Addressing Disparities through Public Health Practice
Health Disparity: differences in disease prevalence, outcomes or access to care Health Inequality: differences in health that can be ranked Health Inequity: systematic differences in health or major social determinants of health) between groups with different levels of social advantage (wealth, power, or prestige) What are we talking about?
Key Concepts • How socioeconomic conditions are linked to inequalities in health outcomes • Model constructs & how to measure them • Brief overview of research on health inequities related to Community Nutrition • Intervention strategies & current knowledge about their effectiveness • What are we doing at the Department of Health?
1. How socioeconomic conditions are linked to inequalities in health outcomes
How are Social Conditions linked to Health Disparities? Conceptual Model created by the World Health Organization Commission on Social Determinants of Health
What do I need to know about health disparities? • (1) Socioeconomic status has a big impact on health, which is not limited to the effects of poverty but occur at all levels. Compared to those who are most privileged, premature death is more than 2 times as likely for middle income Americans, and more than 3 times as likely for those who live in poverty (2) Throughout life, from birth onward, our access to socioeconomic resources affects our chances for living a healthy life. The conditions we live in during childhood affect our health throughout our lives. (3) Health care is important when we are ill but accounts for only a small portion of health disparities. More important are factors that determine if we fall ill in the first place. (4) Each step up the social ladder provides greater access to social and physical environments that enable individuals to engage in health protective behaviors, (e.g., safe places to walk and access to healthier foods). Each step down, greater exposure to potential risks (pollution & unsafe neighborhoods).(5) Work conditions contribute to health & health disparities. Low-wage jobs may involve shift work and physical hazards, low control over how and when tasks are done, job insecurity, and conflicts between family obligations and work requirements. (6) Exposure to extreme and prolonged “toxic” stress is more common lower on the social ladder. Stressors that last a long time, like financial insecurity, interpersonal disputes, work-induced exhaustion, or chronic conflict are recorded in the body.
Data Set Directory of Social Determinants of Health at the Local Level Data Set Directory of Social Determinants of Health at the Local Level Data Set Directory of Social Determinants of Health at the Local Level • University of Michigan SPH project funded by the CDC. Developers included experts in epidemiology, sociology, geography, medicine, demography, economics, developmental psychology, education, and toxicology • Directory includes extensive list of current data sets that can be used to address SDOH. Data sets are organized in 12 dimensions of the social environment. Each dimension is subdivided into various components.
12 Dimensions Source; Hillemeier M.M., J. Lynch, S. Harper, and M. Casper. 2003. "Measuring contextual characteristics for community health." Health Services Research 38(6 part 2):1645–717.
Economic Dimension • This table presents the components and indicators of the economic dimension. Nine economic components are identified: • Income • Wealth • Poverty • Economic Development • Financial Services • Cost of Living • Redistribution • Fiscal Capacity • Exploitation Source; Hillemeier M.M., J. Lynch, S. Harper, and M. Casper. 2003. "Measuring contextual characteristics for community health." Health Services Research 38(6 part 2):1645–717.
Harvard Geocoding Project: Measures of Socioeconomic Position* Key domains: • Occupational class: affects health via occupational hazards and income/standard of living; • Educational attainment: reflects childhood SEP and future economic prospects, also knowledge & health literacy; • Income & subsidies: affects standard of living; • Wealth: referring to accumulated assets, • Relative social ranking: “status” & “prestige.” • * Source:Public Health Disparities Geocoding Project
Area Based Measures of Socioeconomic Class Each of the previous 5 socioeconomic class domains can be assessed at multiple levels--individual, household, and area or neighborhood. Socioeconomic data can be measured at key points in the lifecourse -- in utero, infancy, childhood, and early, middle, and late adulthood. Composite measures combine information on more than one component variable. For example, the Townsend index consists of % unemployment, % renters, % not owning a car, and % crowding. * Source: Public Health Disparities Geocoding Project
Townsend Index: comparing two Boston neighborhoods This economically depressed area in Boston's Chinatown, turned out to be characterized as a highly working class, poor, low income area with high unemployment and few expensive homes. This one house in Beacon Hill looked like it was -- and turned out to be -- in a fairly affluent area: over 75% professionals, low poverty, high income, low unemployment, and lots of expensive homes.
3. Brief overview of research on health inequities related to Community Nutrition
The high-fat, high-salt, and low-vegetable/fruit diets found in disadvantaged populations are often less the result of bad choices than the unfortunate consequence of the shrinking number of good, affordable supermarkets in inner-city neighborhoods, the explosion of fast food restaurants in urban areas, and food traditions originating in deprivation. Similarly… higher rates of smoking and alcohol use…are more a response to the pressures of poverty and lack of employment opportunities than “lifestyle choice.” • Amersbach,G. Through the lens of race: Unequal health care in America. Harvard Public Health Review, Winter 2002. Viewed 3/5/2006. http://www.hsph.harvard.edu/review/review_winter_02
Assembling a Mosaic of Evidence “The community nutrition environment may explain some of the racial, ethnic and socioeconomic disparities in nutrition and health such as the increasing prevalence of overweight in low income children. Supermarkets...are less common in lower income and minority neighborhoods than in other neighborhoods…recent evidence links access to supermarkets with such indicators of healthful eating as fruit and vegetable intake among African American adults (and) household fruit consumption…” The role of the built environments in physical activity, eating and obesity in childhood, Sallis J, Glanz, K. www.futureofchildren.org, vol 16 (1), 2006.
“Supermarkets...are less common in lower income and minority neighborhoods” • A study of access to food markets and restaurants by neighborhood wealth (median HH income) on MS, NC, MD and MN showed that wealthy neighborhoods had 3 times as many grocery stores as poor neighborhoods. Supermarkets were 4 times more common in white neighborhoods compared to black neighborhoods (Moorland et al, Am J Prev Med 2002; 22(1) • Spatial regression analysis of average distance to the nearest supermarket in 869 Detroit neighborhoods showed that distance to nearest supermarket was about the same in wealthier neighborhoods, regardless of racial makeup. Among poor neighborhoods, those with high proportion of African Americans were 1.1 miles further from the nearest market than white neighborhoods. (Zenk et. al,Am J Pub Hlth 2005 95(4)
“…access to supermarkets linked to such indicators of healthful eating as fruit and vegetable consumption…” • A comparison of food frequency questionnaires in 10,623 study participants with geocoded information on subject home addresses and local supermarkets showed that for blacks, fruit and vegetable intake increased by 31% for each additional supermarket in the neighborhood, compared to 11% for whites.Morland, et. al, Am J Pub Hlth 2002; 92(11) • A study of fruit and vegetable consumption among food stamp participants showed that households living more than 5 miles from their principal store consumed less fruit than those living within a mile of their storeRose, et. al, Pub Hlth Nutrition 2004, 7 (8)
World Health Organization Conceptual Framework Conceptual Model created by the World Health Organization Commission on Social Determinants of Health
Whatpolicies would eliminate inequalities? 2. Policies that Blunt Adverse Consequences 1. Policies that Affect the Ladder
Chronic Disease Prevention Unit (CDP)Process to Address Health Disparities • Objectives: • Learn about social and economic factors driving health disparities to create a common understanding • Brainstorm what public health professionals can and should do to address the social determinants of health • Create an action plan to address health disparities in a more upstream fashion. • Process: • Education: 4 half-day sessions covering key concepts linking social and economic determinants to health and potential interventions • Brainstorming: A half-day exploration of what needs to be changed in our public health practice • Action Planning: A half-day planning session, using the Institute for Cultural Affairs model, to determine what we need to do to achieve these changes.