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Provost's Symposium on the Social Determinants of Health
Thomas A. LaVeist, PhD William C. and Nancy F. Richardson Professor in Health Policy
Director, Hopkins Center for Health Disparities Solutions
Johns Hopkins Bloomberg School of Public Health
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Social Determinants of Health
Individual-Level
• Stress • Racism/Discrimination • Social Support • Employment • Social Exclusion • Values, attitudes, beliefs • Acculturation • Social Network
Contextual
Community-level SES Social environments Physical environments Crime & criminal justice Community Amenities Segregation
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Segregation
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Mean Seg 2000 = 0.61 Mean Seg 2010 = 0.57
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Mean Seg 2000 = 0.52 Mean Seg 2010 = 0.48
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Documented Health Affects of Segregation – Risk Exposure • Segregation creates race differences in the
“health risk profiles” of communities in which African Americans and other minorities often live.
• Environmental toxins
• Targeted exposure to hazardous products (tobacco, alcohol, illegal drugs, etc.)
• Crime, Housing (stressful environments)
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Documented Health Affects of Segregation – Resource Deprivation • Segregation creates differential access to health-
supporting resources.
• Food (full service restaurants and super markets)
• Medical Care
• Social capital (social networks)
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A Baltimore Area High School
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A Baltimore Area High School
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A Baltimore Area High School
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A Baltimore Area High School
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A Baltimore Area High School
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A Baltimore Area High School
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A Baltimore Area High School
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“But I adjusted for SES…”
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Racial Status Determines the way in which you “experience” America
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Odds Ratios and 95% Confidence Intervals for National Studies vs. EHDIC
Condition
National Data (Segregated)
EHDIC (Integrated)
Diabetes1 1.61 (1.26-2.04)
1.07 (0.71-1.58)
Obesity2 1.87 (1.48-2.36)
1.25 (0.90-1.75)
Hypertension3 2.01 (1.63-2.48)
1.42 (1.09-1.86)
Use of Health Services4
0.74 (0.51-1.07)
1.44 (1.00-1.87)
1 LaVeist, et al. (2009) Journal of General Internal Medicine 2 Bleich, et al. (2010) Journal of Epidemiology and Community Health 3 Thorpe, et al. (2008) Social Science and Medicine 4 Gaskin, et al. (2009) Medical Care Research and Review
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Provost's Symposium on the Social Determinants of Health
“Gendered, Ethnic Health Disparity: The case of Maternal Health among African-
American Women”
Katrina Bell McDonald, Ph.
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Provost's Symposium on the Social Determinants of Health
“Gendered, Ethnic Health Disparity: The case of Maternal Health among African-
American Women”
Katrina Bell McDonald, Ph.D.
Department of Sociology
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To clarify right from the start… African-American (black) women defined: A specific subset of people of African descent living in the U.S. Those whose “identity is based on putative common descent,
claims of a shared history, and symbols of peoplehood,” descended from free and enslaved Africans in the U.S. during the 16th through 19th centuries, and their shared history in the U.S.
Though they clearly share the same forced “racial” category with other groups of African decent, the nature and timing of their involuntary immigration distinguishes them in important ways from other blacks.
The “ethnic” portion of “gender-ethnic” designation is used to convey a shared ethnicity (African-American) and racial status (black) among women.
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Persistently high rates of poor health among African-American women Infant mortality:
Deaths per 1,000 Live Births U.S. Maryland
Blacks 13.4 12.8
Hispanics 5.5 5.4
Whites 5.7 5.2
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Paradoxes
• SES: Black women at low-risk for infant mortality more likely to experience infant death
• “Mexican paradox”: Black women more likely than Mexican Americans to experience infant death
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Revelation
• Research fails to adequately model the etiology of infant mortality for black women; progress retarded by lack of theoretical attention to nontraditional causal factors.
• i.e., the role of socio-cultural detachment or isolation of certain black women from traditional safety nets; psychological ramifications with medical implications.
