1. Improving Health Outcomes for all People

2. - Several researchers have used an iceberg to illustrate the different elements or components of culture
- It has also been suggested that we use a duck swimming across a pond to illustrate this point—the duck may be calm on the surface, but you know those little legs and feet
and working hard to propel the bird through the water
- It is much the same with culture. Some of the hidden parts carry the heavier load of the work
Above: geography, generation, socioeconomic status, language, literacy, beliefs and values, status, facial expressions, gestures, religious rituals, paintings, literature, gender, holiday customs, foods, music, styles of dress
Below: gender, communication preferences, ideas about control, sense of self, obligation, definitions of “fair,” comfort with ambiguity, perspectives on time, face or honor, status, feelings about power differences
What is not here?
This discussion will address culture in a broader sense – we are looking not just at race and ethnicity, which are only components of culture, not the whole of it

3. Do you think health care is a right or a privilege? Why?

4. Answers from Others…
A persons overall health should determine his cost for care. Everyone should pay their own way for health care benefits because some people are sicker than others or have diseases that cost so much to support.
A more local economic argument…

5. Answers from Others…
A population that is sick cannot be productive and benefit the economy. We end up paying more if we don’t provide health care to all. It is not a far leap to consider that improving health care access may be profitable to society as well as improve the health of individuals.
The more global economic argument…

6. Answers from Others…
It is a privilege because people abuse rights when they take advantage of society. Unhealthy lifestyle choices and unwillingness to get health care is favored by the poor people and minorities. People visit the emergency room mainly for convenience. This privilege should be limited or cut. You get what you pay for!
“Us” versus “them”…

7. Answers from Others…
Health care is a privilege because there are many factors that the individual controls themselves, such as practicing good nutrition and getting enough exercise. These are choices.
The middle class perspective…

8. Answers from Others…
Resources and opportunities are not necessarily available to everyone in equal measure. In large part because of these inequities, I believe the right of individuals to health care carries a responsibility to contribute to the health of others, whether they be family members, friends, or strangers in the community
Starting to encompass social determinants and interrelatedness…

9. Answers from Others…
I wonder if we as a nation have done enough to prevent disease in the first place. Health care is a right of every citizen, and we need to do more to help the community be healthier.
Moving past “us” and “them” to “we”…

10. Answers from Others…
I cannot understand how health care can be thought of as a privilege. The asymmetry of information in healthcare is greatly magnified. In a developed country, this is clearly unacceptable, unethical, and reflects a complete lack of morality with respect to the fundamental right to health.
An ethics-based perspective…

11. Third Space
In sociology, anthropology, communication, and education research you will find the term third space

12. Third Space
First space: one created by the majority and imposed on the minority
Second space: one minority groups view as their actual culture
Third space: a part of both the first and second spaces, that allows people to detach from existing parameters and examine the world with new eyes
This is what we will attempt to create during the time we spend together—a space in which we examine a topic and its components, elements, or aspects from new eyes
In this presentation, we will use the term “minority” in a broad sense – it will mean anyone outside or different from the majority

13. What is the mission of the public health system?

14. Mission
“To fulfill society’s interest in assuring conditions in which people can be healthy.”
Institute of Medicine, 1988
What does this mean?
The IOM, in The Future of Public Health, named this the mission of the public health system.

15. Culture and Beliefs Culture affects attitudes
On what beliefs or attitudes was/is United States culture built – in general?
How does history affect our beliefs?
Much of our attitude about health and health care results from our cultural beliefs – again, in a broad sense
US beliefs: individualism, puritanism, paternalism, … these are not the only important beliefs in our system, but they are some of the biggest
Paternalism is the notion that people in authority should help others “for their own good”
One huge piece in the United States is individualism, so let’s spend some time on it

16. Individualism v Collectivism
Individualism: cultures tend to include loose ties between individuals, and everyone is expected to look after him or herself and immediate family
Collectivism: people are born into, raised by, and expected to demonstrate lifelong loyalty to strong, cohesive in-groups in which everyone is responsible for everyone
(Hofstede, 2001)

