Practical Strategies Lauri Andress, MPH, J.D., Ph.D. June, 2010 Senior Health Equity Analyst Center...

Practical Strategies

Lauri Andress, MPH, J.D., Ph.D.June, 2010

Senior Health Equity AnalystCenter to Eliminate Health DisparitiesUniversity of Texas Medical Branch

Developing Chronic Disease Programs around the Social Determinants of Health

Identify 3 key elements of SDOH and the potential relevance of a social determinants of health (SDOH) perspective to chronic disease prevention.

Describe 2 distinctions between universal and targeted interventions and the relevance of each to a comprehensive approach to population health planning at the local level

Describe 2 ways SDOH research and a population perspective can be applied to health planning processes at the local level.

Objectives

A shorthand for the broad and complex array of social, political, economic, environmental and cultural factors which strongly impact health status and equity.

“The structural determinants and conditions of daily life…responsible for a major part of health inequities……. Commission on the SDOH

'the distribution of power, income, goods and services, Locally, nationally, and globally…[and]

the visible circumstances of people's lives - their access to high quality schools and education, their conditions of work and leisure, their homes, communities, towns and cities - and their chances of leading a flourishing life.'

Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health: Commission on Social Determinants of Health final report. Geneva: World Health Organization Commission on Social Determinants of Health; 2008.

Social Determinants of Health

Economy

SOCIAL DETERMINANTS OF

HEALTH

Urban PlanningSchools/

Education

Employment/Job Quality

CommunitySafety

HousingOptions

TransportationOptions

Governance

EconomicDevelopment

Social Determinants of Health

Conceptual Framework-Pathways & Entry Points

Social Context Social stratification

Differential exposure

Social deprivationUnemployment

IlliteracyDeprived neighborhoodsAdverse intrauterine life

Differential vulnerability

Less access to:• Health services• Early detection• Healthy food

Differential outcomes

PovertyOvercrowdingPoor housing

Differential consequences

Rheumatic heart diseaseChagas disease

Lifetime exposure to advertising of fast foods, tobacco, vehicle use, disposable income, urban infrastructure, physical inactivity, high

calorie intake, high salt intake, high saturated fat diet, tobacco use, lack of control over life and work, high deprivation neighborhoods

Raised cholesterol, raised blood sugar, raised bloodpressure, overweight, obesity, lack of access to healthinformation, health services, social support and welfare

assistance, poor health care-seeking behavior

Higher incidence, frequent recurrences,higher case fatality, co morbidities

High out-of-pocket expenditure, poor adherence, lower survival, loss of employment, loss of productivity and income, social and financial

consequences, entrenchment in poverty, disability, poor quality of life

Age Economic development, urbanization, globalization

Equity, social determinants and public health programmes. Edited by Erik Blas and Anand Sivasankara Kurup 2010, 300 pages ISBN 978 92 4 156397 0 World Health Organization 2010

Determinants:a. Government policies: influencing social capital, infrastructure, transport, agriculture, food.b. Health policies at macro, health system and micro levels.c. Individual, household and community factors: use of health services, dietary practices, lifestyle.

a

Tobacco use c

b

b

Obesity b

a

a

b

a

Six broad intervention approaches Social and environmental conditions

favorable to health, Behavioral patterns that promote health, Low population risk, Few events and rare deaths, Fully functional capacity/low risk of

recurrence, and Good quality life until death

Texas Plan to Reduce Cardiovascular Disease and Stroke 2008

Texas Council on Cardiovascular Disease and Stroke 2008 Legislative Report

Major non-modifiable risk factors are: heredity, male gender, and increasing age.

Modifiable risk factors are smoking, high cholesterol, high blood pressure, overweight and obesity, and physical inactivity.

Another major risk factor for CVD is diabetes mellitus.

Risk Factors

Texas Council on Cardiovascular Disease and Stroke 2008 Legislative Report

Risk Factors for the Risk Factors?

Obesity

Smoking

Physical Inactivity

Kickbusch Adelaide April 2010http://www.health.sa.gov.au/pehs/HiAP/Adelaide2010/KickbuschDay1-hiap-phcc-20100423.pdf

Obesity: A Test Case for 21st Century Health

A complex system of determinants Involves a plethora of actors who fulfill many

different functions in society.

Risk patterns are local, national, global Local- the absence of playgrounds or lack of bicycle lanes); national (e.g. the lack of food labeling or advertising requirements)

and global. (Foresight Report)

Both the problem and the solution are systemic. Such systemic challenges can only be resolved through great

political commitment at all levels of government and in many sectors of society……..

