Bringing Up Baby: Social Determinants of Health

1. Bringing Up Baby:Social Determinants of Health Robert W. Block, M.D. Julie E. Miller-Cribbs, MSW, PhD Summer Institute July, 2009

2. Outline of Presentation • What are the social determinants of health? • How do we make sense of medical research, social science, and health disparities? • How do we translate findings into community health?

3. What determines health? Genetics Pre –and perinatal factors Physical health SES Family stability Social capital Work/employment Value system Neighborhood/Housing Religion HC Policy HC System Relations with parents/siblings Family dynamics Personality Resilience Adaptability

4. Social Environment

5. Poverty • Children are almost twice as likely to live in poverty as are Americans in any other age group (Child Welfare League of America [CWLA], 2002). • Children in Oklahoma are more likely to be poor than the elderly (Oklahoma Institute for Child Advocacy [OICA], 2005). • Poverty is the single greatest threat to children’s well-being (National Center for Children in Poverty, 2007). • In 2003, the rate of poverty among children in Oklahoma was 21.1% (Kids Count Fact Book, 2007).

6. Overview of the Effects of Poverty • Economic Instability & Lower Income as Adults (CWLA, 2002) • Poor Health (CWLA, 2002) • Higher teen birth rates (40% vs. 18.7% for non-poverty children) (CWLA, 2002) • Higher school dropout rate (30% vs. 9%) (CWLA, 2002) • Difficulty in School (Childstats.gov, 2007) • No health insurance(Robert Wood Johnson Foundation, 2003) • Higher rates of incarceration (OICA, 2005) • Higher rates of depression (OICA, 2005) • More substance abuse (OICA, 2005) • Increased domestic violence (OICA, 2005) • Increased child abuse and neglect (OICA, 2005) • Dangerous Coping Strategies (OICA, 2005) “The younger the child, the greater the harm.”- OICA, 2005

7. Specific Consequences of Poverty in Oklahoma • School Drop-Out • Almost 20% of females do not graduate from high school in Oklahoma(WFO, 2007). • Incarceration • Oklahoma leads the nation and the world in the rate of female incarcerations(WFO, 2007). • Teen Pregnancy • Oklahoma has the 8th highest rate of teen pregnancy in the nation(Women’s Foundation of Oklahoma [WFO], 2007). • No Health Insurance • Approximately 128,000 children are without health insurance in Oklahoma(WFO, 2007).

8. Exposure to Violence • Family violence • The National Family Violence Survey suggested that rates of “abusive violence” to women with annual incomes below $10,000 are more than 3.5 times those found in households with incomes over $40,000 (Center for Policy Alternatives, 2007). • Higher exposure to gang violence and crime, indirectly or directly – PTSD • Child abuse • Homeless population • Incarceration

9. Consequences of care for violence

10. Neighborhood, SES, Ethnicity

11. ACCESS  Access to and equity in healthcare are key health determinants. NORTH TULSA Shorter Life Expectancy 14 Year difference in Life Expectancy SOUTH TULSA Longer Life Expectancy

12. Access to Healthy Food • St. Louis: residents in high poverty areas and predominantly African-American areas (regardless of income) were less likely than primarily white, higher-income communities to have access to healthy food options • Detroit: fruit and vegetable consumption of low-income women living in Detroit was lower for those who shopped in independent grocery stores compared with those who shopped in supermarkets and specialty shops. • New Orleans & Hartford: fast-food restaurant density was independently correlated with median household income and percentage of African-American residents in the census tract. • Austin: a study revealed that a primarily Latino, low-income community had only one supermarket for every 3,910 households, compared with one supermarket per 3,170 households in the county as a whole

13. Access to safe recreation • Exchange of social capital • Exercise • Teens living in disadvantaged neighborhoods have less access to parks, less physical activity

14. Culture Cultural competence can have a real impact on clinical outcomes. Ignoring culture can lead to negative health consequences in many ways: • Patients may choose not to access needed services for fear of being disrespected, misunderstood • Providers may miss opportunities for screening because they are not familiar with the prevalence of conditions among certain minority groups • Providers may fail to take into account differing responses to medication • Providers may lack knowledge about traditional remedies, leading to harmful drug interactions • Providers may make diagnostic errors resulting from miscommunication • Patients may not adhere to medical advice because they do not understand or do not trustthe provider; • Providers may order fewer diagnostic tests for patients of different cultural backgrounds because they may not understand or believe the patient’s description of symptoms OR order more diagnostic tests to compensate for not understanding what their patients are saying. (Lavizzo-Mourey and Mackenzie 1996; Lawson 1996; Moffic and Kinzie 1996)