17. Individualism v Collectivism
Identification
Self
Group
Priority
Goal of individual
Self-sufficiency
Interdependence
Dx between individuals
Much
Little
Associated with
Men, Urban
Women, Rural
Emphasis
Initiative, achievement
Belonging
Marriages
May involve children
Must involve children
Purpose of education
Learning how to learn
Learning how to do
Individualist—Norms
- People may choose to join groups, but group membership is not essential to identity
- Everyone has a right to a private life
- Guilt cultures, modern societies
- Children should take care of themselves as soon as possible
- Extravert behavior
- Methods for coping with stress are problem-focused
- Science and technology are treated matter-of-factly
- Education for everyone
- People tend to have more control over their job/working hours, work more hours
Collectivism—Norms
- Private life is invaded by institutions and organizations to which one belongs
- Family provides protection in exchange for lifelong loyalty
- Marriages must include children
- Introvert behavior
- The purpose of education is learning how to do
- Methods for coping with stress are emotional
- Science and technology are treated as magic
- Education for the elite
- People tend to have less control over their jobs/working hours, fewer hours worked

18. School & Work Has anyone ever done a group project at work or school?
How did it go?
How much do you enjoy work in which you must depend on other people to get the job done?
What if this was the norm?

19. How is it different at home?
Do you consider your kids and spouse when making decisions?
What does that mean?
What if you had to also consider your parents, siblings and their spouses and kids, grandparents, in-laws, aunts and uncles, cousins and their spouses…?
Would your decisions be different?
This is just one, relatively minor, example of using a more collectivist mindset – think about how your behavior and decisions would change if you needed to function this way all of the time, in every aspect of your life.
This is a difficult concept to grasp – it is very difficult to shift between these particular mindsets

20. HEALTH

21. Factors of Health How do we achieve health? What is involved?
What is health?
Is it strictly the result of choices?
What other factors may be at play?

22. How does poverty affect health?

23. What are the Outcomes?
Do Americans who struggle financially have the same opportunities to be as healthy as others?
Are they more vulnerable to poor health due to circumstances?

24. Factors of Health
America leads the world in medical research and medical care, and for all we spend on health care, we should be the healthiest people on Earth
Yet on some of the most important indicators, like how long we live, we’re not even in the top 25, behind countries like Bosnia and Jordan
Scientists have found that the conditions in which we live and work have an enormous impact on our health, long before we ever see a doctor
Where people live, learn, work and play has an enormous impact whether they stay well in the first place
America leads the world in medical research and medical care, and for all we spend on health care, we should be the healthiest people on Earth. Yet on some of the most important indicators, like how long we live, we’re not even in the top 25, behind countries like Bosnia and Jordan. It’s time for America to lead again on health, and that means taking three steps. The first is to ensure that everyone can afford to see a doctor when they’re sick. The second is to build preventive care like screening for cancer and heart disease into every health care plan and make it available to people who otherwise won’t or can’t go in for it, in malls and other public places, where it’s easy to stop for a test. The third is to stop thinking of health as something we get at the doctor’s office but instead as something that starts in our families, in our schools and workplaces, in our playgrounds and parks, and in the air we breathe and the water we drink. The more you see the problem of health this way, the more opportunities you have to improve it. Scientists have found that the conditions in which we live and work have an enormous impact on our health, long before we ever see a doctor. It’s time we expand the way we think about health to include how to keep it, not just how to get it back.
Copyright 2010 Robert Wood Johnson Foundation

25. Factors of Health Three key ingredients to health
Ensure that everyone can afford to see a doctor when they’re sick
Build preventive care like screening for cancer and heart disease into every health care plan and make it available to people who otherwise won’t or can’t go in for it, in malls and other public places, where it’s easy to stop for a test
Stop thinking of health as something we get at the doctor’s office but instead as something that starts in our families, in our schools and workplaces, in our playgrounds and parks, and in the air we breathe and the water we drink
Copyright 2010 Robert Wood Johnson Foundation

26. Factors of Health Social Social norms and attitudes
Availability of resources
Access to opportunities
Access to health care
Quality of education and job training
Opportunities for recreational and leisure- time activities
Transportation options
Public safety
Social support
Culture
Social norms and attitudes
Exposure to crime, violence, and social disorder
Socioeconomic conditions
Residential segregation
Language/Literacy
Access to mass media and emerging technologies
This list is from Healthy People 2020, and includes not-health factors that can significantly affect health
(US DHHS, 2012)

