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Conceptual Models for Health Disparities Research


Conceptual models used in health disparities research. How to modify models for ... Models are used to identify where to intervene to reduce disparities. ... – PowerPoint PPT presentation

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Title: Conceptual Models for Health Disparities Research

Conceptual Models for Health Disparities Research
  • Luisa Franzini
  • University of Texas School of Public Health
  • June 8, 2008
  • RKJF New Connections

Outline of presentation
  • Conceptual models used in health disparities
  • How to modify models for specific research
  • Interactive discussion of participants models.

How Does A Conceptual Model Differ From Theory?
  • Conceptual models draw on theory, but they are
    not the same as theory
  • Theory is usually concerned with global classes
    of behavior
  • Quantum theory in physics
  • Theory of the consumer in economics
  • Conflict theory in sociology
  • By contrast, conceptual models are usually
    concerned with specific types of behavior in
    specific contexts

Health disparities research
  • Fine, Ibrahim, Thomas, The Role of Race and
    Genetics in Health Disparities Research, Am J
    Public Health. 2005 December 95(12) 21252128.

Fundamentals of conceptual models
  • Models should be rooted in theory.
  • Models are used to understand the causes of
    health disparities and the mechanisms that lead
    to health disparities.
  • Models are used to identify where to intervene to
    reduce disparities.

Models to understand health and disease
  • Era of sanitary statistics
  • Miasma
  • Era of infectious disease
  • Models based on germ theory
  • Era of chronic disease
  • Models based on black box
  • Susser and Susser AJPH 1996

Chinese boxes model
  • New era
  • Models based on Chinese boxes
  • Within localized structures, we envisage
    successive levels of organization, each of which
    encompasses the next and simpler level, all with
    intimates links between them Susser and Susser
    AJPH 1996 page 675

Social conditions
  • Foundation of research into the importance of
    social conditions dates to Shaw and McKay
  • Theory that delinquency is associated with
    physical and social structure of the city.
  • Shaw C, McKay H. Juvenile delinquency and urban
    areas. Chicago University of Chicago Press

Shaw McKay (1942)
  • social disorganization theory
  • high concentrated economic disadvantage, high
    population instability, and high proportion of
    immigrants in a neighborhood were seen to
    contribute to the breakdown of social cohesion
    and an increase in delinquency and crime.
  • The logical extension of this research to
    examining contextual influences on behavior and
    health is clear.

Determinants of health model
  • One of the first model of the determinants of
    health (Evans and Stoddart, 1990).
  • Provides a broad conceptual framework.
  • Model includes well-being as health outcome.
  • Multidisciplinary approach
  • social, environmental, economic, and genetic
    factors are seen as contributing to differences
    in health status and, therefore, as presenting
    opportunities to intervene.

R.G. Evans and G.L. Stoddart, SSM, 1990
Modifying conceptual models
  • General conceptual models can provide the
    framework for the development of more specific
    predictive models.
  • Expansion and greater specificity are needed.
  • Examine segments of the model.

Healthy Passages A Community-based Longitudinal
Study of Adolescent HealthPI Tortolero,
Schuster, Franklin
  • Goal 1 The characterization of developmental
    trajectories and the relative contribution of
    multilevel risk and protective factors (e.g.,
    family, peers, school, and community) on health
    behaviors (e.g., dietary practices, physical
    activity, tobacco use).
  • Goal 2 The elucidation of multilevel risk and
    protective factors that contribute to disparities
    in health, educational, and social outcomes by
    race/ethnicity, gender, and socioeconomic status.

Healthy Passages A Community-based Longitudinal
Study of Adolescent HealthPI Tortolero,
Schuster, Franklin
Ecological model
  • Developed for use in research on physical
    activity as part of Active Living Research.
  • Sallis JF, Cervero RB, Ascher W, Henderson KA,
    Kraft MK, Kerr J. An ecological approach to
    creating active living communities. Annual Review
    of Public Health. 200627297-322.

Motivation for ecological models
  • Behaviors influenced by wide range of factors at
    multiple levels.
  • Multilevel interventions must target individuals,
    social and physical environments, and policies.
  • Ecological models used widely Institute of
    Medicine report on Health and Behavior (2001),
    Healthy People 2010.

