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Determinants of Health and Health Disparities: Conceptual Frameworks . Eliseo J. P é rez-Stable, MD Center for Aging in Diverse Communities April 24, 2008. Types of Diverse Groups. Current health disparities research focuses on differences across race/ethnic groups

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determinants of health and health disparities conceptual frameworks

Determinants of Health and Health Disparities: Conceptual Frameworks

Eliseo J. Pérez-Stable, MD

Center for Aging in Diverse Communities

April 24, 2008

types of diverse groups
Types of Diverse Groups
  • Current health disparities research focuses on differences across race/ethnic groups
  • Much prior research examined differences by socioeconomic status (SES):
    • Low income vs. others
    • Low education vs. others
  • Both are “vulnerable” populations
phases of disparities research
Phases of Disparities Research

Detecting

Define health disparities

Define vulnerablepopulations

Understanding

Identify determinants and mechanisms

of disparities

Reducing

Intervene

Evaluate

Translate/disseminate

Change policy

Adapted from Kilbourne et al, 2006

defining disparities vulnerable populations have worse health than their counterparts
Defining Disparities: Vulnerable populations have worse health than their counterparts….:
  • Premature mortality including infant mortality
  • Morbidity
    • Chronic disease (heart disease, diabetes, 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 disparities
Understanding 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, perceived discrimination, educational experiences, SES, culture
parallel question socioeconomic status disparities
Parallel Question: Socioeconomic Status 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, culture
understanding and reducing disparities role of conceptual frameworks
Understanding and Reducing 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
conceptual frameworks need to depict determinants of health disparities
Conceptual Frameworks Need to Depict Determinants of Health Disparities

Race/ethnic and SES healthdisparities

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
Three Broad Types of Conceptual Frameworks
  • Population science
    • Determinants of health in a population: Model
    • 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
population based determinants multiple levels of influence on health
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
population based determinants multiple levels of influence on health 2
Population-Based Determinants: Multiple Levels of Influence on Health 2
  • 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
Individual Embedded in Ecological Context

Society

Community

Family

Family

Individual

one ecological model of determinants of health
One Ecological Model of Determinants of Health

Living and working conditions

Individual behavior

Bio-behavioralmechanisms, genetics

Over the lifespan

Social, family, community networks

NationalAcademy ofSciences, 2002

Macro social, environmental conditions and policy

an alternative depiction of multi level determinants of health disparities
An Alternative Depiction of Multi-level Determinants of Health Disparities

Contextual

Individual-level

Physical environment

Sociodemographics - age, race, ethnicity, education, income

Social environment

Psychosocial - compliance, coping

Health

disparities

Health care

Organizational,

institutional

Lifestyle - exercise, diet, alcohol, smoking, sexual behavior, illicit drug use

Economic resources

Psychological - beliefs, attitudes,personality

Societal, political

ecological multi level determinants
Ecological, Multi-level Determinants

Context

Individual-level

Physicalenvironment

Sociodemographics - age, race, ethnicity, education

Social environment

Psychosocial - compliance, coping

Health

disparities

Health care

Lifestyle - exercise, diet, alcohol, smoking, sexual behavior

Organizational,

institutional

Psychological -beliefs, attitudes, personality

Economic resources

Biological, physiological

Societal, political

physical environment
Neighborhood safety, attractiveness

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, bicycling

Physical Environment
ecological multi level determinants1
Ecological, Multi-level Determinants

Context

Individual-level

Physical environment

Sociodemographics - age, race, ethnicity, education

Social environment

Psychosocial - compliance, coping

Health

disparities

Health care

Lifestyle - exercise, diet, alcohol, smoking, sexual behavior

Organizational,

institutional

Psychological -beliefs, attitudes, personality

Economic resources

Biological, physiological

Societal, political

social environment
Social Environment
  • Social opportunities
  • Family environment
  • Social support
  • Discrimination or racism
  • Neighborhood cohesiveness
  • Community meeting places
conceptual frameworks of determinants social environment
Conceptual Frameworks of Determinants: Social Environment