27. Factors of Health
In the entire city of Detroit—an area of nearly 150 square miles—there are dozens of “convenience stores” but only five grocery stores. An apple a day may keep the doctor away, but you have to be able to buy an apple.
Copyright 2010 Robert Wood Johnson Foundation

28. Factors of Health Physical
Natural environment, such as green space or weather
Built environment, such as buildings, sidewalks, bike lanes, and roads
Worksites, schools, and recreational settings
Housing and community design
Exposure to toxic substances and other physical hazards
Physical barriers, especially for people with disabilities
Aesthetic elements
Healthy People 2020 separates out these physical determinants that also affect health
(US DHHS, 2012)

29. Key Factors 1. Economic Stability 2. Education Poverty
Employment status
Access to employment
Housing stability
2. Education
High school graduation rates
School policies that support health promotion
School environments that are safe and conducive to learning
Enrollment in higher education
(US DHHS, 2012)

30. Key Factors 3. Social and Community Context 4. Health and Health Care
Family structure
Social cohesion
Perceptions of discrimination and equity
Civic participation
Incarceration/Institutionalization
4. Health and Health Care
Access to health services
Access to primary care
Health technology
(US DHHS, 2012)

31. Key Factors 5. Neighborhood and Built Environment Quality of housing
Crime and violence
Environmental conditions
Access to healthy foods
(US DHHS, 2012)

32. Equality v Equity What is equality? What is equity?
Are they the same thing?

33. Equity v Equality
Equality: fairness in proportion - ensuring everyone has similar access, an equal piece
Equity: fairness in distribution, everyone has access that is appropriate and necessary to their needs – everyone gets what they need regardless of the size of the pieces – equity may also be likened to equality of outcomes

35. Socioeconomic Status
Socioeconomic Status: the social standing or class of an individual or group; often measured as a combination of education, income, wealth, and occupation
This is an official definition of socioeconomic status, but what does it mean?
We will come back to this in a little while…
(American Anthropological Association, 2007)

36. Poverty Is all poverty the same? What does “poverty” mean?
What does it mean to live in poverty?

37. Poverty Economic Social Cultural Political (UNESCO, n.d.)
Poverty undermines human rights
Economic: the right to work and have an adequate income
Social: access to health care and education
Political: freedom of thought, expression, and association
Cultural: the right to maintain one's cultural identity and be involved in a community's cultural life
(UNESCO, n.d.)

38. Poverty
Generational Poverty: families living in poverty for two or more generations
Situational Poverty: people or families who fall into poverty due to lack of resources to address a specific event
How are these different?

39. Poverty
“Poverty is a peculiar, insidious thing: a cause whose effects often cause the original cause, or an effect whose causes are caused by the effect”
(Shipler, 2004, p 53)

40. Mistakes & Achievements
Personal mistakes have larger consequences
Personal achievements yield smaller returns
Middle class: every 3 months
Poverty: every week
What does this mean?
Mistakes: people who live in poverty have less buffer from government, less agility to move around – fewer options
Achievements: poor have less control, less scope of control, so achievements tend to be smaller and have lesser impact
also, things for which poor people work the hardest – feeding the kids – are not appreciated as much as things for which wealthier people work – like opening a plant
There is a crises every 3 months for middle class families, on average, and once a week for those living in poverty.
(Shipler, 2004)

41. Poverty
We’re not just talking about the rich versus the poor. On Average, middle class Americans live shorter lives than those who are wealthy.
We have to take responsibility for our lives and decisions. But all Americans should have an equal opportunity to make the decisions that allow them to live a long, healthy life, regardless of their level of income, education, or ethnicity.
Copyright 2010 Robert Wood Johnson Foundation

42. Related Skills
What skills do you need to work in a fast- food restaurant?
What skills do you need to work in a C- suite?
How are these skills obtained or built?
Who teaches them?
Does anyone not know what a “C-suite” is? It refers to the CEO, CFO, CNO, etc – the executives
(Shipler, 2004)

43. Learning/Education If you do not have a roof over your head
If you do not know with whom you are living
If you do not know whether there will be food for dinner
Are you going to worry about classwork?
(Shipler, 2004)

44. Socioeconomic Class How many social classes are there in the US?
Are there different mindsets that go with each class?
What might be similar?
What might be different?

