Determinants of Health and Health Disparities: Conceptual Frameworks

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Determinants of Health and Health Disparities
Conceptual Frameworks

• Anita L. Stewart, Ph.D.
• UCSF, Institute for Health Aging
• Center for Aging in Diverse Communities
• April 17, 2007

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Types of Diverse Groups

• Current health disparities research focuses on
  differences across race/ethnic groups
• Much prior research examined differences by
  socioeconomic status (SES)
• Low income vs. others
• Low education vs. others
• Both are vulnerable populations

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Phases of Disparities Research
Detecting Define health disparities Define
vulnerablepopulations
Understanding Identify determinants of
disparities
Reducing Intervene Evaluate Translate/disseminate
Change policy
Adapted from Kilbourne et al, 2006
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Defining Disparities Vulnerable populations have
worse health than their counterparts in.

• Premature mortality including infant mortality
• Morbidity
• Chronic disease (heart disease, diabetes, cancer)
• Communicable disease (TB)
• Low birth weight
• Physiological risk factors
• Hypertension
• Obesity/overweight
• Functional limitations, disability
• Self-rated health

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Understanding Disparities Underlying Question

• What is it about being in a minority group that
  could lead to poorer health?
• What does race/ethnicity stand for
• Deconstruct race/ethnic group membership into
  underlying variables
• Behaviors, attitudes, values, beliefs, ethnic
  identity, acculturation, discrimination,
  educational experiences, SES, culture

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PARALLEL Question Socioeconomic Status
Disparities

• What is it about being lower SES that could lead
  to poorer health?
• What does lower SES stand for
• Deconstruct being of lower SES into underlying
  variables
• Behaviors, attitudes, values, beliefs, ethnic
  identity, acculturation, discrimination, culture

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Understanding and Reducing Disparities Role of
Conceptual Frameworks

• Ground research in theory and knowledge
• Help identify and organize key variables
  addressing global objectives
• On the pathway to disparities
• Help develop specific research questions
• Guide selection of measures

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Numerous Frameworks Determinants of Health
Health
Determinants
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Conceptual Frameworks Need to Depict Determinants
of Health Disparities
Race/ethnic and SES health disparities
Determinants
Frameworks cast a broader net of determinants --
relevant to vulnerable groups -- vary across and
within race/ethnic groups -- plausible mechanisms
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Three Broad Types of Conceptual Frameworks

• Population science
• Determinants of health in a population
• Samples are populations or population subgroups
• Health services research
• How health care affects outcomes
• Samples are patients or health plan members
• Biology/physiology
• Biological and genetic pathways to disease

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Population-Based Determinants of Health

• Medical care accounts for only 10 of the
  variance in health (Adler, McGinnis)
• But medical care may have a greater impact on
  the health of vulnerable groups than on their
  counterparts (Williams and Collins)

Williams DR Ann Rev Sociol 199321349
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Population-Based Determinants Multiple Levels of
Influence on Health

• Individual
• biological, behaviors, attitudes, age, education,
  occupation
• Family
• size, structure, support, beliefs
• Neighborhood or community
• resources, toxins, aesthetics, crime/poverty

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Population-Based Determinants Multiple Levels of
Influence on Health (cont)

• Cultural group, ethnic identity
• shared beliefs, values, behaviors
• Occupation or workplace
• hazards, toxins, safety, working conditions
• Organizational/institutional structures
• educational system, health care
• Societal, political

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Individual Embedded in Ecological Context
Society
Community
Family
Family
Individual
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One Ecological Model of Determinants of Health
Living and working conditions
Individual behavior
Bio-behavioralmechanisms, genetics
Over the lifespan
Social, family, community networks
NationalAcademy ofSciences, 2002
Macro social, environmental conditions and
policies
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An Alternative Depiction of Multi-level
Determinants of Health Disparities
Contextual
Individual-level
Sociodemographics - age, race, ethnicity,
education, income
Physical environment
Social environment
Psychosocial - compliance, coping
Health disparities
Health care
Organizational, institutional
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior, illicit drug use
Economic resources
Psychological - beliefs, attitudes,personality
Societal, political
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Ecological, Multi-level Determinants
Context
Individual-level
Sociodemographics - age, race, ethnicity,
education
Physical environment
Social environment
Psychosocial - compliance, coping
Health disparities
Health care
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior
Organizational, institutional
Psychological -beliefs, attitudes, personality
Economic resources
Biological, physiological
Societal, political
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Physical Environment

