Overview of Conceptual Frameworks of Health and Health Disparities

1
Overview of Conceptual Frameworks of Health
and Health Disparities

• Anita L. Stewart, Ph.D.
• UCSF, Institute for Health Aging
• Center for Aging in Diverse Communities
• April 4, 2006

2
Types of Diverse Groups

• Health disparities research focuses on health
  differences across diverse race/ethnic groups
• A sizeable amount of research has examined
  differences in health across levels of
  socioeconomic status (SES)
• Low income vs. others
• Low education vs. others

3
Minority and lower SES persons have worse health
than their counterparts in.

• Premature mortality including infant mortality
• Morbidity
• Chronic disease (heart disease, diabetes, cancer)
• Communicable disease (TB)
• Low birth weight
• Physiological and anthropometric risk factors
• Hypertension
• Obesity/overweight
• Functional limitations, disability
• Self-rated health

4
Purpose of Conceptual Frameworks

• Ground research in theory and knowledge
• Help identify key variables and develop specific
  research questions
• Guide the selection of measures

5
Underlying Question Research in Race/Ethnic
Health Disparities

• What is it about being classified in an ethnic or
  racial group that could lead to poorer health
  compared to mainstream groups?
• What does race/ethnicity stand for
• Deconstruct race/ethnic group membership into
  underlying variables
• Behaviors, attitudes, values, beliefs, ethnic
  identity, acculturation, discrimination,
  educational experiences, socioeconomic status,
  culture

6
Population vs. Health Services Research
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

7
Conceptual Frameworks Needed to Depict
Determinants of Health Disparities
Race/ethnic and SES health disparities
Determinants
Frameworks cast a broader net - add
determinants -- relevant to vulnerable
population groups -- that vary across and within
race/ethnic groups -- that are plausible
mechanisms by which health disparities occur
8
Population vs. Health Services Research
Frameworks Disciplines

• Population science
• Epidemiology - Psychology
• Social epidemiology - Social psychology
• Public health - Sociology
• Health services research
• Medical sociology - Health psychology
• Health administration - Behavioral medicine
• Epidemiology - Economics

9
Population-Based Determinants of Health

• Some believe that medical care accounts for only
  10 of the variance in health (Adler, McGinnis)
• But medical care may have a greater impact on
  the health of vulnerable racial and low SES
  groups than on their counterparts (Williams and
  Collins, p. 373)

Williams DR and Collins C, Ann Rev Sociol
199321349-86
10
Population-Based Determinants Multiple Levels of
Influence on Health

• Individual
• physiological, biological, behaviors, attitudes,
  beliefs
• Family
• size, structure, support, beliefs
• Neighborhood or community
• resources, transportation, toxins, aesthetics,
  crime/poverty

11
Population-Based Determinants Multiple Levels of
Influence on Health (cont)

• Cultural group, ethnic identity
• shared beliefs, values, behaviors
• Occupation or workplace
• occupational hazards, toxins, safety, working
  conditions
• Organizational/institutional structures
• Educational system, health care
• Societal, political

12
Perspectives on Racial and Ethnic Differences (p
34)

• Five categories of factors
• Macrosocial (culture, institutions)
• Behavioral risk factors
• Risk taking and abusive behaviors
• Adaptive health behaviors, coping
• Health care behavior
• PLUS socioeconomic status, other social factors,
  and macrosocial environment

13
Another Depiction Individual Embedded in
Ecological Context
Society
Community
Family
Family
Individual
14
Multi-level Determinants of Health An
Alternative Depiction
Contextual
Individual-level
Sociodemographics - age, race, ethnicity,
education, income
Physical environment
Social environment
Psychosocial - compliance, coping
Health
Health care
Organizational, institutional
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior, illicit drug use
Economic resources
Psychological - beliefs, attitudes,personality
e.g., Larry Green,Dan Stokols
Societal, political
15
Hilary Seligman Access to Healthy Foods and
Health Outcomes
Context
Individual-level
Physical Access toHealthy Food TransportationNu
mber 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 ResourcesIncome/economic strain
16
Population Science Ecological,Multi-level
Determinants of Health
Context
Individual-level
Sociodemographics - age, race, ethnicity,
education
Physical environment
Social environment
Psychosocial - compliance, coping
Health
Health care
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior
Organizational, institutional
Psychological -beliefs, attitudes, personality
Economic resources
e.g., Larry Green,Dan Stokols
Biological, physiological
Societal, political
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Physical Environment

