Determinants of Health and Health Disparities: Conceptual Frameworks, Social, Behavioral and...
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Transcript of Determinants of Health and Health Disparities: Conceptual Frameworks, Social, Behavioral and...
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
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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