1. Assessing and Addressing Inequities in Community Nutrition in Washington State Marilyn Sitaker, WA DOH Public Health Nutrition 1/13/2011

2. What is Health Equity? Health Equity is the absence of differences in health between groups with greater and lesser levels of social advantage Health equity is necessary for individuals & groups to participate in, and benefit from, social and economic development. Health equity is a conscious process requiring effort

3. Today’s Lecture Topics 1. How socioeconomic conditions are linked to inequalities in health status & health outcomes 2. How to measure constructs in the health equity model at the state level 3. How researchers link inequities in access to healthy foods to differences in nutrition behaviors among social groups 4. Intervention strategies 5. Department of Health initiatives (time permitting)

4. 1. How socioeconomic conditions are linked to inequalities in health status & health outcomes

5. Key ideas from “Bad Sugar”

6. “Reaching for a Healthier Life” Facts on Socioeconomic Status & Health in the US  (1) Socioeconomic status has a big impact on everyone’s health. Premature death is 3 times more likely for those who live in poverty compared to those who are most privileged.  (2) Throughout our lives, access to socioeconomic resources affects our chances for living a healthy life. The conditions we live in during childhood affect our health throughout our lives.  (3) Health care is important, but accounts for only a small portion of health disparities. Social determinants are more important in determining whether we fall ill in the first place. http://www.macses.ucsf.edu/downloads/Reaching_for_a_Healthier_Life.pdf

7.  (4) Each step up the social ladder provides greater access to social and physical environments that make it easier to engage in healthy behaviors, (e.g., safe places to walk and access to healthier foods). Each step down, greater exposure to potential risks (pollution & unsafe neighborhoods).  (5) Work conditions contribute to health & health disparities. Low-wage jobs may involve shift work and physical hazards, low control over how and when tasks are done, job insecurity, and conflicts between family obligations and work requirements.  (6) Exposure to extreme and prolonged “toxic” stress is more common lower on the social ladder. Persistent stressors--financial insecurity, interpersonal disputes, work-induced exhaustion, chronic conflict-- are recorded in the body. “Reaching for a Healthier Life” Facts on Socioeconomic Status & Health in the US http://www.macses.ucsf.edu/downloads/Reaching_for_a_Healthier_Life.pdf

8. Conceptual Model created by the World Health Organization Commission on Social Determinants of Health http://www.who.int/social_determinants/resources/csdh_framework_action_05_07.pdf How social conditions influence health equity

9. 2. How to measure the link between disparities in access to social resources and health outcomes

10. Summary Measures to Compare Disparities By Education & Income Absolute measures compare the difference in risk between the highest and lowest group: 11 - 5 = 6% Relative measures use a ratio or risk in the highest & lowest income groups: 11 ÷ 5 = 2.2

11. Disparities in Risk Factors & Chronic Diseases among Washington Adults by Income Data Source: WA Behavioral Risk Factor Surveillance System Note: All differences between highest and lowest income group are statistically significant.

12. How many people are affected? Education Prevalence of Obesity State Population age 25+ Number Obese (population X percent) Number affected if same prevalence as college graduates Excess Cases HS or Less 31.7% 1,480,000470,000300,000170,000 Some College 31.9% 1,530,000470,000310,000160,000 College Graduate 21.1% 1,330,000270,000 0 Total 4,350,0001,210,000880,000330,000 ObesityDiabetesSmokingHypertension Total Number of Excess Cases330,000110,000460,000260,000 Source: Washington BRFSS 2006-2008

13. Physical Activity by SEP; Access to Local Outdoor Recreation by Socioeconomic Position The less education a person has, the less likely it is that he or she lives near a public park, playground, trail or school recreational facility. Less educated adults are also less likely to use nearby recreational facilities, & less likely to get enough physical activity.

14. Directory of Social Determinants of Health at the Local Level University of Michigan SPH project funded by the CDC. Developers had expertise in diverse areas. Directory lists current data sets that can be used to address SDOH. Data sets organized in 12 dimensions of the social environment. Each dimension is subdivided into various components.

15. Source; Hillemeier M.M., J. Lynch, S. Harper, and M. Casper. 2003. "Measuring contextual characteristics for community health." Health Services Research 38(6 part 2):1645–717. 12 Dimensions of social context

16. Economic Dimension This table presents the components and indicators of the economic dimension. Nine economic components are identified: 1. Income Income 2. Wealth Wealth 3. Poverty Poverty 4. Economic Development Economic Development 5. Financial Services Financial Services 6. Cost of Living Cost of Living 7. Redistribution Redistribution 8. Fiscal Capacity Fiscal Capacity 9. Exploitation Exploitation Source; Hillemeier M.M., J. Lynch, S. Harper, and M. Casper. 2003. "Measuring contextual characteristics for community health." Health Services Research 38(6 part 2):1645–717.

