Determinants of Health and Health Disparities: Conceptual Frameworks - PowerPoint PPT Presentation

Loading...

PPT – Determinants of Health and Health Disparities: Conceptual Frameworks PowerPoint presentation | free to download - id: 2176e0-N2Q2M



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Determinants of Health and Health Disparities: Conceptual Frameworks

Description:

Premature mortality including infant mortality. Morbidity ... mortality. morbidity. Structure. of care. Process of care: -technical care -interpersonal ... – PowerPoint PPT presentation

Number of Views:1398
Avg rating:3.0/5.0
Slides: 56
Provided by: ucsf4
Learn more at: http://rds.epi-ucsf.org
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Determinants of Health and Health Disparities: Conceptual Frameworks


1
Determinants of Health and Health Disparities
Conceptual Frameworks
  • Eliseo J. Pérez-Stable, MD
  • Professor of Medicine,
  • Division of General Internal Medicine, Department
    of Medicine,
  • Medical Effectiveness Research Center for Diverse
    Populations
  • April 16, 2009

2
Types of Diverse Groups
  • Current health disparities research focuses on
    differences across race/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
vulnerablepopulations
Understanding Identify determinants and
mechanisms of disparities
Reducing Intervene Evaluate Translate/disseminate
Change policy
Adapted from Kilbourne et al, 2006
4
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
    plus
  • Hypertension
  • Obesity/overweight
  • Diabetes
  • Functional limitations, disability
  • Self-rated health

5
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, genetics, biology

6
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

7
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

8
Numerous Frameworks Determinants of Health
Health
Determinants
9
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
10
Three Broad Types of Conceptual Frameworks
Interactions
  • 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

11
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

12
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

13
Individual Embedded in Ecological Context
Society
Community
Family
Family
Individual
14
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
15
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,allostatic load, opiate
receptors
Societal, political
16
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,allostatic load, opiate
receptors
Societal, political
17
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

18
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,allostatic load, opiate
receptors
Societal, political
19
Social Environment
  • Social opportunities
  • Family environment
  • Social support
  • Discrimination or racism
  • Neighborhood cohesiveness
  • Community meeting places

20
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.
21
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,allostatic load, opiate
receptors
Societal, political
22
Societal Approaches to Health Improvement-Structur
al Interventions
  • Prevention strategies that target population
    health by changing social and community
    environments
  • No smoking ordinances
  • Taxation policies
  • Smog control legislation
  • Food labeling
  • Signage to use stairs (not elevators)
  • Singer BH et al. New Horizons in Health, 2001

23
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

24
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
25
Cigarette Smoking in the U.S. 2006National
Health Interview Survey
26
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

27
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

28
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
29
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

30
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
31
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 200155111.
32
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

33
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
34
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

35
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)
36
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, 20045977-
37
Racism/Discrimination a Plausible Lifecourse
Hypothesis
  • Health outcomes associated with racism
  • Hypertension
  • Psychological distress
  • Poorer self-rated health
  • all are independent of effects of SES

Nazroo JY, AJPH, 93 277 Williams DR, Ethn Dis,
200111800
38
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
39
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

40
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
41
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?

42
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

43
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

44
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

45
Ethnicity and Attitudes toward Patient Autonomy
among Persons 65 yrs
46
Structure-Process-Outcome Paradigm
Process of care -technical care -interpersonal
care
Intermediatepatient outcomes - compliance -
knowledge
Structure of care
Ultimate patient outcomes - health
47
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

48
Structure-Process-Outcome Paradigm
Structure of care
Process of care -technical care -interpersonal
care
Intermediateoutcomes -compliance -knowledge
Providercharacteristics
Ultimate outcomes - health
49
Structure-Process-Outcome Paradigm
Structure of care
Process of care -technical care -interpersonal
care
Intermediateoutcomes -compliance -knowledge
Providercharacteristics
Cultural competenceSystem and providers offer
highest quality care to all patients regardless
of ethnicity,culture, or language proficiency
Ultimate outcomes - health
50
Conceptual Framework for National Healthcare
Disparities Reports (AHRQ)
Equity
51
Structure-Process-Outcome Paradigm
Structure of care
Process of care -technical care -interpersonal
care
Intermediateoutcomes - compliance - knowledge
Providercharacteristics
Patient characteristics
Ultimate outcomes - health
52
Blending Population and Health Services Frameworks
Structure of care
Process of care -technical care -interpersonal
care
Intermediateoutcomes - compliance - knowledge
Providercharacteristics
Patient characteristics
Environment
Ultimate outcomes - health
Neighborhood resources
Family support
53
Alternative Health Services Research Framework
for Health Disparities
Health care system factors
Patientfactors
Provider factors
Interpersonal relationship
Adapted from Kilbourne et al., 2006
54
Second Alternative Health Services Research
Framework for Health Disparities
Health care system factors
Patientfactors
Provider factors
Interpersonal relationship
Visit
Saba et al. J Fam Med., 2006
55
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
About PowerShow.com