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Ecological models
  • Ecological models communicate the complexity of
    influences on physical activity.
  • Most researchers using ecological models focus on
    only parts of the model.
  • Prioritizing research questions is a major
    challenge for ecological models.

Example The built environment and obesity
Example Pathways to obesity Identifying local
modifying determinants of physical activity and
Social conditions as fundamental causes of disease
  • Social factors, such as SES, are fundamental
    causes of disease.
  • Social factors embody access to important
    resources needed for health.
  • Link and Phelan, JHSB, 1995

Link and Phelan, JHSB, 1995
  • Contextualizing risk factors
  • Framework to understand how people are exposed to
    risk or protective factors
  • Determine social conditions under which risk
    factors are related to risk
  • Fundamental causes
  • Health effects of fundamental causes can not be
    eliminated by addressing mechanisms that link
    them to disease.

Social Determinants of Health and Environmental
Health Promotion model
  • Goal of the model
  • To understand how social and environmental
    inequalities contribute to health inequalities.
  • Schultz A, Northridge M. Social determinants of
    health Implications for environmental health
    promotion. Health Education and Behavior. 2004

Social Determinants of Health and Environmental
Health Promotion model
  • Mechanisms through which social factors
    contribute to environmental unequal exposures
    which contribute to health inequalities by
    race/ethnicity, social class, and gender.
  • Emphasizes interplay of social processes with the
    physical environment.

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Social Determinants of Health and Environmental
Health Promotion model
  • Model depicts the implications of social and
    economic inequalities (fundamental factors) for
    the built environment and social contexts
    (intermediate factors) that influence stressors,
    health behaviors, and social relationships
    (proximate factors) that affect health.

Interactive effects of neighborhood physical and
social factors on physical activity in minority
and low income youth
  • Aim 1 To examine how youth race/ethnicity and
    SES moderate the effects of neighborhood social
    and physical factors on PA (arrows G and F),
    controlling for adolescent factors (arrow e).
  • Aim 2 To examine how neighborhood structural
    factors (e.g. economic disadvantage) moderate the
    association between youth PA and neighborhood
    physical and social factors (arrows H and J),
    controlling for adolescent factors (arrow e).

Interactive effects of neighborhood physical and
social factors on physical activity in youth
Social consequences model vs social etiology model
  • Social etiology model focuses on
  • the social antecedents of a specific disorder
  • Social consequences model focuses on
  • the overall mental health consequences of
    various social arrangements
  • Aneshensel CS. Research in mental health
    Social etiology versus social consequences. JHSB

Social consequences model for mental health
  • Social etiology model investigates prevention
    and treatment of depression.
  • Good model if the focus is depression
  • When the goal is to examine how poverty impacts
    mental health, need social consequences model.
  • Mental health consequences of poverty include
    anger, violence, antisocial behavior, alcohol and
    substance abuse, anxiety, antisocial personality
    disorder, and suicide.

Etiological model
Example Study of neighborhoods and adolescent
  • Aim 1 To examine how neighborhood factors
    moderate longitudinal changes from early to late
    adolescence in risky behaviors and health and

Social consequences model adapted for grant
Integrative Model for the Study of Developmental
Competencies in Minority Children
  • Incorporates and emphasizes essential factors
    that affect minority populations.
  • Social position and social stratification are at
    the core of the model.
  • Garcia Coll C, Lamberty G, Jenkins R, et al. An
    integrative model for the study of developmental
    competencies in minority children. Child
    Development. 1996.

Integrative Model for the Study of Developmental
Competencies in Minority Children
  • Anchored in social stratification theory.
  • Attempts to describe intra-group variability in
    minority populations.
  • Social mechanisms such as racism, discrimination,
    prejudice have not been included in general

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Health services research models
  • Health services research models focus on
    disparities in health care use rather than in
    health outcomes.

