Health Inequities in Spokane County June 28, 2012

Questions What does this information mean to you as a Board of Health member? How can you use this information professionally? Personally? How do these social determinants (and others) affect and impact members of your community? Are some more relevant to your community than others? What should/can we do as a Board of Health to address health inequities?

Discriminatory Beliefs (ISMS) A Framework Socio-Ecological Medical Model Individual Health Knowledge Genetics Upstream Downstream Race Class Gender Immigration status National origin Sexual orientation Disability Discriminatory Beliefs (ISMS) Corporations & other businesses Government agencies Schools Institutional Power Neighborhood conditions Social Physical Residential segregation Workplace conditions Education Social Inequities Smoking Nutrition Physical activity Violence Chronic stress Infectious disease Chronic disease Injury (intentional / unintentional) Infant mortality Life expectancy Risk Factors & Behaviors Disease & Injury Mortality Framework for Health Equity Used to understand and address the multiple pathways that lead to stark differences in health outcomes Traditionally , Public Health Departments work on the right side of the chart Providing immunizations, diabetes education, smoking cessation, and other services to individuals in need However, health education and access to healthcare can only influence outcomes, but only partially explain different health outcomes Health Status Healthcare Access Social Factors

Recap Important Points Previous presentations analyzed data thru lens of 4 Social Determinants of Health Inequitable distribution of health in Spokane County Social gradient Composite, not individual characteristics Not only health, but also well being

Components of Health Inequities

Social Determinants of Health Income and income distribution Early childhood development Employment and working conditions Food insecurity Housing Social Inclusion Social safety net Access to health services Gender Race and Ethnicity Disability

Social Determinants of Health Social determinants of health are the economic and social conditions under which people live which determine their health. They are "societal risk conditions", rather than individual risk factors that either increase or decrease the risk for a disease. A key component of this definition is that our health is shaped by our surroundings.

Whitehall Studies Studies of British civil servants Purpose: study mortality rates Socioeconomic factors were not initially on the agenda Finding: Inverse social gradient in mortality Whitehall made it clear that inequalities in health were not limited to the health consequences of being poor! The first Whitehall study was first set up in the 1960s, as a kind of a British Framingham Study (tell them about Framingham), in that it was a longitudinal study of cardiorespiratory disease and diabetes, looking at individual risk factors. The purpose was to study mortality rates among British civil servants, aged 20-64. Socioeconomic factors were not initially on the agenda. The general view at the time was that poor people got diseases because of material deprivation and rich people got heart disease and ulcers because of stress. In this population middle-aged British men, all employed in stable jobs in the British Civil Service, there was an inverse social gradient in mortality: lower the grade, the higher the risk of death. In other words, it showed that the more senior you are in the employment hierarchy, the longer you might expect to live, compared to people in lower employment grades. This is particularly interesting when we reflect that the civil services excludes the richest and the poorest members of society. Low status was also associated with obesity, smoking, less physical activity, and higher blood pressure. RR for death from heart disease was 2.2 for clerical compared to senior administrative staff RR for death from heart disease was 1.6 for those in intermediate professional and professional grades

Whitehall I Study This is one of the important pieces of data from Whitehall I. It’s showing us all-cause mortality in the cohort British civil servants by grade or rank within their system. For orientation, it’s better to have a lower mortality rate, so lower the better. Also in their system, administration (pinkish purple) is the highest ranking and other (in green) is the lowest ranking. This data clearly shows a gradient in mortality rates with the lowest mortality in the high ranking administration workers and the highest in other (messengers, doorkeepers, etc.)

Income per head and life-expectancy: rich & poor countries Source: Wilkinson & Pickett, The Spirit Level (2009) www.equalitytrust.org.uk

Health is related to income differences within rich societies but not to those between them Within societies Between (rich) societies Source: Wilkinson & Pickett, The Spirit Level (2009) www.equalitytrust.org.uk Davey Smith et al., AJPH 1996

Leading Causes of Death (Biomedical Model) Source: Based on Mokdad, Marks, Stroup and Gerberding, JAMA, 291:10, 2004.

Estimated actual causes of death in the US, 2004 Source: Based on Mokdad, Marks, Stroup and Gerberding, JAMA, 291:10, 2004.

McGinnis and Foege editorial “it is also important to better capture and apply evidence about the centrality of social circumstances to health status and outcomes…the data are still not crisp enough to quantify the contributions [of social circumstances] in the same fashion as many other factors.”

Estimated Deaths due to social conditions in the US, 2011 (176,000) Source: Based on Galea, Tracy , Hoggart, DiMaggio and Karpati, AJPH, 11:8, August 2011.

Leading Causes of Death by Model Biomedical model Preventable Causes of Death Social Causes Heart Disease-710,760 Tobacco-435,000 Low Education-245,000 Malignant neoplasm- 553,091 Poor Diet/Physical Inactivity- 400,000 Racial Segration-176,000 Cerebrovascular disease-167,000 Alcohol consumption-85,000 Low Social Support-133,000 Chronic lower respiratory disease-122,009 Microbial agents-75,000 Individual level poverty-119,000

Determinants of Population Health Scientists generally recognize five determinants of health of a population Figure 1 represents rough estimates of how much each of the five determinants contributes to the health of a population. Scientists do not know the precise contributions of each determinant at this time.

Death Rate in the US by Median family income Death rate per 100,000 person years Source: Multiple Risk Factor Intervention Trial

What SRHD is Doing About Health Inequities Health inequity report - Odds Against Tomorrow Creating awareness of health inequities in Spokane County – Presentations (40) with partners and community Strategic Goal #4 – Education of SRHD staff Organizing a community forum Neighborhoods Matter Health Promotion – Community Transformation Grant (CTG)

Social Determinants of Health Conceptual Framework Socioeconomic & Political Context Governance Policy (Macroeconomic, Social, Health) Cultural and Societal Norms and Values Education Occupation Income Gender Race/Ethnicity Social Position Material Circumstances Social Cohesion Psychosocial Factors Behaviors Biological Factors Health Care System Distribution of Heath and Well-being Structural Determinants of Health Inequity Intermediate Determinants of Health Inequity

Purpose of Odds Against Tomorrow Goals – Increase awareness about different health and social factors in Spokane County Provide information that could be used for potential changes affecting health outcomes Identify further areas for exploration Audience – Health professionals Policy makers Community members Those interested in addressing health concerns in Spokane County Project 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, neighborhood Passion and interest in this area of work Data alarming We 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 Part Qualitative Part

Questions What does this information mean to you as a Board of Health member? How can you use this information professionally? Personally? How do these social determinants (and others) affect and impact members of your community? Are some more relevant to your community than others? What should/can we do as a Board of Health to address health inequities?