Social Determinants of Health The Basics Gwendolyn A

Social Determinants of Health: The Basics Gwendolyn A. Daniels, DNP, RN IPH Healthy Start Director

Overview of Training Modules 1. Terminology 2. Data and Context 3. Field Examples

Background • WHO Commission on SDOH www. who. int/social_determinants/thecommission/en/index. html • Unnatural Causes documentary www. unnaturalcauses. org/ • NACCHO Health Equity and Social Justice Committee www. naccho. org/topics/justice/mission. cfm • RWJ Commission on SDOH www. rwjf. org/pr/product. jsp? id=41008 • CDC Expert Panel on SDOH www. healthyohioprogram. org/ASSETS/AF 886060 E 94 E 4823 A 9338 F 7 E 68139947/hepanel. pdf • IOM Committee in SDOH www. iom. edu/Activities/Select. Pops/Health. Disparities. aspx • IOM Local Government Actions to Prevent Childhood Obesity Report www. iom. edu/Reports/2009/Childhood. Obesity. Prevention. Local. Governments. aspx • Healthy People 2020 Report www. healthypeople. gov/hp 2020/advisory/Phase. I. pdf • Policy. Link http: //www. policylink. org/site/c. lk. IXLb. MNJr. E/b. 6728307/k. 58 F 8/Why_Place___Race_Matter. htm#

ADD Picture of Tree

Terminology: Learning a Common Language n n n Photo provided by the CDC REACH program Community Health disparities Health inequities Health equity Social determinants of health (SDOH)

Social Determinants of Health Life-enhancing resources, such as food supply, housing, economic and social relationships, transportation, education and health care, whose distribution across populations effectively determines length and quality of life. Reference: James S. (2002)

Community A group of people with a shared identity, including: living in a particular geographic area, having some level of social interaction, sharing a sense of belonging or having common political or social responsibilities n REACH communities focus on race, ethnicity, and culture. n References: Eng, Parker (1994), Fellin (1995), Hunter (1975), Israel, et al (1994), Mac. Queen, et al (2001), Mc. Knight (1992)

Health Equity The opportunity for everyone to attain his or her full health potential n No one is disadvantaged from achieving this potential because of his or her social position or other socially determined circumstance. n Distinct from health equality n Reference: Whitehead M. et al

Health Inequities n Systematic and unjust distribution of social, economic, and environmental conditions needed for health n n n Unequal access to quality education, healthcare, housing, transportation, other resources (e. g. , grocery stores, car seats) Unequal employment opportunities and pay/income Discrimination based upon social status/other factors Reference: Whitehead M. et al

Health Disparities n Differences in the incidence and prevalence of health conditions and health status between groups, based on: ¦ Race/ethnicity ¦ Socioeconomic status ¦ Sexual orientation ¦ Gender ¦ Disability status ¦ Geographic location ¦ Combination of these

Comparison of Definitions Health Disparities Health Inequities Differences in the incidence and prevalence of health conditions and health status between groups based on: • Race/ethnicity • Socioeconomic status • Sexual orientation • Gender • Disability status • Geographic location • Combination of these Systematic and unjust distribution of social, economic, and environmental conditions needed for health. • Unequal access to quality education, healthcare, housing, transportation, other resources (e. g. , grocery stores, car seats) • Unequal employment opportunities and pay/income • Discrimination based upon social status/other factors

Comparison of Definitions Health Disparities Health Inequities Health Equity SDOH Differences in the incidence and prevalence of health conditions and health status between groups based on: Systematic and unjust distribution of social, economic, and environmental conditions needed for health. The opportunity for everyone to attain his or her full health potential. Life-enhancing resources whose distribution across populations effectively determines length and quality of life. • Race/ethnicity • Socioeconomic status • Sexual orientation • Gender • Disability status • Geographic location • Combination of these • Unequal access to quality education, healthcare, housing, transportation, other resources (e. g. , grocery stores, car seats) • Unequal employment opportunities and pay/income • Discrimination based upon social status/other factors No one is disadvantaged from achieving this potential because of his or her social position or other socially determined circumstance. • Food supply • Housing • Economic relationships • Social relationships • Transportation • Equal access to quality • Education education, healthcare, • Health Care housing, transportation, other resources • Equitable pay/income • Equal opportunity for employment • Absence of discrimination based upon social status/other factors

Discussion: Community n n Who does your community include? Who does it not include? What are the geographic boundaries? What are the cultural and psychosocial experiences of people in the community (e. g. , traditions, social networks, history, representation in the local government)? Does your community have multiple communities within it? How would you describe these communities? What are the relationships between these communities?

Discussion: Health Inequities n n n What social, economic, or environmental conditions affect your whole community (e. g. , air pollution, high concentration of fast food restaurants, inadequate public transportation system)? What conditions differentially affect subgroups in your community? Why are these conditions experienced differentially for subgroups in your community?

Discussion: Health Disparities n n n What health concerns are experienced by people in your community (e. g. , obesity, asthma, diabetes, heart disease)? What behaviors are more or less common among people in your community (e. g. , food and beverage consumption, physical activity, tobacco or substance use, violence)? Do these health concerns or behaviors vary by subgroup? What are the differences?

