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Determinants of Health
Social Factors
Health services
Individual behavior
Biology and Genetics

Disparities are those differences that are indicative of injustice or unfairness.

Although the term “disparities” often is interpreted to mean racial or ethnic disparities, many dimensions of disparity exist in the United States, particularly in health. If a health outcome is seen in a greater or lesser extent between populations, there is disparity. Race or ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual’s ability to achieve good health.

Dissimilarities are the differences that are *not* attributed to injustice or unfairness.

Health Disparitiy
A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion

Health Care Disparity
refers to differences specifically within the healthcare system, access to health care, quality of health care, and utilization of health care services that are a result of injustice

Health Care Dissimilarities
Refers to these same differences within the health care system (access to health care, quality of health care, and utilization of health care services) that are NOT a result of injustice.

Health Equity
Attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities

Leading Causes of Death
Heart Disease
Malignant Neoplasms (tumors)

Whites, blacks, American Indians, Alaskan Natives, and Latinos:
1. Heart Disease
2. Malignant Neoplasms

Asians and Pacific Islanders
1. Malignant Neoplasms
2. Heart Disease

Disparity vs difference: Is injustice involved?

Institute of Medicine Report
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

Enabling Factors
Resources that either facilitate or inhibit someone seeking health care services. For example, having a car is a facilitating factor because it provides transportation, a useful resources for physically traveling to a health care provider. Having no health insurance would be an inhibiting factor because it often deters one from seeking health care services.

Predisposing Factors
An individual’s inclination to use health services, most notably one’s attitudes toward using health care. These attitudes may be facilitating or inhibiting and are largely influences by cultural beliefs and prior experiences. For example, if someone distrusts the medical establishment, or has had negative experiences with the medical establishment, he/she may be less likely to seek health care services. Conversely, is one has a great relationship with a medical provider, he/she is more likely to continue visiting this provider in the future

Perceived Need for Health Care Service
One’s belief that he/she does (or does NOT) need to utilize health care services for health issues. If one does not perceive a need for an action, including health behaviors, he/she is much less likely to engage in that behavior.

Most Likely to be Uninsured
Hispanics, then blacks, then whites

Those Who Fail to Obtain Needed Medical Care Due to Cost
Blacks, then Hispanics, then whites

Theories of Health Disparities
Socio-Environmental Theories (Risk exposure & Resource Deprivation)

Psychosocial/Behavioral Theories (Weathering Hypothesis & John Henryism)

Physiological Theories (Genetic differences among racial/ethnic populations)

Psychosocial/behavioral theories
Among the psychosocial/behavioral theories, these theories relate to aspects of the culture or behavior specific racial/ethnic groups that influence the behavior of individuals.

Risk exposure
First, there is risk exposure theory. Risk exposure theory says that high prevalence of social or environmental health risks in predominantly minority communities lead to a higher prevalence of disease and death. Because the United States is a highly racial segregated country, different rates of health risk in different communities place different populations at different levels of risk in those communities.

Resource Deprivation
Resource deprivation says that racial/ethnic disparities in health status exist because minorities are more likely than whites to live in communities that are lacking in the necessary infrastructure to support a healthy lifestyle. Infrastructure includes road ways, food sources, safety, and health care services, to name a few.

Weathering Hypothesis
The Weathering Hypothesis seeks to explain the differences between African-Americans and Whites in pregnancy outcomes. The Weathering Hypothesis proposes that social stress in the community, in the environment and the society, affects African Americans and other minorities negatively. Specifically, these populations are said to actually “weather” or age at accelerated rates because of increased exposure to stress. We know that excess stress has numerous health implications, including premature aging and associated conditions.

John Henryism
The John Henryism theory was developed by Sherman James, a psychologist who was trying to understand why African Americans have such high rates of hypertension. “The John Henryism hypothesis assumes that lower SES individuals in general, and African-Americans in particular, are routinely exposed to psychosocial stressors (e.g., chronic financial strain, job insecurity, and subtle or not so subtle social insults linked to race or social class) that require them to use considerable energy each day to manage the psychological stress generated by these conditions.” (p. 167). The hypothesis further assumes that individuals exposed to excess psychosocial stressors will respond differently, with varying degrees of success. The John Henry Hypothesis predicts that individuals in lower SES categories who utilize active coping skills related to the excess stressors are more likely to suffer from hypertension due to their effort.