Health services research models
  • Aday and Anderson model
  • Model provides a framework for understanding
    equity in differential levels of access among
  • A Framework for the Study of Access to Medical
    Care Aday and Andersen, Health Services
    Research. 1974 Fall 9(3) 208220

Aday and Andersen model
  • Dependent variable access to health care (actual
    use of health services).
  • Use depends on
  • Predisposing variables demographic and social
    characteristics and beliefs
  • Enabling variables personal resources and
    availability of health services in the community
  • Need variables state of health as self-perceived
    and evaluated by practitioners

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Aday and Andersen model
  • Equity of access depends on the relative weights
    of the determinants.
  • Access should be determined by need and not by
    social characteristics (income, race/ethnicity,
    health insurance).
  • Focus on mutable determinants because relevant
    for intervention and policy purposes.

Aday and Andersen model
  • Example Access to Medical Care
  • Access to medical care in the U.S. Realized and
    potential Andersen and Aday, Medical Care, 1978,
    Vol 6, Issue 7, 533-546

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Health services research model
  • Example of health services research model
  • Chassin and Anderson Quality of care and racial
    health disparities A strategic overview Mount
    Sinai Journal of Medicine, 2008, 757-12

Health services research model
  • Focus on underuse of medical care in
    disadvantaged population using quality
    improvement (QI) principles.
  • Causes of underuse in a community
  • Individual factors
  • Provider factors
  • Health care organization
  • Community

Health services research model
Health services research model
  • Intervention strategy (similar to QI strategy)
  • Articulate specific problem
  • Quantify magnitude of problem
  • Understand and assess causes
  • Design and implement intervention that targets
  • Embed effective intervention into routine work of

List of models presented
  • Determinants of health model (Evans Stoddart)
  • Social determinants of health and environmental
    health promotion model (Schultz Northridge)
  • Ecological model (Sallis)
  • Social consequences model (Aneshensel)
  • Integrative model for studies in minority
    populations (Garcia Coll)
  • Health services research model (Anderson Aday,
    Chassin Anderson)

Other models
  • Bio-psychological models
  • e.g. health belief, social learning theory,
    theory of reasoned action, stages of change,
    transtheoretical, PEN3
  • Health services research models
  • e.g. Donabedian model
  • Social ecological models
  • e.g. Bronfrenbrenner
  • Life course models
  • Community Based Participatory Research models

Developing A Conceptual Model
  • Anchor model development with your research
  • Research question should make clear the
    phenomenon you are studying, the outcome(s), and
    the unit of analysis
  • Specificity is important because it influences
    the determinants (i.e., explanatory variables) in
    the model
  • Decide which broad categories of factors are
    likely to determine the outcome you are modeling

Developing A Conceptual Model
  • You can use
  • Other studies on the same topic
  • Your own knowledge of your social science
  • Conversations with colleagues and mentors
  • Conversations within people in the institutions
    you are studying

Characteristics of a Good Model
  • Comprehensiveness
  • Model provides adequate description of the
    outcomes and determinants
  • Model is sufficiently broad in scope to encompass
    all the relevant dimensions of the phenomenon in

Characteristics of a Good Model
  • Conceptual clarity
  • Model makes clear the assumptions on which the
    model and the causal relationships within it are

Characteristics of a Good Model
  • Logical congruence
  • Models conclusions and predictions flow
    logically from the assumptions and causal

Characteristics of a Good Model
  • Simplicity
  • Model should be simple, but not too simple
  • The model should capture the essential features
    of the phenomenon under study without becoming
    mired in needless details
  • At the same time, the model cannot simplify so
    much that it becomes unmoored from reality

Characteristics of a Good Model
  • Utility
  • Model should help people understand how the
    phenomenon under study works and how the outcomes
    of interest are generated

Representing a Conceptual Model
  • Narrative A text description of the model, its
    components, and its causal relationships
  • Mathematical A set of mathematical equations
    that describe the relationships between the
    determinants and outcomes (usually accompanied by
  • Graphical or Pictorial A set of figures that
    display the components and relationships in the
    model (usually accompanied by narrative)

Limits of Conceptual Models
  • Models are based on assumptions that may or may
    not be right
  • By their nature, models are abstract and
    simplified representations of the world
  • Models overriding use is to guide empirical
  • Empirical results can be consistent with a model,
    but they cannot verify it

  • Importance of theoretical framework
  • Many models to choose from
  • Modify existing model or develop your own