15. Exclusion: Impacts on Health

16. Reaching the top of the pyramid…. Maslow’s Hierarchy of Needs Consequences of constant ‘Survival Mode’: safety & security are continually compromised

17. What does this mean for health? • Impoverished neighborhoods • Higher exposure to stress (unsafe neighborhoods, low levels of social capital, high levels of unemployment) • Higher exposure to environmental toxins and hazards (lead, unsafe housing, parks) • Fewer facilitators of health (safe areas to play, walk, exercise, grocery stores) • Less direct and easy access to health care • Higher exposure to violence, domestic violence, child abuse (particularly neglect) • Cultural (eating habits, attitudes/trust to health care/providers)

18. Psychological

19. Psychological • Compromised parenting & brain development • Compromised parenting – stress, less education, child abuse • Physical and psychological reactions to stressful environment – allostasis and allostatic load • Compromised social relations – less trust

20. Brain Development

23. Brain development in the context of poverty

24. Hardship & Stress, Isolation & Exclusion, Adverse Health

25. Compromised parenting, compromised brain development • ￬￬ stimulation (language and learning) • ￪￪ stimulation (stress)

26. Inadequate stimulation, Inadequate development Children from low SES backgrounds hear 1 million words less during their first 5 years of life due to the difference in socioeconomic status Children of middle class parents experience 1,000 more hours of being read to than lower SES

27. Children at Age 6 – in families of low incomes are more isolated, less likely than other children to • Live in a good neighborhood • Play with friends away from school • Be involved in sport and music • Be involved in any formal activities • Go on a vacation

29. Allostasis and Allostatic Load

30. Physiologic Responses to Stress

31. Positive & Tolerable Stress

32. Toxic Stress

33. Biological

34. Epigenetics

36. Reactions to Fear and Distress • Interprets environment as threatening • Aggression, especially male • Dissociation, especially female • Biology: the hypothalamus-pituitary-adrenal axis – over stimulation can “wear out” the hippocampus, affecting cognition and memory.

37. Hippocampal glucocorticoid receptor expression

38. Hardships get ‘under the skin’ Effect of parental care on the epigenetic regulation of hippocampalglucocorticoid receptor expression

39. Pulling it together, what does it all mean for the health of individuals & communities?

40. How Does Social Environment get Embedded into Biology? Poverty Stress • Unmet needs • 1. Material •  Food • Money • Access • Housing • 2. Caregiving • Emotional • Learning • Neighborhood • Air • Water • Soil • Parks • Libraries • Violence HPA Gene experience ANS • Brain • Immune • CV CV Poor Health in Childhood and Adulthood

41. Adverse Childhood Experience (ACE) Study Summary of Major Findings ACE ‘Score’ (0-9) Adverse Childhood Experiences (ACEs) are very common ACEs are strong predictors of laterhealth risks and disease This combination makes ACEs the leading determinant of the health and social well-being of our nation Recurrent physical abuse Recurrent emotional abuse Contact sexual abuse An alcohol and/or drug abuser in the household An incarcerated household member Someone who is chronically depressed, mentally ill, institutionalized, or suicidal Mother is treated violently One or no parents Emotional or physical neglect

42. ACE Epidemiology More than a third of women in addiction treatment have been physically forced to have sex Patients in substance abuse facilities more likely to have experienced abuse as children In 2004, Oklahoma imprisoned 129 of every 100,000 female residents. High percentages of women in treatment for mental illness have sexual abuse histories

43. Health Consequences of ACE • More likely to smoke, have problems with drugs and alcohol • Chronic Obstructive Pulmonary Disease • Depression • Fetal death • Health-related quality of life • Ischemic heart disease • Liver disease • Risk of intimate partner abuse • Multiple sexual partners • Suicide attempts • Unintended pregnancies

44. Evidence from ACE Study Suggests:Adverse childhood experiences are the most basic cause of health risk behaviors, morbidity, disability, mortality, and healthcare costs.

45. Implications – Clinical Practice • Problems that come into the clinic are complex and providers should be aware of the link between those problems and social determinents • Redefining ‘resistence’ ‘non-compliant’ • In all stages of the encounter – assessment & evaluation, treatment plan – providers must avoid easy answers • If the problems are complex, why would the solutions be simple?

46. Implications- Clinical Practice How do I think broadly about my patient(s)? Can I put myself in my patient’s shoes? Do my interventions empower?

47. Implications -Policy

50. Implications - Research • Asking the questions that will have impact • Importance of moving beyond the lab/clinic into the community  community based research • Trans-disciplinary problems require trans-disciplinary partners and teams Culture Policy Systems Environment Individual Programs and Outcome Measures Hays-Grudo (2008)