Addressing Disparities through

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Addressing Disparities through Public Health
Practice
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What are we talking about?

• Health Disparity differences in disease
  prevalence, outcomes or access to care
• Health Inequality differences in health that can
  be ranked
• Health Inequity systematic differences in health
  or major social determinants of health) between
  groups with different levels of social advantage
  (wealth, power, or prestige)

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Key Concepts

• How socioeconomic conditions are linked to
  inequalities in health outcomes
• Model constructs how to measure them
• Brief overview of research on health inequities
  related to Community Nutrition
• Intervention strategies current knowledge about
  their effectiveness
• What are we doing at the Department of Health?

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1. How socioeconomic conditions are linked to
inequalities in health outcomes
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How are Social Conditions linked to Health
Disparities?
Conceptual Model created by the World Health
Organization Commission on Social Determinants of
Health
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What do I need to know about health disparities?

• (1) Socioeconomic status has a big impact on
  health, which is not limited to the effects of
  poverty but occur at all levels. Compared to
  those who are most privileged, premature death is
  more than 2 times as likely for middle income
  Americans, and more than 3 times as likely for
  those who live in poverty   (2) Throughout
  life, from birth onward, our access to
  socioeconomic resources affects our chances for
  living a healthy life. The conditions we live in
  during childhood affect our health throughout our
  lives.   (3) Health care is important when we
  are ill but accounts for only a small portion of
  health disparities. More important are factors
  that determine if we fall ill in the first place.
    (4) Each step up the social ladder provides
  greater access to social and physical
  environments that enable individuals to engage in
  health protective behaviors, (e.g., safe places
  to walk and access to healthier foods). Each step
  down, greater exposure to potential risks
  (pollution unsafe neighborhoods).  (5) Work
  conditions contribute to health health
  disparities. Low-wage jobs may involve shift work
  and physical hazards, low control over how and
  when tasks are done, job insecurity, and
  conflicts between family obligations and work
  requirements.   (6) Exposure to extreme and
  prolonged toxic stress is more common lower on
  the social ladder. Stressors that last a long
  time, like financial insecurity, interpersonal
  disputes, work-induced exhaustion, or chronic
  conflict are recorded in the body.

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2. Model constructs how to measure them
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Data Set Directory of Social Determinants of
Health at the Local Level
Data Set Directory of Social Determinants of
Health at the Local Level
Data Set Directory of Social Determinants of
Health at the Local Level

• University of Michigan SPH project funded by the
  CDC. Developers included experts in epidemiology,
  sociology, geography, medicine, demography,
  economics, developmental psychology, education,
  and toxicology
• Directory includes extensive list of current data
  sets that can be used to address SDOH. Data sets
  are organized in 12 dimensions of the social
  environment. Each dimension is subdivided into
  various components.

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12 Dimensions
Source Hillemeier M.M., J. Lynch, S. Harper, and
M. Casper. 2003. "Measuring contextual
characteristics for community health." Health
Services Research 38(6 part 2)1645717.
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Economic Dimension

• This table presents the components and indicators
  of the economic dimension. Nine economic
  components are identified
• Income
• Wealth
• Poverty
• Economic Development
• Financial Services
• Cost of Living
• Redistribution
• Fiscal Capacity
• Exploitation

Source Hillemeier M.M., J. Lynch, S. Harper, and
M. Casper. 2003. "Measuring contextual
characteristics for community health." Health
Services Research 38(6 part 2)1645717.
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Indicators Measures
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Harvard Geocoding Project Measures of
Socioeconomic Position

• Key domains
• Occupational class affects health via
  occupational hazards and income/standard of
  living
• Educational attainment reflects childhood SEP
  and future economic prospects, also knowledge
  health literacy
• Income subsidies affects standard of living
• Wealth referring to accumulated assets,
• Relative social ranking status prestige.
• Source Public Health Disparities Geocoding
  Project

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Area Based Measures of Socioeconomic Class

• Each of the previous 5 socioeconomic class
  domains can be assessed at multiple
  levels--individual, household, and area or
  neighborhood.
• Socioeconomic data can be measured at key points
  in the lifecourse -- in utero, infancy,
  childhood, and early, middle, and late adulthood.
  
