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Overview of Conceptual Frameworks
of Health and Health Disparities
Anita L. Stewart, Ph.D.University of California, San Francisco
Institute for Health & AgingCenter for Aging in Diverse Communities
April 5, 2005
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Health Disparities Research
Document health disparities Identify determinants of health
disparities Understand pathways or mechanisms
for disparities
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Types of Diverse Groups
Health disparities research focuses on health differences across diverse race/ethnic groups
A sizeable amount of research has examined differences in health across levels of socioeconomic status (SES):– Low income vs. others– Low education vs. others
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Racial/ethnic and SES Disparities Observed in Virtually All Health Domains
Premature mortality including infant mortality Morbidity
– Chronic disease (heart disease, diabetes, cancer)– Communicable disease (TB)– Low birth weight
Physiological and anthropometric risk factors – Hypertension– Obesity/overweight
Functional limitations, disability Self-rated health
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Purpose of Conceptual Frameworks
For research to identify determinants of health disparities and understand pathways:– Ground research in theory and knowledge
– Help identify key variables in developing research questions
– Guide the selection of measures
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Population vs. Health Services Research Frameworks
Population science
– Determinants of health in a population Health services research
– How health care affects outcomes
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Population-Based Approaches
Samples– Population-based– Population subgroups
» by age, ethnicity» community members
Disciplines– Social epidemiology– Public health– Sociology– Psychology
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Social Epidemiology
…studies the social distribution and social determinants of states of health (p. 6)
Determinants:– Socioeconomic position– Discrimination– Working conditions– Social integration, social networks– Health behaviors– Physical and social environments
Berkman LF and Kawachi I, Social Epidemiology, Oxford, 2000.
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Population-Based Determinants of Health
Medical care accounts for only 10% of the variance in health
But… medical care may have a greater impact on the health of vulnerable groups than on their counterparts (Williams and Collins)
Williams DR and Collins C, Ann Rev Sociol 1993;21:349-86
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Geneticpredisposition
30%
Health care
10%
Population Based Determinants of Premature Mortality
Behavior 40%
Social circumstances15%
Environmental exposure 5%
McGinnis JM, et al. Health Affairs, April 2002, p. 83
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Multiple Levels of Influence on Health
Individual– physiological, biological factors– behaviors, attitudes, beliefs
Family– size, structure, support, beliefs
Neighborhood or community– resources, transportation, – toxins, aesthetics, crime/poverty
Social support, social networks
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Multiple Levels of Influence on Health
Cultural group, ethnic identity– shared beliefs, values, behaviors
Occupation or workplace – occupational hazards, toxins, safety, working
conditions Health care
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Multi-level Determinants of Health
Psychosocial - social support, compliance, coping
Lifestyle - exercise, diet, alcohol, smoking, sexual behavior, illicit drug use
Health care
Sociodemographics - age, race, ethnicity, education, income
Physical environment
Social environment
Health
Psychological - beliefs, attitudes,personality
Contextual Individual-level
Organizational,institutional
Economic resources
Societal, political e.g., Larry Green,Dan Stokols
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Multi-level Determinants of Health
Psychosocial - social support, compliance, coping
Lifestyle - exercise, diet, alcohol, smoking, sexual behavior, illicit drug use
Health care
Sociodemographics - age, race, ethnicity, education, income
Physical environment
Social environment
Health
Psychological - beliefs, attitudes,personality
Contextual Individual-level
Organizational,institutional
Economic resources
Societal, political e.g., Larry Green,Dan Stokols
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Conceptual Frameworks of Determinants: Social Support/Networks
Berkman LF and Glass T, Social integration, social networks, social support, and health, in Social Epidemiology, ch 7, p. 143.
Socialstructuralconditions
(macro)
Social networks (mezzo)
Psycho-social
mechanisms (micro)
Pathways
•Culture•Socio economic factors
•Network structure•Frequency of contact
•Social support•Social influence•Access to resources
•Health behaviors•Psychological•Physiologic
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Multi-level Determinants of Health
Psychosocial - social support, compliance, coping
Lifestyle - exercise, diet, alcohol, smoking, sexual behavior, illicit drug use
Health care
Sociodemographics - age, race, ethnicity, education, income
Physical environment
Social environment
Health
Psychological - beliefs, attitudes,personality
Contextual Individual-level
Organizational,institutional
Economic resources
Societal, political e.g., Larry Green,Dan Stokols
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Multi-level (Ecological) Determinants of Health Behavior
Psychosocial - social support, compliance, coping
Health care
Sociodemographics - age, race, ethnicity, education, income
Physical environment
Social environment
HealthBehavior
Psychological - beliefs, attitudes
Contextual Individual-level
Organizational,institutional
Economic resources
Community resources
Emmons, K Health behavior in a social context, in Social Epidemiology, 2000, ch. 11.Policy
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Multi-level Determinants of Health
Psychosocial - social support, compliance, coping
Lifestyle - exercise, diet, alcohol, smoking, sexual behavior, illicit drug use
Health care
Sociodemographics - age, race, ethnicity, education, income
Physical environment
Social environment
Health
Psychological - beliefs, attitudes,personality
Contextual Individual-level
Organizational,institutional
Economic resources
Societal, political e.g., Larry Green,Dan Stokols
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The Role of Socioeconomic Status (SES)
Because minority status and SES are usually confounded– SES has been a key hypothesis for observed
race/ethnic health disparities
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Socioeconomic Status: Underlying Constructs
SES is multidimensional Prestige
– Social stratification, social class– Relative social standing– Occupation
Resources– Education– Income, wealth, assets– Poverty, material deprivation
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Research on SES and Health Most researchers studying racial/ethnic
differences in health “adjust” for SES Many studies find that race/ethnicity remains a
significant determinant of health after controlling for SES– What else is going on?