45. We can’t eradicate illness, but we can foster health.
Health begins with healthy relationships, healthy communities, and healthy jobs, which protect us from the stress of everyday life.
We are social by nature, and when the ties that bind begin to unravel, so does our health.
Health begins at home in our families, with a loving relationship between parents and their children, where kids can expect to be safe, nurtured and protected.
Health begins with healthy communities, with safe streets, freedom from violence, and parks where kids can play.
Health begins with a good education, where children learn not only how to read, write, and prepare for fulfilling, prosperous life, but how to treat each other with dignity and respect.
And health begins with safe jobs and fair wage, where people derive a sense personal satisfaction from their work and connection to their co-workers.
No institution alone can restore a healthy America that nurtures families and communities. That will require leadership, and a partnership of business, government, and civic and religious institutions.
We can’t eradicate illness, but we can foster health. And health begins with healthy relationships, healthy communities, and healthy jobs, which protect us from the stress of everyday life. That’s one prescription that doesn’t require a co-pay.
Copyright 2010 Robert Wood Johnson Foundation

46. We need a few good volunteers…
Line of Inequity…

47. Some Statistics
People in the highest income group live an average of 6.5 years longer than those in the lowest
People in the middle class will die an average of 2 years sooner than those at the top
Low income people are 50% more likely to have heart disease than the wealthy
Middle class people are 20% more likely to have heart disease than the wealthy
(California Newsreel, 2008)

48. Some Statistics
Children living in poverty are about 7 times more likely to be in poor or fair health as those in the top
Middle class children are twice as likely to be in poor or fair health as the wealthy
Rates of illness for poor people in their 30’s and 40’s are comparable to those of wealthy people in their 60’s and 70’s
(California Newsreel, 2008)

49. Some Statistics
If they get sick, 47% of US private sector workers must choose between staying home or losing a day’s pay
The US is the only industrialized nation that does not require employers to provide paid sick leave
The US is the only industrialized country in which paid vacations are not required by law
1 in 4 American workers receive NO paid holidays or vacations
(California Newsreel, 2008)

50. Current Efforts: Federal
National Partnership for Action to End Health Disparities
Awareness—increase awareness of the significance of health disparities, their impact on the nation, and the actions necessary to improve health outcomes
Leadership—Strengthen and broaden leadership for addressing health disparities at all levels
Health System and Life Experience—Improve health and healthcare outcomes
Cultural and Linguistic Competency—Improve cultural competency and linguistic competency
Research and Evaluation— Improve coordination and utilization of research and evaluation outcomes
The NPA also includes some structures to ensure continuing communication and collaboration among established partners and ongoing efforts to recruit additional partners.
One of those is the Regional Health Equity Council (RHEC) structure…

51. Current Efforts: Nebraska
People are People are People: Increasing Your CQ
Community Health Worker Coalition
OHDHE Strategic Plan
Promote chronic disease prevention, maternal child health promotion, reduction of obesity, and improve physical activity and nutrition
Enhance awareness of health disparities and advance CQ
Establish coordinated data collection, evaluation methods and outcomes, and provide relevant statistical data
Expand and sustain statewide community partnerships and collaboration
Encourage full racial and ethnic minority engagement
Enhance collaboration/coordination and technical assistance efforts regarding tribal health

52. What are you/your organization doing? How do you fit in?

53. Final Comments? Questions? Thoughts?

54. References
American Anthropological Association. (2007). Race: Are we so different? Retrieved from
California Newsreel. (2008). Unnatural causes: Is inequality making us sick? Retrieved from
Hentoff, N. (1999, November). Expelling ‘Huck Finn.’ The Washington Post. Retrieved from hentoff p.htmHofstede, G. (2001). Cultures consequences: Comparing values, behaviors, institutions, and organizations across nations. Thousand Oaks, CA: Sage Publications.
Institute of Medicine. (1988, January 1). The future of public health. Washington, DC: National Academies Press.
Shipler, D. K. (2004). The Working Poor: Invisible in America. New York NY: Knopf.
United States Department of Health and Human Services. (2012). Healthy people Retrieved from

55. More information
Nebraska Office of Health Disparities & Health Equity