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Practical Strategies
Lauri Andress, MPH, J.D., Ph.D.June, 2010
Senior Health Equity AnalystCenter to Eliminate Health DisparitiesUniversity of Texas Medical Branch
Developing Chronic Disease Programs around the Social Determinants of Health
Identify 3 key elements of SDOH and the potential relevance of a social determinants of health (SDOH) perspective to chronic disease prevention.
Describe 2 distinctions between universal and targeted interventions and the relevance of each to a comprehensive approach to population health planning at the local level
Describe 2 ways SDOH research and a population perspective can be applied to health planning processes at the local level.
Objectives
A shorthand for the broad and complex array of social, political, economic, environmental and cultural factors which strongly impact health status and equity.
“The structural determinants and conditions of daily life…responsible for a major part of health inequities……. Commission on the SDOH
'the distribution of power, income, goods and services, Locally, nationally, and globally…[and]
the visible circumstances of people's lives - their access to high quality schools and education, their conditions of work and leisure, their homes, communities, towns and cities - and their chances of leading a flourishing life.'
Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health: Commission on Social Determinants of Health final report. Geneva: World Health Organization Commission on Social Determinants of Health; 2008.
Social Determinants of Health
Economy
SOCIAL DETERMINANTS OF
HEALTH
Urban PlanningSchools/
Education
Employment/Job Quality
CommunitySafety
HousingOptions
TransportationOptions
Governance
EconomicDevelopment
Social Determinants of Health
Conceptual Framework-Pathways & Entry Points
Social Context Social stratification
Differential exposure
Social deprivationUnemployment
IlliteracyDeprived neighborhoodsAdverse intrauterine life
Differential vulnerability
Less access to:• Health services• Early detection• Healthy food
Differential outcomes
PovertyOvercrowdingPoor housing
Differential consequences
Rheumatic heart diseaseChagas disease
Lifetime exposure to advertising of fast foods, tobacco, vehicle use, disposable income, urban infrastructure, physical inactivity, high
calorie intake, high salt intake, high saturated fat diet, tobacco use, lack of control over life and work, high deprivation neighborhoods
Raised cholesterol, raised blood sugar, raised bloodpressure, overweight, obesity, lack of access to healthinformation, health services, social support and welfare
assistance, poor health care-seeking behavior
Higher incidence, frequent recurrences,higher case fatality, co morbidities
High out-of-pocket expenditure, poor adherence, lower survival, loss of employment, loss of productivity and income, social and financial
consequences, entrenchment in poverty, disability, poor quality of life
Age Economic development, urbanization, globalization
Equity, social determinants and public health programmes. Edited by Erik Blas and Anand Sivasankara Kurup 2010, 300 pages ISBN 978 92 4 156397 0 World Health Organization 2010
Determinants:a. Government policies: influencing social capital, infrastructure, transport, agriculture, food.b. Health policies at macro, health system and micro levels.c. Individual, household and community factors: use of health services, dietary practices, lifestyle.
a
Tobacco use c
b
b
Obesity b
a
a
b
a
Six broad intervention approaches Social and environmental conditions
favorable to health, Behavioral patterns that promote health, Low population risk, Few events and rare deaths, Fully functional capacity/low risk of
recurrence, and Good quality life until death
Texas Plan to Reduce Cardiovascular Disease and Stroke 2008
Texas Council on Cardiovascular Disease and Stroke 2008 Legislative Report
Major non-modifiable risk factors are: heredity, male gender, and increasing age.
Modifiable risk factors are smoking, high cholesterol, high blood pressure, overweight and obesity, and physical inactivity.
Another major risk factor for CVD is diabetes mellitus.
Risk Factors
Texas Council on Cardiovascular Disease and Stroke 2008 Legislative Report
Risk Factors for the Risk Factors?
Obesity
Smoking
Physical Inactivity
Kickbusch Adelaide April 2010http://www.health.sa.gov.au/pehs/HiAP/Adelaide2010/KickbuschDay1-hiap-phcc-20100423.pdf
Obesity: A Test Case for 21st Century Health
A complex system of determinants Involves a plethora of actors who fulfill many
different functions in society.
