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Disrupting the Single Stories About Health Equity among Boys and Men of Color

Wizdom Powell, PhD, MPHBetter Health Conference

June 6, 2019


The Dangers of a Single Story: The stories we tell about Boys and Men

►Single stories:

►Tell incomplete and isolated truths

►Flatten lived experiences

►Emphasize stereotypes


The Dangers of a Single Story: The stories we tell about Boys and Men


The Dangers of a Single StoryWidening empathy gaps for boys and men


The Whole Story About The Health of Boys and MenShorter Life-Expectancy at Birth

ELIMINATING HEALTH DISPARITIES AMONG MEN AND BOYS

Even as sex differences in life-expectancy gaps narrow, males in the U.S. continue to live shorter lives than women and they have consistently lived shorter lives than their global peers since 1980.


Men are diagnosed with depression less often than women

The Whole Story About The Health of Boys and MenMen have Higher Suicide Rates than Women

Men have higher rates of suicide completion than women

Source: National Health and Nutrition Examination Survey, 2007-2010 (Depression Rates Figure); National Vital Statistics System (Suicide Rates Figure).

Death Rates from Suicide* for Persons Aged ≥12 ,— United States, 1991–2009

Current Depression * for Persons Aged ≥12 years, by Age group and Sex — United States, 2007-2010


The Whole Story About The Health of Boys and MenMen in the U.S. Have the Highest Rates of Drug Overdose Deaths


Boys are more negatively affected by early environmental stress, inside and outside the womb, than are girls.

Despite lower PTSD rates, men are more frequently exposed to traumatic events.

Highest rates of opioid use disorders among individuals reporting traumatic events exposure and PTSD (Lawson et al., 2013).

StressTrauma

Risky Health

Behaviors

The Whole Story About The Health of Boys and MenBoys and Men May be Uniquely Vulnerable to Stress and Trauma


The Economic Costs of Health Disparities in Boys and Men Male health disparities have direct costs on healthcare spending and

indirect costs on worker productivity and income.

Male health disparities also negatively impact economic growth.

Source: Trautmann, S., Rehm, J., & Wittchen, H. (2016). The economic costs of mental disorders: Do our societies react appropriately to the burden of mental disorders? EMBO Reports, 17(9), 1245–1249.


The Economic Costs of Health Disparities in Boys and Men

Over the past six decades, there has been the slow decline in the labor force participation rate of men 25–54.


The Economic Costs of Health Disparities in Boys and Men

From: Krueger, Alan B. (2017) ““Where have all the Workers Gone? An Inquiry into the Decline of the U.S. Labor Force Participation Rate.

Nearly half of working age men not in the labor force take opioids daily.


Our fates are linked. Communities, families, and our nation are deeply impacted by unmet health needs of boys and men.

Key Point


Why Disparities in Life Expectancy among Boys & Men Exist Evolutionary & Biological Explanations

Starting in the womb, male fetuses have male survival disadvantage begins at birth

Heterogametic sex (or unguarded X) hypothesis = males are the shorter-lived sex because they have only a single X chromosome

Men have less connective tissue responses to sex hormones = less resistance to oxidative damage; greater suppression of immunity

Men have greater shorter telomere shortening than women = heightened susceptibility to rapid biological aging


Males take a lot of

behavioral risks.

Why Health Disparities in Boys and Men ExistCommon Behavioral Explanations

Males delay health

screenings and wait longer to seek acute

medical and mental health

attention.

Males are reluctant to

disclose physical and mental health

problems.

?


Missing Pieces of the Male Health Disparities Story

Limited focus on the role played by inequitable distribution of power, opportunity, and social determinants that uniquely compromise the mental health of socially disadvantaged boys and men.

?


Why Focus on Socially DisadvantagedBoys and Men?

Health disparities are even more pronounced among groups of boys and men who have not had full and equitable access to opportunities for securing socioeconomic power and stability even in contrast to other males in the U.S.


