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Health Disparities, in Los Angeles, the state of California, & the US. Antronette (Toni) Yancey, MD, MPH Professor (7/1/07), Health Services Co-Director, Center to Eliminate Health Disparities. Staying healthy is easier for some than for others…. UPPER SES LOWER SES

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health disparities in los angeles the state of california the us

Health Disparities, in Los Angeles, the state of California, & the US

Antronette (Toni) Yancey, MD, MPH

Professor (7/1/07), Health Services

Co-Director, Center to Eliminate Health Disparities

staying healthy is easier for some than for others
Staying healthy is easier for some than for others…

UPPER SES LOWER SES

Education College GED or HS

Housing Own / Safe Rent / Safe?

Physical activity Gyms /Parks, “move Parks?, “move insecure”

secure”

Neighborhood stores Fruit/Veg, food secure Drugs/Alcohol, food insecure

Police Helpful Abusive

Healthcare Private Doc ER, VA

Sick leave Accrued None

Leisure priority Exercise Rest

Work conditions Safe, hi decis. lat., Hazardous, lo decis. lat., no +flex time no flex time

Child care Nanny/hi-qual facil. Family/neighbor, lo-qual facil.

Elder/disabled care HHW/hi-qual facil. Family/neighbor, lo-qual facil.

Criminal just. sys. Little contact Much contact

Premature M&M Low High

slide14

Death rates by cause for persons aged 45 to 65, 1995

Men

Women

Deaths per 100,000 persons

Source: National Center for Health Statistics

slide15

Years of Potential Life Lost to Diabetes

YPLL before age 75 y per100,000 population

Age-adjusted, 1998 data

Source: National Center for Health Statistics, Health US 2000, table 31

slide17

Age-Adjusted Prevalence of Overweight & Obese by Race – NHANES Adults

Left bars = BMI 25.0 or higher; right bars = BMI 30.0 or higher

slide18

Adult Obesity: 1988-94 to 1999-2000

Race/Ethnicity

1988-94

Target

Total

White

Female

Male

Black

Female

Male

Mexican American Female

Male

0 10 20 30 40 50

Percent

Note: Data are for ages 20 years and over, age adjusted to the 2000 standard population. Obesity is defined as BMI >= 30.0. Black and white exclude persons of Hispanic origin. Persons of Mexican-American origin may be any race.

Source: National Health and Nutrition Examination Survey, NCHS, CDC.

Obj. 19-2

race ethnic composition of the los angeles county population 1990 and 2000
Race / Ethnic Composition of the Los Angeles County Population, 1990 and 2000

1990

n= 8,863,164

2000

n=9,519,338

37.8%

44.6%

10.5%

9.5%

10.2%

0.7%

12.0%

40.8%

31.1%

2.8%

slide21

Percentage of Adults (Age 18 years and older) living below 200% of Federal Poverty Level, by Service Planning Area, Los Angeles County, 1999

LA County

40%

1999-2000 Los Angeles County Health Survey

Department of Health Services, Public Health

slide22
Percentage of Children (17 years old) Living in Poverty by Race/Ethnicity, Los Angeles County, 1999-2000

1999-2000 Los Angeles County Health Survey

Department of Health Services, Public Health

slide31
Prevalence of Overweight Among Children in Grades 5, 7, and 9, Los Angeles County, 2001(California Physical Fitness Testing Program)
slide32

Percentage of Children (Age 3 to 17 years) Whose Parents Report Not Having a Park, Playground, or Other Safe Place They Can Get to Easily, by Household Income, Los Angeles County, 1999-2000

1999-2000 Los Angeles County Health Survey

Department of Health Services, Public Health

*Federal Poverty Level

major points
Major Points
  • Significant reductions in mortality in the county population over the past decade.
  • Large disparities in health persist across racial/ethnic and socioeconomic groups.
  • Chronic non-infectious diseases and injuries comprise the predominant sources of morbidity and mortality; need to address underlying determinants.
  • Ongoing demographic shifts likely to shape future public health and health care needs.
current population status
Current Population Status
  • Little change in leisure time physical activity (PA) during past several decades of obesity increases (1 in 5), but marked increases in sedentary entertainment, transportation, and other ADLs (Sturm, 2004)
  • PA levels within increasingly sedentary, deconditioned, overweight population are unlikely to increase primarily through individual motivation and volition—relatively little demand for goods & services or political will to push for aggressive legislative policy change, e.g., radical alteration in the built environment favoring bicycle, pedestrian, and mass transit over private automobile transportation
population benefit estimates of risk factor change pa
Population benefit estimates of risk factor change: PA
  • 3-minute bouts of PA 10 times per day lowers serum triglycerides to same extent as 1 continuous 30-minute bout of PA (Miyashita et al., 2006)
  • Type 2 DM risk was 50% lower among individuals physically active at any level, and 66% lower among those at least moderately active (James et al., 1998)
  • Sedentary behaviors (e.g., TV watching) as well as sub-optimal >moderate PA levels contributed to DM & obesity risk over 6 yrs in women (Hu et al., 2003)
population obesity control early stage in development
Population Obesity Control: Early stage in development