• Neighborhood safety, attractiveness
• Housing quality
• Transportation
• Segregation
• Hazardous materials
• Occupational hazards

• of liquor stores
• of full service grocery stores
• Availability of fresh fruits and vegetables
• of areas for walking, bicycling

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Ecological, Multi-level Determinants
Context
Individual-level
Sociodemographics - age, race, ethnicity,
education
Physical environment
Social environment
Psychosocial - compliance, coping
Health disparities
Health care
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior
Organizational, institutional
Psychological -beliefs, attitudes, personality
Economic resources
Biological, physiological
Societal, political
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Social Environment

• Social opportunities
• Family environment
• Social support
• Discrimination or racism
• Neighborhood cohesiveness
• Community meeting places

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Social Epidemiology

• studies the social distribution and social
  determinants of states of health (p. 6)
• Determinants
• Socioeconomic position
• Discrimination
• Working conditions
• Social integration, social networks
• Health behaviors
• Physical and social environments

Berkman LF and Kawachi I, Social Epidemiology,
Oxford, 2000.
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Conceptual Frameworks of Determinants Social
Environment
Socialstructuralconditions(macro)
Social networks (mezzo)
Psycho-socialmechanisms (micro)
Pathways

• Culture
• Socio economic factors

• Network structure
• Frequency of contact

• Social support
• Social influence
• Access to resources

• Health behaviors
• Psychological
• Physiologic

Berkman LF and Glass T, Social integration,
social networks, social support, and health, in
Social Epidemiology, ch 7, p. 143.
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Ecological, Multi-level Determinants
Context
Individual-level
Sociodemographics - age, race, ethnicity,
education, SES
Physical environment
Social environment
Psychosocial - compliance, coping
Health disparities
Health care
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior
Organizational, institutional
Psychological -beliefs, attitudes, personality
Economic resources
Biological, physiological
Societal, political
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Societal Approaches to Health Improvement

• Prevention strategies that target population
  health by changing social and community
  environments
• No smoking ordinances
• Taxation policies
• Smog control legislation
• Food labeling

• Singer BH et al. New Horizons in Health, 2001

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Societal Approaches Example

• New York bans most trans fats in restaurants
  (NY Times, Dec 6, 2006)
• First municipal ban on use of all but tiny
  amounts of trans fat
• NY Board of Health
• Also approved a measure to require some
  restaurants (mostly fast food) to prominently
  display caloric content of menu items

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Multi-level Determinants Lifestyle as a Pathway
Contextual
Individual-level
Sociodemographics - age, race, ethnicity,
education, income
Physical environment
Social environment
Psychosocial - compliance, coping
Health disparities
Health care
Organizational, institutional
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior, illicit drug use
Economic resources
Psychological - beliefs, attitudes,personality
Societal, political
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Multi-level Determinants Lifestyle as a Pathway
Contextual
Individual-level
Sociodemographics - age, race, ethnicity,
education, income
Physical environment
Lifestyle, health behavior
Social environment
Psychosocial - compliance, coping
Health care
Organizational, institutional
Health
Psychological - beliefs, attitudes
Economic resources
Community resources
Emmons, K Health behavior in a social context,
in Social Epidemiology, 2000, ch. 11.
Policy
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The Role of Socioeconomic Status

• Minority groups on average have lower
  socioeconomic status than Whites
• Lower SES is thus a key hypothesis for observed
  race/ethnic health disparities
• But SES is its own major determinant

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Socioeconomic Status Underlying Constructs and
Mechanisms