Socialstructuralconditions(macro)

Social networks (mezzo)

Psycho-socialmechanisms (micro)

Pathways

  • Culture
  • Socio economic factors
  • Network structure
  • Frequency of contact
  • Social support
  • Social influence
  • Access to resources
  • Health behaviors
  • Psychological
  • Physiologic

Berkman LF and Glass T, Social integration, social networks, social support, and health, in Social Epidemiology, chapter 7, p 143.

ecological multi level determinants2
Ecological, Multi-level Determinants

Context

Individual-level

Physical environment

Sociodemographics - age, race, ethnicity, education, SES

Social environment

Psychosocial - compliance, coping

Health

disparities

Health care

Lifestyle - exercise, diet, alcohol, smoking, sexual behavior

Organizational,

institutional

Psychological -beliefs, attitudes, personality

Economic resources

Biological, physiological

Societal, political

societal approaches to health improvement
Societal Approaches to Health Improvement
  • Prevention strategies that target population health by changing social and community environments
    • “No smoking” ordinances
    • Taxation policies
    • Smog control legislation
    • Food labeling

Singer BH et al. New Horizons in Health, 2001

societal approaches
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
Lifestyle as a Pathway

Contextual

Individual-level

Physical environment

Sociodemographics - age, race, ethnicity, education, income

Social environment

Psychosocial - compliance, coping

Health

disparities

Health care

Organizational,

institutional

Lifestyle - exercise, diet, alcohol, smoking, sexual behavior, other substance use

Economic resources

Psychological - beliefs, attitudes,personality

Societal, political

lifestyle as a pathway 2
Lifestyle as a Pathway 2

Contextual

Individual-level

Physical environment

Sociodemographics - age, race, ethnicity, education, income

Lifestyle, health behavior

Social environment

Health care

Psychosocial - compliance, coping

Organizational,

institutional

Health

Psychological - beliefs, attitudes

Economic resources

Community resources

Emmons, K Health behavior in a social context, in Social Epidemiology, 2000, ch. 11.

Policy

the role of socioeconomic status
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 determinants3
Ecological, Multi-level Determinants

Low SES context

Low individual-level SES

Physical environment

Sociodemographics - age, race, ethnicity, education, SES

Social environment

Psychosocial - compliance, coping

Health

disparities

Health care

Lifestyle - exercise, diet, alcohol, smoking, sexual behavior

Organizational,

institutional

Psychological -beliefs, attitudes, personality

Economic resources

Biological, physiological

Societal, political

living in poor neighborhoods increases health risk
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-level factors

KE Pickett, J Epidemiol Comm Health 2001;55:111.

access to markets with healthy foods for diabetics in new york city
Access to Markets with Healthy Foods for Diabetics in New York City
  • Food targets: Fruit, vegetables, 1% fat milk, diet drinks, high fiber bread
  • 173 stores in East Harlem and 152 stores in Upper East Side
  • Had all 5 categories: 9% vs. 48%
  • More likely to live on a block with no store selling foods in E Harlem–50% vs. 24%
  • Example of disparities in environmental justice issues complicating behavior

AJPH 2004; 94: 1549-54

example from hilary seligman access to healthy foods and health
Example from Hilary Seligman: Access to Healthy Foods and Health

Context

Individual-level

Physical Access toHealthy Food:

TransportationNumber of grocery stores

Distance to nearest grocery store

Food insecurity- not enough money to buy food

Obesity,diabetes

Lifestyle behaviors- shop at stores with healthy food- buy healthy food

- eat healthy food

Financial Resources:Income/economic strain

cumulative pathways or lifecourse issues
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
framework socioeconomic status over the lifecourse and health
Framework: Socioeconomic Status Over the Lifecourse and Health

Socioeconomic Position

Intrauterineconditions

Education,environment

Work conditions,

income

Income,

assets

Birth

Childhood

Adulthood

Old Age

Inadequate

medical care

Low birth weight

Growth retardation

Smoking,diet, exercise

Job stress

Atherosclerosis

CVD

Reducedfunction

Lynch J and Kaplan G, Social Epidemiology, Oxford, 2000 (Ch 2, p. 28)

example of lifecourse research
Example of Lifecourse Research

“Compared with middle- and high-income children, low-income children are disproportionately exposed to more adverse social and physical environmental conditions.” (Evans, 2004, p. 88)

