SOCIAL DETERMINANTS OF HEALTH INEQUALITIES: MEASUREMENT & - PowerPoint PPT Presentation

SOCIAL DETERMINANTS OF HEALTH INEQUALITIES: MEASUREMENT & INTERVENTION Presentation for Council of Michigan Foundations September 19, 2016 Angela G. Reyes, MPH Founding and Executive Director Detroit Hispanic Development Corporation Amy J. Schulz, PhD, MPH Professor, Department of Health Behavior and Health Education University of Michigan School of Public Health

2 Objectives • Describe social determinants of health equity • Consider implications of social determinants of health for interventions to promote health & health equity • Discuss four brief case examples of interventions that address social determinants of health, and evaluation/measurement of effects.

3 SOCIAL DETERMINANTS OF HEALTH

Social determinants of health • Social & economic & physical conditions under which people are born, live, work, learn & age, & which determine their health • These conditions determine the availability of resources that are necessary to maintain health.

Introduction 5

Introduction 6

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8 HEALTH DISPARITIES VS . HEALTH INEQUITIES

Introduction 9 “HEALTH DISPARITIES” “BROADLY DEFINED AS POPULATION-SPECIFIC DIFFERENCES IN HEALTH INDICATORS” “most dictionaries define disparity as: inequality; difference in age, rank, condition, or excellence.” Carter-Pokras, O. and Baquet, C. “What is a Health Disparity?” PHR. Vol 117. September–October 2002. pp. 425-434.

Introduction 10 Health Inequities are inequalities that are related to differences in health status or medical treatment that are unfair to disadvantaged people and that are avoidable . Source: Braveman and Tarimo, Soc Sci and Med:54:1621-1635 (2002). Image from “Unnatural Causes: When the Bough Breaks”.

11 An Enduring Relationship Exists Between Race and Income/Educational Levels High School Dropouts Below the Poverty Level 30% 27% 25% 24% 20% 15% 13% 12% 11% 10% 8% 4% 4% 5% 0% White Asian or Pacific Black Hispanic Islander Sources: US Census Bureau, Statistical Abstract of the United States: 2014; US Department of Education, National Center for Education Statistics. 2014. The Condition of Education 2014.

12 There is also an enduring relationship between various demographic and social factors and health

13 Self-Reported Health and Activity Limitation by Level of Education, 2011 Fair/Poor Health Activity Limitations (all causes) 40% 35% 31% 30% 25% 25% 19% 19% 20% 14% 10% 7% 0% Less than High School High School or Equivalent Some post-High School College Graduate Source: Behavioral Risk Factor Surveillance System, Prevalence and Trends Data, 2011. Accessed Apr. 19, 2015 at: http://apps.nccd.cdc.gov/brfss/page.asp?yr=2011&state=UB&cat=CH#CH.

15 What do social determinants of health have to do with health inequities? Health inequities occur when there are systematic differences in the distribution of social and economic resources – the social determinants of health – across communities or groups of people. Differences in the distribution of these social determinants of health are largely responsible for health inequities.

16 Health and the Built Environment The design of neighborhoods impacts residents’ health

17 Health and the Physical Environment

18 Allostatic Load: Stress and Health • Definition of Allostatic Load: “ A measure of the cumulative physiological burden exacted on the body through attempts to adapt to life's demands.” • Sources of stress include:  Economic insecurity  Job insecurity  Lack of social support  Inadequate child care  Low-control jobs  Racism  Sexism  Discrimination  Unsafe neighborhoods  Elements of the built environment

19 Connection between Stress and Health Neighborhood poverty  higher stress  poorer health • People who live in disadvantaged neighborhoods are more likely to suffer heart attacks than people in • middle-class neighborhoods People in neighborhoods with many abandoned buildings have higher rates of early death from cancer • and diabetes Higher allostatic load is associated with significantly increased risk for 7-year mortality, declines in • cognitive and physical functioning, increased risk for cardiovascular disease and metabolic disorders Innovative research on telomeres • Short telomeres are linked to heart disease, diabetes, cancer – and • chronic stress Ways to protect telomeres include through diet, exercise – and easing • emotional stress Sources: Teresa E. Seeman, Bruce S. McEwen, John W. Rowe, and Burton H. Singer. Allostatic load as a marker of cumulative biological risk: MacArthur studies of successful aging. PNAS 2001 98: 4770-4775; Helen Epstein, New York Times , Ghetto Miasma: Enough to Make you Sick? 10/12/2003.; Denise Grady, New York Times , “Profiles in Science: Charting Her Own Course, 4/8/2013, http://www.nytimes.com/2013/04/09/science/elizabeth-blackburn-molecular-biologist-charts-her-own-course.html?pagewanted=1&_r=0&smid=tw-share

