Social Detrminats of Equity

7/21/2019 Social Detrminats of Equity

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Social Determinants of Equity

and

Social Determinants of Health


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Levels of health intervention


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Addressing the

social determinants of health

Primary prevention

Safety net programs and

secondary prevention

Medical care and

tertiary prevention


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But how do disparities arise?

Differences in the quality of care receivedwithin the health care system

Differences in access to health care, includingpreventive and curative services

Differences in life opportunities, exposures,and stresses that result in differences inunderlying health status


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Differences in

exposures andopportunities

Differencesinaccesstocare

Differences in quality of care

(ambulance slow or goes the wrong way)


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Addressing the

social determinants of equity:

Why are there differences

in resources

along the cliff face?

Why are there differences

in who is found

at different parts of the cliff?


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Determinants of health

Individual

behaviors


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Social determinants

of health (contexts)

Individual

behaviors


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Determinantsof health andillness that areoutside of theindividual

Beyond geneticpredispositions

Beyond individualbehaviors

Social determinants


Individual

behaviors


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Determinantsof health andillness that areoutside of theindividual

Beyond geneticpredispositions

Beyond individualbehaviors

Social determinants


Individual

behaviors

The contexts inwhichindividualbehaviors arise


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Individualresources

Education,occupation, income,wealth

Social determinants


Individual

behaviors


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Individualresources


Neighborhoodresources

Housing, foodchoices, publicsafety,

transportation,parks andrecreation, politicalclout

Social determinants


Individual

behaviors


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Individualresources





Social determinants


Individual

behaviors

Hazards andtoxic exposures

Pesticides, lead,reservoirs ofinfection


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Individualresources





Social determinants


Individual

behaviors

Hazards andtoxic exposures

Pesticides, lead,reservoirs ofinfection

Opportunitystructures

Schools, jobs,justice


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Societal determinants of context

Social determinants


Individual

behaviors


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Determine therange of

observed contexts

Societal determinants of context


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observed contextsSocietal determinants of context

Social determinants


Individual

behaviors

Determine thedistribution ofdifferent populationsinto those contexts


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Social determinants


Individual

behaviors


Include capitalism,racism, and other

systems of power


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Social determinants


Individual

behaviors


The socialdeterminants ofequity

Include capitalism,racism, and other

systems of power


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Addressing the social determinantsof health

Involves the medical care and public healthsystems, but clearly extends beyond these

Requires collaboration with multiple sectorsoutside of health, including education,housing, labor, justice, transportation,

agriculture, and environment


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Addressing the social determinantsof equity

Involves monitoring for inequities inexposures and opportunities, as well as fordisparities in outcomes

Involves examination of structures, policies,practices, norms, and values

Requires intervention on societal structuresand attention to systems of power


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We need to do both

Address the social determinants of health,including poverty, in order to achieve large

and sustained improvements in healthoutcomes

Address the social determinants of equity,

including racism, in order to achieve socialjustice and eliminate health disparities


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Naming and Addressing

the Impacts of Racismon Health


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Why racism?

To eliminate racial disparities in health,need examine fundamental causes

Race is only a rough proxy for SES,culture, or genes

Race precisely measures the social

classification of people in our race-conscious society

Hypothesize racism as a fundamentalcause of racial disparities in health


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What is racism?

A system


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What is racism?

A system of structuring opportunity andassigning value


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What is racism?

A system of structuring opportunity andassigning value based on the social

interpretation of how one looks (race)


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What is racism?


interpretation of how one looks (race) Unfairly disadvantages some individuals

and communities


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What is racism?



and communities

Unfairly advantages other individuals andcommunities


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What is racism?



and communities

Unfairly advantages other individuals andcommunities

Saps the strength of the whole societythrough the waste of human resources

Source: Jones CP, Phylon 2003


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Reactions to Race module

Six-question optional module on the

Behavioral Risk Factor Surveillance System

Piloted by six states in 2002

Now available to all states

St t i R ti t R


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States using Reactions to RaceArkansas 2004California 2002