Empirical Example
Burden of risk factors
Access to Care (Acute, Rehabilitation & Prevention)
Quality of Care
Participation in Research

Burden of risk factors
Blacks have a higher prevalence of hypertension, diabetes, mellitus, and left ventricular hypertrophy than whites

Hispanics have a higher prevalence of metabolic syndrome and diabetes than whites and blacks

American Indians and Alaskan Natives are at a heightened risk of stroke compared to whites

Incidence/Prevalence of Stroke
The incidence and prevalence of stroke are higher among blacks, Hispanics, American Indians and Alaskan Natives than among whites

Recurrent stroke risk is also higher among blacks and Hispanics

Impairment after a stroke is higher among blacks

A lack of awareness of stroke symptoms was found among all racial/ethnic groups

A lack of awareness was found even after having a stroke, especially among women

Denial of disease, concern for medication side effects, burden of filling prescriptions and burden of attending doctor appointments were found to decrease compliance among minorities more than among white.

Perceived or true presence of racial discrimination with the healthcare system also had a negative impact on compliance

Access to Care
Racial/ethnic disparities in access to stroke care is multifaceted and included SES, insurance coverage, mistrust of medical establishment, limited number of providers belonging to a minority group, and poor awareness/education.
In particular:
Minorities were less likely to use emergency medical services. Blacks and Hispanics had delayed arrival at the emergency department and had longer waiting time in the ED. The authors concluded that these disparities in access to acute stroke treatment were related to lack of awareness/education, language barriers, reluctance to seek attention because of immigration status, as well as potential biases in the delivery of care.
Information presented on access to rehabilitation services was conflicting: minorities have equal access to these services and have longer stays, but poorer functional status than whites.
Secondary prevention treatments were underused by all racial/ethnic groups; but minorities were less likely to receive medications dues to SES, education and insurance coverage.

Quality of Care
Minority patients with stroke are less likely to be evaluated by a neurologist.

Limited evidence shows that minorities are less likely to receive evaluation or testing for CVD and stroke than whites.

Minorities are inadequately treated with both primary and secondary stroke prevention strategies. Disparities are reduced when people have health insurance and ready access to health care. Physical activity rates are lower among minorities than among whites.

Participation in Research
There is limited participation of minorities in clinical research due to cultural beliefs, mistrust of the medical establishment, awareness and education, and economic issues.

Information about a patient’s racial/ethnic background is important for the identification, tracking and investigation of the rationale for differences in the prevalence and severity of disease and responses to treatment. This is especially important when genetic factors.

The Caucasian/White population is decreasing as compared to other races/ethnicities.
1980 Census: 188 million people
2000 Census : 211 million people
2010: 233 million people
There may be an increase in total numbers, but they are decreasing as a percentage.

Use waist circumference to measure visceral and abdominal subcutaneous fat

Age and body image in males (White)
43% dissatisfied with body image
Body dissatisfaction more common in young men
Ideal lean muscular build can lead to disordered eating and depression
Aging effects ability to achieve higher muscle mass

Heredity and Breast Cancer
BRCA1 and BRCA2 : Predisposing genes
Patients with BRCAI carriers had better overall survival
BRCA1 carriers: High probability of hereditary breast cancer. Long term survival. White women have this gene which gives them a higher probability of surviving. Why do black women not have this gene?

