Determinants of Health and Health Disparities: Conceptual Frameworks, Social, Behavioral and Biological Mechanisms

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Determinants of Health and Health Disparities
Conceptual Frameworks, Social, Behavioral and
Biological Mechanisms

• Eliseo J. Pérez-Stable, MD
• Professor of Medicine,
• Division of General Internal Medicine, Department
  of Medicine,
• Medical Effectiveness Research Center for Diverse
  Populations
• April 8, 2010

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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

3
Phases of Disparities Research
Detecting Define health disparities Define
vulnerable populations
Understanding Identify determinants and
mechanisms of disparities
Reducing Intervene Evaluate Translate/disseminate
Change policy
Adapted from Kilbourne et al, 2006
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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

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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

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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

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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

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Numerous Frameworks Determinants of Health
Health
Determinants
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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
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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

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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

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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

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Individual Embedded in Ecological Context
Society
Community
Family
Family
Individual
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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
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An Alternative Depiction of Multi-level
Determinants of Health Disparities
Contextual
Individual-level
Sociodemographics - age, race, ethnicity,
education, income
Physical environment
Social environment
Psychosocial - beliefs, attitudes, adherence,
coping, personality
Health disparities
Health care
Organizational, institutional
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior, illicit drug use
Economic resources
Biological - genetics,stress, allostatic load,
opiate receptors, metabolism
Societal, political
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Ecological/Multi-level Determinants
Context
Individual-level
Sociodemographics - age, race, ethnicity,
education
Physical environment
Social environment
Psychosocial - adherence, coping
Health disparities
Health care
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior
Organizational, institutional
Psychological -beliefs, attitudes, personality
Economic resources
Biological - genetics,stress, allostatic load,
opiate receptors, metabolism
Societal, political
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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

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Ecological/Multi-level Determinants
Context
Individual-level
Sociodemographics - age, race, ethnicity,
education
Physical environment
Social environment
Psychosocial - adherence, coping
Health disparities
Health care
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior
Organizational, institutional
Psychological -beliefs, attitudes, personality
Economic resources
Biological - genetics,stress, allostatic load,
opiate receptors, metabolism
Societal, political
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Social Environment

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

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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.
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Ecological/Multi-level Determinants
Context
Individual-level
Sociodemographics - age, race, ethnicity,
education, SES
Physical environment
Social environment
Psychosocial - adherence, coping
Health disparities
Health care
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior
Organizational, institutional
Psychological -beliefs, attitudes, personality
Economic resources
Biological - genetics,stress, allostatic load,
opiate receptors, metabolism
Societal, political
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Societal Approaches to Health Improvement-Structur
al 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

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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

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Lifestyle as a Pathway
Contextual
Individual-level
Sociodemographics - age, race, ethnicity,
education, income
Physical environment
Social environment
Psychosocial - compliance, coping
Health disparities
Health care
Organizational, institutional
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior, other substance use
Economic resources
Biological - genetics,metabolism, allostatic
load, opiate receptors
Societal, political
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Cigarette Smoking in the U.S. 2006National
Health Interview Survey
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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 1999280152-56

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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

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Lifestyle as a Pathway 2
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
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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 its own major determinant
• May vary by race/ethnic group

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Ecological/Multi-level Determinants
Low SES context
Low individual-level SES
Sociodemographics - age, race, ethnicity,
education, SES
Physical environment
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 - genetics,allostatic load, opiate
receptors
Societal, political
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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 200155111.
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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 Harlem50 vs. 24
• Example of disparities in environmental justice
  issues complicating behavior
• AJPH 2004 94 1549-54

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Access to Healthy Foods and Health
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
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Cumulative Pathways or Lifecourse Issues

• Health disparities due to lifetime of adverse
  conditionsSpecific 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

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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)
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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, 93 277 Williams DR, Ethn Dis,
200111800
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Biopsychosocial Effects of Perceived Racism on
Health
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
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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

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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
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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?

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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?

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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

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Ethnicity in Patient-Doctor Relationship

• Refusal whose issue?
• DNR discussionsRace of clinician is an
  independent predictor
• Cultural competence or humility
• Language factors
• Racism may affect behavior
• Fewer cardiology referrals in Blacks

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Ethnicity and Attitudes toward Patient Autonomy
among Persons 65 yrs
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Structure-Process-Outcome Paradigm
Process of care -technical care -interpersonal
care
Intermediatepatient outcomes - compliance -
knowledge
Structure of care
Ultimate patient outcomes - health
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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

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Structure-Process-Outcome Paradigm
Structure of care
Process of care -technical care -interpersonal
care
Intermediateoutcomes -adherence -knowledge
Cliniciancharacteristics
Ultimate outcomes - health status
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Structure-Process-Outcome Paradigm
Structure of care
Process of care -technical care -interpersonal
care
Intermediateoutcomes -adherence -knowledge
Cliniciancharacteristics
Cultural competenceSystem and clinicians offer
highest quality care to all patients regardless
of ethnicity,culture, or language proficiency
Ultimate outcomes - health status
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Conceptual Framework for National Healthcare
Disparities Reports (AHRQ)
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 Timeliness
Staying healthy
Getting better
Living with illness or disability
Coping with the end of life
Equity
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Structure-Process-Outcome Paradigm
Structure of care
Process of care -technical care -interpersonal
care
Intermediateoutcomes -adherence - knowledge
Cliniciancharacteristics
Patient characteristics
Ultimate outcomes - health status
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Blending Population and Health Services Frameworks
Structure of care
Process of care -technical care -interpersonal
care
Intermediateoutcomes -adherence - knowledge
Cliniciancharacteristics
Patient characteristics
Environment
Ultimate outcomes - health status
Neighborhood resources
Family support
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Alternative Health Services Research Framework
for Health Disparities
Health care system factors
Patientfactors
Clinician factors
Interpersonal relationship
Adapted from Kilbourne et al., 2006
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Alternative Health Services Research Framework
for Health Disparities
Health care system factors
Patientfactors
Clinician factors
Interpersonal relationship
Visit
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