• Neighborhood safety, attractiveness
• Quality of housing
• Transportation
• Segregation
• Hazardous materials
• Occupational hazards
• Number of liquor stores
• Number of full service grocery stores
• Availability of fresh fruits and vegetables
• Number of areas for walking, bicycling

18
Population Science Ecological,Multi-level
Determinants of Health
Context
Individual-level
Sociodemographics - age, race, ethnicity,
education
Physical environment
Social environment
Psychosocial - compliance, coping
Health
Health care
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior
Organizational, institutional
Psychological -beliefs, attitudes, personality
Economic resources
e.g., Larry Green,Dan Stokols
Biological, physiological
Societal, political
19
Social Environment

• Social opportunities
• Family environment
• Social support
• Discrimination or racism
• Neighborhood cohesiveness
• Community meeting places

20
Discipline of Social Epidemiology

• studies the social distribution and social
  determinants of states of health (p. 6)
• Determinants
• Socioeconomic position
• Discrimination
• Working conditions
• Social integration, social networks
• Health behaviors
• Physical and social environments

Berkman LF and Kawachi I, Social Epidemiology,
Oxford, 2000.
21
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, ch 7, p. 143.
22
Population Science Ecological,Multi-level
Determinants of Health
Context
Individual-level
Sociodemographics - age, race, ethnicity,
education, SES
Physical environment
Social environment
Psychosocial - compliance, coping
Health
Health care
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior
Organizational, institutional
Psychological -beliefs, attitudes, personality
Economic resources
e.g., Larry Green,Dan Stokols
Biological, physiological
Societal, political
23
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

24
Multi-level Determinants of Health Lifestyle as
a Pathway
Contextual
Individual-level
Sociodemographics - age, race, ethnicity,
education, income
Physical environment
Social environment
Psychosocial - compliance, coping
Health
Health care
Organizational, institutional
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior, illicit drug use
Economic resources
Psychological - beliefs, attitudes,personality
e.g., Larry Green,Dan Stokols
Societal, political
25
Multi-level Determinants of Health Lifestyle as
a Pathway
Contextual
Individual-level
Sociodemographics - age, race, ethnicity,
education, income
Physical environment
Lifestyle, health behavior
Social environment
Psychosocial - compliance, coping
Health care
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
26
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

27
Socioeconomic Status Underlying Constructs and
Mechanisms

• SES is multidimensional
• Prestige mechanism
• Social stratification, social class
• Relative social standing
• Occupation
• Resources mechanism
• Education
• Income, wealth, assets
• Poverty, material deprivation

28
Research on SES and Health

• Most researchers studying racial/ethnic
  differences in health adjust for SES
• Many studies find that race/ethnicity remains a
  significant determinant of health after
  controlling for SES
• What else is going on?
• Need to focus on how SES affects health
• Whether the SES-health relationship varies by
  race/ethnicity

29
Lifecourse Issues Regarding SES, Race/Ethnicity,
and Health

• Hypothesis health disparities are due to the
  accumulation over ones lifetime of
  stresses/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

30
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,
Berkman and Kawachi (eds), Oxford, 2000 (Ch 2,
p. 28)
31
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 rather than singular exposure is
  critical

Evans GW, The environment of childhood
poverty,Amer Psychol, 20045977-
32
Racism/Discrimination a Plausible Lifecoures
Hypothesis

• Health outcomes of racism
• Hypertension
• Psychological distress
• Poorer self-rated health
• More days in bed (disability days)
• all are independent of effects of SES

Nazroo JY, AJPH, 93 277 Williams DR, Ethnicity
Disease, 200111800
33
Racism as a Stressor for African Americans A
Biopsychosocial Model

