Transcript The Health of the Black Population in the United States

Moving Upstream:
How Interventions that Address the Social
Determinants of Health can Improve Health
and Reduce Disparities
David R. Williams, PhD, MPH
Florence & Laura Norman Professor of Public Health
Professor of African & African American Studies and of Sociology
Harvard University
Reducing Inequalities
Health Care
• Improve access to care and the quality of care
– Give emphasis to the prevention of illness
– Provide effective treatment
– Develop incentives to reduce inequalities in the
quality of care
Care that Addresses the Social context
• Effective health care delivery must take the socioeconomic context of the patient’s life seriously
• The health problems of vulnerable groups must be
understood within the larger context of their lives
• The delivery of health services must address the
many challenges that they face and take the
characteristics and needs of vulnerable
populations into account
• This will involve consideration of: the strengths of
the client, the support and barriers in the client’s
environment and the non-medical resources that
may be mobilized to assist the client
Nurse Family Partnership
• Nurses make prenatal and postnatal visits to pregnant
women.
• Nurses enhance parents’ economic self-sufficiency by
addressing vision for future, subsequent pregnancies,
educational and job opportunities.
• Three randomized control trials (Elmira, NY;
Memphis, TN; Denver, CO)
• Improved prenatal behaviors, pregnancy outcomes,
maternal employment, relationships with partner.
• Reduces child abuse and neglect, subsequent
pregnancies, welfare and food stamp use
• $17,000 return to society for each family served
Olds 2002, Prevention Science
Service Delivery and Social Context
•244 low-income hypertensive patients, 80% black
(matched on age, race, gender, and blood pressure
history) were randomly assigned to:
•
•
•
Routine Care: Routine hypertensive care from a physician.
Health Education Intervention: Routine care, plus weekly clinic
meetings for 12 weeks run by a health professional.
Outreach Intervention: Routine care, plus home visits by lay health
workers*. Provided info on hypertension, discussed family difficulties,
financial strain, employment opportunities, and, as appropriate,
provided support, advice, referral, and direct assistance.
* Recruited from the local community, one month of training to address
social and medical needs of persons with hypertension.
Source: Syme et al.
Service Delivery and Social Context: Results
After seven months of follow-up, patients in the outreach
group:
1. Were more likely to have their blood pressure controlled
than patients in the other two groups.
2. Knew twice as much about blood pressure as patients in
the other two groups. Those in the outreach group with
more knowledge were more successful in blood pressure
control.
3. Were more compliant with taking their hypertensive
medication than patients in the health education
intervention group. Moreover, good compliers in the
outreach third group were twice as successful at
controlling their blood pressure as good compliers in the
health education group.
Source: Syme et al.
Needed Interventions
Policies to reduce inequalities in health
must also address fundamental nonmedical determinants.
Moving Upstream
Effective Policies to reduce inequalities
in health must address fundamental
non-medical determinants.
WHY?
WHY?
WHY?
Centrality of the Social Environment
An individual’s chances of getting sick are largely
unrelated to the receipt of medical care
Where we live, learn, work, play and worship
determine our opportunities and chances for being
healthy
Social Policies can make it easier or harder to
make healthy choices
Redefining Health Policy
Health Policies include policies in all sectors of
society that affect opportunities to choose health,
including, for example,
• Housing Policy
• Employment Policies
• Community Development Policies
• Income Support Policies
• Transportation Policies
• Environmental Policies
Neighborhood Change and Health
• The Moving to Opportunity Program
randomized families with children in high
poverty neighborhoods to move to less poor
neighborhoods.
• It found, three years later, that there were
improvements in the mental health of both
parents and sons who moved to the lowpoverty neighborhoods.
Leventhal and Brooks-Gunn, 2003
Yonkers Housing Intervention
City-wide de-concentration of public housing
 Half of public housing residents selected via a
lottery to move to better housing
 2 years later, movers reported better overall health,
less substance abuse, neighborhood disorder and
violence than those who stayed
 Movers also reported greater satisfaction with
public transportation, recreation facilities and
medical care
 Movers had higher rates of employment and lower
welfare use
Fauth et al. Social Science and Medicine, 2004
Increased Income and Health
• A study conducted in the early 1970s found that
mothers in the experimental income group who
received expanded income support had infants
with higher birth weight than that of mothers in
the control group.
• Neither group experienced any experimental
manipulation of health services.
• Improved nutrition, probably a result of the
income manipulation, appeared to have been the
key intervening factor.
Kehrer and Wolin, 1979
Income Change and Health
• A natural experiment assessed the impact of
an income supplement on the mental health
of American Indian children.
• It found that increased family income
(because of the opening of a casino) was
associated with declining rates of deviant
and aggressive behavior.
