1. Health Inequities in Spokane County Income Board of Health March 22, 2012

2. Purpose of Health Inequity Report
The goal of this assessment is to increase and provide a perspective on different health and social inequities in Spokane County and provide information that can be used for potential changes that affect health outcomes.
Build awareness
Identify further areas for exploration
Identify community partners
Intended for health professionals, legislators (policy makers), administrators, community members, and anyone interested in addressing health concerns in Spokane County
Project has taken 1 year to complete.
Passion and interest in this area of work
Data alarming
We want to look at health in Spokane County and Washington State through an inequity lens for various social determinants of health i.e. education, poverty, race/ethnicity, neighborhood and we want to provide information that can be used for potential changes in policies that affect human life and health outcomes.
Before we get started, I want to go over a few definitions that are used when discussing health inequities.
Quantitative Part
Qualitative Part

3. Data Sources Washington State Population Survey
Behavioral Risk Factor Surveillance Survey (BRFSS)
Birth Certificates
Death Certificates
Community Health Assessment Tool (CHAT)
Office of Financial Management, Washington State
Washington State HIV Surveillance Report
Strategic Research Associates, Omnibus Survey

4. Definitions Health Disparity Health Inequity
Differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups.
Health Inequity
Health Disparity- simply two quantities that are not equal. Rate A does not equal rate B (observed differences). That’s all a health disparity is. A difference.
Health Inequity-What does our definition mean? Health inequity is a bit more complicated. In deciding if something is an equity, we need to make an ethical judgment and ask ourselves is the health difference fair? Its true poor people die younger than wealthy people but should they? Is it fair? Should infants born into low SES have lower birth rates? Should women live longer than men?
Disparity-Sickle –Cell Anemia
Inequity-HIV Prevalence
Concerns those differences in population health that can be traced to unequal economic and social conditions and are systemic and avoidable; thus being inherently unjust and unfair.

5. Social Determinants of Health
Definitions
Social Determinants of Health
Through research, factors (i.e., determinants) in our social and economic environment that have been found to negatively (or positively) affect health.
Social Gradient
For the sake of this report we will be talking about education, income, race/ethnicity, neighborhoods.
I would like to explore what social gradient means and use a metaphor to explain social gradient. (Next slide)
An individual's or population group's position in society and different access to and security of resources such as education, employment and housing, as well as different levels of participation in civic society and control over life.

6. The Ladder Position
Using ladder as a metaphor to explain health inequities
Societies are structured like ladders
The rungs of the ladder represent the resources that determine whether people can live a good life or a life plagued by difficulties
We will use a ladder to explain social gradient
Regardless of what we talk about i.e. education, income, neighborhood, race/ethnicity YOU will find yourself somewhere on this ladder.
Where you are on the ladder matters
At the top-Wealthy individuals, decrease morbidity and mortality, increase LE, people die older, people less sick
In the middle-Less resources than those at the top i.e. money opportunities, still at risk for negative outcomes compared to those at the top. Increased morbidity and mortality and lower LE than those at the top
Bottom-Poor individuals, increased morbidity and mortality, decreased LE, die younger, sicker, less resources an opportunities
The theory suggest that mortality/morbidity are more likely to occur for those at the bottom than those at the top, but also suggest that those in the middle are still at high risk of negative health outcomes than those at the top
In other words your position on the ladder predicts how long you will live and how healthy you are during your lifetime
The findings regarding social gradient were surprising because we tend to think of health as something that is fixed by our genetic heritage- genes are only part of the picture
The more advantaged our lives are the longer we live and the healthier we are from birth to old age
People who grow up at the bottom die younger and are sicker throughout their lifetimes than those who are born to the rungs above them
The rungs affect our health and in turn our health affects our ability to reach higher rungs
Let’s explore this in our next slide.

7. A Framework for Health Inequity
Race
Class
Gender
Immigration status
National Origin
Sexual orientation
Disability
Discriminatory Beliefs (ISMS)
Corporations & other businesses
Government agencies
Schools
Institutional
Power
Neighborhood conditions
Social
Physical
Residential segregation
Workplace conditions
Education
Social Inequities
Smoking
Nutrition
Physical activity
Violence
Chronic Stress
Infectious disease
Chronic disease
Injury (intentional / unintentional)
Infant mortality
Life expectancy
A Framework for Health Inequity
Socio-Ecological
Medical Model
Individual Health Knowledge
Genetics
Upstream Downstream
Risk Factors & Behaviors
Disease & Injury
Mortality
We want to look at the root causes or sources of negative health outcomes
Framework for Health Equity
Used to understand and address the multiple pathways that lead to stark differences in health outcomes
Traditionally in the past, Public Health Departments work on the right side of the chart
Providing immunizations, diabetes education, smoking cessation, and other services to individuals in need
Note: These PH strategies are essential because they affect risk behaviors and access to health care services, which we know influence health outcomes
However, health education and access to healthcare can only influence differences in health outcomes, but it only partially explains the observed differences in health outcomes
But what if we looked upstream and looked at social factors, what would we find? Could it be possible that Social Inequities, Institutional Power, and Discriminatory Beliefs affect health outcomes?
You find that policies and practices of powerful institutions strongly influence the environment where people live, work, and play AND
Broad social inequalities create and structure differential access to power, resources, life chances, and opportunities
We need to bridge both downstream and upstream to address health inequities. If we move upstream, we see that health inequities do not merely arise from individual variation in genes, health knowledge, and risk behaviors. We see that economic, social, and physical environment, as well as available services in a neighborhood all shape behavioral choices, disease risk factors, and disease
Health Status
Healthcare Access
Social Factors