White Male: Leading Causes of Death
Heart disease
Unintentional injuries
Chronic lower respiratory disease
Influenza and pneumonia
Alzheimer’s disease
Kidney disease

White Female: Leading Causes of Death
Heart disease
Chronic lower respiratory disease
Alzheimer’s disease
Unintentional injuries
Influenza and pneumonia
Kidney disease

Perception of Health and Self Care: Women
Women struggle to maintain healthy lifestyle due to personal and work responsibilities

Many low-income Euro-American mothers are single parents and employed but had poorer health due to multiple stressors

Social Message : “take care of yourself for health of those you love”

Races with a light complexion


Native of the West

Originating from Western or European countries

Native of Europe

General Population
Everyone studied within a population

Reference, control, and comparison populations
Standard population for comparison

African American Introduction
There are 38.9 million Americans of African decent

*African Americans make up 15% of the U.S. population*

55% of the African American population lives in the Southern region

Beliefs, attitudes, institutional arrangements and acts that tend to denigrate individuals or groups because of phenotypic characteristics or ethnic group affiliations

Stressors of Racism
Environmental Factors
Constitutional Factors
Sociodemographic Factors
Psychological and Behavioral Factors

How Segregation Affects African American Health
Infant mortality rates segregate blacks and whites within the U.S and internationally

Reasons for High Infant Mortality Rate (Black)
Black urban communities are highly toxic environments

Lack adequate medical services

Higher housing costs

Poverty and African American Health Status
Socioeconomic Status is an important risk factor for Infant Mortality

Poverty is more prevalent among African American than among White Americans

Why Political power can be used as a Strategy for Health:
Feelings of *hopelessness and alienation* from societal institutions leads to *poorer health status among African Americans*
Example of political power in the works:
Post neonatal mortality rates were *lower* where African Americans had higher levels of political power

Death Rates
African Americans generally have higher death rates compared to all other racial and ethnic groups

The largest disparities are found in comparisons with Asians and Pacific Islanders

The death rate is 50% higher than the Asian/Pacific Islander.

The largest death rate disparity between African Americans and Hispanics is 2.4%, for the 40-44 age groups

Black Male: Leading Causes of Death
*Heart disease
Unintentional injuries
Chronic lower respiratory diseases
*HIV disease*
Kidney disease
Perinatal conditions

Black Female: Leading Causes of Death
*Heart disease
Kidney disease
Unintentional injuries
Chronic lower respiratory diseases
Alzheimer’s disease

Health Care Utilization
Revolves around access to availability of health care resources:
African Americans were 1.6x more likely to identify their usual source of care as a facility rather than a person

Differential management of disease and illness
African American patients with similar needs are half as likely to receive diagnostic and interventional treatments for heart disease as compared with White patients

Racial discrimination
In many medical encounters race plays a role in communication

Blacks: Major Health Risks and Issues- Poverty and low SES
Over 22% live below the poverty line. Poverty and low SES are linked to living in communities with greater exposure to physical environment

Blacks: Major Health Risks and Issues- HIV/AIDS
African Americans representation is 3x greater than their proportion of the population
Leading risk factors: Poverty & Stigmatization

Blacks: Major Health Risks and Issues- Homicide
High poverty
Social disorganization
Homicides: 34% are African Americans

Blacks: Major Health Risks and Issues- Obesity
Risk factor for many diseases

Obesity is a significant complicating factor in many medical and surgical techniques

Cultural factors :
Standards of beauty
Perception of “normal” weight

Blacks: Weight Loss Interventions
African American adolescents are disproportionately affected by obesity

Families tend to leave programs early:
Distrust of mental health providers
Work barriers

Phenomenology method
Understand the individuals background and culture

Specific reasons for leaving/staying:
Life problems
Collaboration and Reinforcement of Therapy
Confidence levels

Blacks: Major Health Risk and Issues
Maternal and Child Health
Maternal mortality exceeds Hispanic and Whites
Highest infant mortality of all groups
Rates decrease as education levels increase

Cigarette smoking remains the leading preventable cause of death
Used as a coping mechanism

John Henryism
A strong behavioral predisposition to cope actively with psychosocial environmental stressors:
Hypertension is the most prevalent health problem among African Americans
Inverse relationship between hypertension and socioeconomic status.
This hypothesis suggest low socioeconomic are routinely exposed to psychosocial stressors.
Low SES and high John Henryism = highest mean blood pressure (vice versa)

Native American Introduction
There is a lack of good-quality data for these groups: One of the most limiting issues is that data systems within healthcare settings do not code patients race

According to the 2010 Census, there are more than 3 million American Indians and Alaska Natives (AIAN)

Native American Health Status: Historically, this population has experienced extreme health problems
They had little or no immunity to the disease brought by the Europeans. Smallpox infested blankets were given to the Indians when they trusted the Americans. Americans burned the Indian’s food, infected them with poisons, and took/infected/killed the meat sources.

