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Tackling Health Disparities A Population Health Approach Lauri Andress, Ph.D. March 6, 2009 Texas Society for Public Health Education Spring Conference 2009 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. 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. Geoffrey Rose British epidemiologist Population Health 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. 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 Child-Early childhood ed. Diabetes Teen- Social inclusion, Cancer Adult-Income, wealth, autonomy What Is Population Health? David Kindig, MD, PhD, and Greg Stoddart, PhD (Am J Public Health. 2003;93:380–383) 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.” Health Equity An approach to public health that includes: 1. a well-structured set of scientific evidence and 2. a political and educational ideology to encourage reflection on and changes in usual public policy practices. Social Structure Cultural Toolkit Institutions, systems, policies, regulations Inequitable distribution of the Social Determinants of Health Andress, 2007 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. Labor market Educational system, policies Social inclusion- exclusion Social welfare state Access to productive resources & social goods Social Status Power & wealth Imbalances Absence of civic capacity & Political Influence Lack of affordable housing Job security Hazards Community decay Poverty –low wages Transportation What causes social status and what is the result of social status? Health inequities Psychosocial Stress Unhealthy behaviors 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. 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 Primary care infrastructure if wide spread and accessible Must be aimed at decreasing the inequity, Ex. Legislation to de-lead gasoline reduced overall lead levels but not in low income kids not disease strategies Policies directed at infants and children Physical and social environments policies…… strategies desegregation, affirmative action, green space, zoning Health Equity Readiness Competencies SDOH Knowledge Public Policy Political efficacy Agenda setting Social movements Community organizing Social change ethos Values Ideology Scientific evidence Theories Multi-sectored collaboration 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 Health Equity Initiatives Behavioral Lifestyle Downstream Educate landlords Family education on asthma triggers Home assessments Health disparities The facts Health outcomes Upstream Vouchers to eradicate triggerssmokers, moving fees 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 Asthma State law Home sales Legal aide with rental issues Health inequities Context, structural, SDOH Health Equity Initiatives Behavioral Lifestyle Downstream Upstream Examine sewage system Treat infection Target bacteria Health disparities Residents in one communitySewage in flood water The facts Health outcomes Outbreak of diarrheal infection Council w. Planning authority Law building on flood plains Residents from routine and manual occupations, were living in less expensive housing areas. Health inequities Context, structural, SDOH Health Equity Readiness Checklist 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; facilitator- enabling face-to-face discourse; and Advocate- social critic- protecting citizens from societal conditions Lauri Andress, Ph.D. www.bridgingthehealthgap.com [email protected]