Assessing and Addressing Assessing and Addressing Inequities in Community Inequities in Community

Nutrition in Washington StateNutrition in Washington State

Marilyn Sitaker, Battelle Public Health Nutrition 3/12/2013

What is Health Equity?What is Health Equity? Health Equity is the absence of differences in health

between groups with greater and lesser levels of social advantage

Health equity is necessary for individuals & groups to participate in, and benefit from, social and economic development.

Health equity is a conscious process requiring effort

Today’s Lecture TopicsToday’s Lecture Topics1. Dimensions of inequalities in access to

healthy foods2. What we know about health inequities 3. WHO Health Equity conceptual model 4. Measuring health equity5. Policy intervention strategies

1. Dimensions of inequalities in access to healthy foods

The high-fat, high-salt, and low-vegetable/fruit diets found in disadvantaged populations are often less the result of bad choices than the unfortunate consequence of the shrinking number of good, affordable supermarkets in inner-city neighborhoods, the explosion of fast food restaurants in urban areas, and food traditions originating in deprivation.[1][1] Amersbach,G. Through the lens of race: Unequal health care in America. Harvard Public Health Review, Winter 2002. Viewed 3/5/2006. http://www.hsph.harvard.edu/review/review_winter_02

Inequitable nutrition environmentsInequitable nutrition environments

1. Access to healthy food is challenging for many, particularly in low-income and rural areas, and in communities of color Lack of supermarkets Lack of healthy, high

quality foods in nearby food stores.

Too many convenience & liquor stores.

Lack of transportation access to stores

Urban U.S. Food-store Availability by Income, Mean Number per ZIP Code

Powell et al, Am J of Prev Med , 44(3): 189–195, March 2007.

For each additional supermarket in a census tract, produce consumption increases by 32% for African Americans and 11% for whites, according to a multistate study. A survey of produce availability in New Orleans’ neighborhood stores found that for each additional meter of shelf space with fresh vegetables, residents eat an added 0.35 servings per day. In rural Mississippi, adults living in “food desert” counties lacking large supermarkets are 23% less likely to eat enough fruits and vegetables than those in counties that have supermarkets, controlling for age, sex, race, and education.

2. Residents with greater access to supermarkets & availability of healthy food options eat more fresh produce

2. What we know about health inequities

““Reaching for a Healthier Life”Reaching for a Healthier Life”Facts on Socioeconomic Status & Health in the USFacts on Socioeconomic Status & Health in the US

                               

February 2010Volume 1186 The Biology of Disadvantage: Socioeconomic Status and HealthPages 1–275

http://www.macses.ucsf.edu/downloads/reaching_for_a_healthier_life.pdf

1. Socioeconomic status has a big impact on everyone’s health. Premature death is 3 x more likely for those in poverty compared to those who are most privileged

2. Access to socioeconomic resources affects our chances for living a healthy life. The conditions we live in during childhood drives many health problems

2. Childhood living conditions influences health as we age. Throughout our lives, access to socioeconomic resources affects our chances to live a healthy life.

3. Health care is important, but accounts for only a small portion of health disparities. Social determinants are more important in determining whether we fall ill in the first place.

Source: McGinnis JM, et al., Health Affairs, 2002

4. Each step up the social ladder provides greater access to social and physical environments that make it easier to engage in healthy behaviors, (e.g., safe places to walk and access to healthier foods). Each step down, greater exposure to potential risks (pollution & unsafe neighborhoods).

5. Work conditions contribute to health & health disparities. Low-wage jobs may involve shift work and physical hazards, low control over how and when tasks are done, job insecurity, and conflicts between family obligations and work requirements

6. Exposure to extreme and prolonged “toxic” stress is more common lower on the social ladder. Persistent stressors--financial insecurity, interpersonal disputes, work-induced exhaustion, chronic conflict-- are recorded in the body.