8. Components to Health Inequities

9. Why Income/Poverty Level?
What We Heard
Focus group participants were asked about their perceptions of stereotypes that others may have of people from their socioeconomic level:
“I think the biggest stereotype is that we don’t try. I think that’s a problem. People are at this bracket for whatever reason, but I certainly don’t think it’s for lack of trying.”
Focus Group Participant (income <35k)
Several reasons why we looked at Income/Poverty
Direct correlation with a person’s health
Different levels of income have significant differences in health outcomes – Social gradient
Measures material resources – living standards
Access to better quality of food
Housing
Healthcare services
Access to certain advantages
Higher education
Professional occupation w/benefits
Better living environment
With each step down ladder opportunities for better health diminish
Health outcomes associated with low income:
We see higher mortality rates from CVD and suicide
Lower income = higher unemployment rate
Unemployment can lead to
Anxiety
Depression
Substance abuse
Poor mental health

10. Scott Finyalson
At age 32, after working 15 years in retail, Spokane resident Scott Finyalson decided he wanted more from his professional life, including medical and dental coverage. He went back to school to focus on a trade and get a “real” job as a CAD drafter. Five years into a job he loved with a small firm, the work dried up and they were forced to let Scott go. He’s been diligent in his search for work since, but to no avail, and his third unemployment extension is about to run out.

11. Poverty
Poverty was defined as 200% FPL using the Federal Registrar’s 2008 Percent of Poverty Guidelines
For a family of 4 (2 adults and 2 children) at 200% FPL, the gross annual household income equates to $42,0000
Household income was calculated based on total income in that household and determined as a percent of FPL
The number of members in a household and the total income in the household was used to determine a households poverty level
When a poverty level was determined for a household, all individuals in that household were given the same poverty level

12. Increasing Income Inequality in Spokane County
Data Source: Washington State Population Survey

13. Looking at Growth of Income at Each Level of Wealth in Spokane County and Washington State from 2000 to 2008
Change in Median Household Income (2008 Inflation-Adjusted Dollars) from 2000 to 2008
Change in Income from
2000 to 2008
5th Percentile
10th Percentile
25th Percentile
50th Percentile
75th Percentile
90th Percentile
95th Percentile
Spokane County
↓1.2K
No change
↑4.3K
↑4.7K
↑8K
↑14K
↑11.5K
Washington State
↑1.1K
↑1.8K
↑5.3K
↑10.4K
↑15K
↑19.2K
↑21K
Data Source: Washington State Population Survey

14. Overall Poverty Overall Poverty by Categories, 2000 to 2008
Poverty significantly increases for children whose mother is a single parent.
SC increase by 40% single female parent from all families
WS increase by 25%
Data Source: Washington State Population Survey

15. General Health Status by Income
General Health Status by Household Income among Adults 25 Years of Age or Older, 2000 to 2008
This figure illustrates that as income increases, fair or poor health decreases among adults for both Spokane County and Washington State. Adults below 100% FPL are 7.1 times more likely to be in fair or poor health compared to adults at or above 400% FPL in Spokane County and 6.8 times more likely in Washington state.
SC WS
<100%FPL
100%FPL
200%FPL
300%FPL
Household Income as Percent of Federal Poverty Level
Data Source: Washington State Population Survey

16. Parents’ Income and a Child’s Chance for Health
Child’s Health Status by Household Income, 2000 to 2008
SC WS
<100%FPL
100%FPL
200%FPL
300%FPL No difference No difference
Household Income as Percent of Federal Poverty Level
Data Source: Washington State Population Survey

17. Effects of Chronic Illness on Physical Activity by Income
Physical Activity Limitations Due to Chronic Illness among Adults 25 Years of Age or Older by Household Income, 2000 to 2008
This graph illustrates that lower income groups are more likely to have their activity limited by chronic illness than adults in higher income groups for Spokane County and Washington State. In Spokane County, 4 in 10 very poor adults has their activity limited by chronic illness compared with fewer than one in 10 adults in the highest income group. In addition, adults below 100% FPL are 6.6 times more likely to have physical activity limitations due to chronic illness compared to adults at or above 400% FPL in Spokane County and 4.9 times more likely in Washington State.
In SC Odds Ratio:
<100FPL vs. >=400FPL – 6.6
100FPL-199FPL vs. >=400FPL – 3.8
200FPL-299FPL vs. >=400FPL – 2.7
300FPL-399FPL vs. >=400FPL – 1.8
Household Income as Percent of Federal Poverty Level
Data Source: Washington State Population Survey

