Addressing Social Determinants through Community & System Change

1. Addressing Social Determinants through Community & System Change By Aida L. Giachello, Ph.D. Associate Professor& Director Midwest Latino Health Research, Training and Policy Center University of Illinois at Chicago aida@uic.edu Presentation at the State Workshop on Latino Health, Columbia, MD

2. Objectives • Briefly list selected health disparities of Hispanics/Latinos (H/L) and the sources of the disparities • Share some strategies on how to address the health and social needs of the growing Hispanic/Latino population through community and system change

3. Public Interest in Hispanic/Latino Health Disparities in Montgomery County & in Maryland • Dramatic population growth • In 2006, 128,365 H/L lives in Montgomery Country representing the 2nd largest minority in the County • MC has the largest concentration of H/L in MD • Most H/L are from Central America (44%), followed by South America (22.4%) • 65% of H/L are foreign born

4. Interest in H/L Health Disparities issues……. 2. Mobilization of H/L groups and forming partnership with the Montgomery Dept of HHS and other sectors • Hispanic Health Initiatives • BluePrints for Latino Health in Montgomery County

5. Heart Disease (65+) Cancer (particularly breast, cervical (45+) and lung (25-44) cancer) Injuries-- leading cause of death: 24-44 yrs Cerebrovascular diseases Diabetes- 3rd cause of death for persons 45+ Homicide-- leading cause of death: 15-24 yrs Pneumonia and influenza (65+) Liver diseases (cirrhosis) Pulmonary diseases HIV/AIDS (25-64) Kidney failure (65+) Maternal deaths Public Interest in H/L health Disparities 3. Increased Research & DataNational Mortality Data:

6. Interest in H/L Health Disparities issues…Res & Data… Montgomery County • HIV/AIDS • In 2005, H/L accounted for 1.6 times as many new HIV diagnoses as non H/L whites (MD Dept of PH, 2007). • Tuberculosis • TB for H/L in Maryland is 3.5 times • Foreign-born Latinos in Maryland is 12.5 higher than for the US

7. Interest in H/L Health Disparities issues…Res & data... • Type 2 Diabetes • Leading cause of death • Latinos are diagnosed after the age of 38 • New cases are emerging among children and adolescents and young adults • Diabetes complications serious problems • Diabetic end-stage renal disease among 55+ is 10%-20% higher than whites • Hypertensive end-stage renal disease rates is 1.5 to 5 times higher than whites

8. Interest in H/L Health Disparities issues…Res & Data… • Over-weight and obesity • In 2005, 3 out of 4 H/L 40 years of age were overweight (46%) or obese (30%) • Community Safety issues discourage physical activity • Limited income lead to limited access to healthy food options • Communities designated food dessert • Occupation injuries & fatalities • Social stress, violence, suicide/homicide, social discrimination & anti-immigrant sentiment

9. Hispanic/Latino Health Vary By • Age • Socio-economic status • Place of birth • National origin • Acculturation and assimilation • “Push” and “pull” factors related to immigration • Neighborhood, place of employment, etc

10. +Infant mortality +Low birth weight babies +blood pressure +Obesity +Teen pregnancy +Smoking +Alcohol use +Other drug use -breast-feeding High acculturation impact negatively Latino Health

11. TRUE SOURCES OF DISPARITIES • Poverty & Low SES • Neighborhoods and school segregation and neighborhood quality • Poor neighborhood becomes market for tobacco, alcohol and fast food • Large families, average size of 3.96 • 44% have more than 4 members • H/L has the lowest per capita income in Montgomery Country ($20,165), representing 37.4% of whites ($53,926). • 52% work in the Service or Construction industries

12. Low education Low earnings High unemployment High poverty among married couple families High teen pregnancy & parenthood High no. of families headed by women Factors affecting poverty rates

13. Public Response to Health Disparities: Blaming the Victim • Don’t be poor • Don’t be unemployed • Change jobs • Change neighborhood • etc

