center on social disparities in health

CENTER ON SOCIAL DISPARITIES IN HEALTH University of California, San Francisco

Where health disparities begin: the role of social and economic determinants

March 20 9th Annual Health Disparities Symposium University of Alabama, Birmingham Paula Braveman, MD, MPH Professor of Family & Community Medicine Director, Center on Social Disparities in Health University of California, San Francisco

A few definitions

Health disparities: health differences closely linked with social & economic disadvantage adversely affect groups who are at an underlying social disadvantage– e.g., based on race, wealth, gender, disability, LGBT – because of historical discrimination or exclusion

Health equity : the principle underlying a commitment to eliminate disparities. implies addressing social (including economic) determinants of health, as well as health care Justice

Social determinants: non-medical factors that influence health and can be shaped by policies; includes economic factors

Infant mortality rate: England and Wales

0

20

40

60

80

100

120

140

160

1842 1860 1873 1888 1903 1915 1932 1946 1962

Source: T. McKeown, 1974.

NICU’s

Penicillin

Age-adjusted mortality by occupation, UK civil servants aged 40-64, Whitehall Study

Source: Marmot, M. G., et al (1984). "Inequalities in death--specific explanations of a general pattern?" Lancet 1(8384): 1003-1006.

Life expectancy in US varies by income in a stepwise gradient pattern

45.5

51.5

47.7

54.5

51.1

56.5

53.5

58.2

40

45

50

55

60

Men Women

Life

exp

ecta

ncy

at a

ge 2

5 ≤100% FPL 101-200% FPL201-400% FPL401%+ FPL

Family Income: Percent of Federal Poverty Level

Source: National Longitudinal Mortality Study, 1988-98.

Child health varies by parents’ income (& education): Poor/fair child health reported by parent

4.3

2.4

1.4

1.0

0.6

0

1

2

3

4

5

6

% o

f chi

ldre

n ag

e 0-1

7 yea

rs

with

poo

r/fai

r hea

lth

<100% FPL100%-199% FPL200-299% FPL300-399% FPL≥400% FPL

Source: National Health Interview Survey (NHIS) 2001-2005. Age-Adjusted.

Family Income (% of Federal Poverty Level)

Family Income (Percent of Federal

Poverty Level)

Racial/ethnic differences do not explain differences in adult health by income

23.9

19.2 20.9

18.3

15.6 14.8

11.2 10.3

7.7 6.8 6.4

4.0

0

5

10

15

20

25

Black, Non-Hispanic Hispanic White, Non-Hispanic

Perc

ent o

f per

sons

with

poo

r/fa

ir he

alth

<100%

100%-199%

200%-399%

≥400%

Family Income: Percent of Federal Poverty Level

Source: CDC/NCHS, National Health Interview Survey 2010. Age adjusted.

How could income affect health? A body of literature supports:

Income can shape options for: • Housing • Neighborhood conditions • Diet • Exercise • Services (e.g., childcare,

transportation, repairs, medical care…) that can alleviate stress

• Most of above can affect stress and thus family stability

Parents’ income shapes the next generation’s: • Education • Work • Income

Income shapes neighborhood options. How could a neighborhood affect health?

Safe places to exercise Access to healthy food Ads for harmful substances Social networks & support Norms, role models, peer

pressure Fear, anxiety, despair, stress Quality of schools Racial segregation tracks

Blacks & Latinos into poorer neighborhoods than Whites of similar income

Image: http://www.seattlemet.com/news-and-profiles/publicola/ articles/some-rich-architects-mansion.

CENTER ON SOCIAL DISPARITIES IN HEALTH University of Cali fornia, San Francisco

The stress-health link: biologically plausible?

• Advances in neuroscience help elucidate how social factors “get into the body”

• HPA axis, sympathetic nervous system, and immune/inflammatory mechanisms have been demonstrated as responses to stress – Mediators include cortisol, other stress hormones,

cytokines, telomerase

• Chronic stress is a plausible and likely major contributor to both socioeconomic and racial/ethnic inequalities in health

CRH

DAMAGE TO MULTIPLE ORGANS & SYSTEMS

chronic disease, immune suppression, inflammation

STRESSOR

CORTISOL

Hypothalamus

Pituitary Gland

Adrenal Glands

ACTH

Source: Center on Social Disparities in Health, UCSF.

How could stress affect health?

Less income, more stressors Separation or divorce during pregnancy (similar patterns for 11 major stressors)

12.7

7.0

3.63.0

1.2

0

3

6

9

12

15

% o

f wom

en s

epar

ated

or d

ivor

ced

durin

g pr

egna

ncy

Family Income (% of Federal Povery Level)

≤100%

101-200%

201-300%

301-400%

>400%

Family Income:Percent of Federal Poverty Level

Source: CA Maternal & Infant Health Assessment 2003-2006.

More education, longer life

47.1

51.7 51.4

57.0

52.3

58.1 56.4

60.3

40

45

50

55

60

65

Men Women

Life

Exp

ecta

ncy

at a

ge 2

5

Less than high schoolHigh-school graduateSome collegeCollege graduate

Educational Attainment:

Source: CDC/NCHS, National Health Interview Survey Linked Mortality File, 2006.

Racial/ethnic differences do not explain adult health differences by education

Source: Braveman, Cubbin et al., analyses of BRFSS 2008-2010. Age-Adjusted.