Need to focus on how SES affects health– Whether the SES-health relationship varies by
race/ethnicity
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Complex Mechanisms by Which SES Affects Health
Education
EnvironmentHealth Care
Health behaviorsSocial capitalChronic stress
Psychological resourcesHealth care
HealthIncome Occupation
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Lifecourse Issues
Hypothesis: health disparities are due to the accumulation over one’s lifetime of stresses/adverse conditions
Specific research– Childhood levels of SES and cumulative
disadvantageous economic circumstances are associated with poor health in mid-life
– Lifetime experiences of discrimination due to race/ethnicity adversely affect health
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Framework: Socioeconomic Status Over the Lifecourse and Health
Lynch J and Kaplan G, Social Epidemiology, Berkman and Kawachi (eds), Oxford, 2000 (Ch 2, p. 28)
Socioeconomic Position
Birth Childhood Adulthood Old Age
Low birth weightGrowth retardation
Smoking,diet, exercise
Job stressInadequate
medical care
Intrauterineconditions
Education,environment
Work conditions,income
Income,assets
Atherosclerosis CVD Reducedfunction
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Example of Lifecourse Research
“Compared with middle- and high-income children, low-income children are disproportionately exposed to more adverse social and physical environmental conditions.” (Evans, 2004, p. 88)
Cumulative rather than singular exposure is critical…
Evans GW, The environment of childhood poverty,Amer Psychol, 2004:59:77-
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Health Services Research
Conceptual frameworks guide research in how health care affects outcomes
Health care is “the total societal effort, whether public or private, to provide, organize, and finance services that promote the health status of individuals and the community”
p. 477, Cooper LA et al., JGIM, 2002;17:477-486
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Health Services Research Frameworks
Study samples– Patients – Health plan members– Providers
Classic frameworks – Donabedian– Aday and Anderson
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Donabedian’s Structure-Process-Outcome Paradigm for Assessing Outcomes of Care
Patient outcomes
Structure of care
•Structure - features of a system of care•Process – what is done for patients
•Technical care - knowledge and judgment skills •Interpersonal care - the way care is provided
Donabedian A. Quality Review Bulletin, 1992, p. 356
Process of care:-technical care-interpersonal
care
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Donabedian’s Structure-Process-Outcome Paradigm
Patient outcomes
Structure of care
Process of care:-technical care-interpersonal
care
•Quality of care is indicated when outcomes can be attributed to antecedent processes of care
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Donabedian’s Structure-Process-Outcome Paradigm
Ultimate outcomes- health
Structure of care
Process of care:-technical care-interpersonal
care
Intermediateoutcomes:
- compliance- knowledge
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Donabedian’s Structure-Process-Outcome Paradigm
Ultimate outcomes- health
Structure of care
Process of care:-technical care-interpersonal
care
Intermediateoutcomes:
- compliance- knowledge
Providercharacteristics
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Examples of Research - How Structure of Care Affects Health Disparities
If systems provide medical interpreters, do patients with limited English proficiency have better health outcomes?
If systems offer a broad choice of minority providers, do minority patients have better health outcomes?
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Examples of Research Questions - How Technical Processes Affect Health Disparities
Are treatments less effective for racial/ethnic minorities than for whites?
Are appropriate diagnostic procedures used less often for minorities than for whites?