• Composite measures combine information on more
  than one component variable. For example, the
  Townsend index consists of unemployment,
  renters, not owning a car, and crowding.
• Source Public Health Disparities Geocoding
  Project

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Townsend Index comparing two Boston neighborhoods
This economically depressed area in Boston's
Chinatown, turned out to be characterized as a
highly working class, poor, low income area with
high unemployment and few expensive homes.
This one house in Beacon Hill looked like it was
-- and turned out to be -- in a fairly affluent
area over 75 professionals, low poverty, high
income, low unemployment, and lots of expensive
homes.
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Use of Area-based measures in Washington
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• 3. Brief overview of research on health
  inequities related to Community Nutrition

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• The high-fat, high-salt, and low-vegetable/fruit
  diets found in disadvantaged populations are
  often less the result of bad choices than the
  unfortunate consequence of the shrinking number
  of good, affordable supermarkets in inner-city
  neighborhoods, the explosion of fast food
  restaurants in urban areas, and food traditions
  originating in deprivation. Similarly higher
  rates of smoking and alcohol useare more a
  response to the pressures of poverty and lack of
  employment opportunities than lifestyle
  choice.1
• 1 Amersbach,G. Through the lens of race
  Unequal health care in America. Harvard Public
  Health Review, Winter 2002. Viewed 3/5/2006.
  http//www.hsph.harvard.edu/review/review_winter_0
  2

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Assembling a Mosaic of Evidence

• The community nutrition environment may
  explain some of the racial, ethnic and
  socioeconomic disparities in nutrition and health
  such as the increasing prevalence of overweight
  in low income children. Supermarkets...are less
  common in lower income and minority neighborhoods
  than in other neighborhoodsrecent evidence links
  access to supermarkets with such indicators of
  healthful eating as fruit and vegetable intake
  among African American adults (and) household
  fruit consumption

The role of the built environments in physical
activity, eating and obesity in childhood, Sallis
J, Glanz, K. www.futureofchildren.org, vol 16
(1), 2006.
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Supermarkets...are less common in lower income
and minority neighborhoods

• A study of access to food markets and restaurants
  by neighborhood wealth (median HH income) on MS,
  NC, MD and MN showed that wealthy neighborhoods
  had 3 times as many grocery stores as poor
  neighborhoods. Supermarkets were 4 times more
  common in white neighborhoods compared to black
  neighborhoods (Moorland et al, Am J Prev Med
  2002 22(1)
• Spatial regression analysis of average distance
  to the nearest supermarket in 869 Detroit
  neighborhoods showed that distance to nearest
  supermarket was about the same in wealthier
  neighborhoods, regardless of racial makeup. Among
  poor neighborhoods, those with high proportion of
  African Americans were 1.1 miles further from the
  nearest market than white neighborhoods. (Zenk
  et. al, Am J Pub Hlth 2005 95(4)

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access to supermarkets linked to such
indicators of healthful eating as fruit and
vegetable consumption

• A comparison of food frequency questionnaires in
  10,623 study participants with geocoded
  information on subject home addresses and local
  supermarkets showed that for blacks, fruit and
  vegetable intake increased by 31 for each
  additional supermarket in the neighborhood,
  compared to 11 for whites. Morland, et. al, Am
  J Pub Hlth 2002 92(11)
• A study of fruit and vegetable consumption among
  food stamp participants showed that households
  living more than 5 miles from their principal
  store consumed less fruit than those living
  within a mile of their store Rose, et. al, Pub
  Hlth Nutrition 2004, 7 (8)

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4. Intervention strategies current knowledge
about their effectiveness
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World Health Organization Conceptual Framework
Conceptual Model created by the World Health
Organization Commission on Social Determinants of
Health
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What policies would eliminate inequalities?
1. Policies that Affect the Ladder
2. Policies that Blunt Adverse Consequences
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5. What are we doing at the Department of Health?
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Chronic Disease Prevention Unit (CDP)Process to
Address Health Disparities

• Objectives
• Learn about social and economic factors driving
  health disparities to create a common
  understanding
• Brainstorm what public health professionals can
  and should do to address the social determinants
  of health
• Create an action plan to address health
  disparities in a more upstream fashion.
• Process
• Education 4 half-day sessions covering key
  concepts linking social and economic determinants
  to health and potential interventions
• Brainstorming A half-day exploration of what
  needs to be changed in our public health practice
  
• Action Planning A half-day planning session,
  using the Institute for Cultural Affairs model,
  to determine what we need to do to achieve these
  changes.

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