Data and Context Photo provided by the CDC REACH program

Social Determinants of Health n n n Access to health care Access to resources Education Employment Environment n n n Income/Poverty Insurance Coverage Housing Racism/Discrimination Segregation Transportation

Share of Population that is a Racial/Ethnic Minority by State 2005 -2006

Intersection of Health, Place & Equity Access to Healthy Food Health facilities Schools/ Child care Health Community Safety/ Violence Housing Environment Parks/Open Space/ Playgrounds Reference: Policy. Link Equity Work environments Transportation Traffic patterns

Place Matters Communities of Opportunity Parks Sidewalks Grocery Stores Financial Institutions Better Performing Schools Good Public Transportation Reference: Policy. Link Good Health Status Poor Health Status contributes to health disparities: Obesity Diabetes Asthma Infant mortality Low- Income Communities Fast Food Restaurants Liquor Stores Unsafe/Limited Parks Poor Performing Schools Increased Pollution and Toxic Waste Sites Limited Public Transportation

Across America, Differences in How Long and How Well We Live

Within States, Large Gaps in Life Expectancy . 22

Examples of Health Inequities Education Infants born to African American mothers with only a high school education were 2. 2 times more likely to die in the first year of life compared to their White counterparts. Income Low socioeconomic status is associated with an increased risk for many diseases, including CVH, arthritis, diabetes, chronic respiratory diseases, cervical cancer and frequent mental distress. 1 Access to resources Lower income and racial/ethnic minority communities are less likely to have access to grocery stores with a wide variety of fruits and vegetables. 2, 3 References: 1 Pleis, Lethbridge-Cejku (2006), 2 Morland, et al (2002), 3 Baker, et al (2006)

Place Matters http: //www. commissiononhealth. org/PDF/adaed 392 -81 b 0 -4 c 3 f-80150 bc 10 dfed 2 fd/whereyoulivematters_philadelphia. pdf http: //www. commissiononhealth. org/PDF/7 d 8 e 7 a 6 c-1989 -4257 -885 b 25782 cf 7 ec 4 a/RWJ 045_Denver_5 x 7_3 b. pdf Reference: Robert Wood Johnson Foundation (2008)

Distribution of U. S. Population by Race/Ethnicity 2000 and 2050 Total = 419. 9 million Total = 282. 1 million NOTES: Data do not include residents of Puerto Rico, Guam, the U. S. Virgin Islands, or the Northern Marina Islands. “Other” category includes American Indian/Alaska Native, Native Hawaiian or Other Pacific Islander, and individuals reporting “Two or more races. ” African-American, Asian, and Other categories jointly double-count 1% (2000) and 2% (2050) of the population that is of these races and Hispanic; thus, totals may not add to 100%. SOURCE: Kaiser Family Foundation, based on http: //www. census. gov/population/www/projections/popproj. html, U. S. Census Bureau, 2004, US Interim Projections by Age, Sex, Race, and Hispanic Origin.

Cancer Screening Rates by Race/Ethnicity* 2003 l. Breast Cancer (Mammography) l. Cervical Cancer (Pap Test) l. Colon and Rectum Cancer (Fecal Occult Blood Test) l. NOTES: * Data for American Indians/Alaska Natives and Native Hawaiians/Pacific Islanders do not meet the criteria for statistical reliability, data quality or confidentiality. Age-adjusted percentages of women 40 and older who reported a mammography within the past 2 years, women 18 and older who reported a pap test within the past 3 years, and adults 50 and older (male and female) who reported a fecal occult blood test within the past 2 years. l. SOURCE: Kaiser Family Foundation, based on the National Healthcare Disparities Report, 2005, available at: http: //www. ahrq. gov/qual/nhdr 05/index. html, using data from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey.

Examples of Health Disparities Diabetes As of 2007, Native Americans and Alaska Natives (17%), African Americans (12%), and Hispanics/Latinos (10%) were all significantly more likely to have been diagnosed with diabetes compared to their White counterparts (7%). 1 Heart Disease In 2000, rates of death from diseases of the heart were 29 percent higher among African American adults than among white adults, and death rates from stroke were 40 percent higher. 2 Infant Mortality In 2002, Sudden Infant Death Syndrome (SIDS) deaths among American Indian and Alaska Natives was 2. 3 times the rate for non-Hispanic white mothers. 3 References: 1 CDC (2008), 2 NCHS (2002), 3 NICHD (2007)

Health Insurance Status, by Race/Ethnicity: Children 2007 Private (Employer and Individual) Medicaid and Other Public Uninsured * * Total Child Population 2007 White Hispanic African American Asian/ Pacific Islander American Indian/ Alaska Native Two or More Races 44. 7 million 16. 5 million 11. 6 million 3. 3 million 0. 5 million 2. 1 million NOTES: “NSD” = Not sufficient data; “Other Public” includes Medicare and military-related coverage. All racial groups non-Hispanic. * = Estimate has a large 95% confidence interval of +/- 5. 0 - 7. 9 percentage points. SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured analysis of the March 2008 Current Population Survey. http: //facts. kff. org/chartbook. aspx? cb=55

