Transcript Cultural Competence in Palliative and End

WHAT TO DO WITH SOCIAL
DETERMINANTS OF HIV?
Dula F. Pacquiao, EdD, RN, CTN-A, TNS
Professor, Rutgers University School of Nursing
Newark, NJ
OBJECTIVES
1.
Describe social determinants of health in
vulnerable populations affected by HIV.
2.
Analyze evidence of the pathways by which social
determinants create differential epidemiological
vulnerability in population groups.
3.
Evaluate current strategies and initiatives in HIV
prevention and management using research
evidence on social determinants of health.
2
HIV- RELATED HEALTH DISPARITIES
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Despite prevention efforts, some groups of people
are affected by HIV/AIDS, viral hepatitis, STDs, and
TB more than other groups of people.
Differences may occur by gender, race or ethnicity,
education, income, disability, geographic location
and sexual orientation among others.
Social determinants of health like poverty, unequal
access to health care, lack of education, stigma,
and racism are linked to health disparities.
HIV-RELATED HEALTH DISPARITIES
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Poorer communities have higher rates of HIV/AIDS
Patients with low SES have lower rates of survival
Patients without adequate insurance are less likely to be on
ART
Substance abusers and minorities are more likely to delay
medical care
Minorities continue to experience higher death rates , even
after introduction of combination therapy
Patients who are homeless or unstably housed do not have
regular source of care and less likely to receive or stay on ART
RACIAL/ETHNIC DISPARITIES IN TB: 2010 (CDC, 2013)
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Compared with whites, TB rates were
approximately:
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7x higher among Hispanics
8x higher among Blacks
25 x higher among APIs
Compared with whites, the relative difference in TB
rates was:
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614% for Blacks
429% for APIs
286% for Hispanics
757% for AI/ANs
TB DISPARITIES BASED ON NATIVITY
1993-2010
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TB cases among foreign-born increased from 29% to 60%.
2006–2010
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59% of reported TB cases occurred among foreign-born.
Relative difference in TB rates among foreign-born vs. US born was
857% in 2006 and 1,031% in 2010.
2010: Among foreign-born, the relative difference in TB rates compared with
whites was:
 2,271% for APIs
 1,771% for Blacks
 836% for Hispanics
TB DISPARITIES BY EMPLOYMENT
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TB cases among unemployed persons was 53% in 2006 and 59% in 2010.
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Relative difference in reported TB cases among unemployed persons
compared with those employed in fields other than health care was 74%, a
change of 44.2% over time
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Relative difference in reported TB cases among persons whose primary
health-care provider for TB disease was a health department compared with
persons whose primary health-care provider for TB disease was
private/other providers was 217%, a change in the relative difference of
109% over time.
HEALTH DISPARITY (CDC, HRSA, DHHS)
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A type of difference in health closely linked with social or
economic disadvantage that negatively affect groups of people
who have systematically experienced greater social or
economic obstacles to health.
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Obstacles stem from characteristics historically linked to
discrimination or exclusion such as race or ethnicity, religion,
socioeconomic status, gender, mental health, sexual
orientation, or geographic location.
INEQUALITY VS. INEQUITY (Sadana & Blas, 2013)
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Health inequalities- differences in access to a range of
promotional, preventive, curative, or palliative health services
or differences in outcomes including disability, morbidity, and
mortality spanning physical, mental, and social health.
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Health inequities -differences in health that are judged to be
avoidable, unfair, and unjust; often revealed through systematic
patterns or gradients in access or outcomes across populations
with different levels of underlying social advantage or
disadvantage (wealth, power, prestige, or other markers of
social stratification).
HEALTH DISPARITY AS A CHAIN OF EVENTS
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4.
Environment
Access to, utilization of, and quality of care
Health status, or
A particular health outcome deserving scrutiny
(Carter-Pokras & Baquet, 2002)
ENVIRONMENT
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Natural and Built environment
Social environment
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Linked with:
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SES (income, education, occupation) (Babones, 2011)
Race and ethnicity (Kawachi et al 2005)
Social status (Marmot, 2006)
SOCIAL DETERMINANTS OF HEALTH (Marmot & Bell, 2009)
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Life conditions that tend to be cumulative in
their influence on health
Conditions where people are born, grow, live
and work
ECOSOCIAL /EMBODIMENT THEORY (Krieger, 2011)
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Humans embody their material and social world
Health and disease in populations patterned by:
 Societal arrangements of power, property, production, consumption and
reproduction
 Possibilities of the human body shaped by evolution, ecology, context
and history.
These causal pathways create the cumulative interplay of exposure,
susceptibility and resistance to diseases or illness.