0

10

20

30

40

50

60

Black, Non-Hispanic Hispanic Asian American Indian orAlaska Native

White, Non-Hispanic

Perc

ent o

f adu

lts, a

ges 2

5-74

yea

rs,

in p

oor/

fair

heal

th

Less than high school

High-school graduate

Some college

College graduate

Educational Attainment:

Braveman et al. analyses of NHIS 2001-2005. Age-Adjusted.

0

5

10

15

20

25

30

35

40

<100% 100%-199% 200-299% 300-399% ≥400%

% o

f adu

lts a

ge ≥

25 y

ears

w

ith se

lf-re

port

ed p

oor/

fair

heal

th

Family Income (% of Federal Poverty Level)

Black, Non-HispanicHispanicWhite, Non-Hispanic

Both race and socioeconomic factors matter

•Diet

•Exercise •Smoking

•Health/disease management

Education can shape health behaviors by determining knowledge and skills

•Health knowledge •Literacy

•Problem-solving

• Coping skills

Educational attainment

Other plausible pathways from education to health, e.g., via work & income

HEALTH Educational attainment

Health insurance Sick leave Stress

Neighborhood/ school environment Diet & exercise

options Stress

Working conditions

Work-related

resources

Income

Work

Control / demand imbalance Stress

Psychosocial pathways from education to health


Social & economic resources Norms

Social support Stress

HEALTH

Social & economic resources

Perceived status Stress

Control beliefs (powerlessness, sense/locus of

control, fatalism, mastery)

Social standing

Social networks

Coping Response to

stressors


HEALTH

Exposure to hazards Control / demand imbalance Stress

Work-related resources

Housing Neighborhood environment Diet & exercise options Stress

Work Health insurance Sick leave Stress

Working conditions

Income

HEALTH

HEALTH

How could education affect health? Diet Exercise Smoking Health/disease management


Control beliefs Coping & problem solving Response to stressors Health-related behaviors

Social standing

Social networks

Social & economic resources Perceived status Stress

Social & economic resources Social Support Norms for healthy behavior Stress

HEALTH

Health knowledge, literacy, coping & problem solving


Social position, e.g. by race & class

Social consequences

of ill health

Disease

1. Social stratification

SOCIETY INDIVIDUAL

Specific exposure

5. Further social stratification

3. Differential vulnerability

2. Differential exposure

4. Differential consequences

Social Context

Policy Context

Understanding health disparities across the life course and across generations

Adapted from Finn Diderichsen, U. Copenhagen 20

Preventing unequal consequences

Decreasing exposures

Decreasing vulnerability

Influencing social stratification


Childhood social/economic conditions shape adult health

Adult health is shaped by early experiences Lasting effects of in utero/early childhood deprivation, e.g.,

– Low SES in adulthood (by limiting education) – Neuro-endocrine or immune dysregulation – May not be erased by later circumstances

Chronic stress/deprivation in childhood chronic disease in childhood and adulthood Critical or sensitive periods

Cumulative effects of disadvantage


Epigenetics: “Genetics loads the gun. The environment pulls the trigger” (J. Stern)

Features of social and physical environments can interact with an individual’s genome to influence whether a gene is expressed Experience can become biologically embedded --Some alterations in gene expression are heritable! May be important in intergenerational transfer of health risk and social disadvantage Policies can alter the social/physical environmental exposures that trigger/suppress gene expression

Social environment

Physical, chemical,

& built environments

Nutrition

Gene- environment interaction

Physiological adaptations

& disruptions

Health-related behaviors

Educational achievement & economic productivity Physical &

mental health

Biological embedding during sensitive periods

Cumulative effects over time

Foundations of healthy development and sources of early adversity

Lifelong outcomes

How early experiences get into the body

Adapted from Harvard Center on the Developing Child


Residual confounding of observed racial/ethnic differences in health by unmeasured

socioeconomic factors & racism-related stress

At the same education level, whites have more income At the same income, whites have more wealth and live in

better-off neighborhoods At same current SES, whites had higher SES in childhood Residual confounding by unmeasured SES -- direct and

indirect effects And: unmeasured stressors related to racial

discrimination


Structural racial bias transmits socioeconomic disadvantage across generations The legacy of (once-legal) discrimination: Lower incomes, wealth, education, occupations And, at a given income or educational level, African Americans and Latinos on average: Have less wealth Live in under-resourced, often unhealthier neighborhoods Were worse off in childhood More hardship with fewer resources to cope Rarely measured but studies often conclude a racial difference

is genetic if it persists after “control for SES” Race often captures unmeasured socioeconomic factors


Can racial discrimination harm health in other ways – other than by limiting education, income, wealth…?

Overt incidents still occur But considerable stress even without overt incidents Pervasive subtle incidents. Chronic, pervasive concern

about being judged or treated unfairly based on race Discrimination could affect health through pathways

involved in stress; chronic stress is particularly toxic, even in absence of dramatic events

Internalized racism could harm health by undermining self-esteem and sense of control

Economic & Social Opportunities and Resources

Living & Working Conditions in Homes and Communities

Behaviors Medical

Care

Interactions between genes and experiences

Pursuing health equity: Understanding the role of social factors

Policies to promote healthier homes, neighborhoods,

schools and workplaces

Policies to promote child and youth development

and education, infancy through college

Policies to promote economic development and reduce poverty,

and reduce racial segregation

HEALTH

© 2013 Robert Wood Johnson Foundation Commission to Build a Healthier America | Overcoming Obstacles to Health in 2013 and Beyond

center on social disparities in health

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