SDOH as Risk Factors

Cardiovascular Disease

Obesity

Access to Healthy Food

Income

Transportation system

Community development; Planning

Agricultural Policies

The links between agriculture and health: an intersectoral opportunity to improve the health and livelihoods of the poorC Hawkes, M Ruel - Bulletin of the world Health Organization vol.84 no.12 Genebra Dec. 2006.

Conceptual framework of the links between agriculture and health

Risk Factors & Possible Policy Responses

Policy sector - Farming & Agriculture

Goal to ensure nutrition include: Farm and Commodity Policy; WIC policy

Means available: Grants. Agricultural policy framework

Examples: Animal and plant breeding; price and income supports; acreage limits and storage programs

Adapted from LANG ET AL. (2009). FOOD POLICY- INTEGRATING HEALTH, ENVIRONMENT & SOCIETY


Policy sector - Agricultural Research and Productivity; Processing

Goal to ensure nutrition include: Agricultural productivity; investments in agricultural research and

technology; more efficient agricultural machinery, agricultural chemicals and fertilizers, genetic improvements in crops, and changes in farm management techniques

Means available: Intellectual property rights

Examples: Product reformulation. Change fat content in meat regulations



Policy sector - Housing and Community Development-Related Policy

Goal to ensure nutrition include: Improving access to health enhancing foods

Means available: zoning and land-use planning decisions that determine the relationship of residential to

commercial land uses

Examples: Transportation decisions; Location of stores through town-neighborhood planning



Policy sector - Federal Trade Commission, Food & Drug Administration, USDA

Goal to ensure nutrition include: Change thinking about food to reshape demand

Means available: Advertising, Labeling

Examples: Controls on marketing to children. Reform Nutrition Labeling and Education Act of 1990 (NLEA)


MeasurementInterventionsMain entry-pointsSocial determinants and pathways

Priority public health

conditions level

Information on policies and structural

environment measures conducive

to healthy behavior, e.g. tobacco

cessation, consumption of fruits and

vegetables, reduce salt in processed

food, regular physical activity

Information on legislative and

regulatory frameworks to support

healthy behavior

Measurement of gaps in

implementation of policies and

legislative and regulatory frameworks

International trade agreements that promote availability and

affordability of healthy foods

International agreements on marketing of food to children

Use tobacco tax for promotion of health of the population

Develop urban infrastructures to facilitate physical activity

Government legislation and regulation, e.g. tobacco advertising and pricing

Voluntary agreement with industry, e.g. trans fats and salt in processed food

User-friendly food labeling to help customers to make healthy food choices

Strengthen positive and

counteract negative

health effects of

modernization

Community

infrastructure

development

Reduce affordability of

harmful products

Increase availability

of and accessibility to

healthy food

Poor living conditions in childhood

Community structures

Control over life and work

Attitudes towards health

Marketing

Television exposure

Psychosocial and work stress

Unemployment

High-deprivation neighborhoods

Availability of preventive health services

Health-related behaviors

Residence: urban/rural


Access to employment opportunities,

poverty alleviation schemes and

education

Level of investment in interventions

that improve health (including

cardiovascular health) that lie outside

the health sector

Universal primary education

Programs to alleviate undernutrition in women of childbearing age and pregnant women

Tax-financed public services, including education and health

Multifaceted poverty reduction strategies at country level, including employment opportunities

Define, institutionalize,

protect and enforce

human rights

to education,

employment, living

conditions and health

Redistribution of power

and resources in

populations

Social status

Education

Occupation

Poverty

Parents’ social class

Ageing of populations

Poor governance

Socioeconomic context

and position

(entry-points and

interventions are common

to other areas of health)



conditions level

Information on policies and structural

environment measures conducive

to healthy behavior, e.g. tobacco

cessation, consumption of fruits and

vegetables, reduce salt in processed

food, regular physical activity

Information on legislative and

regulatory frameworks to support

healthy behavior

Measurement of gaps in

implementation of policies and

legislative and regulatory frameworks

International trade agreements that promote availability and

affordability of healthy foods

International agreements on marketing of food to children

Use tobacco tax for promotion of health of the population

Develop urban infrastructures to facilitate physical activity

Government legislation and regulation, e.g. tobacco advertising and pricing

Voluntary agreement with industry, e.g. trans fats and salt in processed food

User-friendly food labeling to help customers to make healthy food choices

Strengthen positive and

counteract negative

health effects of

modernization

Community

infrastructure

development

Reduce affordability of

harmful products

Increase availability

of and accessibility to

healthy food

Poor living conditions in childhood

Community structures

Control over life and work

Attitudes towards health

Marketing

Television exposure

Psychosocial and work stress

Unemployment

High-deprivation neighborhoods

Availability of preventive health services

Health-related behaviors

Residence: urban/rural


Access to employment opportunities,

poverty alleviation schemes and

education

Level of investment in interventions

that improve health (including

cardiovascular health) that lie outside

the health sector

Universal primary education

Programs to alleviate undernutrition in women of childbearing age and pregnant women