Infant Mortality Rates for Mothers Age 20+ by Race/Ethnicity and Education, 2001 -2003 l. Infant deaths per 1, 000 live births: l. Less than High School l. Colleg e+ l. SOURCE: Kaiser Family Foundation, based on Health, United States, 2006, Table 20, using data from the National Center for Health Statistics, National Vital Statistics System, National Linked Birth/Infant Death Data. www. kaiseredu. org/tutorials/. . . /REHealthcare_download. ppt

Diseases and Behaviors Tobacco Use Poor Nutrition Physical Activity Physician Visits Arthritis/Lupus ✓ ✓ ✓ Asthma ✓ ✓ ✓ Breast Cancer ✓ ✓ ✓ Colorectal Cancer ✓ ✓ ✓ COPD (Lung Disease) ✓ ✓ Diabetes ✓ ✓ Heart Disease and Stroke ✓ ✓ Hepatitis B ✓ Immunizations (for adults) ✓ ✓ ✓ ✓ Lung Cancer ✓ ✓ ✓ Oral Health ✓ ✓ ✓ Pneumonia and Influenza ✓ ✓ Infant Health Problems Injury from falls

SDOH and Health

SDOH and Health

Figure 5: Pathways from social determinants to health

Figure 4: Social Determinants of Health

Field Examples n n n Photo provided by the CDC REACH program http: //www. youtube. com/ watch? v=m. Ox. Miugtji. U http: //www. youtube. com /watch? v=di. MVgcb 8 Qzk http: //www. youtube. com/ watch? v=k 8 fuzh 4 d 544&f eature=related

Types of Initiatives n n n Eliminating racial and ethnic disparities in breast and cervical cancer by promoting screening, education, prevention, treatment, and access to care for black women and women of African descent Addressing disparities in diabetes education and quality of care by building community capacity, identifying people at high risk for diabetes, offering training and education, supporting health promotion activities, and creating diabetes self-care centers. Improving community health by addressing social factors that have been linked to high infant death rates. These include violence, substance abuse, crime, poor nutrition, food insecurity, and lack of community and leadership.

Discussion: Social Determinants of Health n How are resources (e. g. , food, housing, local businesses, transportation, health care services) distributed within your community? n How does this compare to surrounding communities? n What are the relationships among social determinants, cultural and psychological?

Six Ways to Talk about Social Determinants of Health n n n Health starts – long before illness – in our homes, schools, and jobs. All Americans should have the opportunity to make the choices that allow them to live a long, healthy life, regardless of their income, education or ethnic background. Your neighborhood or job shouldn’t be hazardous to your health. Your opportunity for health starts long before you need medical care. The opportunity for health begins in our families, neighborhoods, schools, and jobs. Robert Wood Johnson Foundation

References n n n n Baker E, Schootman M, Barnidge E, Kelly C. The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines. Preventing Chronic Disease 2006; 3(3): 1– 11. Braveman P. Health disparities and health equity: concepts and measurement. Annual Review of Public Health 2006; 27: 167– 194. CDC. National Diabetes Fact Sheet; 2007; http: //apps. nccd. cdc. gov/DDTSTRS/Fact. Sheet. aspx Eng E, Parker E. Measuring community competence in the Mississippi Delta: the interface between program evaluation and empowerment. Health Education Quarterly 1994; 21(2): 199– 220. Fellin P. Understanding American Communities. In: Rothman J, Erlich JL, Tropman JE, editors. Strategies of Community Organization. 5 th edition. Itasca, IL: Peacock; 1995. Hunter A. The loss of community: an empirical test through replication. American Sociology Review 1975; 40(5): 537– 552. Israel BA, Checkoway B, Schulz A, Zimmerman M. Health education and community empowerment: conceptualizing and measuring perceptions of individual, organizational, and community control. Health Education Quarterly 1994; 21(2): 149– 170. James S. Social determinants of health: implications for intervening on racial and ethnic health disparities. Paper presented at: Minority Health Conference, 2002; University of North Carolina.

References n n n Mac. Queen K, Mc. Lellan E, Metzger D, Kegeles S, Strauss R, Scotti R, et al. What is community? An evidence-based definition for participatory public health. American Journal of Public Health 2001; 91(12): 1929– 1938. Mc. Knight JL. Redefining community. Social Policy 1992; 23(2): 56– 62. Morland et. al. (2002) NIH. National Institute of Child Health and Human Development, SIDS; 2007; http: //www. nichd. nih. gov/health/topics/Sudden_Infant_Death_Syndrome. cfm Pleis JR, Lethbridge-Çejku M. Summary health statistics for U. S. adults: national health interview survey, 2005. National Center for Health Statistics. Vital Health Statistics 2006; 10(232). Available at http: //www. cdc. gov/nchs/nhis. htm. Whitehead M, Dahlgren G. Levelling Up (Part 1): A Discussion Paper on Concepts and Principles for Tackling Social Inequities in Health. World Health Organization. Available at http: //www. euro. who. int/document/e 89383. pdf.