Why Focus on Boys & Men of Color?Our Nation’s Demographic Transition

•The U.S. population is expected to grow more slowly in future decades than it did in the previous century.

•The U.S. population as a whole is expected to follow a similar trend, becoming a majority African-American and Hispanic/Latino nation in 2044. The minority population is projected to rise to 56 percent of the total in 2060, compared with 38 percent in 2014.

Source: Colby, S. L., & Ortman, J. M. (2017). Projections of the size and composition of the US population: 2014 to 2060: Population estimates and projections.


Why Focus on Black Boys & Men? Black Men Have Some of the Highest Death Rates

Age-adjusted death rates for selected populations: United States, 2015 and 2016

SOURCE: NCHS, National Vital Statistics System, Mortality.


Why Focus on Black Boys and Men?Suicide Rates Recently Increased in Black Boys

Suicide rates increased among black children aged 5 to 11 years from 1.36 to 2.54 per million between the years 2008 and 2012.

In black boys, the suicide rate increased between 1993 to 1997 and 2008 to 2012, whereas suicide rates in white boys decreased during this period.


Gabriel Taye (8 years-old)Died by suicide following bullying.

Rylan Thai Hagan (11 years-old)Died by suicide following bullying.

Nigel Shelby (15 years-old) Died by suicide following bullying.

Why Focus on Black Boys and Men?Suicide Rates Recently Increased in Black Boys


The Whole Story about the Health of Black Boys and MenMissing, Forgotten, or Stolen?

Stolen


KALIEF BROWDER

1993-2015

“Ma, I Can’t Take it

Anymore.”

Many Black men are “missing” because ofre-traumatization following incarceration


Many Black men are “missing” because of disproportionate exposure to racism

Stop & Frisks in NYC


US deaths due to legal intervention: national and city-specific annual 5-year moving average rate (per 100,000) among US black men and white men ages 15–34, 1960–2011

Krieger N, Chen JT, Waterman PD, Kiang MV, Feldman J (2015) Police Killings and Police Deaths Are Public Health Data and Can Be Counted. PLoS Med 12(12): e1001915. doi:10.1371/journal.pmed.1001915http://journals.plos.org/plosmedicine/article?id=info:doi/10.1371/journal.pmed.1001915

►Over the past 50 years, Black men have faced significantly greater risk than white men of being killed by police.

Many Black men are “missing” because of disproportionate exposure to racism

http://journals.plos.org/plosmedicine/article?id=info:doi/10.1371/journal.pmed.1001915


Get away [garbled] for what? Every time you see me, you want to mess with me. I'm tired of it. It stops today. Why would you...? Everyone standing here will tell you I didn't do nothing. I did not sell nothing. Because every time you see me, you want to harass me. You want to stop me [garbled] Selling cigarettes. I'm minding my business, officer, I'm minding my business. Please just leave me alone. I told you the last time, please just leave me alone. please please, don't touch me. Do not touch me. I can't breathe. I can't breathe. I can't breathe. I can't breathe. I can't breathe. I can't breathe. I can't breathe. I can't breathe. I can't breathe. ---Eric Garner


Re-framing Health Disparities in Boys and MenFocusing on the Social Determinants of Health


Re-framing Health Disparities in Boys and MenKey Assumptions & Approaches

Risk for health disparities form in childhood and can continue as boys and men age.

While genetics and individual health behaviors are important,disparities are primarily determined by the social conditions in which people are born, grow, live, work, and age.

Birth Childhood Adolescence Adulthood

Context

Biology Behavior


►Pressure to “be a man about it” impacts men’s risk-taking, stress response, and health behavior.

►Men are socialized to value the display of physical/mental toughness.►“Boys Don’t Cry”► “Take It Like a Man”

►Men with more rigid definitions of masculinity also have poorer health outcomes.

Re-framing Health Disparities in Boys and MenWhy Masculinities Matter


► Multidimensional, plural, and situational. ► Precarious (i.e., it must be fought for

and won) and failure-prone.► Socially constructed and not rooted in

biology or personality characteristics.