To avoid exacerbating health risk/disease burden disparities, push strategies (skip-stop or slowed hydraulic elevators, proximal parking restrictions, non-discretionary time exercise breaks, walking meetings, mass transit & distant parking incentives) should be prioritized over pull strategies (building trails & parks, offering gym membership subsidies/discounts)—make it easier to do it than not to do it!

lesser effectiveness of key environmental interventions in underserved groups example
Lesser Effectiveness of Key Environmental Interventions in Underserved Groups: Example

Posting of Signs Promoting Stair Usage

(suburban Baltimore mall)

  • Overall, stair use increased from 4.8% to 6.9%, 7.2%, depending upon which of 2 signs used
  • Among whites, increased from 5.1% to 7.5%, 7.8%
  • Among blacks, changed from 4.1% to 3.4%, 5.0%
  • Among n’l wt, inc from 5.4% to 7.2%, 6.9%
  • Among overwt, inc from 3.8% to 6.3%, 7.8%

Andersen, Franckowiak, Snyder et al., Ann Int Med, 1998;129:363-369.

community cost sharing policy change opportunities
Community “Cost-Sharing:”Policy Change Opportunities

1. Leveraging your managerial and fiscal roles to mandate or incentivize healthy/fit workplace practices for your subsidiaries, suppliers, community-based organizations (CBOs) to which you donate $, health plans with which you contract, etc.

2. Changing your internal organizational culture (social norms) to create healthy/fit organizational practices, in your social life and in your workplaces.

community cost sharing
Community “Cost-Sharing”

“Healthy/fit” organizational PA promotion practicesinclude core & elective components, e.g., 10’ movement (or walking) breaks in meetings/ functions & at certain time(s) of day; walking meetings; stair prompts & improvements; leading employee groups to stairs in moving between work activities; restricted near parking; distant parking & mass transit incentives; model & reward fidgeting and lifestyle PA integration (e.g., less high heel & tie wearing, more pedometer wearing, formal recognition/ kudos to those who walk/jog/swim during lunchtime)

translating evidence based cdc acsm recommendation into practice building on cultural assets
Translating Evidence-Based CDC/ACSM Recommendation into Practice: Building on cultural assets

Integrating 10-’ PA into organizational routine:

  • Movement to music integral to African-American, Latino culture—dancing normative for adults
  • Short bouts minimize perspiration, hairstyle disturbance
  • Social support & conformity desires drive participation (collectivist vs. indiv. orientation)
  • Addresses less activity conducive outdoor environments (safety, utility, aesthetics)
  • Designed for organizational settings for work, worship, other purposes--less disposable t, $
lift offs work the rapidly growing evidence base
Lift Offs Work!: the Rapidly Growing Evidence Base
  • Documented individual and organizational receptivity to integrating PA on paid work time
  • Contribute meaningfully to daily accumulation of MVPA
  • Motivational “teachable moment” linking sedentariness to health status for inactive folks
  • Improvements in clinical outcomes from as little as one 10-min. break/day—BP, BMI, waist circ., mood, attention span, cumulative trauma disorders
  • “Spill-over” or generalization to inc. active leisure
  • Favorable cost-benefit ratio, eg, L.L. Bean mfg plant
community cost sharing48
Community “Cost-Sharing”

3. Address K-12 PE deficiencies:

  • Require use of evidence-based curricula focusing on cooperation vs. competition, lifetime PA, maximizing MVPA/session, behavioral mgt (e.g., self-monitoring, goal set.) vs. motor skill dev. focus
  • Include in core curriculum, with same resources, monitoring & accountability as reading, math
  • Increase mandated t to 1 hr daily instruction K-12
  • Require training in PE instruction in all undergraduate education curricula
  • Require elementary-level PE to be taught by certified PE specialists
  • Institute PE class size caps of <35
slide50

Avg. amount of PE class time in MVPAby class size (secondary schools only)

N=6

N=12

N=12

N=10

Class Size

The amount of P.E. class time that students were physically active was less in larger classes.

community cost sharing52
Community “Cost-Sharing”

4. Local legislative policy advocacy:

Redress inequitable distribution of free-for-use recreational facilities favoring high-income areas and poor upkeep of parks & playgrounds in low-income areas

--explore litigation (Public Health Law Center)

--explore limited liability protection (“Good Samaritan” laws) for organizations making facilities available for joint use before-/after-hours

--explore incentives for locating supermarkets & other produce vendors in low-income areas

slide53

Community “Cost-Sharing”

“We must be the change

we wish to see in the world.”

--Mahatma Gandhi