Conceptual Models for Health Disparities Research

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Conceptual Models for Health Disparities Research

• Luisa Franzini
• University of Texas School of Public Health
• June 8, 2008
• RKJF New Connections

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Outline of presentation

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

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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
  

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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.

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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.

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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

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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

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Social conditions

• Foundation of research into the importance of
  social conditions dates to Shaw and McKay
  (1942).
  
• 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
  1942.
  

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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.

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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.

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R.G. Evans and G.L. Stoddart, SSM, 1990
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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.

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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.

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Healthy Passages A Community-based Longitudinal
Study of Adolescent HealthPI Tortolero,
Schuster, Franklin
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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.

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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.

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Example The built environment and obesity
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Example Pathways to obesity Identifying local
modifying determinants of physical activity and
diet
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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

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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.

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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
  

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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.

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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).

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Interactive effects of neighborhood physical and
social factors on physical activity in youth
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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
  2005.

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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.

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Etiological model
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Example Study of neighborhoods and adolescent
health

• Aim 1 To examine how neighborhood factors
  moderate longitudinal changes from early to late
  adolescence in risky behaviors and health and
  educational.

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Social consequences model adapted for grant
proposal
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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.

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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
  models.
  

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Health services research models

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

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Health services research models

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

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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.
  

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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
  

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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

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Health services research model
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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
  causes
  
• Embed effective intervention into routine work of
  organization
  

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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)
  

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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

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Developing A Conceptual Model

• Anchor model development with your research
  question
  
• 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
  

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Developing A Conceptual Model

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

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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
  question
  

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Characteristics of a Good Model

• Conceptual clarity
• Model makes clear the assumptions on which the
  model and the causal relationships within it are
  premised
  

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Characteristics of a Good Model

• Logical congruence
• Models conclusions and predictions flow
  logically from the assumptions and causal
  relationships
  

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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
  

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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
  

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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
  narrative)
• Graphical or Pictorial A set of figures that
  display the components and relationships in the
  model (usually accompanied by narrative)
  

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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
  analysis.
  
• Empirical results can be consistent with a model,
  but they cannot verify it

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Conclusions

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