• A conceptual model for systematic studies of the
  biopsychosocial effects of perceived racism
• Model helps elucidate one major mechanism for
  racial disparities in health

• Clark R et al., Amer Psychol 1999, 54805-816

34
Biopsychosocial Effects of Perceived Racism on
Health (Clark et al., 1999)
Environmental stimulus
Constitutional, Sociodemographic, Psychological,
Behavioral factors
Perception
Perception of racism
Perception of different stressor
No perception of racism or other stressor
Coping responses
Blunted or no psychological and physiological
stress responses
Psychological and physiological stress responses
Health outcomes
35
Health Services Research

• Conceptual frameworks guide research in how
  health care affects outcomes
• Health care is the total societal effort,
  whether public or private, to provide, organize,
  and finance services that promote the health
  status of individuals and the community

p. 477, Cooper LA et al., JGIM, 200217477-486
36
Donabedians Structure-Process-Outcome Paradigm
for Assessing Outcomes of Care
Process of care -technical care -interpersonal
care
Structure of care
Patient outcomes

• Structure - features of a system of care
• Process what is done for patients
• Technical care - knowledge and judgment skills
• Interpersonal care - the way care is provided

Donabedian A. Quality Review Bulletin, 1992, p.
356
37
Donabedians Structure-Process-Outcome Paradigm
Process of care -technical care -interpersonal
care
Structure of care
Patient outcomes

• Quality of care is indicated when outcomes can
  be attributed to antecedent processes of care

38
Donabedians Structure-Process-Outcome Paradigm
Process of care -technical care -interpersonal
care
Intermediatepatient outcomes - compliance -
knowledge
Structure of care
Ultimate patient outcomes - health
39
Donabedians Structure-Process-Outcome Paradigm
Process of care -technical care -interpersonal
care
Intermediatepatient outcomes - compliance -
knowledge
Structure of care
Providercharacteristics
Ultimate patient outcomes - health
40
Examples Research Questions on How Structure of
Care Affects Health 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?

41
Examples Research Questions on How Technical
Processes Affect Health 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

42
Examples Research Questions on How Interpersonal
Processes Affect Health Disparities

• What ar the effects on health of differences in
• Communication
• Elicitation of patient concerns
• Respectfulness
• Perceived discrimination
• Participatory decision making

43
The Structure-Process-Outcome Paradigm Adding
Access to Care
Patient healthoutcomes - clinical - individual
Process of care -technical care -interpersonal
care
Structure of care
Access to care
Aday LA and Anderson RM Major contributors to
access issues
44
Defining Access to Care

• Typical Definitions
• Availability of health care providers in area
• Availability of health insurance/being uninsured
• Type of health insurance (public versus private)
• Quality of health insurance coverage
• Utilization of (appropriate) services

45
IOMs Definition of Access

• the timely use of personal health services to
  achieve the best possible health outcomes
• Much more inclusive than Aday and Anderson

• IOM, Access to health care in America A model
  for monitoring access, National Academy Press,
  1993

46
Within a System Access to

• Providers of same race/ethnicity
• Providers who speak preferred language
• Timely care
• Someone to talk to by phone
• Waiting time for appointments
• Waiting time in office

47
Framework for Studying Access

• Potential Access Structure
• Characteristics of healthdelivery system
• Availability
• Organization

• Potential Access Process
• Characteristics of population at risk
• Predisposing
• Enabling
• Need

Realized Access Objective Utilization of
services
Realized Access Subjective Consumer
satisfaction
Aday LA, Anderson R, and Fleming GV. Health care
in the U.S. Equitable for whom? London Sage,
1980
48
Extensive Disparities in Health Care Summarized
in Two Major Reports

• Unequal Treatment (IOM) 2003
• National Healthcare Disparities Report (AHRQ for
  DHHS)
• 2003, 2004

49
National Healthcare Disparities Report

• Issued by DHHS through the Agency for Healthcare
  Research and Quality
• Annual report to Congress on racial, ethnic,
  socioeconomic, and geographic disparities
• Institute of Medicine provided technical guidance
  
• Guidance for the National Healthcare Disparities
  Report, Swift (ed), Institute of Medicine,
  National Academies Press, 2002