Colorado 2004Delaware 2002 2004 2005District of Columbia 2004

Florida 2002Michigan 2006

Mississippi 2004Nebraska 2008New Hampshire 2002

New Mexico 2002North Carolina 2002

Ohio 2003 2005Rhode Island 2004 2007South Carolina 2003 2004

Virginia 2008Washington 2004

Wisconsin 2004 2005 2006


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States using Reactions to Race module on 2004 BRFSS

Arkansas, Colorado, Delaware, District of Columbia,

Mississippi, Rhode Island, South Carol ina, Wisconsin

S i ll i d


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Socially-assigned raceHow do other people usually classify you in

this country? Would you say:

White

Black or African-American

Hispanic or Latino

Asian

Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native Some other group

G l h lth t t


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General health statusWould you say that in general your health

is:

Excellent

Very good

Good

Fair

Poor

G l h lth t t b i ll i d " " 2004 BRFSS


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00

1

08

06

04

02

58.3 43.7 41.2 36.1

0

White Black Hispanic AIAN

Report excellent or very good health

percentofre

spondents

General health status by socially-assigned "race", 2004 BRFSS



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00

1

08

06

04

02

58.3 43.7 41.2 36.1

0



percentofre

spondents



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00

1

08

06

04

02

58.3 43.7 41.2 36.1

0



Report fair or poor health

13.9 21.5 20.9 22.1

percentofre

spondents

percentofre

spondents


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General health status and race

White social experience associated withbetter health

S lf id tifi d th i it


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Self-identified ethnicityAre you Hispanic or Latino?

Yes

No

S lf id tifi d


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Self-identified raceWhich one or more of the following would

you say is your race?

White

Black or African-American

Asian Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

Other

Which one of these groups would you say

best represents your race?

S lf id tifi d / th i it


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Self-identified race /ethnicityHispanic

Yes to Hispanic/Latino ethnicity question

Any response to race question

White

No to Hispanic/Latino ethnicity question

Only one response to race question, White

Black


Only one response to race question, Black

American Indian/Alaska Native


Only one response to race question, AI/AN

T f


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White Black Hispanic AIAN . . .

White

26,37398.4 0.1 0.3 0.1 1.1

Black

5,2460.4 96.3 0.8 0.3 2.2

Two measures of race

How usually classified by others

How

self-identify

T f


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White

26,37398.4 0.1 0.3 0.1 1.1

Black

5,2460.4 96.3 0.8 0.3 2.2

Hispanic

1,52826.8 3.5 63.0 1.2 5.5

How

self-identify

T f


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White

26,37398.4 0.1 0.3 0.1 1.1

Black

5,2460.4 96.3 0.8 0.3 2.2

Hispanic

1,52826.8 3.5 63.0 1.2 5.5

How

self-identify

General health status by self identified and socially assigned "race" 2004


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General health status, by self-identified and socially-assigned race , 2004

