Five Generations of Research on Health Disparities Nancy E. Adler, PhD University of California, San Francisco Center for Health Equity University of Minnesota April 4, 2013
Articles with key term “health disparity,” “health inequality,” or “health inequity” Health Health Health Years Disparity Inequality Inequity ‘83 - ’92 6 1 0 ’ 93- ’02 205 18 0 ‘03 - ’12 4,019 82 30 2
Health Disparities Research Generations Each generation: – Asked more complex, nuanced questions – Left unresolved issues 3
1 st generation – Poverty and Race 4
Threshold Effect of Poverty Health Income Poverty Line 5
6
Unresolved issues: • Nature of association • Intersection of race and poverty • Other bases of social stratification 7
Second Generation: SES – health gradients 8
Source: Marmot M, et al., Society & Health , 1995 9
3.5 3 Adjusted Odds Ratio 2.5 2 1.5 1 0.5 0 >70,000 50,001-70,000 30,001-50,000 20,001-30,000 15,001-20,000 <15,000 Income (in dollars) Adjusted odds ratio for death from all causes according to annual household income, 1972-1989 The group with an annual household income of more than $70,000 (in 1993 dollars) is the reference group. Data are from McDonough et al. Am. J Pub Hlth, 1997. Source: Issacs & Schroeder (2004) New England Journal of Medicine 10
Prevalence of Health Problems in Children Any limiting chronic condition 18 Asthma prevalence Ear disease 15 Injury 12 Physical inactivity Percentage 9 6 3 0 1 2 3 4 5 SES (lowest to highest) 11 Chen, Matthews & Boyce, Psychological Bulletin . 2002, 128:295-329
Unresolved issues Diseases: Reversals for some diseases Populations: Reversals in some countries 12
Diseases • Gradient for CVD, stroke, diabetes, mood disorders, lung cancer (now) • Reverse gradient: Breast cancer, skin cancer 13
Populations Reverse gradient in lower income nations 14
SES & health: lower income and developing countries • In developing countries, higher socio-economic status (SES) is associated with: –↓ Blood pressure (Chile, Brazil, Colombia) –↑ Blood pressure (Nigeria) –↑ Hypertension (India) –↑ & ↓ Hypertension (Jamaica) 15
Why the inconsistencies? — Methodologic concerns (i.e. definitions of SES) — Sample sizes — Truly different patterns in developing countries? 16
Oportunidadas: SES & blood pressure • Lowest income women in a middle income country • Blood pressure in relation to: – Education – Income – Housing/Assets – Subjective Social Status (community) 17
Anomalous finding? 124 Systolic blood pressure 123 122 121 120 1 2 3 4 5 6 7 8 9 Subjective social status 18
Systolic blood pressure β (95% C.I.) Household income per capita Second tertile +1.01 (0.30, 1.73)*** Third tertile +1.95 (1.21, 2.69)*** Education Primary school -0.86 (-1.75, 0.03)* Secondary school -2.03 (-3.13, -0.94)*** Body mass index 0.57 (0.51, 0.64)*** Subjective social status +0.23 (0.10, 0.36)*** N=8840, *Significant at 10%, *** Significant at 1% Model adjusted for age Results are from multiple linear regression, adjusted for clustering at household level R-squared for model is 0.18 19 Fernald & Adler J Epidemiol Comm Health (2008)
Income is a risk factor for high BP 130 Systolic blood pressure (mmHg) 129 128 127 126 No education 125 Some primary 124 Some secondary 123 122 121 120 1 1.5 2 2.5 3 3.5 4 Income per capita (log-transformed) 20 Fernald & Adler J Epidemiol Comm Health (2008)
Third Generation: Mechanisms 21
How does socioeconomic status get under the skin? 22
Environmental Resources & Access to Medical Care Health Outcomes Constraints SES Neighborhood Factors Health Education Social Capital Cognitive fx Occupation Work Situation Physical fx Income Family Environment Exposure to Subjective SES Social Support Carcinogens & SES Inequality Discrimination Pathogens Disease Disease Trajectories Health Related Psychological Influences Behaviors Recovery Resilience/Reserve Capacity Relapse Negative Affect Secondary Events Race (anxiety, depression, hostility) Gender Lack of Control CNS & Endocrine Negative Expectations Response Perceived Discrimination Mortality Allostatic Load Reactive Responding Life Course MaArthur Foundation Research Network model 23
Proportions Determinants (Premature Mortality) of Health (Premature Mortality) Social Genetic Genetic predisposition 15% 30% Behavioral patterns Environment 5% Environmental exposures Social circumstances Health care Health care 10% Behavior 40% 24 Source: McGinnis JM, Russo PG, Knickman, JR. Health Affairs, April 2002.
