5 The Ladder Position A metaphor to explain health inequities Societies are structured like laddersThe rungs of the ladder represent the resources that determine whether people can live a good life or a life plagued by difficultiesWhere you are on the ladder matters a lotThe theory suggest that mortality/morbidity are more likely to occur for those at the bottom than those at the top, but also suggest that those in the middle are still at high risk of negative health outcomes than those at the topIn other words your position on the ladder predicts how long you will live and how healthy you are during your lifetimeThe finding was surprising because we tend to think of health as something that is fixed by our genetic heritage- genes are only part of the pictureThe more advantaged our lives are the longer we live and the healthier we are from birth to old agePeople who grow up at the bottom die younger and are sicker throughout their lifetimes than those who are born to the rungs above themWe will use a ladder to explain social gradientRegardless of what we talk about i.e. education, income, neighborhood, race/ethnicity YOU will find yourself somewhere on this ladder.Where you are on the ladder mattersAt the top-Wealthy individuals, decrease morbidity and mortality, increase LE, people die older, people less sickIn the middle-Less resources than those at the top i.e. money opportunities, still at risk for negative outcomes compared to those at the top. Increased morbidity and mortality and lower LE than those at the topBottom-Poor individuals, increased morbidity and mortality, decreased LE, die younger, sicker, less resources an opportunitiesThe rungs affect our health and in turn our health affects our ability to reach higher rungsLet’s explore this in our next slide.
6 Dynamic Relationship Between Health and Ladder Position Birth/ChildhoodParentalSocioeconomic ResourcesHealthAdolescence/Young AdultEducational AttainmentWork/CareerOccupation andIncomeElderlyRetirementIncomeRetirement/IncomeThe relationship between health and socioeconomic resources is complicated because each affects the other.The rung affects our health, and in turn our health affects our ability to reach higher rungsSo children born to families lower on the ladder who have few SE resources tend to experience more illness and injuries and suffer more chronic conditions, like asthma.In turn, children who experience disease or disability tend to miss school and ultimately complete fewer years of schooling.This then limits the kind of occupation they qualify for, relegating them to poor paying jobs.Poorly paid jobs tend to be jobs with little working control and stressful working conditions, both of which contribute to the onset of health problems.The onset of health problems during the working life of an adult impacts the ability to continue working or advance occupationally.This impacts the economic security people experience in retirement.HealthHealth
7 Discriminatory Beliefs (ISMS) A FrameworkSocio-EcologicalMedical ModelIndividual Health KnowledgeGeneticsUpstream DownstreamRaceClassGenderImmigration statusNational originSexualorientationDisabilityDiscriminatory Beliefs (ISMS)Corporations & other businessesGovernment agenciesSchoolsInstitutionalPowerNeighborhood conditionsSocialPhysicalResidential segregationWorkplace conditionsEducationSocial InequitiesSmokingNutritionPhysical activityViolenceChronic stressInfectious diseaseChronic diseaseInjury (intentional / unintentional)Infant mortalityLife expectancyRisk Factors & BehaviorsDisease & InjuryMortalityFramework for Health EquityUsed to understand and address the multiple pathways that lead to stark differences in health outcomesTraditionally , Public Health Departments work on the right side of the chartProviding immunizations, diabetes education, smoking cessation, and other services to individuals in needHowever, health education and access to healthcare can only influence outcomes, but only partially explain different health outcomesHealth StatusHealthcare AccessSocial Factors
8 Socio-ecological Model IndividualEnhancing skills, knowledge, attitudes and motivationInterpersonalIncreasing support from friends, family and peersOrganizationalChanging policies andpractices of organizationsCommunityCollaborating and creating partnerships to effect change in the communityPublic PolicyDeveloping, influencing, and enforcing local, state and national laws
9 That which does not kill us makes us stronger. Friedrich Nietzche
11 Data Sources Washington State Population Survey Behavioral Risk Factor Surveillance Survey (BRFSS)Birth CertificatesDeath CertificatesCommunity Health Assessment Tool (CHAT)Office of Financial Management, Washington StateWashington State HIV Surveillance ReportStrategic Research Associates, Omnibus Survey