““Reaching for a Healthier Life”Reaching for a Healthier Life”Facts on Socioeconomic Status & Health in the USFacts on Socioeconomic Status & Health in the US

3. WHO Health Equity conceptual model

Conceptual Model created by the World Health Organization Commission on Social Determinants of Health http://www.who.int/social_determinants/resources/csdh_framework_action_05_07.pdf

How social conditions influence health equityHow social conditions influence health equity

4. Measuring health equity

Disparities in Smoking Prevalence by IncomeDisparities in Smoking Prevalence by Income

We compare the size of the disparity between the highest & lowest income by constructing a ratio . Dividing the percent in the lowest income group by the percent in the highest income group:The ratio of smoking is

31 ÷ 11 = 2.8

Cigarette Smoking Among Adults by Income in Washington, 2005-2007

11

22

31

0 10 20 30 40 50

<$20,000

$20,000-$49,999

$50,000 ormore

Hou

seho

ld In

com

e

Age-Adjusted Percent

Source: Washington Behavioral Risk Factor Survey

Disparities in Risk Factors, Risk Conditions, and Chronic Diseases among Washington Adults by Income

Washington: Disparities in Eating F&V Washington: Disparities in Eating F&V

Washington State adults with the lowest incomes & education are less likely to eat enough fruit and vegetables.

21

26

30

0 10 20 30 40 50

<$35,000

$35,000-$74,999

$75,000 or more

Age-Adjusted Percent

Hou

seho

ld In

com

e

Eats Fruits and Vegetables 5 + times a Day Among Adults by Income in Washington, 2007 & 2009

Source: Washington Behavioral Risk Factor

19

24

32

0 10 20 30 40 50

High school or less

Some College

College graduate or more

Age-Adjusted Percent

Edu

catio

n

Eats Fruits and Vegetables 5 + Times a Day Among Adults by Education in Washington, 2007 & 2009

Source: Washington Behavioral Risk Factor

Example: Physical Activity and Access to Local Example: Physical Activity and Access to Local Outdoor Recreation by Socio Economic PositionOutdoor Recreation by Socio Economic Position

The less education a person has, the less likely it is that he or she lives near a public park, playground, trail or school recreational facility. Less educated adults are also less likely to use nearby recreational facilities, & less likely to get enough physical activity.

Influence of neighborhood features on physical activity, all adults in

Washington 2005

0 20 40 60 80 100

Gets enough physicalactivity

Uses park, playground,school or trail

Lives near park,playground, school or trail

Percent

College or more

Some college

High school orless

Washington: Trends in Disparities in Eating Washington: Trends in Disparities in Eating F&V F&V

0

2

4

6

8

10

12

14

1990 1995 2000 2005 2010

Age

Adj

uste

d Pe

rcen

t

Year

Excess risk of obesity by education, comparing HS education or less to college graduate

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

1990 1995 2000 2005 2010Ri

sk R

atio

Year

Relative risk of obesity by education, comparing HS education or less to college graduate

0

5

10

15

20

25

30

35

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Age

Adj

uste

d Pe

rcen

t

Year

Obesity prevalence by education

HS or less

Some college

College grad

Indicators: Directory of Social Determinants Indicators: Directory of Social Determinants of Health at the Local Levelof Health at the Local Level

University of Michigan SPH project funded by the CDC. Developers had expertise in diverse areas.

Directory lists current data sets that can be used to address SDOH. Data sets organized in 12 dimensions of the social environment.

Each dimension is subdivided into various components.

Source; Hillemeier M.M., J. Lynch, S. Harper, and M. Casper. 2003. "Measuring contextual characteristics for community health." Health Services Research 38(6 part 2):1645–717.

12 Dimensions of Social Context12 Dimensions of Social Context

Economic DimensionEconomic Dimension This table presents the components and indicators of the

economic dimension. Nine economic components are identified:1. Income 2. Wealth 3. Poverty 4. Economic Development 5. Financial Services 6. Cost of Living 7. Redistribution 8. Fiscal Capacity 9. Exploitation

Source; Hillemeier M.M., J. Lynch, S. Harper, and M. Casper. 2003. "Measuring contextual characteristics for community health." Health Services Research 38(6 part 2):1645–717.

Components and Indicators Data Sources and Notes 1. Income: Earned income Median and per capita annual income Census Bureau Mean hourly and annual wage Bureau of Labor Statistics

Data by occupation available in downloadable Excel files. Hourly wage, union, and nonunion workers

Union Membership and Earnings Data Book (http://www.bna.com/bnaplus/labor/ laborrpts.html). Separate tables for public and private sector workers and for manufacturing and nonmanufacturing workers. Customized reports available for any or all years since 1983.

Per capita personal income Bureau of Economic Analysis Downloadable compressed comma–separated–value files.

Income: Disposable income Median and per capita Effective Buying Index

Demographics U.S.A. (http://www.tradedimensions.com/ p_demographics.html). Effective Buying Index represents money income minus taxes. Data available on CD–ROM.