14. True Sources of Disparities: 2. Access to Care Barriers • No regular source of care—in MC Over 50% have no medical home) • Lack of health insurance (50-58%)[2005 and 2007 cancer study] • System barriers • Limited bilingual and bicultural staff • Long traveling time to go to healthcare facility • Lack/limited transportation

15. True Source of Health Disparities…Access to care… Systems- barriers • Lack of capacity of health care facilities • Long waiting time between calling for an appointment and the actual visit • Long waiting time once you get to doctor’s office • Lack of hours of services during evening or weekends

16. Other Healthcare Systems-level barriers • In managed care organizations, financial incentives to providers tend to limit services • “Fragmentation” of services and poor coordination

17. True Source of Health Disparities…Access to care…System Barriers. • Lack of interpreters • For example 1 out 5 have Gone Without Care When Needed Due to Language Obstacles • Poor pt-doctor communication • NO interpreter services available • Only 1 out of 4 requests received interpreter in MC • 1 of 6 failed to make an appt due to language barrier in MC • 1 in 5 could not complete their phone calls in MC

18. True Source of Health Disparities…Access to Care… • Low use of health and medical care • Delays seeking care and using preventive services • Limited familiarity with the health care system and low health literacy • Uses home remedies and OTC • Uses medication from their country of origin • Seek non professionals (e.g., faith healers)

19. True Source of Disparities…Access to care… • Eligibility issues • 1996 Immigration reform made eligibility for public funder programs more restrictive for more immigrants • Concerns about deportation

20. July 29 – August 6

21. Source: Kaiser Health Tracking Poll, Election 2008: August 2008

22. The Obama Plan • Mandated coverage for kids • Pay-or-play for employers • New public plan offered • No tax credits/changes • Expansion of Medicaid/SCHIP • Invest $10 B in HIT • Cost: estimates range from $50-110 B a year

23. 3. Sources of Health Disparities: Poor Quality of Medical Care • Most of the improvements in health in the last 100 years have been the results of improvement in public health, sanitation, nutrition and living conditions • Physicians and other health professionals are not familiarized with clinical guidelines for the management and control of chronic diseases

24. Racial and ethnic minorities and women receive poor care due to physicians’ biases and stereotypes

25. 3. Source of Health Disparities:Poor medical care… • Due to long history of race/ethnic and gender bias in the medical care system • Mexican Americans received 38% fewer medications (antiarrhythmics) than whites • Hispanics in a Los Angeles hospital ER, were least likely to receive no analgesia for their injuries Source: Goldberg et al. 1992; Herholz et al. 1996; Blustein et al, 1995; Todd et al, 1993

26. 3. Source of Disparities: Poor Medical Care…Conclusions of IOM Report • “Across virtually every therapeutic intervention, ranging from high technology procedures to the most elementary forms of diagnostic and treatment interventions, minorities receive fewer procedures and poorer quality medical care than whites • Differences persist after controlling for health insurance, SES, stage and severity of disease, comobidity, and the type of medical facility”

27. Disparities in the Clinical Encounter: The Core Paradox (Williams, 2004) How could well-meaning and highly educated health professionals, working in their usual circumstances with diverse patient populations, create a pattern of care that appears to be discriminatory? Williams argues that it has to due with stereotyping

28. Unconscious Discrimination • When one holds a negative stereotype about a group and meets someone who fits the stereotype s/he will discriminate against that individual • It is automatic and unconscious process • It occurs even among persons who are not prejudiced • “I am not racist: I know I don’t stereotype”

29. Factors that Increase Stereotype Usage in Medical Care • Time Pressure • Need for Quick Judgments • High Cognitive demands • Task Complexity • Resource constraints • Anger or Anxiety Source: Williams, 2004; Van Ryan 2002

30. Conclusions • Many sources are responsible for health disparities • Socioeconomic and environmental conditions • Financial, linguistic, cultural and system barriers to access to care; • Poor medical care as a result of Medical Professional behaviors in clinical settings

31. STRATEGIES & RECOMMENDATIONSFOR ACTION

32. To address the social determinants of health we must work at different levels: • Individual Empowerment of H/L • Family • Neighborhood • Macro: • Health and other systems • Other systems

