assessing and addressing inequities in community nutrition in washington state
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Assessing and Addressing Inequities in Community Nutrition in Washington State. Marilyn Sitaker, WA DOH Public Health Nutrition 1/13/2011. Health Equity is the absence of differences in health between groups with greater and lesser levels of social advantage - PowerPoint PPT PresentationTRANSCRIPT
Assessing and Addressing Inequities in Community
Nutrition in Washington State
Marilyn Sitaker, WA DOH Public Health Nutrition 1/13/2011
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 Topics1. How socioeconomic conditions are linked to
inequalities in health status & health outcomes2. How to measure constructs in the health equity
model at the state level3. How researchers link inequities in access to healthy
foods to differences in nutrition behaviors among social groups
4. Intervention strategies5. Department of Health initiatives (time permitting)
1. How socioeconomic conditions are linked to inequalities in
health status & health outcomes
Key ideas from “Bad Sugar”
“Reaching for a Healthier Life”Facts on Socioeconomic Status & Health in the US
(1) Socioeconomic status has a big impact on everyone’s health. Premature death is 3 times more likely for those who live in poverty compared to those who are most privileged.
(2) Throughout our lives, access to socioeconomic resources affects our chances for living a healthy life. The conditions we live in during childhood affect our health throughout our lives.
(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.
http://www.macses.ucsf.edu/downloads/Reaching_for_a_Healthier_Life.pdf
(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”Facts on Socioeconomic Status & Health in the US
http://www.macses.ucsf.edu/downloads/Reaching_for_a_Healthier_Life.pdf
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 equity
2. How to measure the link between disparities in access to
social resources and health outcomes
Summary Measures to Compare Disparities
By Education & IncomeAbsolute measures compare the difference in risk between the highest and lowest group: 11 - 5 = 6%Relative measures use a ratio or risk in the highest & lowest income groups: 11 ÷ 5 = 2.2
11
7
5
0 5 10 15 20
<$35,000
$35,000-$74,999
$75,000 or more
Age-Adjusted Percent
Hou
seho
ld In
com
e
Diabetes Among Adults by Income in Washington, 2007-2009
Source: Washington Behavioral Risk Factor Survey
Disparities in Risk Factors & Chronic Diseases among Washington Adults by
IncomeChronic Disease Risk Factors Absolute RatioSmoking 2007-2009 1.7% 3.1Insuffi cient physical activity 2007 & 2009 7.0% 1.2Insuffi cient fruit & vegetables 2007 & 2009 8.4% 1.1Chronic Disease Risk ConditionsObesity 2007-2009 9.5% 1.4Hypertension 2007 & 2009 9.8% 1.5High Cholesterol 2007 & 2009 6.1% 1.2Chronic Disease PrevalenceAsthma 2007-2009 4.1% 1.5CVD 2007-2009 5.5% 2.4Diabetes 2007-2009 6.0% 2.3
Adults with household incomes above $75K compared to those <$35K
Data Source: WA Behavioral Risk Factor Surveillance SystemNote: All differences between highest and lowest income group are statistically significant.
How many people are affected?
EducationPrevalence of Obesity
State Population
age 25+
Number Obese (population
X percent)
Number affected if same prevalence as college
graduatesExcess Cases
HS or Less 31.7% 1,480,000 470,000 300,000 170,000Some College 31.9% 1,530,000 470,000 310,000 160,000College Graduate 21.1% 1,330,000 270,000 270,000 0Total 4,350,000 1,210,000 880,000 330,000
Obesity Diabetes Smoking Hypertension
Total Number of Excess Cases 330,000 110,000 460,000 260,000
High School; 34.0%
Some College; 35.2%
College Grad; 30.5%
Source: Washington BRFSS 2006-2008
Physical Activity by SEP; Access to Local Outdoor Recreation by Socioeconomic
PositionThe 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
Directory of Social Determinants of 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 context
Economic 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: Income
Harvard Geocoding Project: Measuring 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
Assessments can be made within socioeconomic class domains at the individual, household, and area or neighborhood level.
Socioeconomic data can be measured at key points in the lifecourse -- in utero, infancy, childhood, and early, middle, and late adulthood.
Composite measures can be constructed to combine information. For example, the Townsend index consists of % unemployment, % renters, % not owning a car, and % crowding.
Area 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 neighborhoods
3. Evidence for impact of inequity in the distribution of social
resources that support healthy eating
Assembling a Mosaic of Evidence
“The community nutrition environment may explain some of the racial, ethnic and socioeconomic disparities in nutrition and health such as the increasing prevalence of overweight in low income children. Supermarkets...are less common in lower income and minority neighborhoods than in other neighborhoods…recent evidence links access to supermarkets with…fruit and vegetable intake among African American adults…”
The role of the built environments in physical activity, eating and obesity in childhood, Sallis J, Glanz, K. www.futureofchildren.org, vol 16 (1), 2006.
“Supermarkets...are less common in lower income and minority neighborhoods”
A study of access to food markets and restaurants by neighborhood wealth (median HH income) in MS, NC, MD and MN showed that wealthy neighborhoods had 3 times as many grocery stores as poor neighborhoods. Supermarkets were 4 times more common in white neighborhoods compared to black neighborhoods (Moorland et al, Am J Prev Med 2002; 22(1)
Spatial regression analysis of average distance to the nearest supermarket in 869 Detroit neighborhoods showed that distance to nearest supermarket was about the same in wealthier neighborhoods, regardless of racial makeup. Among poor neighborhoods, those with high proportion of African Americans were 1.1 miles further from the nearest market than white neighborhoods. (Zenk et. al, Am J Pub Hlth 2005 95(4)
“…access to supermarkets linked to…fruit and vegetable consumption…”
Analysis of 10,623 food frequency questionnaires with geocoded home address compared with geocoded location of local supermarkets showed that for each additional supermarket in the neighborhood, fruit and vegetable intake increased by 31% for blacks and 11% for whites.