Masculinity refers to shared cultural expectations or standards about how males should behave.(Levant & Richmond, 2006)

Re-framing Health Disparities in Boys and MenDefining Masculinities


Build It With Them and They Will ComeMeeting Black Men Where They Are


Three Fundamental or Root Causes of Black Male Health Inequities

Shared sociocultural expectations about 'appropriate' behaviors for males.

Lack of faith in or suspicion of medical organizations and providers.

Transactions between individuals or groups and their environment that emerge from the dynamics of racism and threaten well-being.

Masculinity Beliefs/Norms

Medical Mistrust

Everyday Racism


Changing the Dominant Masculinity NarrativeManhood meaning among African American men (Hammond & Mattis, 2005)

Black men’s definitions of masculinity are relational, reflect a desire for redemption and an orientation towards pro-action.

Black men’s definitions of masculinity are constructed as responses to everyday and structural racism.Black men’s displayed emotional stoicism as a defensive coping strategy and method of preserving masculinity.

•


Key Point

The single story about masculinity ignores the possibility that boys and men of color are enacting masculinities in response to unique social experiences.


Two Dimensions of Masculinity NormsLinked to Male Health Inequities

Self-Reliance

Restrictive Emotionality

Masculinity norms that encourage independent decision-making and problem solving

Masculinity norms that encourage men to display stoicism, shut down, or suppress emotion


Three Fundamental or Root Causes of Black Male Health Inequalities/Inequities





Medical Mistrust

Everyday Racism


Black Men’s Medical Mistrust is About More than Tuskegee(Hammond, 2010)

When Black men endorse masculinity norms that discourage emotional disclosure and report more frequent racism experiences, they also report higher mistrust of medical organizations.


When Black males endorse masculinity norms that encourage self-reliance they are less likely to delay key preventive health screenings.

Endorsement of Masculinity Norms Decrease Black Male Preventive Services Delays(Hammond et al., 2010)


Masculinity Norms and Race-Related Factors Produce Joint Barriers to Health Help-Seeking among Black men (Powell et al., 2016)

When Black men experience everyday racism and endorse masculinity, they report more help-seeking barriers.


Key Point

The single story about Black men’s medical mistrust frames it as an immutable person characteristic. It links mistrust solely to past incidents rather than what is occurring in the here and now.


Three Fundamental or Root Causes of Black Male Health Inequalities/Inequities





Medical Mistrust

Everyday Racism


Racism-related transactions between individuals or groups and their environment that emerge from the dynamics of racism, and that are perceived to tax or exceed existing individual and collective resources or threaten well-being. (Harrell, 2000)

Everyday Racism as a Driver of Black Male Health Disparities

Brief, subtle, and ambiguousCommonplace

Verbal or behavioral indignities

Micro-aggressions


Black Men’s Stories of Racism & Depression

Racism is positively associated with depression and depressive symptomatology (Williams et al., 2003; Gee et al., 2006).

It is more likely that racism leads to depression not that more depressed individuals report more racism (Schulz et al., 2006).

Racism contributes to depressive symptoms among African American men above and beyond general stress (Pierterse& Carter, 2007).

“Racism has caused many of us to believe that we don’t count

and that our needs are not important.”

“Racism has forced a lot of Black men to sit on top of their pain.

They feel there are very few outlets to share

their feelings of frustration with the

system.”

Source: “Souls of Black Men: African American Men discuss mental health.” Community Voices. Item #555, July 2003. Photo courtesy of Sondjata Olatunji.

“Black Men Cry in the Dark”


Taking Everyday Racism Like a Man, May Increase Black Men’s Depression Risk (Hammond, 2012)

When Black men experience frequent everyday racism and endorse masculinity norms that encourage them to suppress emotions, they have more pronounced depression.