33. Long term institutional/structural changes This calls for an improvement in the levels of education and income, and better distribution of resources and services for all Hispanics/Latinos H/L health must be viewed within a broader societal context

34. Stronger Government & Private Sector Commitment at all Levels For Example: To eliminate health disparities, in addition to the DHHS, you need to involve the Depts. of Education, housing, Commerce, Environmental Protection Agencies, etc. • You need Strong commitment from businesses, foundations, and many other key players • For example, MC DHHS should establish a multi-sectorial council across departments

35. For Example: Structural Conditions Impacting Health • Type and location of employment within the economic structure (i.e., services industry) • Environmental and occupational hazards. By not addressing the origins of the problems we are treating the most costly symptoms

36. We need to Recognize Health Inequities • Systematic and unjust distribution of social, economic, and environmental conditions needed for health • Access to healthcare • Employment • Education • Access to resources (e.g. grocery stores, car seats) • Housing • Transportation • Freedom from discrimination Source: Whitehead M. et al

37. Social Determinants of Health: Socio-ecological Model Source: Institute of Medicine, 2003

38. Social Determinants of Health

39. Social Determinants of Health:Refers to… 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. Source: James S., 2002

40. Adopt Population based approach including multiple determinants of Health For example: Public Health Working with the Business Community • Why should business care about diabetes prevention and control? • Loss productivity • Increased health care expenditures • Poorer quality of life for employees • Consequences related to permanent disability • What can the food industry do?: • Educate its members, make available fruits and vegetables

41. 5. Adopt a Population-level Approach, including Multiple Determinants of Health… • Work with the school system to change the School Environment • Changing School Environment Curbs Weight Gain In Children, Study Shows (Apr. 7, 2008) • Public Health Law Reform (federal, state, local) • Arkansas Act 1220, An Act to Combat Childhood Obesity Act 1220 is now codified, in part, at Ark. Code Ann. 20-7-135 (2005)

42. Population approach to address multiple determinants of health • New York - The Board of Health voted to make New York the nation’s first city to ban artery-clogging artificial trans fats at restaurants--MSNBC News Services, Dec. 5, 2006 • U. S. District Court for the Southern District of New York upheld the constitutionality of New York City’s calorie-posting requirement for restaurants of a certain size and type. Apr. 16, 2007)

43. Develop & Sustain different partners • Role of the Workplace • What can employers do • Employee risk assessments • Employee education • Health plan benefit design/disease management vendors • Environmental change (supportive environment)

44. Sustaining partnerships Partnerships will require: • Forging a common language and understanding • Exchange of information and data • Learning together about effective strategies for the workplace • Recognizing efforts

45. Increase accountability Review the regulatory authorities of DHHS agencies to maximize effectiveness and collaboration across departments, and with other state and local health agencies • How can WIC be used to impact on the childhood obesity epidemic? • How can the DOT integrate health and physical activity goals into transportation planning? • What is the role of DOE in supporting implementation of K-12 Health Education Standards? • Is there a body that coordinates activities across agencies to address the obesity epidemic? Do we need one? • Can we eliminate tobacco use in public housing

46. Advocate & Support Health Care reform and Single-payer System • Health care is a right and not a privilege • Sooner or later we must have a national solution • Without health we cannot work, we cannot take care of our families, and we cannot be productive citizens

47. Need for close monitoring of Managed-care Networks Concerns exist with • Access to specialists and/or hospitalization • Marketing strategies • Limited support services and follow-up • Possible violations of patients’ rights • Assure that Health insurance plans/managed care cover preventive services according to guidances

48. Improve H/L Access and use of Health and mental health services &Advocate for better quality of health/medical care, mental health & Human services

49. Develop and implement Creative Public Health Solutions and Models Example: • Racial and Ethnic Approaches to Community Health (REACH) 2010, a CDC Initiative • & Center of Excellence for the Elimination of Disparities

50. REACH 2010: Building partnerships • Calls for community mobilization and system change • Encourage coalition building and establishing partners with non-traditional sectors • Chamber of Commerce, food industry • Faith communities • etc