Native American Health Status: Tend to have
Income below the federal poverty level
High unemployment rate

Native American Health Status: Cultural differences are a challenge to their health care status
Acess to care with the Indian Health Service is limited

Native American Health status:
Having experienced severe oppression lead them to mistrust the US government. They are 2.3x more likely to have diabetes than general US population

Native American Major Health Risks
Poverty and Low SES
Language and Cultural Barriers

Native American Specific Health Issues
Mental illness
Childhood obesity and early onset of Type 2 diabetes
Adult obesity : 50% of the population is obese. 80% have a BMI above normal range. There are even more problems such as high BP, arthritis, high cholesterol, type 2 diabetes, and gall bladder disease

Native American Age-Specific Death Rates
Generally have a higher death rate compared to other racial/ethnic groups

Death rates when compared to African Americans, AIAN death rates are equal or higher. When compared to Hispanics, the death rate is 1.7x higher for most age categories

At age 80, selective survival leads to a crossover in death rates whereby AIAN’s have lower death rates than other ethnic/racial groups

American Indian Male: Leading Causes of Death
*Heart disease
Unintentional injuries
Chronic liver disease
Chronic lower respiratory disease
Influenza and pneumonia

American Indian Female: Leading Causes of Death
Heart disease
Unintentional injuries
Chronic lower respiratory disease
Chronic liver disease
Kidney disease
Influenza and pneumonia

American Indian Health Care Access and Utilization
The government’s lack of respect of treaty provisions has lead to a mistrust among the population

The Bureau of Indian Affairs was developed to oversee health care for the American Indian population.
In 1955 Indian Health Services (IHS) was formed to oversee healthcare

When Alaska became part of the US, Alaska Natives became eligible for IHS services.

Native American Strategies to Improve Health
Target leading causes of death

Target the prevention of obesity in order to decrease risk of diabetes: Make physical activity programs work in order to tackles obesity and type 2 diabetes

Understand the role of caregiving among American Indians and their traditional medicines

Advocate whole health and better nutrition

Decrease high alcohol consumption among youth

Asian Introduction
Known as the “model minority”: Many members of this group have few health risks
The most urgent health problem found among Chinese and Filipino populations is hypertension and high cholesterol.
Diabetes is high among Hmong populations

Leading cause of death among Asian or Pacific Islander (API)Americans is cancer.

According to the 2010 Census, there are 15.2 million Asian and Pacific Islanders.
5.9% of the total population

Asian Male: Leading Causes of Death
Heart disease*
Unintentional injuries
Chronic lower respiratory diseases
Influenza and pneumonia
Kidney disease

Asian Female: Leading Causes of Death
Heart disease*
Unintentional injuries
Influenza and Pneumonia
Chronic lower respiratory diseases
Alzheimer’s disease
Kidney disease

Asian Diabetes
Highly prevalent among API populations
Particularly high among the Hmong, Guamanian and Chamorro populations
More likely to develop secondary complications from the disease and die prematurely

Asian BMI
API have higher prevalence of metabolic syndrome than whites at each level of BMI
The World Health Organization recommends a lower BMI for this population

Asian Mental Health
Much of what is know about mental health comes from hospitals:
This is a severe limitation
Such data can only asses persons who seek and obtain health care

A large portion of Asian Pacific Islanders are immigrants:
Have a higher prevalence of mental health problems

Asian Health Care Access and Utilization
Underutilized Health Care:
Caused by cultural factors-
Different attitudes towards suffering
Some believe that life is predetermined

