mental health and health disparities - nhms mental health and... · 2015-06-18 · –common in the...

Mental Health and Health Disparities

Shani A. Dowd, Director, Culture InSight

Ass’t Clinical Professor of Psychiatry, Boston University School of Medicine

November 10, 2013

© 2009 Harvard Pilgrim Health Care Foundation

Learning Objectives

At the end of this presentation, participants will be able to:

Identify at least three factors in the social determinants of health

Describe at least four ways in which social determinants influence mental health

Identify at least three ways in which culture influences mental health presentations

Identify at least three disparities in mental health

2


Social Determinants of Health

Developed by the World Health Organization (WHO)

Identifies social factors beyond the health care system that influence

Factors can be integrated into understanding patient’s socio-emotional well-being

3

© 2009 Harvard Pilgrim Health Care Foundation 4

The Social Gradient

Poor economic circumstances affect life throughout the life-cycle.

Low relative social ranking increases chances of disease: Among middle class office workers, lower ranking staff suffer much more disease than higher ranking staff.

The longer people live in stressful circumstances, the greater the physiological wear and tear they suffer, and the greater the odds of decreased quality of life.


The Social Gradient

Disadvantage may have many forms:

– Poor education

– Insecure employment

– Hazardous or dead end job

– Poor housing

– Inadequate retirement or pension

– Physical/mental disability

– Victimization by violence


The Social Gradient

These disadvantages tend to accumulate in the same people:

– Poor education, tends to lead to inadequate housing, jobs, income, etc.


The Social Gradient

Social Gradient influences management of life transitions:

– Emotional mastery in early childhood

– Transition from primary to secondary education

– Starting work

– Leaving home

– Starting a family

– Changing jobs

– Preparation for or ability to retire


The Social Gradient

Each life stage transition can push people into a more or less disadvantaged position.

Those who are disadvantaged in the past, are at greatest risk in each subsequent transition.

Policies that reduce levels of educational failure and under- and unemployment, also support good health.


Stress

Social factors contribute to long term stress levels

Long-term stress has a greater impact on health than high stress.

But the combination of HIGH and LONG-TERM stress set individuals up for greater chances of chronic, poor health.


Stress

Factors that increase stress:

– Continuing anxiety

– Insecurity

– Low self-esteem

– Lack of control over work and/or home life

– Social Isolation

– Low income


Social Exclusion

Poverty creates conditions that impair people’s

– Access to adequate housing

– Access decent education

– Transportation options

– Ability to be included in social life of the community


Social Exclusion

Increases risks of:

– Divorce and separation

– Disability

– Illness

– Addiction

– Creates vicious cycle


Work/ Unemployment

Health suffers when people have little opportunity to utilize their skills, and/or have low decision making authority. Increases risk of:

– Low back pain

– Cardiovascular disease

– Repetitive stress injuries (e.g. Carpal tunnel syndrome)

– Absenteeism

– Presenteeism


Built Environment

Influences the physical surroundings and options for healthy behaviors:

– Lack of parks

– Safe play/exercise spaces

– Lack of green space

– Presence of environmental toxins (air, ground, water)

– Presence of highways, truck and bus routes

– Sidewalks, street crossings

– Sidewalk “cut outs” for wheeled chairs, strollers

– Sheltered bus stops

– Street lights


Transportation

Healthy Transport means less driving and more walking, and cycling, backed up by safe reliable public transportation

Promotes regular exercise, reduces:

– Heart disease

– Obesity

– Stress

– Auto accidents

– Reliance on non-renewable fuels


Food

Having it is good! Having healthy food is much better!

Lack of healthy food creates malnutrition and food insufficiency.

Excess intake is often related to a variety of illness conditions

US is prone to overconsumption of energy dense, high sodium, high fat, high sugar foods.


Culture

• The learned and shared knowledge, beliefs, and rules that people use to interpret experience and to generate social behavior. The guiding forces behind what people think, say, expect, and do.

• “While there are observable general characteristics associated with cultural groups, there is significant heterogeneity among individuals within groups. Culture is dynamic.”


Complexities of Identity

Depending on the health condition or behavior, one aspect of one’s identity may be more salient than others.

Aspects of identity interact: a Trinidadian woman experiences femininity differently than a Puerto Rican woman. Both filter “womanhood” against what it means to them to be of their ethnic group.


Working

Style Organizational

Culture

Occupation

Personality

Military

Experience

Religious

Beliefs

Geographical

Location Background

Education/Degree

Thinking

Style

Marital Status

Socio-Economic

Status Work

Experience

Medical Specialty

Family Size

Neighborhood

Parental Status

Appearance Title Own/Rent

Friends

Hobbies

Values

Accent Birth Order

Citizenship

Full/Part Time

Suburban/Urban

Vocabulary

Age Race

Physical

Abilities/

Qualities

Ethnicity Gender

Sexual

Orientation

DIVERSITY LENS

Adopted from:

Marilyn Loden & Judy B. Rosener, 1991

© Harvard Pilgrim Health Care, Inc.


Culture Influences:

Definitions of illness

Decisions to use or not use medications

Help-seeking behaviors

US dominant culture has ambivalent relationship to concepts of mental illness, e.g.“Mad vs Bad”

The organizational cultures of our health care organizations influence access to mental health care, e.g., how late or missed appointments are handled, language used for communication

20

Alegria M, Atkins M, et al. (2010) One size does not fit all: Taking diversity, culture and context seriously. Adm Policy Ment Health, 37:48-60.


“..a Culture of No Culture”

….”that is, a community defined by the shared cultural conviction that its shared convictions were not in the least cultural, but, rather, timeless truths.”

