Tackling Health Disparities A Population Health Approach

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Tackling Health DisparitiesA Population Health
Approach
Lauri Andress, Ph.D. March 6, 2009
Texas Society for Public Health EducationSpring
Conference 2009
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Objectives

• A common framework to identify a health
  disparities project based on population health
  principles. 
• Creating a basic health disparities intervention
  based on population health principles.  
•   

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Population Health Definition
Dunn Hayes, 1999, p. S7

• The health outcomes of a group of individuals,
  including the distribution of outcomes within
  the group.
• Measured by health status indicators that have
  been influenced by
• Social, economic and physical environments
• Personal health practices
• Individual capacity and coping skills
• Human biology
• Early childhood development, and health services
• Concerned about the interactions between the SDOH
  and health outcomes.

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Population Health
Geoffrey Rose British epidemiologist

• Focusing on population level variables such as
  socioeconomic position or environmental pollution
  would have greater utility in prevention
  strategies, because removal of such factors would
  potentially decrease the incidence of disease as
  opposed to strategies where small numbers of
  people have been exposed to a high risk, i.e.,
  heart disease
• Measures to improve public health, relating as
  they do to such obvious and mundane matters as
  housing, smoking, and food, may lack the glamour
  of high-technology medicine, but what they lack
  in excitement they gain in their potential impact
  on health, precisely because they deal with the
  major causes of common disease and
  disabilities.Rose, Geoffrey, The strategy of
  preventive medicine. Oxford (Oxford University
  Press), 1992.

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Schematic definition of the field of population

Health outcomes and distribution in a
population Dependent variables
Patterns of health Determinants over the life
course Independent variables
Policies Interventions At the individual and
social levels
Infant mortality Diabetes Cancer
Child-Early childhood ed. Teen- Social inclusion,
Adult-Income, wealth, autonomy
What Is Population Health? David Kindig, MD, PhD,
and Greg Stoddart, PhD (Am J Public Health.
200393380383)
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Social Determinants of Health

• Social determinants of health SDH refer to
  both specific features of and pathways by which
  societal conditions affect health and that
  potentially can be altered by informed action.
• As determinants, these social processes and
  conditions are conceptualized as essential
  factors that set certain limits or exert
  pressures, albeit without necessarily being
  deterministic in the sense that were
  circumstances to change the outcome would change
  as well.

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Health Equity

• An approach to public health that includes
• a well-structured set of scientific evidence and
• a political and educational ideology to encourage
  reflection on and changes in usual public policy
  practices.

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Cultural Toolkit Shared values, language,
religion, rituals, norms of behavior, and systems
of belief. A set of distinctive spiritual,
material, intellectual, and emotional features a
society uses to interpret phenomena, data and
experiences.

• Social Structure
• Cultural Toolkit

• Institutions, systems, policies, regulations

• Labor market
• Educational system, policies
• Social inclusion- exclusion
• Social welfare state
• Access to productive resources social goods

What causes social status and what is the result
of social status?

• Social Status
• Power wealth Imbalances
• Absence of civic capacity Political Influence

• Health inequities

• Lack of affordable housing
• Job security
• Hazards
• Community decay
• Poverty low wages
• Transportation

Inequitable distribution of the Social
Determinants of Health

• Psychosocial Stress
• Unhealthy behaviors

Andress, 2007
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The Explanatory Model

• Improving population health requires that we
  examine social, genetic, and physical
  environments.
• Currently it is believed that these determinants
  of population health may influence multiple risk
  factors and health outcomes by shaping
• Social inclusion
• individual health behaviors
• access to living conditions,
• lifestyles,
• goods and services such as healthcare and social
  services.
• Many of these factors involve public policy
  decisions made by government.
• In some cases these policy decisions and issues
  can undermine population health by influencing
  those social determinants of health leading to
  health inequities.

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Implications for Action
State of the Art in Research on Equity in Health.
Barbara Starfield Journal of Health Politics,
Policy and Law, Vol. 31, No. 1, February 2006.

• Increase inequities
• Efforts to improve overall distribution of health
• Behavior change strategies
• dependent on education, material wealth, or
  social connectedness
• Prevention and management of some illness-
  material wealth
• Decrease inequities
• Policy changes
• Must be aimed at decreasing the inequity, Ex.
  Legislation to de-lead gasoline reduced overall
  lead levels but not in low income kids
• Primary care infrastructure if wide spread and
  accessible
• not disease strategies
• Policies directed at infants and children
• Physical and social environments policies
  strategies
• desegregation, affirmative action, green space,
  zoning

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Health Equity ReadinessCompetencies
Values Ideology Scientific evidence Theories
SDOH Knowledge
Public Policy Political efficacy
Multi-sectored collaboration
Social change ethos
Neutral implementer of policy directives
emanating from the policymaker, or the public
administrator as an agent of change, using
autonomous judgment to operate in ways that may
change societal arrangements
Agenda setting Social movements Community
organizing
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Health Equity Initiatives
Behavioral Lifestyle
Upstream
Downstream
Educate landlords
Vouchers to eradicate triggers-smokers, moving
fees
State law Home sales
Family education on asthma triggers
Home assessments
Legal aide with rental issues
2005 Houston MSA, women are more likely than men
to report current asthma. Blacks and Hispanics
are more likely to report current asthma than
whites
Health disparities
Health inequities
Context, structural, SDOH
The facts Health outcomes
Asthma
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Health Equity Initiatives
Behavioral Lifestyle
Upstream
Downstream
Examine sewage system
Law building on flood plains
Treat infection
Council w. Planning authority
Target bacteria
Residents from routine and manual occupations,
were living in less expensive housing areas.
Residents in one community- Sewage in flood
water
Health disparities
Health inequities
Context, structural, SDOH
Outbreak of diarrheal infection
The facts Health outcomes
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Health Equity ReadinessChecklist

• How far upstream can you go?
• Will there be a change in a fundamental SDOH that
  affects a large number of people?
• Who is on your team?
• Anyone from outside health?
• What is the role of the community?
• Does it enhance the autonomy of the community?
• Does it increase civic- political participation?
• Did the community select the issue?
• Were you invited in to help?
• What is the health equity value?
• Any SDOH theories and research to support?
• Who gets helped and how? i.e., the gradient, the
  bottom, close the gap
• What is your role?
• professional expert/technician- the autonomous
  technician

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Lauri Andress, Ph.D. www.bridgingthehealthgap.
com landress_at_bridgingthehealthgap.com