18. Physical Inactivity Among Adults by Income
Physical Inactivity by Household Income among Adults 25 Years of Age or Older, 2005 to 2009
SC WS
<100%FPL
100%FPL
200%FPL
300%FPL No difference 1.2
Household Income as Percent of Federal Poverty Level
Data Source: Behavioral Risk Factor Surveillance System (BRFSS)

19. Smoking by Income Level
Smoking by Poverty Level, 2005 to 2009
Lower income adults are more likely to smoke than adults in higher income groups.
SC WS
<100%FPL
100%FPL
200%FPL
300%FPL
Household Income as Percent of Federal Poverty Level
Data Source: Behavioral Risk Factor Surveillance System (BRFSS)

20. Diabetes by Income
Diabetes by Poverty Level among Adults 25 Years of Age or Older, 2005 to 2009
This figure illustrates that diabetes significantly decreases as income increases in Spokane County and Washington State. Adults whose poverty level is below 100% FPL are 2.2 times more likely to have diabetes compared to adults at or above 400% FPL in Spokane County and 1.7 times in Washington State.
SC WS
<100%FPL
100%FPL
200%FPL
300%FPL No difference No difference
Household Income as Percent of Federal Poverty Level
Data Source: Behavioral Risk Factor Surveillance System (BRFSS)

21. Obesity by Income
Obesity by Poverty Level among Adults 25 Years of Age or Older, 2005 to 2009
Figure 20 illustrates that obesity significantly decreases as income increases in Spokane County and Washington State. Adults whose poverty level is below 100% FPL are 2.0 times more likely to be obese compared to adults at or above 400% FPL in Spokane County and Washington State.
SC WS
<100%FPL
100%FPL
200%FPL
300%FPL No difference 1.1
Household Income as Percent of Federal Poverty Level
Data Source: Behavioral Risk Factor Surveillance System (BRFSS)

22. Poor Mental Health by Income
Poor Mental Health by Household Income among Adults 25 Years of Age or Older, 2005 to 2009
Includes: stress, depression, and problems with emotions on 14 or more days in the last 30 days (self reported).
Graph demonstrates the likelihood of an adult with poor mental health based on their income.
Good mental health enables a person to think and act productively, to cope with adversity, and to build strong relationships.
Individuals with 14 or more days of poor mental health in a month would likely benefit from intervention.
SC WS
<100%FPL
100%FPL
200%FPL
300%FPL No difference No difference
Household Income as Percent of Federal Poverty Level
Data Source: Behavioral Risk Factor Surveillance System (BRFSS)

23. A Framework for Health Inequity
Race
Class
Gender
Immigration status
National Origin
Sexual orientation
Disability
Discriminatory Beliefs (ISMS)
Corporations & other businesses
Government agencies
Schools
Institutional
Power
Neighborhood conditions
Social
Physical
Residential segregation
Workplace conditions
Education
Social Inequities
Smoking
Nutrition
Physical activity
Violence
Chronic Stress
Infectious disease
Chronic disease
Injury (intentional / unintentional)
Infant mortality
Life expectancy
A Framework for Health Inequity
Socio-Ecological
Medical Model
Individual Health Knowledge
Genetics
Upstream Downstream
Risk Factors & Behaviors
Disease & Injury
Mortality
We want to look at the root causes or sources of negative health outcomes
Framework for Health Equity
Used to understand and address the multiple pathways that lead to stark differences in health outcomes
Traditionally in the past, Public Health Departments work on the right side of the chart
Providing immunizations, diabetes education, smoking cessation, and other services to individuals in need
Note: These PH strategies are essential because they affect risk behaviors and access to health care services, which we know influence health outcomes
However, health education and access to healthcare can only influence differences in health outcomes, but it only partially explains the observed differences in health outcomes
But what if we looked upstream and looked at social factors, what would we find? Could it be possible that Social Inequities, Institutional Power, and Discriminatory Beliefs affect health outcomes?
You find that policies and practices of powerful institutions strongly influence the environment where people live, work, and play AND
Broad social inequalities create and structure differential access to power, resources, life chances, and opportunities
We need to bridge both downstream and upstream to address health inequities. If we move upstream, we see that health inequities do not merely arise from individual variation in genes, health knowledge, and risk behaviors. We see that economic, social, and physical environment, as well as available services in a neighborhood all shape behavioral choices, disease risk factors, and disease
Health Status
Healthcare Access
Social Factors

24. All we see of someone at any moment is a snapshot of their life, there in riches or poverty, in joy or despair. Snapshots don't show the circumstances and the million decisions that led to that moment. Richard Bach

25. Adrian E. Dominguez, M.S. Epidemiologist Spokane Regional Health District Disease Prevention and Response Community Health Assessment, Planning , and Evaluation