Are optimal treatments provided less often for racial/ethnic minorities than for whites?– e.g., pain medication in emergency departments
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Examples of Research Questions - How Interpersonal Processes Affect Health Disparities
Effects on health of differences in:– Communication
– Elicitation of patient concerns
– Respectfulness
– Perceived discrimination
– Participatory decision making
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Extensive Disparities in Health Care: Summarized in Two Major Reports
Unequal Treatment (IOM) 2003 National Healthcare Disparities Report
(AHRQ for DHHS) – 2003, 2004
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Unequal Treatment Requested by Congress to assess
differences in healthcare received by U.S. racial/ethnic minorities and non-minorities
Focused on – healthcare systems and their legal and
regulatory climate – provider discrimination
Institute of Medicine, Unequal treatment: Confronting racial and ethnic disparities in healthcare, National Academy Press, 2003
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Unequal Treatment: Summary Racial/ethnic minorities receive lower quality
of care then non-minorities Disparities occur in the context of broad
historic and contemporary social/economic inequality, including discrimination
Sources are complex– involve systems, administrative processes, utilization
managers, healthcare professionals, and patients A comprehensive, multi-level strategy is
needed to eliminate these disparities
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National Healthcare Disparities Report
Issued by DHHS through the Agency for Healthcare Research and Quality– Annual report to Congress on racial, ethnic,
socioeconomic, and geographic disparities Institute of Medicine provided technical
guidance – Guidance for the National Healthcare
Disparities Report, Swift (ed), Institute of Medicine, National Academies Press, 2002
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Conceptual Framework for National Healthcare Disparities Report
Components of Health Care Quality
Consumer Perspectives on health care needs:
Safety Effectiveness Patient centered-
ness
Timeliness
Staying healthy
Getting better
Living with illness or disability
Coping with the end of life
Equity
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National Healthcare Disparities Reports
2003 report:– http://www.qualitytools.ahrq.gov/
disparitiesreport/download_report.aspx 2004 report
– 2004 National Healthcare Disparities Report, USDHHS, AHRQ publication number 05-0014, December, 2004
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Key Findings: NHDR
Inequality in health care quality exists Differential access may lead to inequalities Opportunities to provide preventive care
often missed Knowledge of why disparities exist is limited Improvement is possible Data limitations hinder improvement efforts
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How Population “Variables” Affect Process and Outcomes of Care
Ultimate outcomes- health
Structure of care:
-providercharacteristics
Process of care:-technical care-interpersonal
care
Intermediateoutcomes:
- compliance- knowledge
Patient characteristicsEnvironment
Neighborhood resources
Family support
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The Structure-Process-Outcome Paradigm: Adding Access to Care
Patient healthoutcomes- clinical
- individual
Structure of care
Process of care:-technical care-interpersonal
care
Access to care
Aday LA and Anderson RM – Major contributors to access issues
Access to a system of care
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Defining Access to Care
Typical Definitions– Availability of health care providers in area
– Availability of health insurance/being uninsured» Type of health insurance (public versus private)» Quality of health insurance coverage
– Utilization of (appropriate) services
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IOM’s Definition of Access
“ the timely use of personal health services to achieve the best possible health outcomes”
IOM, Access to health care in America: A model for monitoring access, National Academy Press, 1993
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Within a System – Access to …
Providers of same race/ethnicity Providers who speak preferred language Timely care
– Someone to talk to by phone
– Waiting time for appointments
– Waiting time in office
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Framework for Studying Access
Potential Access – StructureCharacteristics of health
delivery systemAvailabilityOrganization
Potential Access – ProcessCharacteristics of population at riskPredisposing
EnablingNeed
Realized Access – ObjectiveUtilization of services
Realized Access – SubjectiveConsumer satisfaction
Aday LA, Anderson R, and Fleming GV. Health care in the U.S.: Equitable for whom? London: Sage, 1980
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The Behavioral Model for Vulnerable Populations: Access to Care Model
Population Characteristics
Predisposing Enabling Need Health behavior Outcomes
Gelberg L, et al., Health Serv Res 2002, 34:1273
Vulnerable populations: “at risk of poor physical, psychological,or social health”
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Conceptual Models for Health Services Research Interventions
Adapted IOM model of access to care– Incorporated elements relevant to eliminating
disparities in health care Focused on 2 types of interventions:
– Improving access to effective care
– Reducing barriers to healthy lifestyles
Cooper LA et al., JGIM, 2002;17:477-486
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Barriers to & Mediators of Equitable Health Care for Racial/Ethnic Groups: Modified IOM Model
•Personal/family•Structural•Financial
•Visits•Procedures
•Quality of providers•Appropriateness of care•Efficacy of treatment•Patient adherence
• Health status• Equity of services• Patient views of care
Barriers Use of Services Mediators Outcomes
Cooper LA et al., JGIM, 2002;17:477-486
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The Behavioral Model for Vulnerable Populations: Traditional Domains
Population Characteristics
Predisposing Enabling Need Health behavior Outcomes
DemographicsHealth beliefsSocial structure - ethnicity - education - social networks
Personal/family resources- insurance, incomeCommunity resources- residence, region
Perceived healthEvaluated health-general population conditions
Personal health practices- diet, exercise, tobaccoUse of health services- ambulatory, inpatient
HealthSatisfaction -general -technical -interpersonal
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The Behavioral Model for Vulnerable Populations: Vulnerable Domains
Population Characteristics
Predisposing Enabling Need Health behavior Outcomes
DemographicsHealth beliefsSocial structure-acculturation-literacy
Personal/family resources- competing needs, hunger- transportationCommunity resources-crime rates
Perceived healthEvaluated health-vulnerable population conditions
Personal practices- food sources- hygiene- unsafe sex
HealthSatisfaction-general-technical-interpersonal
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The Behavioral Model for Vulnerable Populations: Vulnerable Domains
Population Characteristics
Predisposing Enabling Need Health behavior Outcomes
DemographicsHealth beliefsSocial structure-acculturation-literacy
Personal/family resources- competing needs, hunger- transportationCommunity resources-crime rates
Perceived healthEvaluated health-vulnerable population conditions
Personal practices- food sources- hygiene- unsafe sex
HealthSatisfaction-general-technical-interpersonal