12 Purpose of Health Inequity Report The goal of this assessment is to increase awareness about different health and social factors in Spokane County and provide information that can be used for potential changes that affect health outcomes.Build awarenessIdentify further areas for explorationIntended for health professionals, legislators (policy makers), administrators, community members, and anyone interested in addressing health concerns in Spokane CountyProject has taken 1 year to complete.You will find yourself somewhere on the ladder regardless of what component we are looking at i.e. education, income, race/ethnicity, neighborhoodPassion and interest in this area of workData alarmingWe want to look at health in Spokane County and Washington State through an inequity lens for various social determinants of health i.e. education, poverty, race/ethnicity, neighborhood and we want to provide information that can be used for potential changes in policies that affect human life and health outcomes.Before we get started, I want to go over a few definitions that are used when discussing health inequities.Quantitative PartQualitative Part
13 Definitions Health Disparity Health Inequity Differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups.Health InequityHealth Disparity- simply two quantities that are not equal. Rate A does not equal rate B (observed differences). That’s all a health disparity is. A difference.Health Inequity-What does our definition mean? Health inequity is a bit more complicated. In deciding if something is an equity, we need to make an ethical judgment and ask ourselves is the health difference fair? Its true poor people die younger than wealthy people but should they? Is it fair? Should infants born into low SES have lower birth rates? Should women live longer than men?Disparity-Sickle –Cell AnemiaInequity-HIV PrevalenceConcerns those differences in population health that can be traced to unequal economic and social conditions and are systemic and avoidable; thus being inherently unjust and unfair.
14 Social Determinants of Health DefinitionsSocial Determinants of HealthFactors (i.e., determinants) in our social and economic environment that researchers have been found to negatively (or positively) affect health.Social GradientFor the sake of this report we will be talking about education, income, race/ethnicity, neighborhoods.I would like to explore what social gradient means and use a metaphor to explain social gradient. (Next slide)An individual's or population group's position in society and different access to and security of resources such as education, employment and housing, as well as different levels of participation in civic society and control over life.
16 Why Education? What We Heard When invited to discuss what could be done to improve quality of life, many focus group participants discussed the importance of jobs and education:“You said jobs, I say schooling to get a job. Jobs are good, but I think to get a solid job is to get an education.”Focus Group Participant (income <35k)Indirectly effects and influences health and LEA strong determinant of future employment and predictor of incomeA person’s well-being is directly correlated to their incomeDifferent levels of education affect outcomes differently – increased LE and better health (This is the social gradient using education)Affects type of job you haveAnd remember a person’s health affects their education
17 The Faces of Inequities in Spokane For the Health Inequity report, in addition to the quantitative data you will see today, I will also be sharing with you the voice of our community. For the report we conducted focus groups and I’ve included some of the comments made in those groups as folks discussed issues impacting their quality of life. I will also be sharing with you some stories. The stories are real, the people are real, and the inequities are real.When Spokane native Jim Martin was completing his military service in his 20s, he was optimistic about his prospects for a good job back in the “real” world. The military classes he took to prepare him to re-enter civilian life produced a lengthy list of jobs he’d be qualified to perform. As he began looking for jobs though, James discovered a big problem. He’d never “done” any of the jobs he was qualified for, for instance, as a boiler tech, when he’d never even looked at a boiler.Now a welder in his late 30s, without any education after high school to fall back on, Jim, along with his wife Jenny, describe themselves as financially comfortable, but are hamstrung by debt. In the military, Jim made decent money and although it took him several months to locate work afterward, he and Jenny continued to live the life they’d been accustomed to. They fell into a common trap of opening several credit cards to pay off others. In retrospect, they both take responsibility for digging themselves deeper, but Jenny still has qualms about how easily they were extended credit.Jim has also suffered from asthma his whole life, and now his years of hard labor are catching up to him. He suffers from a chronic bad back and knees. He watched his dad work at the same plant for 43 years, so he knew hard work was going to take its toll. He expected his body to give out; he didn’t expect it to start this early. He’s worried for his future, about his asthma, about his body giving out five or ten years down the road. He has concerns about how his employment affects his nutrition and well-being, but without any education and limited career options, he focuses on today. If he can’t get out of bed one day to go to work, then he’ll deal with it then. Until then, his motto is “As long as I’m breathing, I’m working.”
