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C A N P A N N U A L C O N F E R E N C E
J A N E T H I L D E B R A N D , F N P - B C
Social Determinants of Health: Looking Upstream for Answers
Shadows of Healthcare
Objectives
Assess the role of cultural, social and political influences to health and disease
Review key issues concerning poverty and social inequity in America
Analyze nursing science in the context of translating findings to enhance the health of individuals and communities
C U L T U R A L , S O C I A L A N D P O L I T I C A L I N F L U E N C E S T O H E A L T H A N D D I S E A S E
Vulnerable Populations
http://www.slate.com/blogs/behold/2014/07/17/brenda_ann_kenneally_documents_life_below_the_poverty_line_in_troy_york.html
Lia Lee
Language Barriers
Cultural Beliefs
Health literacy
Social norms
Past experiences
Rural environment
Adherence
The Cambodian Culture
Khmer Rouge Dictatorship from 1975 – 1979
Massive social trauma
Killed over 2 million Cambodians
Suffered human rights violations
Torture/Rape
Enslaved – worked in the rice fields
Starvation
Reinforced an environment of mistrust
Friends would turn on each other
Children would turn on parents
Families would turn on each other
The Cambodian Culture
Suffered human rights violations
Radically change their lifestyle
Loss of religious freedom
Mass graves
Buddhist ceremonial burial
Forced to move from homes – loss of land
Highest refugee population in Long Beach, CA
Marshall Islands
The Marshallese Culture
Located between Hawaii and Australia
US nuclear weapons testing from 1946 – 1958
Total destruction of natural food source
Fruits & vegetables & fish
US supplements
Canned foods – high fat and high salt
Compact of Free Association allowed the Marshallese to migrate to US without a visa
The Marshallese Culture
Mostly concentrated in Arkansas & Hawaii
Collectivist culture
Strong distrust of US health care
Shame and stigma of diabetes
Cultural insensitivity from providers
Loss of land
Massive social trauma
Alaskan Native & Native American
Health issues
Alternative Healing Practices
Shaman healers
Herbal remedies
Association of American Indian Physicians (aaip.org)
Isolation/Loss of history
Massive social trauma
Enslaved
Experienced radical change in lifestyle
White – Latino
Latino Origin
Numerous cultures clumped into broad term
Various dialects within this population
Numerous cultural beliefs
Alternative healing practices
Curanderos – Healers
Massage therapist
Spiritual emphasis
External locus of control
White – Non-Latino
Numerous cultures clumped into broad term
Genetic/Chronic Diseases
Loss of land
Enslaved
Massive social trauma
Radically changed their lifestyle
Black
Numerous cultures clumped into broad term
Genetic/Prevalent diseases
Enslaved
Forced to move from rural to urban
Massive social trauma
Experienced radical change to lifestyle
Risk Patterns – Social Histories
Enslaved
Land taken away
Forced to move from rural to urban region
Radically changed their lifestyle
Massive social change
Review Key Issues Concerning
Poverty and Social Inequity in America
Poverty & Social Inequalities
http://www.huffingtonpost.com/2013/09/17/poverty-america-census_n_3940812.html
Poverty
West Migrant Farm Worker
Working children
Midwest Industrialization
Migration of laborers
South Industrialization
East Displaced laborers
Union formation
Drug experimentation
Poverty
Lyndon B. Johnson
“Our aim is not only to relieve the symptoms of poverty, but to cure it and, above all, to prevent it.“
Social Security Amendments of 1965
Food Stamp Act of 1964
Expansion of AFDC
Job Corps, Vista Program, Office of Economic Opportunity
Title I program – target for impoverished students –No Child Left Behind Act
Poverty
Recession of 2008 & 2012
Healthy Families
TANF
SNAP
Food pantries
Homeless
Statistical Data Sources
Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care
HHS Action Plan to Reduce Racial and Ethnic Health Disparities
2013 National Healthcare Quality Report – AHRQ US Department of Health and Human Services
Unequal Treatment
Healthcare systems
Poor cultural match between minority patients and their providers
Language barriers – use of family members
Lack of continuity in care
In-patient to outpatient transition
Services are geographically separated
Reimbursement
Limited trauma units & tertiary NICU
Increase liability costs
Unequal Treatment
Providers of care – clinical encounter
Diagnoses influenced by race
Chest pain – cardiac or emotional anxiety
Categorization of ethnicities – stereotyping
Referral to drug rehabilitation – success or failure
Self-fulfilling prophecy
Expectations based on stereotypes
Bring own biases, beliefs, cultural experiences
Unequal Treatment
Patient
Genetic differences
Poor historian
Unable to explain symptoms
Health literacy – medical terminology
Mistrust in the healthcare system
Misconceptions in the recommendations
Religious beliefs and practices
Cultural beliefs and practices
Poor adherence to medications or recommendations
A N A L Y Z E N U R S I N G S C I E N C E I N T H E C O N T E X T O F T R A N S L A T I N G F I N D I N G S T O E N H A N C E T H E H E A L T H O F
I N D I V I D U A L S A N D C O M M U N I T I E S
Enhance the Health of Individuals and Communities
http://www.specialolympics.org/RegionsPages/content.aspx?id=37368
GoalCreate social and physical environments
that promote good health for all
Healthy People 2020
Lesbian, Gay, Bisexual and Transgender Health
Older Adults
Sleep health
Social Determinants of Health
Social Determinants of Health
http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health
EnvironmentalMeasures
Policy
Community Awareness & Action
School & Work Support
Clinical Expertise & Systems
Family
Self-CareManagement
Adapted from Managing Chronic Disease Website
Health Belief Model
Perceived susceptibility
Perceived benefits
Perceived barriers
Perceived self-efficacy
Perceived severity of
disease
Cues to Action
IndividualBehaviors
Stress
McEwen & Gianaros (2011)
Stress
Acute time-limited stressors Laboratory challenges
Brief naturalistic stressors Confronting a real-life short-term challenge
Stressful event sequences A focal event such as natural disaster or loss of spouse
Chronic stressors Pervades a person’s life; forcing restructuring of one’s social role or
identity Traumatic injury or chronic disease
Distant stressors Traumatic experiences that occurred in the past Potential to continuously modify immune system due to long lasting
cognitive and emotional sequelae
Allostatic Load
Definition: an imbalance in systems that promote adaptation (McEwen)
3 types of physiological responses that make up allostatic load
Lack of adaptation or habituation
Prolonged response due to shut-down
Chronic activity and failure to shut off
Inadequate response that leads to hyperactivity
Failure to respond to challenge
Recommendations
Affordable Care Act
Signed into law on March 23, 2010 and upheld by Supreme
Court on June 28, 2012.