Tax-financed public services, including education and health

Multifaceted poverty reduction strategies at country level, including employment opportunities

Define, institutionalize,

protect and enforce

human rights

to education,

employment, living

conditions and health

Redistribution of power

and resources in

populations

Social status

Education

Occupation

Poverty

Parents’ social class

Ageing of populations

Poor governance

Socioeconomic context

and position

(entry-points and

interventions are common

to other areas of health)

Inequity and CVD

Equity, Social Determinants and Public Health Programmes. (2010). Edited by Erik Blas and Anand Sivasankara Kurup. WHO, WHO Press, 1211 Geneva 27, SwitzerlandISBN 978 92 4 156397


Priority Public Health Conditions Level Socioeconomic Context & Position

Social Determinants and Pathways Social Status, Education, Occupation, Poverty, Parent’s Social class, Ageing of Population, Poor governance

Main Entry Points Define, institutionalize, protect and enforce human rights to education, employment, living

conditions and health; Redistribution of power and resources in populations

Interventions Universal primary education Programs to alleviate under nutrition in women of childbearing age and pregnant women Tax-financed public services, including education and health Multifaceted poverty reduction strategies at country level, including employment opportunities


Priority Public Health Conditions Level Differential exposure

Social Determinants and Pathways Poor living conditions in childhood Community structures Control over life and work Marketing; Television exposure Psychosocial and work stress Unemployment High-deprivation neighborhoods; Residence: urban/rural Availability of preventive health services Health-related behaviors

Main Entry Points Strengthen positive and counteract negative health effects of modernization Community infrastructure development Reduce affordability of harmful products Increase availability of and accessibility to healthy food

Interventions International trade agreements that promote availability-affordability of healthy foods International agreements on marketing of food to children Use tobacco tax for promotion of health of the population Develop urban infrastructures to facilitate physical activity Government legislation and regulation, e.g. tobacco advertising &pricing Voluntary agreement with industry, e.g. trans fats and salt in processed food User-friendly food labelling to help customers to make healthy food choices

Priority Public Health Conditions Level Differential vulnerability Social Determinants and Pathways Access to education plus Access to welfare assistance Health care-seeking behaviors Co-morbidity Lack of social support Health care-seeking behaviors plus Accessibility of health services Under nutrition Physical inactivity Access to health education Gender Main Entry Points Subsidize healthy items to make healthy choices easy choices Compensate for lack of opportunities Empower people Interventions Provide healthy meals free or subsidized to schoolchildren Subsidize fruits and vegetables in worksite canteens and restaurants Facilitate a price structure of food commodities to promote health, e.g. lower price for low-fat milk Improve early case detection of individuals with diabetes and hypertension by targeting vulnerable groups, e.g.

deprived neighbourhoods, slum dwellers Improve population access to health promotion by targeting vulnerable groups in health education programmes Combine poverty reduction strategies with incentives for utilization of preventive services, e.g. conditional cash

transfers, vouchers Provide social insurance and fee exemptions for basic preventive and curative health interventions Education and employment opportunities for women

Inequity and CVD (cont’d)

Access to essential medicines and

basic technologies in primary health

care

Levels of population coverage related

to essential CVD interventions

Support for smoking cessation

for high-risk groups among low

socioeconomic segments of the

population

Increase awareness among providers of ethical norms and patient rights

Provide universal access to a package of essential CVD interventions through a primary health care approach

Provide incentives within public and private health systems

to increase equity in outcomes, e.g. fees and bonuses for

disadvantaged groups

Provide dedicated services for particular groups, e.g. smoking

cessation programs for people in deprived neighborhoods

Medical procedures

Provider practices:

compensate for

differential outcomes

Cost of appropriate care

Differential utilization by patients

Prescription practices not based on evidence

Poor adherence

Discriminating services

Poor access to essential medicines

Frequent recurrences and hospitalizations

Life stress and social isolation

Lack of education

Comorbidity

Differential health care

outcomes



conditions level

Social and economic effects of health

outcomes

Access to cardiac rehabilitation

Policies for linking health and social

welfare

Policies and environments in worksites to reduce differential

consequences

Increase access of services for people with specific health conditions, e.g. cardiac rehabilitation

Improve referral links to social welfare and health education services

Social and physical

access

Lower survival and worse outcomes

Loss of employment

Social and financial consequences

Lack of access to welfare assistance

Heavy health expenditure

Lack of safety nets


Access to media, e.g. print, radio

and television and health education

programs broadcast through these

media

Affordability of fruits, vegetables and

low-fat food items

Population coverage of screening and

early detection of high-risk groups

Access to treatment and follow-up

including to essential drugs, basic

technologies and special interventions,

e.g. bypass surgery

Provide healthy meals free or subsidized to schoolchildren

Subsidize fruits and vegetables in worksite canteens and restaurants

Facilitate a price structure of food commodities to promote health, e.g. lower price for low-fat milk