• SES is multidimensional
• Prestige mechanism
• Social stratification, social class
• Relative social standing
• Occupation
• Resources mechanism
• Education
• Income, wealth, assets
• Poverty, material deprivation

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Ecological, Multi-level Determinants
Low SES context
Low individual-level SES
Sociodemographics - age, race, ethnicity,
education, SES
Physical environment
Social environment
Psychosocial - compliance, coping
Health disparities
Health care
Lifestyle - exercise, diet, alcohol, smoking,
sexual behavior
Organizational, institutional
Psychological -beliefs, attitudes, personality
Economic resources
Biological, physiological
Societal, political
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Living in Poor Neighborhoods Increases Health Risk

• Contextual analysis
• Examine whether neighborhood-level factors
  contribute to risk controlling for
  individual-level factors
• Metaanalysis of 25 studies
• All but 2 reported significant effect of social
  environment (neighborhood) and health,
  controlling for individual-level factors

KE Pickett, J Epidemiol Comm Health 200155111.
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Example from Hilary Seligman Access to Healthy
Foods and Health
Context
Individual-level
Physical Access toHealthy Food TransportationNu
mber of grocery stores Distance to nearest
grocery store
Food insecurity- not enough money to buy food
Obesity,diabetes
Lifestyle behaviors- shop at stores with healthy
food- buy healthy food - eat healthy food
Financial ResourcesIncome/economic strain
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Cumulative Pathways or Lifecourse Issues

• Health disparities due to lifetime of adverse
  conditions
• Specific research
• Childhood levels of SES and cumulative
  disadvantageous economic circumstances are
  associated with poor health in mid-life
• Lifetime experiences of discrimination due to
  race/ethnicity adversely affect health

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Framework Socioeconomic Status Over the
Lifecourse and Health
Socioeconomic Position
Intrauterineconditions
Education,environment
Work conditions, income
Income, assets
Birth
Childhood
Adulthood
Old Age
Inadequate medical care
Low birth weight Growth retardation
Smoking,diet, exercise
Job stress
Atherosclerosis
CVD
Reducedfunction
Lynch J and Kaplan G, Social Epidemiology,
Oxford, 2000 (Ch 2, p. 28)
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Example of Lifecourse Research

• Compared with middle- and high-income
  children, low-income children are
  disproportionately exposed to more adverse social
  and physical environmental conditions. (Evans,
  2004, p. 88)
• Cumulative exposure is critical

Evans GW, The environment of childhood
poverty,Amer Psychol, 20045977-
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Racism/Discrimination a Plausible Lifecourse
Hypothesis

• Health outcomes of racism
• Hypertension
• Psychological distress
• Poorer self-rated health
• all are independent of effects of SES

Nazroo JY, AJPH, 93 277 Williams DR, Ethn Dis,
200111800
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Biopsychosocial Effects of Perceived Racism on
Health (Clark et al., 1999)
Environmental stimulus
Sociodemographic, Psychological, Behavioral
factors
Perception
Perception of racism
Perception of different stressor
No perception of racism or other stressor
Coping responses
Blunted psychological and physiological stress
responses
Psychological and physiological stress responses
Health outcomes
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Three Broad Types of Conceptual Frameworks

• Population science
• Determinants of health in a population
• Samples are populations or population subgroups
• Health services research
• How health care affects outcomes
• Samples are patients or health plan members
• Biology/physiology
• Biological and genetic pathways to disease

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Structure-Process-Outcome Paradigm
Process of care -technical care -interpersonal
care
Structure of care
Patient outcomes

• Structure - system of care
• Technical process - knowledge and judgment skills
  
• Interpersonal process - the way care is provided

Donabedian A. Quality Review Bulletin, 1992, p.
356
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Examples of Research on How Structure of Care
Affects Disparities

• If systems provide medical interpreters, do
  patients with limited English proficiency have
  better health outcomes?
• If systems offer a broad choice of minority
  providers, do minority patients have better
  health outcomes?