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Dimensions of Black Maternal Health • Medical
• Sociodemographic
• Psychosocial
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Psychosocial dimension: an alternative systemic approach
• Psychosocial stress defined (Kaplan, 1983) • Pathways? • Black women seem to suffer higher exposure
to this stress due to historical and pervasive devaluing of black women in American society.
• Stress rooted in socio-cultural contexts and arise from historical and contemporary conditions
• Race, gender, and social class intersections
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Disaggregating the Psychosocial Dimension
• Racism
• Sexism
• Classism
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Moving toward new research:
• Need to encourage an intellectual sensitivity to the nuances of social oppression in the everyday lives of black women
• Observe the processes by which the oppression of black mothers materializes in the form of psychosocial stress and poor health outcomes.
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Unlocking the mysteries?
• The puzzle of black women’s health issues may be revealed through the examination of how black women’s stress is experienced and responded to from within and without their cultural communities.
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Black women’s Health “Struggle”
A critical intersection of race, class, and gender
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Reflections on the Health Effects of Discrimination
Provost’s Symposium on the Social Determinants of Health
Jean G. Ford, M.D. May 8, 2012
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Health Effects of Discrimination
■ Poorer physical and mental health status
■ Limited evidence on mechanisms
■ Gaps in the literature Measurement of discrimination
Research designs
Life course perspective
■ Research on stress points to important directions
Williams DR et al. Am J Public Health. 2003; 93: 200–208
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Health Effects of Discrimination:
Results of a Meta-Analysis Weighing for each study’s sample size, perceived
discrimination is associated with
■ Negative effects on both mental and physical health
■ Heightened stress responses
■ Effects on behavior Participation in unhealthy behaviors
Nonparticipation in healthy behaviors
Pascoe and Richmen. Psychol Bull. 2009; 135: 531–554.
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Pathways by which perceived discrimination influences health outcomes*
Pascoe and Richmen. Psychol Bull. 2009; 135: 531–554.
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Two IOM Reports
1999 2002
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Unconscious Bias in Diagnosis and Treatment
Controlling for insurance and source of care, minorities are:
■ Undertreated for acute cardiac symptoms: Catheterization
Angioplasty
Bypass surgery
Beta blockers
Defibrillator implants
■ Less pain medications when presenting to emergency care with long bone fracture
■ More likely to get lower limb amputations as a result of diabetes than limb saving procedures
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Explicit and Implicit Preferences for Race and Social Class
Haider AH et al., 2011. JAMA; 306:942-951
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Perceived Chance of Harm from Clinical Trial
Braunstein JB et al. Medicine: 87: 1-9
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Trust or Ethics of Aversion?
Michael Hanchard, 2006. Party Politics. Oxford University Press.
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Methodological Challenges ■ Measurement problems (Gee et al.) :
Lifecourse perspective
Sensitivity and context change over time
Effects of discrimination experienced by others
Latency
Stress proliferation
■ Question framing (Williams et al.): Racial categorization
Type of discrimination
Variation in assessment of discriminatory experiences by race and SES
Stress proliferation
Krieger et al; Shavers et al. 2012; AJPH: 9 (5)
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Racial/Ethnic Cancer Disparities (Adapted from Capitman et al., 2003)
CommunityNorms andLifestyles
Physical &SocialEnvironment
BROADER SOCIAL/POLITICALENVIRONMENT:
Historical/Current Patterns of systemic Racial/Ethnic inequalitiesHistorical/Current Patterns of systemic SES, gender, age inequalities
Federal, State,and PrivateFinancing &Organizational
Social LocationRace/Ethnicity, SES,
Gender, Age
Cumulative Lifetime &Current Exposure toIndividually ModifiableBehavioral Risks
Cumulative & LifetimeExposure to Social,Environmental, & GeneticRisks
Differential Health Care Quality and AccessUsual source of care Primary treatmentHealth risk management Screening adherence Secondary treatment
Co-morbid condition care Complete diagnosis Adjuvant therapies
Benefits coordination Follow-up care
R/E Health OutcomeDisparities
MortalityMorbidity
Quality of LifeSatisfaction with health care
CommunityDifferences inHealth CareAvailability