17. Indicators & Measures: Income

18. Harvard Geocoding Project: Measuring Socioeconomic Position (SEP) Key domains: Occupational class: affects health via occupational hazards and income/standard of living Educational attainment: reflects childhood SEP and future economic prospects, also knowledge & health literacy Income & subsidies: affects standard of living Wealth: referring to accumulated assets Relative social ranking: “status” and “prestige” Source: Public Health Disparities Geocoding Project

19. Assessments can be made within socioeconomic class domains at the individual, household, and area or neighborhood level. Socioeconomic data can be measured at key points in the lifecourse -- in utero, infancy, childhood, and early, middle, and late adulthood. Composite measures can be constructed to combine information. For example, the Townsend index consists of % unemployment, % renters, % not owning a car, and % crowding. Area Based Measures of SEP

20. This economically depressed area in Boston's Chinatown, turned out to be characterized as a highly working class, poor, low income area with high unemployment and few expensive homes. This one house in Beacon Hill looked like it was -- and turned out to be -- in a fairly affluent area: over 75% professionals, low poverty, high income, low unemployment, and lots of expensive homes. Comparing two Boston neighborhoods

21. 3. Evidence for impact of inequity in the distribution of social resources that support healthy eating

22. Assembling a Mosaic of Evidence “The community nutrition environment may explain some of the racial, ethnic and socioeconomic disparities in nutrition and health such as the increasing prevalence of overweight in low income children. Supermarkets...are less common in lower income and minority neighborhoods than in other neighborhoods…recent evidence links access to supermarkets with…fruit and vegetable intake among African American adults…” The role of the built environments in physical activity, eating and obesity in childhood, Sallis J, Glanz, K. www.futureofchildren.org, vol 16 (1), 2006.www.futureofchildren.org

23. “Supermarkets...are less common in lower income and minority neighborhoods” A study of access to food markets and restaurants by neighborhood wealth (median HH income) in MS, NC, MD and MN showed that wealthy neighborhoods had 3 times as many grocery stores as poor neighborhoods. Supermarkets were 4 times more common in white neighborhoods compared to black neighborhoods (Moorland et al, Am J Prev Med 2002; 22(1) Spatial regression analysis of average distance to the nearest supermarket in 869 Detroit neighborhoods showed that distance to nearest supermarket was about the same in wealthier neighborhoods, regardless of racial makeup. Among poor neighborhoods, those with high proportion of African Americans were 1.1 miles further from the nearest market than white neighborhoods. ( Zenk et. al, Am J Pub Hlth 2005 95(4)

24. “…access to supermarkets linked to…fruit and vegetable consumption…” Analysis of 10,623 food frequency questionnaires with geocoded home address compared with geocoded location of local supermarkets showed that for each additional supermarket in the neighborhood, fruit and vegetable intake increased by 31% for blacks and 11% for whites. Morland, et. al, Am J Pub Hlth 2002; 92(11) A study of fruit and vegetable consumption among food stamp participants showed that households living more than 5 miles from their principal store consumed less fruit than those living within a mile of their store Rose, et. al, Pub Hlth Nutrition 2004, 7 (8)

25. 4. Disparities in nutrition behaviors and environments that support healthy eating in Washington State

26. Washington: Disparities in Eating F&V Adults with the lowest incomes & educational level are less likely to eat enough fruit and vegetables. Certain racial groups are also less likely to meet dietary guidelines.

27. Likelihood of being food insecure, taking multiple causal factors into account Causal Factors: Age Education Income Race/ethnicity Marital Status Sex Smoking Status Health Status

28. Income & Age are the Strongest Determinants of Food Insecurity Income <$25,000/year: 38 times more likely than income $75,000+ Ages 20-44: 15 times more likely to be food insecure than ages 75+.

29. Washington: Trends in Disparities in Eating F&V

30. Washington: Trends in Disparities in Obesity

31. Deep green = Washington Counties most likely to have insufficient F&V consumption Insufficient F&V consumption BRFSS, 2005-2007

33. 4. Intervention strategies promoted in Reaching for a Healthier Life

34. Policies to Promote Health Equity 1. Policies that Affect the Ladder 2. Policies that Blunt Adverse Consequences

35. 5. Initiatives within the Department of Health Initiatives (Community Wellness and Protection)

36. Partners in Action Website www.wapartnersinaction.org www.wapartnersinaction.org

38. Paula Braveman: Thoughts on Health Inequities Systematic differences in health or health determinants that are plausibly influenced by social policy are health inequities if they a)Occur between groups with different social position (place in the hierarchy according to power, wealth, prestige) b)Place groups already at social disadvantage at even greater disadvantage due to poor health You do not need to attribute causation or prove that the disparity is avoidable if social policies were changed, as long as the impact is plausible. Braveman, 2004, Health Policy and Development 2(3) 180-185

39. Thank You! Marilyn Sitaker, MPH Chronic Disease Prevention Unit Lead Epidemiologist and Evaluation Coordinator (360) 236-3463 marilyn.sitaker@doh.wa.gov