18 Effects of Education on Poverty Adults 25 Years of Age or Older Living in Poverty by Education, 2000 to 2008This graph demonstrates that approximately half of adults with less than a high school education live in poverty compared to less than 10 percent with an advanced degree in Spokane County. Moreover, residents of Spokane County with the same level of education are more likely than Washington State residents to live in poverty, with the exception of adults with less than a high school education. Adults in Spokane County with less than a high school education are approximately 9.0 times more likely to live in poverty compared to adults with an advanced degree and 21.5 times more likely in Washington State.Data Source: Washington State Population Survey
19 General Health Status by Education General Health Status by Education among Adults 25 Years of Age or Older, 2000 to 2008Adults with less education are more likely to rate their health as poor or fair.1/3 of people with less than a high school degree report fair/poor health compared to less than 10% of persons with an advanced degree.Data Source: Behavioral Risk Factor Surveillance System (BRFSS)
20 Smoking by EducationSmoking by Education among Adults 25 Years of Age or Older, 2005 to 2009More adults with less education smoke compared to adults with a higher education.explains that more adults with less education smoke compared to adults with a higher education for Spokane County and Washington State. Additionally, Figure 12 shows that as the level of education increases, adults are less likely to smoke in both Spokane County and Washington State.Data Source: Behavioral Risk Factor Surveillance System (BRFSS)
21 Effects of Education on Cardiovascular Disease Cardiovascular Disease by Education among Adults 25 Years of Age or Older, 2005 to 2009This graph illustrates that adults who did not finish high school are 2.4 times more likely to have cardiovascular disease compared to adults with a bachelor’s or advanced degree in Spokane County and 2.6 times more likely in Washington State.Data Source: Behavioral Risk Factor Surveillance System (BRFSS)
22 Diabetes significantly decreases as the level of education increases. Diabetes by EducationDiabetes by Education among Adults 25 Years of Age or Older, 2005 to 2009Diabetes significantly decreases as the level of education increases.diabetes significantly decreases as the level of education increases in Spokane County and Washington State.Data Source: Behavioral Risk Factor Surveillance System (BRFSS)
23 Children in Poverty by Parent’s Education Children Living in Poverty by Parent’s Highest Level of Education, 2000 to 2008shows that as the parent’s level of education increases, the child’s chance of living in poverty significantly decreases for both Spokane County and Washington State.Data Source: Washington State Population Survey
24 Infant Mortality by Mother’s Education Infant Mortality by Mother’s Education of Women 25 Years or Older, 2003 to 2009Infants born to mothers who did not finish high school are more likely to die before their first birthday as babies born to college graduates.Figure 17 shows the rate of infant mortality significantly decreases as the mother’s level of education increases for Spokane County and Washington State. Babies born to mothers who do not finish high school are 2.5 times more likely to die before their first birthday as babies born to mothers with a bachelor’s or advanced degree in Spokane County and Washington State.Data Source: Birth and Death Certificates
25 Health Starts in Our Homes, Schools and Communities
26 Discriminatory Beliefs (ISMS) A FrameworkSocio-EcologicalMedical ModelIndividual Health KnowledgeGeneticsUpstream DownstreamRaceClassGenderImmigration statusNational originSexualorientationDisabilityDiscriminatory Beliefs (ISMS)Corporations & other businessesGovernment agenciesSchoolsInstitutionalPowerNeighborhood conditionsSocialPhysicalResidential segregationWorkplace conditionsEducationSocial InequitiesSmokingNutritionPhysical activityViolenceChronic stressInfectious diseaseChronic diseaseInjury (intentional / unintentional)Infant mortalityLife expectancyRisk Factors & BehaviorsDisease & InjuryMortalityFramework for Health EquityUsed to understand and address the multiple pathways that lead to stark differences in health outcomesTraditionally , Public Health Departments work on the right side of the chartProviding immunizations, diabetes education, smoking cessation, and other services to individuals in needHowever, health education and access to healthcare can only influence outcomes, but only partially explain different health outcomesHealth StatusHealthcare AccessSocial Factors
27 Adrian E. Dominguez, M.S. Epidemiologist Spokane Regional Health District Disease Prevention and Response Community Health Assessment