupations And, at a given income or educational level, African Americans and Latinos on average: Have less wealth Live in under-resourced, often unhealthier neighborhoods Were worse off in childhood More hardship with fewer resources to cope Rarely measured but studies often conclude a racial difference
is genetic if it persists after “control for SES” Race often captures unmeasured socioeconomic factors
CENTER ON SOCIAL DISPARITIES IN HEALTH University of Cali fornia, San Francisco
Can racial discrimination harm health in other ways – other than by limiting education, income, wealth…?
Overt incidents still occur But considerable stress even without overt incidents Pervasive subtle incidents. Chronic, pervasive concern
about being judged or treated unfairly based on race Discrimination could affect health through pathways
involved in stress; chronic stress is particularly toxic, even in absence of dramatic events
Internalized racism could harm health by undermining self-esteem and sense of control
Economic & Social Opportunities and Resources
Living & Working Conditions in Homes and Communities
Behaviors Medical
Care
Interactions between genes and experiences
Pursuing health equity: Understanding the role of social factors
Policies to promote healthier homes, neighborhoods,
schools and workplaces
Policies to promote child and youth development
and education, infancy through college
Policies to promote economic development and reduce poverty,
and reduce racial segregation
HEALTH
© 2013 Robert Wood Johnson Foundation Commission to Build a Healthier America | Overcoming Obstacles to Health in 2013 and Beyond