Need separate data for API because diseases like AIDS may be underreported or misclassified

Asian Culturally Related Beliefs and Values
Some believe that ancestral spirits influence health
Exhibit respect for nature
Emphasize collective over individual needs

Asian Acculturation and Health
May result in improvements and decreases in health status of migrating individuals and groups

The robust association between SES positions and health in general population is due to their proficiency in English which leads to positive effects on health

Chinese Americans have a high SES due to bimodal education and income has led to have positive health outcomes

Hispanic Introduction
In the last decades of the twentieth century Hispanic / Latino expanded rapidly
1980 Census: 14.6 million people
2000 Census: 35.3 million people
2010: 50.4 million people
Hispanics have the highest fertility rate
Causes a “natural increase” in the population
The term *Latino should be recognize as a nationality: NOT a language and race*

Hispanic Male: Leading Causes of Death
*Heart disease
Unintentional injuries
Chronic liver disease
Chronic lower respiratory diseases
Perinatal conditions

Hispanic Female: Leading Causes of Death
*Heart disease
Unintentional injuries*
Alzheimer’s disease
Chronic lower respiratory diseases
Influenza and pneumonia
Kidney disease
Perinatal conditions

Hispanic Health Care Access and Utilization
Nearly 31% of Hispanics/Latinos DO NOT have a usual source of health care

Variations in health insurance coverage is likely due to differences in legal status:
Not as likely to obtain employment in companies that offer health benefits

Health Issues for Hispanics/Latinos
Language is a huge barrier

Disproportionately affected by Type 2 diabetes: Poverty prevents them from accessing healthy food

Latina breast cancer survivors were generally dissatisfied with their oncologist

Many doctors do not understand their cultural beliefs

Language barriers can be a major impediment to deliver good quality care

Hispanic Acculturation and Health
Research show that the:
More acculturation leads to the worse health effects
Less acculturation leads to the better health effects

Acculturation to US health care:
Constantly changing

Among Latino boys and girls, acculturation affects their view on gender roles and racial stereotypes

Broadly defined as a common heritage or set of beliefs, norms and values (DHHS, 1999).
o How you are raised
o Lifestyles you adapt by learning
o Common throughout the culture
o Not specific, but group orientated

Defined as a biological category as a way to label different groups according to a set of common inborn biological markers: skin color, shape of eyes, nose and face, etc.

No consistent racial groups emerge when people are sorted by physical and biological characteristics. You cannot tell by genes.

Overwhelming evidence shows that greater genetic variation occurs within a racial group than across racial groups.

Refers to a common heritage shared by a particular group (Zenner, 1996 as cited in Surgeon General’s Report).

Heritage includes similar history, language, rituals, and preferences for music and foods, etc.

Cultural Competence
Refers to a group of skills, attitudes, and knowledge that allows a person, organizations, and systems to work effectively with diverse racial, ethnic, and social groups.

Defined as a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations.

Operationally defined, it is the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of health care; thereby producing better health outcomes

Effectively operating in different cultural contexts. Knowledge, sensitivity, and awareness do not include this concept.This is beyond awareness or sensitivity.

Cultural Competence is Achieved
How is cultural competence achieved?

By identifying and understanding the needs and help-seeking behaviors of individuals and families.

Designing and implementing services that are tailored or matched to the unique needs of individuals, children, families organizations and communities served.

Practice is driven in service delivery systems by client preferred choices, not by culturally blind or culturally free interventions.

Culturally competent organizations have a service delivery model that recognizes mental health as an integral and inseparable aspect of primary health care.

Cultural Sensitivity
Knowing that cultural differences as well as similarities exist, without assigning values to those cultural differences (National Maternal and Child Health Center on Cultural Competency, 1997)
i.e., better or worse, right or wrong,

Cultural Specificity
Understanding that ethnic and racial groups will have values that they hold that are specific to their culture.
African Americans – a spiritual component may need to be a part of health education programs.