ECOSOCIAL/EMBODIMENT THEORY
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Health disparities understood by examining the
proximal pathway of embodiment stemming
from social inequities (race, class, gender,
economic and political) that create differences
in health and biology.
Pathways of embodiment can occur in multilevel contexts of global, national and local
communities or neighborhood, family and
individual.
ALLOSTATIC LOAD (McEwen, 2008)
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Acute stress produces responses that promote adaptation and
survival through neural, cardiovascular, autonomic, immune
and metabolic systems
vs.
Chronic stress promotes and exacerbate pathophysiology
through the same systems that are dysregulated.
ALLOSTATIC LOAD OR OVERLOAD
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Resulting wear and tear from too much stress,
inefficient allostasis
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Inability to turn off the stress response when not needed
Ineffective response to stress or not adapting to the same
stressor over time.
Changes in personal behaviors that aggravate allostatic load
as smoking, overeating, drinking, poor quality sleep,
violence, risky sexual behaviors.
Affects memory, attention, cognition, learning, fear and
unlearned fears, anxiety, aggression
Health effects: PTSD, HTN, obesity, Type 2 diabetes, cancer,
mood disorders
Race/ethnicity
Residential Segregation
Residential location
Neighborhood
resources
Community
Stressors
Structural
Factors
Environmental
Hazards and
pollutants
Community Stress
Exposure
Individual stressors
Individual coping
Appraisal process
Internal Dose
Biologically
Effective dose
Community-level
vulnerability
Individual-level
vulnerability
Individual stress
Health effect
(disparities)
Stress Exposure Disease Framework ( Gee and Payne Sturges,2004)
WHAT IS HEALTH (WHO, HEALTH CANADA)
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A capacity or resource rather than a state of being
Capacity of people to adapt to, respond to, or control life's
challenges and changes" (Frankish et al., 1996).
 Being able to pursue one's goals, to acquire skills and
education, and to grow.
 Recognizes the range of social, economic and physical
environmental factors that contribute to health.
HEALTH (WHO, 1946)
HEALTH PROMOTION WITHIN PHC
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Health promotion - the process of enabling people
to increase control over, and to improve their
health (WHO, 1986).
Enabling or empowering people to address factors
that affect their health
Improvement of health rather than just
maintenance of health built on a system focused
on individuals and the communities where they
live.
Health promotion is holistic and integrates mental,
physical and social well-being.
POPULATION HEALTH
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An approach to health that aims to:
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Improve the health of the entire population
Reduce health inequities among population groups.
Examines and acts upon the broad range of
factors and conditions that have a strong
influence on health.
CRITIQUE OF POPULATION-APPROACHES (Frohlich & Potvin,
2008)
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Population at-risk – individuals with elevated risk for specific
disease (biological risk)
versus
Vulnerable populations – subgroup or subpopulations at higher
risk of risks because of shared social characteristics (social
vulnerability; implications for chronic disease)
UPSTREAM
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Improving education,
housing, minimum wage
Occupational and
environmental safety
Better zoning and land use
Fair taxation
DOWNSTREAM
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Early detection of diseases
Disease-prevention
education
Disease-based health care
Use of appropriate
pharmaceutical agents to
combat stress
IMPLICATIONS OF ECOSOCIAL THEORY AND
ALLOSTATIC LOAD
POPULATION FOCUSED AND HEALTH-FOCUSED
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Address social determinants
 Poverty
 Employment, sufficient wages
 Residential and work environment
 Access to healthy, safe and affordable food
 Access to healthy, safe and affordable housing
 Access to healthy and safe environment
 Access to safe and quality schools
 Combat stigma, marginalization and discrimination
POPULATION FOCUSED AND HEALTH-FOCUSED
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Focus on communities and populations where
they live, grow and work
Emphasize health promotion rather than
disease-focused prevention alone
Focus on families/populations and
communities rather than just individual
patients
INITIATIVES ON SOCIAL DETERMINANTS
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Moving to Opportunity (Leventhal & Brooks-Gunn, 2003)
Health in all policies (Avey, et al 2013)
Primary health care (Chu & Selwyn, 2011)
Project LEAD in Australia to combat racism (Ferdinand, et al
2013)
Community engagement (Hardy, et al 2013).
Community and academic partnership (Ramos, et al 2013)
Health impact assessment of zoning (Thornton et al 2013)
Protecting labor rights (Bhatia, et al., 2013)
Binational collaboration for occupational safety (Flynn et al.,
2013)
LESSONS LEARNED
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Economic improvement
 Employment
 Education
 Wages
Addressing work and residential environments
 Safety and quality
 Transportation
 Access to resources
Combating discrimination
Multisectoral collaboration
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Building social capital and social networks
Policy and program development and evaluation
Research and measurements on social determinants