50
National Healthcare Disparities Reports

• 2003 report
• http//www.qualitytools.ahrq.gov/disparitiesreport
  /download_report.aspx
• 2004 report
• 2004 National Healthcare Disparities Report,
  USDHHS, AHRQ publication number 05-0014,
  December, 2004

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Key Findings NHDR

• Inequality in health care quality exists
• Differential access may lead to inequalities
• Opportunities to provide preventive care often
  missed
• Knowledge of why disparities exist is limited
• Improvement is possible

52
Conceptual Framework for National Healthcare
Disparities Report
Components of Health Care Quality Components of Health Care Quality Components of Health Care Quality Components of Health Care Quality
Consumer Perspectives on health care needs Safety Effectiveness Patient centered-ness Timeliness
Staying healthy
Getting better
Living with illness or disability
Coping with the end of life
Equity
53
How do the Two Types of Conceptual Frameworks
Work Together?

• Conceptual models that link population and health
  services research perspectives
• Especially critical in health disparities research

54
Linking Population and Health Services Frameworks
Process of care -technical care -interpersonal
care
Intermediatepatient outcomes - compliance -
knowledge
Structure of care
Providercharacteristics
Ultimate patient outcomes - health
Patient characteristics
Environment
Neighborhood resources
Family support
55
Unequal Treatment

• Requested by Congress to assess differences in
  healthcare received by U.S. racial/ethnic
  minorities and non-minorities
• Focused on
• healthcare systems and their legal and regulatory
  climate
• provider discrimination

Institute of Medicine, Unequal treatment
Confronting racial and ethnic disparities in
healthcare, National Academy Press, 2003
56
Unequal Treatment Summary

• Racial/ethnic minorities receive lower quality of
  care then non-minorities
• Disparities occur in the context of broad
  historic and contemporary social/economic
  inequality, including discrimination
• Sources are complex
• involve systems, administrative processes,
  utilization managers, healthcare professionals,
  and patients
• A comprehensive, multi-level strategy is needed
  to eliminate these disparities

57
The Behavioral Model for Vulnerable Populations
Access to Care Model

• Population Characteristics
• Predisposing Enabling Need
  Health behavior Outcomes

Vulnerable populations at risk of poor
physical, psychological,or social health
Gelberg L, et al., Health Serv Res 2002, 341273
58
The Behavioral Model for Vulnerable Populations
Traditional Domains

• Population Characteristics
• Predisposing Enabling Need
  Health behavior Outcomes

Demographics Health beliefs Social structure -
ethnicity - education - social networks
Perceived health Evaluated health -general
population conditions
Health Satisfaction -general -technical
-interpersonal
Personal/family resources - insurance,
income Community resources - residence, region
Personal health practices - diet, exercise,
tobacco Use of health services - ambulatory,
inpatient
59
The Behavioral Model for Vulnerable Populations
Vulnerable Domains

• Population Characteristics
• Predisposing Enabling Need
  Health behavior Outcomes

• Demographics
• Health beliefs
• Social structure
• acculturation
• literacy

Perceived health Evaluated health -vulnerable
population conditions
Health Satisfaction -general -technical -interpers
onal

• Personal/family resources
• - competing needs, hunger
• transportation
• Community resources
• crime rates

• Personal practices
• - food sources
• hygiene
• unsafe sex

60
A Conceptual Model for Health Services Research
Interventions

• Adapted IOM model of access to care
• Incorporated elements relevant to eliminating
  disparities in health care
• Focused on 2 types of interventions
• Improving access to effective care
• Reducing barriers to healthy lifestyles

Cooper LA et al., JGIM, 200217477-486
61
Barriers to Mediators of Equitable Health Care
for Racial/Ethnic Groups Modified IOM Model
Barriers
Use of Services
Mediators
Outcomes

• Personal/family
• Structural
• Financial

• Visits
• Procedures

• Quality of providers
• Appropriateness of care
• Efficacy of treatment
• Patient adherence

• Health status
• Equity of services
• Patient views of care

Cooper LA et al., JGIM, 200217477-486
62
Summary

• 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