Details on website HHS.gov:
http://www.hhs.gov/healthcare/about-the-law/index.html
Improve fragmentation of health care
Improve gaps in research – clinical guidelines
Report cards to evaluate quality of care services
Recommendations
Providers
Structural competence
Evidence-based practice
Ethno-pharmacology
Disease prevention
Cultural Humility
Focus on clinical case
Know your biomedical biases
Nursing Science – Areas of Research
Translate research into practice Healthy lifestyles
Supportive networks Diet & exercise promotion
Employers Encourage healthy lifestyles
Governmental Policies Education, housing, minimum wage Occupational health and safety Environmental pollution
Communities Community Centers Senior Centers
Social Justice
Structural violence Political
Premature suffering and
Institutional violence
Marginalization
Exclusion
Public Health
Racial disparities Impact on health
Don’t just treat – get involved
Dis
ea
se
Community
Evaluation
L
i
t
e
r
a
c
y
Chronic
Hypertension
Women
Intervention
D
i
a
b
e
t
e
s
Asthma
Ca
re
Health
Ma
na
ge
me
nt
Families
Ac
tio
ns
O
u
t
c
o
m
e
s
Disparities
Environment
Poverty
Symptoms
Assessment
Social
Patient
Program
Children
Adults
Heart
Imp
ac
t
Factors
Elderly
Treatment
Data
Services
Medical
Illness
Imp
ro
ve
Assist
Required
Affordable
Act
Behavior
Food
Age
Prevention
Promotion
EthnicityCulture
Challenges
United
Medical
Group
Skills
Self-managementDesigns
Rates
Alternative
Public
Policy
Support
EMR
Evidence
Practice
Indicators
Cli
nic
al
Guidelines
Communication
WICTANF
Costs
Medications
National
Depression
Cancer
Pr
ov
ide
rs
Process
Life
Primary
Prevention
Determinants
Cultural Humility
References
Abramsky, S. (2013). The American Way of Poverty How the other half still lives. New York: National Books.
Affordable Care Act (ND). Retrieved from http://www.hhs.gov/healthcare/about-the-law/index.html
Braveman, P. A., Heck, K., Egerter, S., Marchi, K. S., Dominguez, T. P., Cubbin, C., . . . Curtis, M. (2015). The role of socioeconomic factors in Black-White disparities in preterm birth. Am J Public Health, 105(4), 694-702. doi:10.2105/ajph.2014.302008
Centers for Disease Control and Prevention. (ND). Retrieved from http://www.cdc.gov/
Hallgren, E. A., McElfish, P. A., & Rubon-Chutaro, J. (2015). Barriers and opportunities: a community-based participatory research study of health beliefs related to diabetes in a US Marshallese community. Diabetes Educ, 41(1), 86-94. doi:10.1177/0145721714559131
Harrington, M. (1963). The Other America: Poverty in the United States. Maryland: Penguin Books
Healthy People 2020. (ND). Retrieved from http://www.healthypeople.gov/
L. (2000). Heaven Becomes Hell. New Haven, Connecticut: Yale University Southeast Asia Studies.
Merriam-Webster (ND). Retrieved from http://www.merriam-webster.com
Mollica, R. F. (2009). Healing Invisible Wounds Paths to Hope and Recovery in a Violent World. Nashville, TN: Vanderbilt University Press.
Strutz, K. L., Hogan, V. K., Siega-Riz, A. M., Suchindran, C. M., Halpern, C. T., & Hussey, J. M. (2014). Preconception stress, birth weight, and birth weight disparities among US women. Am J Public Health, 104(8), e125-132. doi:10.2105/ajph.2014.301904
Weltin, A. M., & Lavin, R. P. (2012). The effect of a community garden on HgA1c in diabetics of Marshallese descent. J Community Health Nurs, 29(1), 12-24. doi:10.1080/07370016.2012.645724