1. Determinants of Health and Health Disparities: Conceptual Frameworks Eliseo J. P é rez-Stable, MD Center for Aging in Diverse Communities April 24, 2008

2. Types of Diverse Groups u Current health disparities research focuses on differences across race/ethnic groups u Much prior research examined differences by socioeconomic status (SES): –Low income vs. others –Low education vs. others u 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

4. Defining Disparities: Vulnerable populations have worse health than their counterparts….: u Premature mortality including infant mortality u Morbidity –Chronic disease (heart disease, diabetes, cancer) –Communicable disease (Tuberculosis, HIV) –Low birth weight u Physiological risk factors related to behavior + –Hypertension –Obesity/overweight –Diabetes u Functional limitations, disability u Self-rated health

5. Understanding Disparities u What is it about being in a minority group that could lead to poorer health? –What does race/ethnicity “stand for” u Deconstruct “race/ethnic group membership” into underlying variables –Behaviors, attitudes, values, beliefs, ethnic identity, acculturation, perceived discrimination, educational experiences, SES, culture

6. Parallel Question: Socioeconomic Status Disparities u What is it about being lower SES that could lead to poorer health? –What does lower SES “stand for” u 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 u Ground research in theory and knowledge u Help identify and organize key variables addressing global objectives –On the pathway to disparities u Help develop specific research questions u 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 u Population science –Determinants of health in a population: Model –Samples are populations or population subgroups u Health services research –How health care affects outcomes –Samples are patients or health plan members u Biology/physiology –Biological and genetic pathways to disease

11. Population-Based Determinants: Multiple Levels of Influence on Health u Individual –biological, behaviors, attitudes, age, education, occupation u Family and Social Network –size, structure, support, beliefs u Neighborhood or community –resources, toxins, aesthetics, crime/poverty

12. Population-Based Determinants: Multiple Levels of Influence on Health 2 u Cultural group, ethnic identity –shared beliefs, values, behaviors u Occupation or workplace –toxins, safety, working conditions u Organizational/institutional structures –educational system, health care, parks u Societal, political

13. Individual Embedded in Ecological Context Family Individual Family Community Society

14. One Ecological Model of Determinants of Health Bio-behavioral mechanisms, genetics Individual behavior Macro social, environmental conditions and policy Living and working conditions Social, family, community networks Over the lifespan National Academy of Sciences, 2002

15. An Alternative Depiction of Multi-level Determinants of Health Disparities Psychosocial - compliance, coping Lifestyle - exercise, diet, alcohol, smoking, sexual behavior, illicit drug use Health care Sociodemographics - age, race, ethnicity, education, income Physical environment Social environment Health disparities Psychological - beliefs, attitudes, personality ContextualIndividual-level Organizational, institutional Economic resources Societal, political

16. Ecological, Multi-level Determinants Psychosocial - compliance, coping Lifestyle - exercise, diet, alcohol, smoking, sexual behavior Health care Sociodemographics - age, race, ethnicity, education Physical environment Social environment Biological, physiological ContextIndividual-level Organizational, institutional Economic resources Societal, political Psychological -beliefs, attitudes, personality Health disparities

17. Physical Environment u Neighborhood safety, attractiveness u Housing quality u Transportation u Segregation u Hazardous materials u Occupational hazards u # of liquor stores u # of full service grocery stores u Availability of fresh fruits and vegetables u # of areas for walking, bicycling

18. Ecological, Multi-level Determinants Psychosocial - compliance, coping Lifestyle - exercise, diet, alcohol, smoking, sexual behavior Health care Sociodemographics - age, race, ethnicity, education Physical environment Social environment Biological, physiological ContextIndividual-level Organizational, institutional Economic resources Societal, political Psychological -beliefs, attitudes, personality Health disparities

19. Social Environment u Social opportunities u Family environment u Social support u Discrimination or racism u Neighborhood cohesiveness u Community meeting places

20. Conceptual Frameworks of Determinants: Social Environment Berkman LF and Glass T, Social integration, social networks, social support, and health, in Social Epidemiology, chapter 7, p 143. Social structural conditions (macro) Social networks (mezzo) Psycho- social mechanisms (micro) Pathways Culture Socio economic factors Network structure Frequency of contact Social support Social influence Access to resources Health behaviors Psychological Physiologic

21. Ecological, Multi-level Determinants Psychosocial - compliance, coping Lifestyle - exercise, diet, alcohol, smoking, sexual behavior Health care Sociodemographics - age, race, ethnicity, education, SES Physical environment Social environment Biological, physiological ContextIndividual-level Organizational, institutional Economic resources Societal, political Psychological -beliefs, attitudes, personality Health disparities

22. Societal Approaches to Health Improvement u 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

23. Societal Approaches u “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 u 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 Psychosocial - compliance, coping Lifestyle - exercise, diet, alcohol, smoking, sexual behavior, other substance use Health care Sociodemographics - age, race, ethnicity, education, income Physical environment Social environment Psychological - beliefs, attitudes, personality ContextualIndividual-level Organizational, institutional Economic resources Societal, political Health disparities

25. Lifestyle as a Pathway 2 Psychosocial - compliance, coping Health care Sociodemographics - age, race, ethnicity, education, income Physical environment Social environment Psychological - beliefs, attitudes ContextualIndividual-level Organizational, institutional Economic resources Community resources Emmons, K Health behavior in a social context, in Social Epidemiology, 2000, ch. 11. Policy Health Lifestyle, health behavior

26. The Role of Socioeconomic Status u Minority groups on average have lower socioeconomic status than Whites u Lower SES is thus a key hypothesis for observed race/ethnic health disparities u But SES is it’s own major determinant u May vary by race/ethnic group

27. Ecological, Multi-level Determinants Psychosocial - compliance, coping Lifestyle - exercise, diet, alcohol, smoking, sexual behavior Health care Sociodemographics - age, race, ethnicity, education, SES Physical environment Social environment Biological, physiological Low SES contextLow individual-level SES Organizational, institutional Economic resources Societal, political Psychological -beliefs, attitudes, personality Health disparities

28. Living in Poor Neighborhoods Increases Health Risk u Contextual analysis –Examine whether neighborhood-level factors contribute to risk controlling for individual- level factors u 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.