Taylor, J. (2003) Confronting “Culture” in medicine’s “Culture of No Culture”, Acad Med, 78(6):555-559.


Resilience Factors

Contributors to resilience:

Sense of purpose in life

Mastery

Frequent attendance at religious services

Lower negative religious coping (i.e. internalizing shame based and punitive concepts from religion)

Optimism

Higher emotional expression

Active Coping

Social support

22

Alim TM, Feder A, Graves, RE et al. (2008) Trauma resilience and recovery in a high risk African American population. Am J Psychiatry, 165:1566-1575.


Communication of Mental Health Issues

Minority patients are less likely to fully communicate emotional states

May convey distress in subtle manner, through hints and cues.

Those who are not fully fluent in English may not have the vocabulary to convey emotional states.

Even those who are fluent, may be unable to access that fluency if they are upset or in a great deal of emotional distress.

23

De Maesschalck S, Deveugele M & Willems, S (2011) Language, culture and emotions: Exploring ethnic minority patients’ emotional expressions in primary healthcare consultations. Pat Educ and Counseling, 84:406-412.


Disparities in Use of Psychotherapy

No difference in accessing mental health services between American Caucasians, African Americans and Latinos.

African Americans and Latinos more likely to be uninsured

However, higher drop out rates among Latinos and African Americans

English language proficiency greatest predictor of use of MH services.

24

Chen J & Rizzo, J (2010) Racial and Ethnic disparities in use of psychotherapy: Evidence from US National Survey data. Psychiatric Services, 61(4):364-372


Role of Racial Discrimination

A study of Asian Americans compared low family cohesion, poverty, acculturative strain, self-reports of discrimination and incidence of mental disorders.

Self report of discrimination was the MOST ROBUST predictor of mental disorders, including anxiety

25

Gee GG, Spencer M Chen JC et al. (2007) The association between self-reported racial discrimination and 12-month DSM-IV mental disorders among Asian Americans Soc Sci Med, 64(10):1984-1996.


We don’t need or want you here. If immigrants weren’t here we americans would do the jobs you are doing. We need our troops home from Iraq, etc... send immigrants back where they came from, patrol our airports and borders with machine guns! None of the immigrants appreciate being here. They get free everything (food stamps WIC medical care etc). Let a white ENGLISH speaking american try to get help. Almost impossible! By the way our language is ENGLISH!!!! LEARN it READ it SPEAK it!!!Show some respect to us AMERICANS. Since you fled your pathetic country to come to ours!!GO BACK!!!

Fed up american

Apr 09, 2009


Report Difficulty Communicating with MD

27

The Commonwealth Fund Health Care Quality Survey, 2001


Differences in Symptom Presentation:

Depression may present with few or no affective symptoms. Somatic symptoms may predominate.

Anxiety often misdiagnosed as depression among ethnic patients.

Overdiagnosis of schizophrenia, under-diagnosis of bipolar illness in ethnic populations.

Patients may lack vocabulary to express and describe emotional states. Easier to learn names of parts of the body, than to differentiate vocubularies of emotion.

28


Culturally influenced Anxiety SX Presentations in Asian Populations.

29

Country of Origin Most Common Anxiety Presentations

China Dizziness, attribution to “weak heart” or “weak kidney”.

“Weak Kidney” is associated with dizziness, blurry vision,

tinnitus and back pain. “Weak nerves”: excessive worry,

headache, fatigue

Japan Dizziness upon standing, fatigue, headache. Fear of

people (distinguished from social phobia) that focuses on

fear of offending people

Korea Fear of choking, palpitations, fear of cardiac arrestIndia

Cambodia “weakness”: body percieved a weakened by

worry.Characterized by woory, tinnitus, shortness of breath,

feeling depleted. “Disturbed wind flow”, “Wind overload”

Hinton DE, Park L, Hsia C. et al. (2009) Anxiety disorder presentations in Asian populations: A review. CNS Neuroscienc & Therapeutics, 15:295-303.


Mental Illness among Ethnic Minority Elders

Non-US born Asians had 2x lifetime prevalence of anxiety disorders, especially GAD

Latinos born abroad had higher rates of dysthymia and GAD than US born Latinos.

African Americans had lower rates of depression, dysthymia and anxiety, but higher rates of substance use, especially alcohol.

Latino and Asian elders less likely to attain fluency in English, more likely to be socially isolated, and may experience disappointment in the elusive “American Dream”

30

Jimenez DE, Alegria M, Chen C et al. (2010) Prevalence of psychiatric illnesses among ethnic minority elderly. J Am Geriatric Soc 58(2):256-264.


Power and Control

Many campaigns and programs are seen by others as efforts to control behavior and personal choices.

We are, after all, trying to influence people in order to change behavior.

31


Who do we trust to give us information?

Many ethnic cultures are oral cultures: This does not mean that they are not literate, but that information, especially important information is transmitted orally.

32


Explanatory Models

Responsibility for illness falls mainly on the patient

– Common in the industrial West

– Often encouraged by health campaigns

– Ill health blamed on “not taking care of self” or “risky behavior”

– Illness can be ascribed to incorrect behavior, e.g. “sitting in a draft after a hot bath

33

Helman, C. (1994) Culture, Health and Illness


Expalnatory Models

34

Fate Moral

Failure

Retribution

Heredity Religion


Common Explanatory Models: US

–Debilitation

–Degeneration

– Invasion

– Imbalance

–Stress

–Mechanical causes

–Environmental causes

–Hereditary proneness

35

mental health and health disparities - nhms mental health and... · 2015-06-18 · –common in the...

Documents