Environmental Resources & Access to Medical Care Constraints Health Outcomes SES Health Neighborhood Factors Education Social Capital Cognitive fx Occupation Work Situation Physical fx Income Family Environment Exposure to Subjective SES Social Support Carcinogens & SES Inequality Discrimination Pathogens Disease Disease Trajectories Health Related Psychological Influences Behaviors Recovery Resilience/Reserve Capacity Relapse Negative Affect Secondary Events Race (anxiety, depression, hostility) Gender Lack of Control CNS & Endocrine Negative Expectations Response Perceived Discrimination Mortality Allostatic Load Reactive Responding Life Course MaArthur Foundation Research Network model 25
Environmental Resources & Access to Medical Constraints Health Outcomes Care SES Health Neighborhood Factors Education Social Capital Cognitive fx Occupation Work Situation Physical fx Income Family Environment Exposure to Subjective SES Social Support Carcinogens & SES Inequality Discrimination Pathogens Disease Disease Trajectories Health Related Psychological Influences Behaviors Recovery Resilience/Reserve Capacity Relapse Negative Affect Secondary Events Race (anxiety, depression, hostility) Gender Lack of Control CNS & Endocrine Negative Expectations Response Perceived Discrimination Mortality Allostatic Load Reactive Responding Life Course MacArthur Foundation Research Network model 26
Health Behaviors by Education – U.S. Adults 60 50 40 Percentage 30 20 10 0 No HS diploma HS diploma Some college BA degree or more Education Cigarette smoking Recommended activity level 27
Environmental Resources & Access to Medical SES Constraints Health Outcomes Care Health Education Neighborhood Factors Occupation Social Capital Cognitive fx Income Work Situation Physical fx Subjective SES Family Environment Exposure to SES Inequality Social Support Carcinogens & Discrimination Pathogens Disease Disease Trajectories Health Related Psychological Influences Behaviors Recovery Resilience/Reserve Capacity Relapse Negative Affect Race Secondary Events (anxiety, depression, hostility) Gender Lack of Control CNS & Endocrine Negative Expectations Response Mortality Perceived Discrimination Allostatic Load Reactive Responding Life Course MacArthur Foundation Research Network model 28
29
Telomeres cap ends of chromosomes (Blackburn, 1978) 30
Telomere Length and Survival 31
Scatter plots of chronicity of stress by telomere length in caregivers and perceived stress scores by telomere length 32 Epel et al. (2004). PNAS
Cherkas et al. (2006). Aging Cell 33
Environmental Resources & Access to Medical Care Health Outcomes Constraints SES Neighborhood Factors Health Education Social Capital Cognitive fx Occupation Work Situation Physical fx Income Family Environment Subjective SES Exposure to Social Support SES Inequality Discrimination Carcinogens & Pathogens Disease Disease Trajectories Health Related Psychological Influences Behaviors Recovery Resilience/Reserve Capacity Relapse Negative Affect Secondary Events Race (anxiety, depression, hostility) Gender Lack of Control Negative Expectations CNS & Endocrine Perceived Discrimination Response Mortality Allostatic Load Reactive Responding Life Course MacArthur Foundation Research Network model 34
SES & Interpretations 2 Low SES Threatening High SES 1 0 -1 -2 Ambiguous Negative Benign A: t (28) = 2.99, p < .01 N: t (28) = 0.25, ns 35
Adolescents who make negative interpretations have higher mean night time heart rate 72 71 HR 70 69 68 67 1 2 3 4 Quartile of Negative Interpretation Scores 36 Chen et al. Ann Behav Med , 2007
Unresolved issues: Third generation Why do health behaviors vary by SES? Do psychosocial resources mediate or moderate SES effects? What is the time lag between exposure and health problem? 37
Fourth Generation: Multiple-levels 38
Neighborhood as proxy for individual Neighborhood independent of individual 39
Significant, independent impact of neighborhood (but small effect) 40
Built environment: Supermarkets Recreational facilities Parks 41
Individual vs. social determinants of obesity 42
Behavioral Justice 43
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