29. 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

30. Example from Hilary Seligman: Access to Healthy Foods and Health Lifestyle behaviors - shop at stores with healthy food - buy healthy food - eat healthy food Physical Access to Healthy Food: Transportation Number of grocery stores Distance to nearest grocery store Obesity, diabetes ContextIndividual-level Financial Resources: Income/economic strain Food insecurity - not enough money to buy food

31. Cumulative Pathways or Lifecourse Issues u Health disparities due to lifetime of adverse conditions u 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

32. Framework: Socioeconomic Status Over the Lifecourse and Health Lynch J and Kaplan G, Social Epidemiology, Oxford, 2000 (Ch 2, p. 28) Socioeconomic Position BirthChildhoodAdulthoodOld Age Low birth weight Growth retardation Smoking, diet, exercise Job stress Inadequate medical care Intrauterine conditions Education, environment Work conditions, income Income, assets AtherosclerosisCVDReduced function

33. 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-

34. Racism/Discrimination: a Plausible Lifecourse Hypothesis Health outcomes of racism: u Hypertension u Psychological distress u Poorer self-rated health … all are independent of effects of SES Nazroo JY, AJPH, 93: 277 Williams DR, Ethn Dis, 2001;11:800

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

36. Three Broad Types of Conceptual Frameworks u Population science –Determinants of health in a population –Samples are populations or population subgroups u Health services research –How health care affects outcomes –Samples are patients or health plan members u Biology/physiology –Biological and genetic pathways to disease

37. Structure-Process-Outcome Paradigm Patient outcomes Structure of care 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 Process of care: -technical care -interpersonal care

38. Research on How Structure of Care Affects Disparities u If systems provide medical interpreters, do patients with limited English proficiency have better health outcomes? u If systems offer a broad choice of minority providers, do minority patients have better health outcomes?

39. Research Questions on How Technical Processes Affect Disparities u Are treatments less effective for racial/ethnic minorities than for whites? u Are appropriate diagnostic procedures used less often for minorities than for whites? u Are optimal treatments provided less often for racial/ethnic minorities than for whites? –e.g., pain medication in emergency departments

40. Research Questions on How Interpersonal Processes Affect Disparities u What are the effects on health of differences in: –Communication –Elicitation of patient concerns –Respectfulness –Perceived discrimination –Participatory decision making

41. Ethnicity in Patient-Doctor Relationship u Refusal: whose issue? u DNR discussions – Race of clinician is an independent predictor u Cultural competence u Language factors u Racism may affect behavior: –Fewer cardiology referrals in Blacks

42. Ethnicity and Attitudes toward Patient Autonomy among Persons ≥ 65 yrs

43. Structure-Process-Outcome Paradigm Ultimate patient outcomes - health Structure of care Process of care: -technical care -interpersonal care Intermediate patient outcomes: - compliance - knowledge

44. Another Type of Intermediate Outcome Ultimate patient outcomes -mortality -morbidity Structure of care Process of care: -technical care -interpersonal care Intermediate patient outcomes: -blood pressure -weight -HbA1c

45. Structure-Process-Outcome Paradigm Ultimate outcomes - health Structure of care Process of care: -technical care -interpersonal care Intermediate outcomes - compliance -knowledge Provider characteristics

46. Structure-Process-Outcome Paradigm Ultimate outcomes - health Structure of care Process of care: -technical care -interpersonal care Intermediate outcomes - compliance -knowledge Provider characteristics Cultural competence: System and providers offer highest quality care to all patients regardless of ethnicity, culture, or language proficiency

47. Conceptual Framework for National Healthcare Disparities Reports (AHRQ) Components of Health Care Quality Consumer Perspectives on health care needs: SafetyEffectivenessPatient centered- ness Timeliness Staying healthy Getting better Living with illness or disability Coping with the end of life Equity

48. Structure-Process-Outcome Paradigm Ultimate outcomes - health Structure of care Process of care: -technical care -interpersonal care Intermediate outcomes - compliance - knowledge Patient characteristics Provider characteristics

49. Blending Population and Health Services Frameworks Ultimate outcomes - health Structure of care Process of care: -technical care -interpersonal care Intermediate outcomes - compliance - knowledge Patient characteristics Provider characteristics Environment Neighborhood resources Family support

50. Alternative Health Services Research Framework for Health Disparities Patient factors Provider factors Health care system factors Interpersonal relationship Adapted from Kilbourne et al., 2006

51. Second Alternative Health Services Research Framework for Health Disparities Patient factors Provider factors Health care system factors Interpersonal relationship Saba et al. J Fam Med., 2006 Visit

52. Summary: Conceptual Frameworks u Numerous frameworks –Health services –Population science –Biological/physiological u Reflect theories and research from many disciplines u Frameworks can integrate population, health services, and biological approaches u Worth reviewing in designing all research