Health Insurance Policies Also Matter……


The Potential Impact of the Affordable Care Act and Medicaid Expansion on Reducing Colorectal Cancer Screening Disparities in African American Males (Powell et al., Under Review)

Individual microsimulation-based model study in a non-expansion state (NC)

Used a combination of health insurance claims and Behavioral Risk Factor Surveillance System (BRFSS) data

Modeled six scenarios & treatment costs: Control (no ACA) Five ACA policy scenarios (health exchange only, low/high

enrollment, low/high screening compliance) Costs for the initial year of treatment only

Three CRC Outcomes: screening, stage-specific incidence, and deaths.


43.7%45.0%

46.9%46.2%

48.4%

46.2%

49.0%

50.0%

35%

37%

39%

41%

43%

45%

47%

49%

51%

2013 2014 2015 2016 2017 2018

African American ControlAfrican American Health Exchanges OnlyAfrican American Medicaid Expansion (High Enrollment & Compliance)White ControlWhite Health Exchanges OnlyWhite Medicaid Expansion (High Enrollment & Compliance)

North Carolinian White and African American males predicted up-to-date with colorectal cancer screening by 2018 as a result of ACA policies.



The ACA health exchange and Medicaid expansion policy scenarios had larger relative impacts on CRC screening rates for African American males than for White males and resulted in decreased disparities



Potential cases and deathsper 100,000

Potential cases and deaths

prevented per 100,000

Potential cases and deaths per 100,000

Potential cases and deaths

prevented per 100,000Health Exchange + Medicaid expansion*

Control (no ACA)Health Exchange Only (Status Quo)

Health Exchange Only (Status Quo)

(High Enroll, Low Compliance)

(High Enroll, High Compliance)

(Low Enroll, Low Compliance)

(Low Enroll, High Compliance)

Mean (SD) Mean (SD)African American Males (N=338,288)CRC Deaths 1,589.4 16.0 (3.4) 1,573.4 6.6 (2.6) 14.7 (2.7) 3.4 (1.1) 12.7 (1.6)CRC Cases 3,178.7 28.0 (4.6) 3,150.6 11.4 (3.0) 25.5 (5.6) 7.1 (4.6) 14.1 (3.8)

Stage 1 727.6 4.9 (1.8) 722.8 3.1 (0.9) 4.3 (2.5) 2.1 (1.4) 2.0 (1.4)Stage 2 842.8 5.7 (3.1) 837.2 2.8 (0.9) 5.9 (2.8) 1.8 (0.8) 4.0 (2.3)Stage 3 728.4 6.9 (1.8) 721.6 1.9 (1.1) 4.8 (2.0) 1.4 (0.8) 2.7 (1.2)Stage 4 879.8 10.6 (2.6) 869.1 3.6 (2.7) 10.5 (4.5) 1.8 (1.4) 5.5 (2.2)

White Males (N=1,495,527)CRC Deaths 1,517.3 4.7 (1.0) 1,512.6 4.7 (1.0) 9.5 (1.2) 2.3 (0.6) 5.1 (0.6)CRC Cases 3,132.9 7.9 (1.0) 3,125.0 7.8 (2.0) 16.4 (5.0) 4.1 (0.9) 9.3 (0.3)

Stage 1 724.0 1.1 (0.5) 722.9 1.2 (0.5) 2.1 (0.3) 0.5 (0.4) 1.3 (0.2)Stage 2 821.3 2.0 (0.6) 819.4 2.0 (0.6) 3.9 (1.0) 1.2 (0.3) 2.3 (0.4)Stage 3 754.2 1.9 (0.7) 752.2 1.9 (0.8) 4.7 (0.8) 1.0 (0.5) 2.5 (0.7)Stage 4 833.4 2.9 (0.4) 830.5 2.6 (0.6) 5.7 (0.4) 1.5 (0.5) 3.2 (0.4)

Table 1. CRC cases and deaths per 100,000 prevented by ACA’s health exchanges and Medicaid expansion among White and African American males in NC.