Linguistic Competence
The capacity of an organization and its personnel to communicate effectively and convey information in a manner that is easily understood by diverse audiences including:
persons of limited English proficiency
those who have low literacy skills or
are not literate and individuals with disabilities. (Goode & Jones, 2004)

Why address culture?
Health disparities among Racial/Ethnic Groups exist

Institute of Medicine Report on Unequal Treatment among Racial/Ethnic Groups

America has a very diverse population and it is becoming more diverse.

Examples of Culturally competent
The Perinatal Program:
A Community Health Worker Model of La Clinica del Carino Family Health Center

The Community Health Education Center of the Massachusetts Department of Public Health

Other Culturally Related Issues
“Communication is more than simply shared language it must also include a shared understanding and shared context as well.”

Providing Culturally & Linguistic Appropriate Health Care
Key Concepts to recognize:

Linguistic variation within a cultural group

Cultural variation within a language group

Variation in literacy levels in all language groups:
Medical Interpretation

Cultural Competence Works
Eight Guiding Principles:
1. Define culture broadly
2. Value clients’ cultural beliefs
3. Recognize complexity in language interpretation
4. Facilitate learning between providers and communities
5. Involve the community in defining and addressing service needs
6. Collaborate with other agencies
7. Professionalize staff hiring and training
8. Institutionalize cultural competence

Conclusions and Suggestions
Implement recommended National Standards into Organizational Health Structures
Implement Culturally and Linguistically Appropriate Services (CLAS)
Involve target community in decision making about health care needs.
Hire target community as workers
Train staff, allocate budget and time for training staff to be culturally competent
Adequately document client’s cultural and linguistic histories and collect personal information during intake
Partner with other agencies to combine and expand culturally competent services
Culturally competency has to be on-going no one ever masters a culture
Culturally appropriate programs are also community specific rather than ethnic group in general
Institutionalize culturally competent policies into the organization

Who has the highest rate of disability? How much percent?
African Americans and Native Americans, about 20% of their populations.

More than 1 in 3 Hispanics and American Indians/Alaskan Natives do not have health insurance

1 in 5 African Americans or Asians do not have health insurance

Who is more likely to rely on hospitals?
African Americans and Hispanic Americans are more likely to rely on hospitals or clinics than white Americans (16% and 13%, respectively, compared to 8%)

Minority Uninvolvement
A 2006 National Science Foundation study reported African Americans, Hispanics, and American Indians make up only 2.65%, 3.53%, and .59%, respectively, of life sciences academics at 4-yr institutions.

Minorities also underrepresented as industry professionals working outside of academia.

Students from underrepresented communities sometimes leave graduate school or post-doctoral programs because they feel socially isolated or unable to find mentors.*****

Institutionalized Racism
Institutionalized racism is normative, sometimes legalized, and often manifests as inherited disadvantage. It is structural, having been codified in our institutions of custom, practice, and law, so there need not be an identifiable perpetrator. Indeed, institutionalized racism is often evident as inaction in the face of need.

Personally Mediated Racism
Personally mediated racism is defined as prejudice and discrimination, where prejudice means differential assumptions about the abilities, motives, and intentions of others according to their race, and discrimination means differential actions toward others according to their race. This is what most people think of when they hear the word “racism.” Personally mediated racism can be intentional as well as unintentional, and it includes acts of commission as well as acts of omission. It manifests as lack of respect, suspicion, devaluation, scapegoating, and dehumanization (police brutality, sterilization abuse, hate crimes).

Internalized Racism
Internalized racism is defined as acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth. It is characterized by their not believing in others who look like them, and not believing in themselves. It involves accepting limitations to one’s own full humanity, including one’s spectrum of dreams, one’s right to self determination, and one’s range of allowable self expression. It manifests as an embracing of “whiteness” (use of hair straighteners and bleaching creams, stratification by skin tone within communities of color, and “the white man’s ice is colder” syndrome); self-devaluation (racial slurs as nicknames, rejection of ancestral culture, and fratricide);and resignation, helplessness,and hopelessness (dropping out of school, failing to vote, and engaging in risky health practices).

Learning the behavior of society other than you own, take on characteristics from another society

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