percentofrespondents

100

80

60

40

20

0

39.8

53.7

58.6

Report excellent or very good healthHispanic-Hispanic Hispanic-White White-White

General health status by self-identified and socially-assigned "race" 2004


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0

20

40

60

80

100

39.8

58.6


Hispanic-Hispanic White-White

Test of H0: That there is no difference in proportions

reporting excellent or very good health

Hispanic-Hispanic versus White-White

p < 0.0001




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0

20

40

60

80

100

39.8

53.7


Report excellent or very good healthHispanic-Hispanic Hispanic-White



Hispanic-Hispanic versus Hispanic-White

p = 0.0019




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0

20

40

60

80

100

53.7

58.6


Report excellent or very good healthHispanic-White White-White



Hispanic-White versus White-White

p = 0.1895

General health status, by self identified and socially assigned race , 2004



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White

26,37398.4 0.1 0.3 0.1 1.1

Black

5,2460.4 96.3 0.8 0.3 2.2

Hispanic

1,52826.8 3.5 63.0 1.2 5.5

AIAN

32147.6 3.4 7.3 35.9 5.8H

ow

self-iden

tify



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White

26,37398.4 0.1 0.3 0.1 1.1

Black

5,2460.4 96.3 0.8 0.3 2.2

Hispanic

1,52826.8 3.5 63.0 1.2 5.5

AIAN

32147.6 3.4 7.3 35.9 5.8H

ow

self-iden

tify

General health status, by self-identified and socially-assigned "race", 2004


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0

20

40

60

80

100

32

52.6

58.6


Report excellent or very good healthAIAN-AIAN AIAN-White White-White



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0

20

40

60

80

100

32

58.6

percentofr

espondents

Report excellent or very good healthAIAN-AIAN White-White



AIAN-AIAN versus White-White

p < 0.0001



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, y y g ,

0

20

40

60

80

100

32

52.6

percentofr

espondents

Report excellent or very good healthAIAN-AIAN AIAN-White



AIAN-AIAN versus AIAN-White

p = 0.0122



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, y y g ,

0

20

40

60

80

100

52.6

58.6

percentofr

espondents

Report excellent or very good healthAIAN-White White-White



AIAN-White versus Whi te-White

p = 0.3070


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Being perceived as White is associated withbetter health

Even within non-White self-identified race/ethnic

groups

"

General health status by education and "race", 2004 BRFSS


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w

w

w

w

w

0

20

4

0

60

80

16+ 13-15 12 9-11 0-8

b

b

bb

b

Education level

Percent"excellent"or"verygood


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groups

Even within the same educational level

d"



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w

w

w

w

w

80

60

4

0

20

0

good

y

er

v"

b

or b"

ent

blel bc

ex

"b

ent

c

er

P16+ 13-15 12 9-11 0-8

Education level

d"



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w

w

w

w

w

80

60

4

0

20

0

good

y

er

v"

b

or b"

lent

bel bc

ex

"b

ent

c

er

P16+ 13-15 12 9-11 0-8

Education level

25

20

ibution

rt 15

s

di

ent

10

c

er

5P

0

16+ 13-15 12 9-11 0-8

non-blackblack

Education level

d"



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w

w

w

w

w

80

60

4

0

20

0

good

y

er

v"

b

or b"

lent

bel bc

ex

"b

ent

c

er

P16+ 13-15 12 9-11 0-8

Education level

25

20

ibution

rt 15

s

di

ent

10

c

er

5P

0

16+ 13-15 12 9-11 0-8

non-blackblack

Education level

d"



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w

w

w

w

w

80

60

4

0

20

0

good

y

er

v"

b

or b"

lent

bel bc

ex

"b

ent

c

er

P16+ 13-15 12 9-11 0-8

Education level

100

80

ibution

rt 60

s

di

ent

40

c

er

20

P

0

16+ 13-15 12 9-11 0-8

non-whitewhite

Education level


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groups


Being perceived as White is associated with

higher education


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Key questions

WHY is socially-assigned race associatedwith self-reported general health status?


groups


WHY is socially-assigned race associated

with educational level?


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Racism


interpretation of how one looks (race)

Unfairly disadvantages some individuals and

communities

Unfairly advantages other individuals and

communities

Saps the strength of the whole society through the

waste of human resources


Levels of racism


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Levels of racism

Institutionalized

Personally-mediated

Internalized

Institutionalized racism


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Institutionalized racism

Differential access to the goods, services, andopportunities of society, by race

Examples Housing, education, employment, income

Medical facilities

Clean environment

Information, resources, voice

Explains the association between SES andrace

Personally-mediated racism


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Personally-mediated racism

Differential assumptions about the abilities,motives, and intents of others, by race

Prejudice and discrimination Examples

Police brutality

Physician disrespect

Shopkeeper vigilance

Waiter indifference

Teacher devaluation

Internalized racism


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Internalized racism

Acceptance by the stigmatized races ofnegative messages about our own abilitiesand intrinsic worth

Examples

Self-devaluation

White mans ice is colder

Resignation, helplessness, hopelessness

Accepting limitations to our full humanity


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Levels of Racism:

A Gardeners Tale

Source: Jones CP,Am J Public Health 2000


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Who is the gardener?

Power to decide

Power to act

Control of resources

Dangerous when

Allied with onegroup

Not concerned withequity

Health equity


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Health equity

Health equity is the realization by ALLpeople of the highest attainable level of

health.