Income: Income distribution Gini coefficient of income inequality; 90%ile/10%ile ratio

Census Bureau

Indicators & Measures: Indicators & Measures: IncomeIncome

Source; Hillemeier M.M., J. Lynch, S. Harper, and M. Casper. 2003. "Measuring contextual characteristics for community health." Health Services Research 38(6 part 2):1645–717.

Harvard Geocoding Project: Measuring Harvard Geocoding Project: Measuring Socioeconomic Position (SEP)Socioeconomic Position (SEP)

Key domains: Occupational class: affects health via occupational hazards

and income/standard of living Educational attainment: reflects childhood SEP and future

economic prospects, also knowledge & health literacy Income & subsidies: affects standard of living Wealth: referring to accumulated assets Relative social ranking: “status” and “prestige”

Source: Public Health Disparities Geocoding Project

Each of the previous 5 socioeconomic class domains can be assessed at multiple levels--individual, household, and area or neighborhood.

Socioeconomic data can be measured at key points in the lifecourse -- in utero, infancy, childhood, and early, middle, and late adulthood.

Composite measures combine information on more than one component variable. For example, the Townsend index consists of % unemployment, % renters, % not owning a car, and % crowding.

Area Based Measures of SEPArea Based Measures of SEP

This economically depressed area in Boston's Chinatown, turned out to be characterized as a highly working class, poor, low income area with high unemployment and few expensive homes.

This one house in Beacon Hill looked like it was -- and turned out to be -- in a fairly affluent area: over 75% professionals, low poverty, high income, low unemployment, and lots of expensive homes.

Comparing Two Boston NeighborhoodsComparing Two Boston Neighborhoods

Insufficient F&V Consumption by CountyInsufficient F&V Consumption by County

5. Policy intervention strategies

Policies to Promote Health EquityPolicies to Promote Health Equity1. Policies that Affect the Ladder 2. Policies that Blunt Adverse Consequences

Health Inequalities: Trends, Progress and PolicyHealth Inequalities: Trends, Progress and Policy(Bleich et al, Ann Rev Pub health 2012 33:7-40)(Bleich et al, Ann Rev Pub health 2012 33:7-40)

Trends: Reviewed time trends in health inequalities by sex,

race/ethncity and socioeconomic status in the US and UK In the US, the gap between best and worst off groups

narrowed for some health issues (e.g., life expectancy), but not others (eg., diabetes)

In the UK, the gap between best and worst off groups narrowed for some health issues (e.g., hypertension), but not others (e.g., life expectancy)

Health Inequalities: Trends, Progress and PolicyHealth Inequalities: Trends, Progress and Policy(Bleich et al, Ann Rev Pub health 2012 33:7-40)(Bleich et al, Ann Rev Pub health 2012 33:7-40)

Policy: Also reviewed policies designed to address health

inequalities enacted between 1980 and 2011 Nine countries reviewed: Australia, Canada, Finland,

Netherlands, New Zealand, Spain, Sweden, UK, and US Policies categorized as information, priority-setting or

action step

Country Policy DescriptionCanada Aboriginal Head Start

(1995)Early childhood development program, for children on and off-reservation

United Kingdom

Tackling Health Inequalities: Program for Action (2001)

National plan to meet public health goals to decrease health inequalites by socioeconomic status

Sweden Public Health Objective Bill (2007)

Recommends health policy address economic security as a means to meet health goals

United States Patient Protection & Affordable Care Act (2010)

Established a national strategy to reduce inequalities in care delivery; provided grants to community wellness initiatives to reduce health disparities.

Health Inequalities: Trends, Progress and PolicyHealth Inequalities: Trends, Progress and Policy(Bleich et al, Ann Rev Pub health 2012 33:7-40)(Bleich et al, Ann Rev Pub health 2012 33:7-40)

Paula Braveman: Thoughts on Health InequitiesPaula Braveman: Thoughts on Health Inequities

Systematic differences in health or health determinants that are plausibly influenced by social policy are health inequities if they

Occur between groups with different social position Place groups already at social disadvantage at even greater disadvantage due to poor health

You don’t need to attribute causation or prove that a change in social policy will resolve the disparity, as long as the impact is plausible.

Braveman, 2004, Health Policy and Development 2(3) 180-185

Thank You!Thank You!

Marilyn Sitaker, MPH

Principal Research ScientistBattelle Memorial Institute

(206) 528-3365Sitakerm@battelle.org