Post on 26-Mar-2020
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
© 2009 Harvard Pilgrim Health Care Foundation
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.
© 2009 Harvard Pilgrim Health Care Foundation 5
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
© 2009 Harvard Pilgrim Health Care Foundation 6
The Social Gradient
These disadvantages tend to accumulate in the same people:
– Poor education, tends to lead to inadequate housing, jobs, income, etc.
© 2009 Harvard Pilgrim Health Care Foundation 7
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
© 2009 Harvard Pilgrim Health Care Foundation 8
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.
© 2009 Harvard Pilgrim Health Care Foundation 9
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.
© 2009 Harvard Pilgrim Health Care Foundation 10
Stress
Factors that increase stress:
– Continuing anxiety
– Insecurity
– Low self-esteem
– Lack of control over work and/or home life
– Social Isolation
– Low income
© 2009 Harvard Pilgrim Health Care Foundation 11
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
© 2009 Harvard Pilgrim Health Care Foundation 12
Social Exclusion
Increases risks of:
– Divorce and separation
– Disability
– Illness
– Addiction
– Creates vicious cycle
© 2009 Harvard Pilgrim Health Care Foundation 13
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
© 2009 Harvard Pilgrim Health Care Foundation 14
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
© 2009 Harvard Pilgrim Health Care Foundation 15
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
© 2009 Harvard Pilgrim Health Care Foundation 16
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.
© 2009 Harvard Pilgrim Health Care Foundation 17
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.”
© 2009 Harvard Pilgrim Health Care Foundation 18
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.
© 2009 Harvard Pilgrim Health Care Foundation 19
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.
© 2009 Harvard Pilgrim Health Care Foundation
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.
© 2009 Harvard Pilgrim Health Care Foundation 21
“..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.
© 2009 Harvard Pilgrim Health Care Foundation
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.
© 2009 Harvard Pilgrim Health Care Foundation
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.
© 2009 Harvard Pilgrim Health Care Foundation
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
© 2009 Harvard Pilgrim Health Care Foundation
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.
© 2009 Harvard Pilgrim Health Care Foundation 26
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
© 2009 Harvard Pilgrim Health Care Foundation
Report Difficulty Communicating with MD
27
The Commonwealth Fund Health Care Quality Survey, 2001
© 2009 Harvard Pilgrim Health Care Foundation
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
© 2009 Harvard Pilgrim Health Care Foundation
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.
© 2009 Harvard Pilgrim Health Care Foundation
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.
© 2009 Harvard Pilgrim Health Care Foundation
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
© 2009 Harvard Pilgrim Health Care Foundation
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
© 2009 Harvard Pilgrim Health Care Foundation
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
© 2009 Harvard Pilgrim Health Care Foundation
Expalnatory Models
34
Fate Moral
Failure
Retribution
Heredity Religion
© 2009 Harvard Pilgrim Health Care Foundation
Common Explanatory Models: US
–Debilitation
–Degeneration
– Invasion
– Imbalance
–Stress
–Mechanical causes
–Environmental causes
–Hereditary proneness
35