Morland, et. al, Am J Pub Hlth 2002; 92(11)
A study of fruit and vegetable consumption among food stamp participants showed that households living more than 5 miles from their principal store consumed less fruit than those living within a mile of their store
Rose, et. al, Pub Hlth Nutrition 2004, 7 (8)
4. Disparities in nutrition behaviors and environments
that support healthy eating in Washington State
Washington: Disparities in Eating F&V
Adults with the lowest incomes & educational level are less likely to eat enough fruit and vegetables. Certain racial groups are also less likely to meet dietary guidelines.
2126
3019
2432
2628
3228
2421
0 20 40
Less than $35,000
$35,000 to $74,999
$75,000 or more
High school or less
Some College
College graduate or more
White*
Black*
Asian*
Pacific Islander*
American Indian/Alaska Native*
Hispanic
Age-Adjusted Percent
Eats F&V 5 times Daily, by race, income, and education Washington State, 2007-2009
* Non-HispanicSource: WA Behavioral Risk Factor Survey (BRFSS), 2007-2009
Race / EthnicityEducation
Household Incom
e
Likelihood of being food insecure, taking multiple causal factors into account
Causal Factors:
AgeEducation Income
Race/ethnicityMarital StatusSex
Smoking StatusHealth Status
1.52.2 2.3 2.6
1.8 1.60.9
1.5 1.4
0
1
2
3
4
Odd
s R
atio
Regression Analysis Results: Relative Odds Ratio for Food Insecurity
Note: Interactions occur between Poor Health & Low Income; Poor Health & Current Smoking and Hispanic
Income & Age are the Strongest Determinants of Food Insecurity
Regression Analysis Results: Relative Odds of Experiencing Food Insecurity: Annual Household Income and Age
38
18
25
11
1515
37
0
10
20
30
40
50
60
70
Less than$25,000
$25,000-34,999 $35,000-49,999 $50,000-74,999 Age 20-34 Age 35-44 Age 45-54 Age 55-64 Age 65-74
Odd
s R
atio
• Income <$25,000/year: 38 times more likely than income $75,000+
• Ages 20-44: 15 times more likely to be food insecure than ages 75+.
Washington: Trends in Disparities in Eating F&V
0
10
20
30
40
50
60
70
80
90
1990 1995 2000 2005 2010
Age
Adju
sted
Per
cent
Year
Eats fruits and vegetables < 5 times a day among Washington Adults, by education 1994-2009*
HS or less
Some collegeCollege grad
Source: Washington Behavioral Risk Factor Surveillance System; date represents the midpoint of 2 year averages of data collected in alternate years.
0
2
4
6
8
10
12
14
1990 1995 2000 2005 2010
Age
Adju
sted
Per
cent
Year
Excess risk of poor diet by education, comparing HS education or less to college
graduate
0.00.20.40.60.81.01.21.41.61.82.0
1990 1995 2000 2005 2010Ri
sk R
atio
Year
Relative risk of poor diet 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 2010
Risk
Rat
ioYear
Relative risk of obesity by education, comparing HS education or less to college graduate
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
1990 1995 2000 2005 2010
Age
Adju
sted
Per
cent
Year
Excess risk of obesity by education, comparing HS education or less to college graduate
0
5
10
15
20
25
30
35
1990 1995 2000 2005 2010
Age
Adj
uste
d Pe
rcen
t
Year
Obesity among Washington Adults, by Education, 1990-2008
HS or less Some college College grad
9.425.6
9.425.6
Source: Washington Behavioral Risk Factor SurveyNote: Only among adults who answered survey in English.
Slope= 1.16
Slope= 0.5
Washington: Trends in Disparities in Obesity
Deep green = Washington Counties
most likely to have insufficient F&V
consumption
Insufficient F&V consumption BRFSS, 2005-2007
4. Intervention strategies promoted in Reaching for a
Healthier Life
Policies to Promote Health Equity1. Policies that Affect the Ladder 2. Policies that Blunt Adverse Consequences
5. Initiatives within the Department of Health Initiatives (Community
Wellness and Protection)
Healthy food/drink availability
Limit unhealthy food/drink availability
Farm to institution, including schools, worksites, hospitals, and other community institutions
Menu labeling
Support breastfeeding through policy change and maternity care practices
Promote Physical Activity
Safe, attractive accessible places for activity
City planning, zoning and transportation
Require daily quality PE in schools
Require daily physical activity in afterschool/childcare settings
Safe routes to school
0 2 4 6 8 10 12 14
4
1
2
1
1
1
2
7
1
1
1
3
8
12
2
2
3
State & Local Policies Adopted in Washington State*Based on MAPPS Strategies, 2005-2010
State Policies = 12 Local Policies = 42
*These are policies in which DOH was directly involved; it does not reflect all Washington policies enacted during this period.
Paula Braveman: Thoughts on Health Inequities
Systematic differences in health or health determinants that are plausibly influenced by social policy are health inequities if they
a) Occur between groups with different social position (place in the hierarchy according to power, wealth, prestige)
b) Place groups already at social disadvantage at even greater disadvantage due to poor health
You do not need to attribute causation or prove that the disparity is avoidable if social policies were changed, as long as the impact is plausible.
Braveman, 2004, Health Policy and Development 2(3) 180-185
Thank You!
Marilyn Sitaker, MPHChronic Disease Prevention Unit
Lead Epidemiologist and Evaluation Coordinator
(360) [email protected]