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Examples of Research Questions on How Technical
Processes Affect Disparities

• Are treatments less effective for racial/ethnic
  minorities than for whites?
• Are appropriate diagnostic procedures used less
  often for minorities than for whites?
• Are optimal treatments provided less often for
  racial/ethnic minorities than for whites?
• e.g., pain medication in emergency departments

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Examples of Research Questions on How
Interpersonal Processes Affect Disparities

• What are the effects on health of differences in
• Communication
• Elicitation of patient concerns
• Respectfulness
• Perceived discrimination
• Participatory decision making

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Structure-Process-Outcome Paradigm
Process of care -technical care -interpersonal
care
Intermediatepatient outcomes - compliance -
knowledge
Structure of care
Ultimate patient outcomes - health
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Another Type of Intermediate Outcome
Process of care -technical care -interpersonal
care

• Intermediatepatient outcomes
• blood pressure
• weight
• HbA1c

Structure of care

• Ultimate patient outcomes
• mortality
• morbidity

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Structure-Process-Outcome Paradigm
Structure of care
Process of care -technical care -interpersonal
care
Intermediateoutcomes -compliance -knowledge
Providercharacteristics
Ultimate outcomes - health
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Structure-Process-Outcome Paradigm
Structure of care
Process of care -technical care -interpersonal
care
Intermediateoutcomes -compliance -knowledge
Providercharacteristics
Cultural competenceSystem and providers offer
highest quality care to all patients regardless
of ethnicity,culture, or language proficiency
Ultimate outcomes - health
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Documenting Healthcare Disparities

• Unequal Treatment
• Institute of Medicine, 2003
• National Healthcare Disparities Reports (AHRQ for
  DHHS)
• 2003, 2004, and 2005

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Key Findings Unequal Treatment

• Racial/ethnic minorities receive lower quality of
  care then non-minorities
• Disparities occur in the context of broad
  historic and contemporary social/economic
  inequality, including discrimination
• A comprehensive, multi-level strategy is needed
  to eliminate these disparities

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2005 Updated Key Findings NHDR

• Unequal quality continues
• Minorities receive poorer quality of care
• Blacks poorer in 43 of measures
• American Indians poorer in 38 of measures
• Hispanics disparities growing wider
• Low income people largest disparities

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Conceptual Framework for National Healthcare
Disparities Reports
Components of Health Care Quality Components of Health Care Quality Components of Health Care Quality Components of Health Care Quality
Consumer Perspectives on health care needs Safety Effectiveness Patient centered-ness Timeliness
Staying healthy
Getting better
Living with illness or disability
Coping with the end of life
Equity
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National Healthcare Disparities Reports

• 2003
• www.ahrq.gov/QUAL/nhdr03/nhdr2003.pdf
• 2004
• www.ahrq.gov/qual/nhdr04/nhdr2004.pdf
• 2005
• www.ahrq.gov/qual/nhdr05/nhdr05.htm

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Structure-Process-Outcome Paradigm
Structure of care
Process of care -technical care -interpersonal
care
Intermediateoutcomes - compliance - knowledge
Providercharacteristics
Patient characteristics
Ultimate outcomes - health
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Blending Population and Health Services Frameworks
Structure of care
Process of care -technical care -interpersonal
care
Intermediateoutcomes - compliance - knowledge
Providercharacteristics
Patient characteristics
Environment
Ultimate outcomes - health
Neighborhood resources
Family support
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Alternative Health Services Research Framework
for Health Disparities
Health care system factors
Patientfactors
Provider factors
Interpersonal relationship
Adapted from Kilbourne et al., 2006
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Second Alternative Health Services Research
Framework for Health Disparities
Health care system factors
Patientfactors
Provider factors
Interpersonal relationship
Visit
Saba et al. J Fam Med., 2006
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Summary Conceptual Frameworks

• Numerous frameworks
• Health services
• Population science
• Biological/physiological
• Reflect theories and research from many
  disciplines
• Frameworks can integrate population, health
  services, and biological approaches
• Worth reviewing in designing all research