1. Why Are We Unhealthy?
Adrian Dominguez
Bob Lutz

2. All of us should have the opportunity to make the choices allowing us to live a healthy life, regardless of income, education, ethnic background or where we live.

3. Health is a resource for everyday life, not the objective of living.
Health is a positive concept emphasizing social and personal resources, as well as physical capacities.

5. The Ladder Position A metaphor to explain health inequities
Societies are structured like ladders
The rungs of the ladder represent the resources that determine whether people can live a good life or a life plagued by difficulties
Where you are on the ladder matters a lot
The 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 top
In other words your position on the ladder predicts how long you will live and how healthy you are during your lifetime
The 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 picture
The more advantaged our lives are the longer we live and the healthier we are from birth to old age
People who grow up at the bottom die younger and are sicker throughout their lifetimes than those who are born to the rungs above them
We will use a ladder to explain social gradient
Regardless 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 matters
At the top-Wealthy individuals, decrease morbidity and mortality, increase LE, people die older, people less sick
In 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 top
Bottom-Poor individuals, increased morbidity and mortality, decreased LE, die younger, sicker, less resources an opportunities
The rungs affect our health and in turn our health affects our ability to reach higher rungs
Let’s explore this in our next slide.

6. Dynamic Relationship Between Health and Ladder Position
Birth/
Childhood
Parental
Socioeconomic Resources
Health
Adolescence/
Young Adult
Educational Attainment
Work/
Career
Occupation and
Income
Elderly
Retirement
Income
Retirement/
Income
The 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 rungs
So 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.
Health
Health

7. 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

8. Socio-ecological Model
Individual
Enhancing skills, knowledge, attitudes and motivation
Interpersonal
Increasing support from friends, family and peers
Organizational
Changing policies and
practices of organizations
Community
Collaborating and creating partnerships to effect change in the community
Public Policy
Developing, influencing, and enforcing local, state and national laws

9. That which does not kill us makes us stronger. Friedrich Nietzche

10. Health Inequities in Spokane County

11. Data Sources Washington State Population Survey
Behavioral Risk Factor Surveillance Survey (BRFSS)
Birth Certificates
Death Certificates
Community Health Assessment Tool (CHAT)
Office of Financial Management, Washington State
Washington State HIV Surveillance Report
Strategic 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 awareness
Identify further areas for exploration
Intended for health professionals, legislators (policy makers), administrators, community members, and anyone 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

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 Inequity
Health 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 Anemia
Inequity-HIV Prevalence
Concerns 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
Definitions
Social Determinants of Health
Factors (i.e., determinants) in our social and economic environment that researchers have been found to negatively (or positively) affect health.
Social Gradient
For 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.

15. Components of Health Inequities

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 LE
A strong determinant of future employment and predictor of income
A person’s well-being is directly correlated to their income
Different levels of education affect outcomes differently – increased LE and better health (This is the social gradient using education)
Affects type of job you have
And 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 2008
This 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 2008
Adults 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 Education
Smoking by Education among Adults 25 Years of Age or Older, 2005 to 2009
More 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 2009
This 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 Education
Diabetes by Education among Adults 25 Years of Age or Older, 2005 to 2009
Diabetes 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 2008
shows 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 2009
Infants 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 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

27. Adrian E. Dominguez, M.S. Epidemiologist Spokane Regional Health District Disease Prevention and Response Community Health Assessment