20 IMPLICATIONS FOR INTERVENING TO REDUCE HEALTH INEQUITIES

21 Social Determinants of Health Frameworks… • …open new possibilities for interventions to promote health • Interventions that mitigate the impact of social, economic or physical environmental conditions on people’s lives & health • Interventions that directly address the social, economic and physical environmental conditions that affect health

22 Core Aspects of Effective Solutions • Place-based solutions. • Assess community to identify the unique ways its environment impacts health outcomes. • Meaningful place-based solutions are holistic, focus on prevention, and engage community members and partners from multiple sectors. • Intentional focus on race, nationality, ethnicity, and culture. • Race affects where and how we all live, work and play. • Attention must be placed on addressing racial equity. • Communication strategies. • Explain and amplify the problem • Highlight inequities with supporting data • Offer solutions. • Policy and systems change. • Critical elements in sustaining health equity efforts and maintaining a culture of health.

23 HEALTH INEQUALITIES: CASE STUDY 1 INTERVENTIONS THAT RECOGNIZE SOCIAL DETERMINANTS OF HEALTH

Healthy Environments Partnership A commu mmunity-based d parti ticipato tory r research p partn tnership working together since 2000 to understand and promote te h heart h t health th i in Detr troit. t. We examine aspects of the socia ial & ph physic ical environm nment nt that contribute to racial & socioeconomic inequ quiti ties in c cardi diovascular di disease (CV CVD), and develop, implement & evaluate interventions to address them. Chandler Park Conservancy | Detroit Health Department | Detroit Hispanic Development Corporation | | Eastside Community Network | Friends of Parkside | Henry Ford Health System | Institute for Population Health | University of Michigan School of Public Health | Community Members At-Large

Age adjusted cardiovascular mortality rates and median household income 700 600 500 400 300 Median Household income (in 100's) 200 Heart Disease Mortality Rate 100 (per 100,000) 0

Community Planning Process: Building placed-based solutions Challenges Facilitating Factors • “There is no equipment – youth play • Outdoor community events basketball in the street” • Dancing/fun • Local recreation centers closed • Activities for youth & families • Places that are not clean • Trails, parks & facilities that are safe • “immigrants don’t want to walk & easy to get to outside – they feel vulnerable to the • More people out walking – more border patrol” likely to use the spaces • “the wooded areas are dangerous – • Support for walking why take the chance?” • Organizations that support walking • Traffic – cars driving up and down and activity friendly spaces the streets fast”

CATCH Multilevel Intervention: Pathways to Heart Health • Promote Walking • Promote Community Leadership & Sustainability • Promote Activity Friendly Neighborhoods

Walk Your Heart to Health • Evaluation: Pre & Post • Walking Group Aims: Surveys (e.g., health indicators, attitudes,  Promote heart healthy behaviors via walking social support)  Pedometers – monitor steps  Provide opportunities for other heart health activity (e.g., food demos)  Participant observation  Offer social support for heart healthy  Attendance records activities  Session summary sheets

What We Learned 1. WALKING GROUPS INCREASE PHYSICAL ACTIVITY Mean Number of Daily Steps Walked by WYHH Participants 12000 11000 10,221 10,161 10,097 9,899 10000 9000 8000 6,993 6,956 6,893 6,839 7000 5,800 5,796 5,751 5,711 6000 4,729 5000 4000 3000 2000 1000 0 Baseline 8 Weeks 16 Weeks 24 Weeks 32 Weeks Steps on days participants did not walk with the group Overall mean steps Steps on days participants walked with the group

What We Learned 2. WYHH WALKING GROUPS REDUCED CVD RISK FACTORS Adjusted High Blood Pressure Prevalence Estimates for WYHH Participants with an Average Increase of 4000 Steps per Day 50.0 HBP prevalence 45.0 (%) 40.0 35.0 30.0 Baseline 8 Weeks 32 weeks