Cumulative exposure is critical…

Evans GW, The environment of childhood poverty,Amer Psychol, 2004:59:77-

racism discrimination a plausible lifecourse hypothesis
Racism/Discrimination: a Plausible Lifecourse Hypothesis

Health outcomes of racism:

  • Hypertension
  • Psychological distress
  • Poorer self-rated health

… all are independent of effects of SES

Nazroo JY, AJPH, 93: 277

Williams DR, Ethn Dis, 2001;11:800

biopsychosocial effects of perceived racism on health clark et al 1999
Biopsychosocial Effects of Perceived Racism on Health (Clark et al., 1999)

Environmental stimulus

Sociodemographic,

Psychological,

Behavioral factors

Perception

Perception of racism

Perception of different

stressor

No perception of racism or other stressor

Coping responses

Blunted psychological and physiological stress responses

Psychological and physiological stress responses

Health outcomes

three broad types of conceptual frameworks1
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
Structure-Process-Outcome Paradigm

Process of care:

-technical care

-interpersonal care

Structure

of care

Patient outcomes

  • 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

research on how structure of care affects disparities
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 providers, do minority patients have better health outcomes?
research questions on how technical processes affect disparities
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?
    • e.g., pain medication in emergency departments
research questions on how interpersonal processes affect disparities
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
Ethnicity in Patient-Doctor Relationship
  • Refusal: whose issue?
  • DNR discussions–Race of clinician is an independent predictor
  • Cultural competence
  • Language factors
  • Racism may affect behavior:
    • Fewer cardiology referrals in Blacks
structure process outcome paradigm1
Structure-Process-Outcome Paradigm

Process of care:

-technical care

-interpersonal care

Intermediatepatient outcomes:

- compliance

- knowledge

Structure

of care

Ultimate patient outcomes

- health

another type of intermediate outcome
Another Type of Intermediate Outcome

Process of care:

-technical care

-interpersonal care

  • Intermediatepatient outcomes:
  • blood pressure
  • weight
  • HbA1c

Structure

of care

  • Ultimate patient outcomes
  • mortality
  • morbidity
structure process outcome paradigm2
Structure-Process-Outcome Paradigm

Process of care:

-technical care

-interpersonal care

Structure

of care

Intermediateoutcomes

-compliance

-knowledge

Providercharacteristics

Ultimate outcomes

- health

structure process outcome paradigm3
Structure-Process-Outcome Paradigm

Process of care:

-technical care

-interpersonal care

Structure

of care

Intermediateoutcomes

-compliance

-knowledge

Providercharacteristics

Cultural competence:System and providers offer highest quality care to all patients regardless of ethnicity,culture, or language proficiency

Ultimate outcomes

- health

structure process outcome paradigm4
Structure-Process-Outcome Paradigm

Process of care:

-technical care

-interpersonal care

Structure

of care

Intermediateoutcomes

- compliance

- knowledge

Providercharacteristics

Patient characteristics

Ultimate outcomes

- health

blending population and health services frameworks
Blending Population and Health Services Frameworks

Process of care:

-technical care

-interpersonal care

Structure

of care

Intermediateoutcomes

- compliance

- knowledge

Providercharacteristics

Patient characteristics

Environment

Ultimate outcomes

- health

Neighborhood resources

Family support

alternative health services research framework for health disparities
Alternative Health Services Research Framework for Health Disparities

Health care system factors

Patientfactors

Interpersonal

relationship

Provider factors

Adapted from Kilbourne et al., 2006

second alternative health services research framework for health disparities
Second Alternative Health Services Research Framework for Health Disparities

Health care system factors

Patientfactors

Interpersonal

relationship

Provider factors

Visit

Saba et al. J Fam Med., 2006

summary conceptual frameworks
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