Improve early case detection of individuals with diabetes and

hypertension by targeting vulnerable groups, e.g. deprived

neighborhoods, slum dwellers Improve population access to health promotion by targeting vulnerable groups in health education programs Combine poverty reduction strategies with incentives for utilization of preventive services, e.g. conditional cash transfers, vouchers Provide social insurance and fee exemptions for basic preventive and curative health interventions

Education and employment opportunities for women

Subsidize healthy

items to make healthy

choices easy choices

Compensate for lack of

opportunities

Empower people

Access to education

Comorbidity

Lack of social support

Access to welfare assistance

Health care-seeking behaviors

Accessibility of health services

Undernutrition

Physical inactivity

Access to health education

Gender


Access to essential medicines and

basic technologies in primary health

care

Levels of population coverage related

to essential CVD interventions

Support for smoking cessation

for high-risk groups among low

socioeconomic segments of the

population

Increase awareness among providers of ethical norms and patient rights

Provide universal access to a package of essential CVD interventions through a primary health care approach

Provide incentives within public and private health systems

to increase equity in outcomes, e.g. fees and bonuses for

disadvantaged groups

Provide dedicated services for particular groups, e.g. smoking

cessation programs for people in deprived neighborhoods

Medical procedures

Provider practices:

compensate for

differential outcomes

Cost of appropriate care

Differential utilization by patients

Prescription practices not based on evidence

Poor adherence

Discriminating services

Poor access to essential medicines

Frequent recurrences and hospitalizations

Life stress and social isolation

Lack of education

Comorbidity

Differential health care

outcomes



conditions level

Social and economic effects of health

outcomes

Access to cardiac rehabilitation

Policies for linking health and social

welfare

Policies and environments in worksites to reduce differential

consequences

Increase access of services for people with specific health conditions, e.g. cardiac rehabilitation

Improve referral links to social welfare and health education services

Social and physical

access

Lower survival and worse outcomes

Loss of employment

Social and financial consequences

Lack of access to welfare assistance

Heavy health expenditure

Lack of safety nets


Access to media, e.g. print, radio

and television and health education

programs broadcast through these

media

Affordability of fruits, vegetables and

low-fat food items

Population coverage of screening and

early detection of high-risk groups

Access to treatment and follow-up

including to essential drugs, basic

technologies and special interventions,

e.g. bypass surgery

Provide healthy meals free or subsidized to schoolchildren

Subsidize fruits and vegetables in worksite canteens and restaurants

Facilitate a price structure of food commodities to promote health, e.g. lower price for low-fat milk

Improve early case detection of individuals with diabetes and

hypertension by targeting vulnerable groups, e.g. deprived

neighborhoods, slum dwellers Improve population access to health promotion by targeting vulnerable groups in health education programs Combine poverty reduction strategies with incentives for utilization of preventive services, e.g. conditional cash transfers, vouchers Provide social insurance and fee exemptions for basic preventive and curative health interventions

Education and employment opportunities for women

Subsidize healthy

items to make healthy

choices easy choices

Compensate for lack of

opportunities

Empower people

Access to education

Comorbidity

Lack of social support

Access to welfare assistance

Health care-seeking behaviors

Accessibility of health services

Undernutrition

Physical inactivity

Access to health education

Gender


Statement of Intent to Pursue Health Equity Strategies The ODH is committed to the elimination of health inequities. All applicant agencies must submit a statement which outlines the intent of this

application to address health disparities. This statement should not exceed 1 ½ pages and must:

(1) explain the extent in which health disparities are manifested within the health status (e.g., morbidity and/or mortality) or health system (e.g., accessibility, availability, affordability, appropriateness of health services) focus of this application;

(2) identify specific group(s) who experience a disproportionate burden for the disease or health condition addressed by this application; and

(3) identify specific social and environmental conditions which lead to health disparities (social determinants).

This statement must be supported by data. The following section will provide a basic framework and links to information to

understand health equity concepts. This information will also help in the preparation of this statement as well as respond to other portions of this application.

Options for Action-Grants

[email protected]

Questions & Answers

Miscellaneous slides

Practical Strategies Lauri Andress, MPH, J.D., Ph.D. June, 2010 Senior Health Equity Analyst Center...

Documents

Transcript of Practical Strategies Lauri Andress, MPH, J.D., Ph.D. June, 2010 Senior Health Equity Analyst Center...