Costello et al. 2003
New Hope Random Experiment
Families in poverty in Milwaukee, WI receive
intervention that provides work support and earnings
supplements to raise total income above poverty
 Five year evaluation showed multiple positive effects
on children aged 6-16, especially boys:
 Better study skills, school-related measures and
positive social behaviors
 Higher school engagement, future expectations and
lower aggression

Huston, et al. Developmental Psychology, 2005
Conditional Cash Transfer Programs
 Mexico’s
PROGRESA (now Oportunidades)
established in 1997
 Low income families, randomized at the community,
level receive additional cash conditional on children’s
school attendance, preventive care visits and
participation in health information sessions
 Compared to controls, the intervention group had
decreased illness rates, child stunting, BMI and
improvements in endurance, language development,
memory, and height for age
 Additional cash is key determinant of program success
Rawlings & Rubin, 2005; Paxson & Shady, 2007; Fernand et al. 2008
Health Effects of Civil Rights Policy
• Civil Rights policies narrowed black-white economic gap
• Black women had larger gains in life expectancy during
1965 - 74 than other groups (3 times as large as those in
the decade before)
• Between 1968 and 1978, black males and females, aged
35-74, had larger absolute and relative declines in
mortality than whites
• Black women born 1967 - 69 had lower risk factor rates as
adults and were less likely to have infants with low-birth
weight and low APGAR scores than those born 1961- 63
• Desegregation of Southern hospitals enabled 5,000 to
7,000 additional Black babies to survive infancy between
1965 to 1975
Kaplan et al. 2008; Cooper et al. 1981; Almond & Chay, 2006; Almond et al. 2006
Median Family Income of
Blacks per $1 of Whites
0.62
0.61
0.6
0.59
Cents
0.58
0.57
0.56
0.55
0.54
1978 1980 1982 1984 1986 1988 1990 1992 1994 1996
Year
Source: Economic Report of the President, 1998
U.S. Life Expectancy at Birth, 1984-1992
80
White
Life Expectency (Year)
75
70
75.3
75.3
69.5
75.4
69.3
75.6
69.1
75.6
69.1
75.9
68.9
76.1
68.8
Black
76.5
76.3
69.1
69.3
69.6
65
60
1984
1985
1986
1987
1988
Year
NCHS, 1995
1989
1990
1991
1992
Policy Matters
Investments in early childhood
programs in the U.S. have been
shown to have decisive beneficial
effects
The High/Scope Perry
Preschool Study to Age
40
Larry Schweinhart
High/Scope Educational Research Foundation
www.highscope.org
High/Scope Perry Preschool
 123 young African-American children, living in poverty
and at risk of school failure.
 Randomly assigned to initially similar program and noprogram groups.
 4 teachers with bachelors’ degrees held a daily class of 2025 three- and four-year-olds and made weekly home visits.
 Children participated in their own education by planning,
doing, and reviewing their own activities.
Results at Age 40
 Those who received the program had better academic
performance (more likely to graduate from high school)
 Program recipients did better economically (higher
employment, annual income, savings & home ownership)
 The group who received high-quality early education had
fewer arrests for violent, property and drug crimes
 The program was cost effective: A return to society of $17
for every dollar invested in early education
_____________________________________________________________________
Schweinhart & Montie, 2005
Country
% Children Child Poverty (%)
1 Parent 1 Parent Other
HH
Spain
2
32
12
Italy
3
22
20
Mexico
4
28
26
France
8
26
6
Ireland
8
48
14
Germany
10
51
6
United States
19
55
16
United Kingdom
20
46
13
Sweden
21
7
2
Source: UNICEF (United Nations Children’s Fund), 2000
Child Poverty Rates
Country
Before Taxes
After Taxes
Netherlands
16.0
7.7
Spain
21.1
12.3
Sweden
23.4
2.6
Canada
24.6
15.5
Italy
24.6
20.5
United States
26.7
22.4
Australia
28.1
12.6
France
28.7
7.9
United Kingdom
36.1
19.8
Poland
44.4
15.4
Source: UNICEF (United Nations’ Children’s Fund), 2000
Research Opportunities: Multiple Levels
• What interventions really work to reduce inequalities in
health? How can we make them cost-effective?
• Which community-based interventions show the greatest
promise?
• How can we more actively support individuals, families, and
communities to make choices that promote health?
• Are there specific interventions targeted at the broader,
social, political and economic determinants of health that
would have larger health enhancing effects on
disadvantaged (socioeconomic and racial/ethnic)
populations than their higher status peers?
• How can we best build on the strengths and capacities of
disadvantaged populations?
Conclusions -I
1. Health officials and organizations cannot
improve health by themselves
2. Improving health and reducing inequalities in
health is not just about more health programs, it
is about a new path to health
3. All policy that affects health is health policy
4. Health officials need to work collaboratively
with other sectors of society to initiate and
support social policies that promote health and
reduce inequalities and health
Conclusions -II
1. Inequalities in health are created by larger
inequalities in society.
2. SES and racial/ethnic disparities in health reflect
the successful implementation of social policies.
3. Eliminating them requires political will for and a
commitment to new strategies to improve living
and working conditions.
4. Our great need is to begin in a systematic and
comprehensive manner, to use all of the current
knowledge that we have.
5. Now is the time