Source: National Partnership for Action, ongoing discussions, 2009

Achieving health equity


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Requires valuing all individuals andpopulations equally




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Requires valuing all individuals andpopulations equally, and

Entails focused and ongoing societal efforts




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Entails focused and ongoing societal efforts To address avoidable inequalities




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By assuring the conditions for optimal health forall groups




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By assuring the conditions for optimal health forall groups,

Particularly for those who have experiencedhistorical or contemporary injustices orsocioeconomic disadvantage.


Addressing racism


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Addressing racism

Opportunity structures

Education, employment, justice, housing,

immigration, transportation, environment,healthcare, social security for children

Societal valuation

Investment Communication: invite contributions, hold

high expectations, celebrateaccomplishments, cherish existence

Our goal: To expand the conversation


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g p

Health services



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g p

Health services

Social determinants

of health



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g p

Health services

Social determinants

of health

Social determinantsof equity

Jones CP et al. Expanding the Fence or Ambulance Debate: Addressing the Social Determinants of Health and Equity. Under review, 2009.

Our tasks


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Our tasks

Put racism on the agenda

Name racism as a force determining the

distribution of other social determinants ofhealth

Routinely monitor for differentialexposures, opportunities, and outcomes by

race

Our tasks


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Our tasks

Ask, How is racism operating here?

Identify mechanisms in structures, policies,

practices, norms, and values Attend to both what exists and what is

lacking

Our tasks


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Our tasks

Organize and strategize to act

Join in grassroots organizing around the

conditions of peoples lives Identify the structural factors creating and

perpetuating those conditions

Link with similar efforts across the countryand around the world


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Camara Phyllis Jones, MD, MPH, PhD

4770 Buford Highway NE

Mailstop K-67Atlanta, Georgia 30341

(770) 488-5268 phone(770) 488-5965 fax

[email protected]

Resources


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Resources

California Newsreel: Unnatural Causes:Is Inequality Making Us Sick?

http://www.unnaturalcauses.org/

World Health Organization:

Commission on Social Determinants ofHealth

http://www.who.int/social_determinants/en/

Resources


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Resources

CityMatCH: Undoing Racism ActionGroup

http://www.citymatch.org/UR.php

National League of Cities: Reducing

Racism and Achieving Racial Justicehttp://www.nlc.org/resources_for_cities/programs__

_services/382.aspx

Resources


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Resources

UNESCO: International Coalition ofCities Against Racism

http://www.unesco.org/shs/citiesagainstracism

United Nations: World Conference

Against Racism, Racial Discrimination,Xenophobia, and Related Intolerance

http://www.un.org/WCAR/

Resources


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Resources

United Nations: Committee to EliminateRacial Discrimination

http://www2.ohchr.org/english/bodies/cerd/

USA CERD report:

http://www2.ohchr.org/english/bodies/cerd/docs/Adv

anceVersion/cerd_c_usa6.doc

NGO shadow reports:

http://www2.ohchr.org/english/bodies/cerd/cerds72-

ngos-usa.htm

Resources


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esou ces

CDC Racism and Health Workgroup

[email protected]

Communications and Dissemination

Education and Development

Global Matters

Liaison and Partnership

Organizational Excellence

Policy and Legislation

Science and Publications

Measuring institutionalized


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gracism

Scan for evidence of racial disparities

Routinely monitor outcomes by race

Could racism be operating here?

Identify mechanisms

Examine structures and written policies Query unwritten practices and norms

How is racism operating here?

Policies of interest


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Policies allowing segregation ofresources and risks

Policies creating inherited group-disadvantage

Policies favoring the differential

valuation of human life by race Policies limiting self-determination


P li i ll i ti


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Policies allowing segregation

of resources and risks

Redlining, municipal zoning, toxicdump siting

Use of local property taxes to fundpublic education

P li i ti


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Policies creating

inherited group disadvantage

Lack of social security for children

Estate inheritance

Lack of reparations for historicalinjustices

P li i f i th


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Policies favoring the

differential valuation of humanlife by race

Curriculum

Media invisibility/hypervisibility

Myth of meritocracy and denial ofracism

P li i li iti


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Policies limiting

self-determination

De jureand de factolimitations tovoting rights

Majority rules when there is a fixedminority

Documents

Social Detrminats of Equity