Producing Evidence-for-Policy ActionWhat gets measured, gets done


Producing Evidence-For-Policy ActionAPA Working Group on Health Disparities in Boys & Men

Interdisciplinary Group of Scholar ExpertsFocusing on stress, trauma, violence, and

substance abuseDeveloping policy briefsEngaging policymakers and local constituentsPublished an evidence-based report in June 2018


Building a State-Wide Multi-Sectoral Alliance for Health Equity in Boys and Men

• Align strategies• Amplify collective impact• Increase, leverage, and

coordinate investments • Incubate and accelerate

rapid cycle health equity innovations.

• Enhance youth and community-led health policy action.


Using Arts-Based Strategies to Unearth Possibilities & Bridge Empathy Gaps

Build on the National Academy of Science and Medicine Visualizing Health Equity Project.

Leverage CT’s rich tradition and ecosystem of arts and cultural centers.

Stimulate dialogue about equity & social justice.

Promote authentic engagement.

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Creating Brave Spaces

• Encouraging intergenerational dialogue.

• Center and amplify community voice.

• Establish trust.


RecommendationsPolicy

Protect achievement and build on advancements of the ACA including Medicaid expansion, coverage of pre-existing conditions, access to the Essential Health Benefits.

Support statewide efforts to increase the quality, availability, and the analysis of disaggregated data.

Devote resources to improve the coordination of and reduce gaps in data sharing.


RecommendationsSystem/Administrative

Fortify infrastructure for clinical-community integration.

Fund culturally and linguistically appropriate Community Health Workers models to eliminate navigation and utilization barriers to community and clinical services.

Establish off-peak hours for primary care (evenings and weekends).

Provide and evaluate ongoing implicit bias training for healthcare providers and staff.


RecommendationsCommunity

Increase knowledge and awareness among CT BMoC’sand their families about risks and opportunities for improving health outcomes.

Meet BMoC where they are in the places they frequently congregate.

Recruit and train R/E minority men as Community Health Workers.


The WAY FORWARD

TELL WHOLE & COMPLEX STORIES

TRANSLATE EVIDENCE INTO ACTION

RE-IMAGINE MASCULINITY INVEST IN SYSTEMS-CHANGE

ALIGN STRATEGIES


Why Telling Whole Stories Matter

“The consequence of the single story is that it robs people of dignity. It makes our

recognition of our equal humanity difficult.”--Chimamanda Adichie


Wizdom Powell PhD, MPHDirector, Health Disparities InstituteUniversity of Connecticut Health241 Main Street, 5th FloorHartford, CT 06106Email: [email protected]

Contact Information


Back-up slides


Why Focus on Racial/Ethnic Minority Males?Opioid Crisis Largely Overlooked in Black and Hispanic Men

Source: Shiels MS, Freedman ND, Thomas D, de Gonzalez AB. Trends in U.S. Drug Overdose Deaths in Non-Hispanic Black, Hispanic, and Non-Hispanic White Persons, 2000–2015. Ann Intern Med.

► Steepest escalation in drug overdose deaths occurred among non-Hispanic Blacks (particularly those between the ages of 45-64).

► From 2012 to 2015, cocaine overdose deaths were almost as common in black men as prescription opioid deaths in white men.

"While overdose death rates are highest among non-Hispanic whites, the increase among African-Americans and Hispanics is alarming and deserves greater public health attention."

-Dr. Brandon Marshall, Brown University


Odds Ratios of Preventive Health Service Delays by Masculinity Dimensions and Medical Mistrust (Hammond et al., 2010)

0.96 0.84

2.64

0.77 0.76

3.03

0.960.62

2.09

00.5

11.5

22.5

33.5

Masculine Self-RelianceMasculine Role Salience Medical Mistrust

Routine Health Examinations§Blood Pressure Screening§† Cholesterol Screening§‡

*p < .05, **p <.01, *p<.001§Adjusted for age, education, employment, income, marital status, Usual Source of Care, and Self-rated health Status (mental/physical)† Adjusted for Hypertension Status‡ Adjusted for Hypertension & Coronary Heart Disease Status

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