Risk patterns are local, national, global Local- the absence of playgrounds or lack of bicycle lanes); national (e.g. the lack of food labeling or advertising requirements)
and global. (Foresight Report)
Both the problem and the solution are systemic. Such systemic challenges can only be resolved through great
political commitment at all levels of government and in many sectors of society……..
SDOH as Risk Factors
Cardiovascular Disease
Obesity
Access to Healthy Food
Income
Transportation system
Community development; Planning
Agricultural Policies
The links between agriculture and health: an intersectoral opportunity to improve the health and livelihoods of the poorC Hawkes, M Ruel - Bulletin of the world Health Organization vol.84 no.12 Genebra Dec. 2006.
Conceptual framework of the links between agriculture and health
Risk Factors & Possible Policy Responses
Policy sector - Farming & Agriculture
Goal to ensure nutrition include: Farm and Commodity Policy; WIC policy
Means available: Grants. Agricultural policy framework
Examples: Animal and plant breeding; price and income supports; acreage limits and storage programs
Adapted from LANG ET AL. (2009). FOOD POLICY- INTEGRATING HEALTH, ENVIRONMENT & SOCIETY
Risk Factors & Possible Policy Responses
Policy sector - Agricultural Research and Productivity; Processing
Goal to ensure nutrition include: Agricultural productivity; investments in agricultural research and
technology; more efficient agricultural machinery, agricultural chemicals and fertilizers, genetic improvements in crops, and changes in farm management techniques
Means available: Intellectual property rights
Examples: Product reformulation. Change fat content in meat regulations
Adapted from LANG ET AL. (2009). FOOD POLICY- INTEGRATING HEALTH, ENVIRONMENT & SOCIETY
Risk Factors & Possible Policy Responses
Policy sector - Housing and Community Development-Related Policy
Goal to ensure nutrition include: Improving access to health enhancing foods
Means available: zoning and land-use planning decisions that determine the relationship of residential to
commercial land uses
Examples: Transportation decisions; Location of stores through town-neighborhood planning
Adapted from LANG ET AL. (2009). FOOD POLICY- INTEGRATING HEALTH, ENVIRONMENT & SOCIETY
Risk Factors & Possible Policy Responses
Policy sector - Federal Trade Commission, Food & Drug Administration, USDA
Goal to ensure nutrition include: Change thinking about food to reshape demand
Means available: Advertising, Labeling
Examples: Controls on marketing to children. Reform Nutrition Labeling and Education Act of 1990 (NLEA)
Adapted from LANG ET AL. (2009). FOOD POLICY- INTEGRATING HEALTH, ENVIRONMENT & SOCIETY
MeasurementInterventionsMain entry-pointsSocial determinants and pathways
Priority public health
conditions level
Information on policies and structural
environment measures conducive
to healthy behavior, e.g. tobacco
cessation, consumption of fruits and
vegetables, reduce salt in processed
food, regular physical activity
Information on legislative and
regulatory frameworks to support
healthy behavior
Measurement of gaps in
implementation of policies and
legislative and regulatory frameworks
International trade agreements that promote availability and
affordability of healthy foods
International agreements on marketing of food to children
Use tobacco tax for promotion of health of the population
Develop urban infrastructures to facilitate physical activity
Government legislation and regulation, e.g. tobacco advertising and pricing
Voluntary agreement with industry, e.g. trans fats and salt in processed food
User-friendly food labeling to help customers to make healthy food choices
Strengthen positive and
counteract negative
health effects of
modernization
Community
infrastructure
development
Reduce affordability of
harmful products
Increase availability
of and accessibility to
healthy food
Poor living conditions in childhood
Community structures
Control over life and work
Attitudes towards health
Marketing
Television exposure
Psychosocial and work stress
Unemployment
High-deprivation neighborhoods
Availability of preventive health services
Health-related behaviors
Residence: urban/rural
Differential exposure
Access to employment opportunities,
poverty alleviation schemes and
education
Level of investment in interventions
that improve health (including
cardiovascular health) that lie outside
the health sector
Universal primary education
Programs to alleviate undernutrition in women of childbearing age and pregnant women
Tax-financed public services, including education and health
Multifaceted poverty reduction strategies at country level, including employment opportunities
Define, institutionalize,
protect and enforce
human rights
to education,
employment, living
conditions and health
Redistribution of power
and resources in
populations
Social status
Education
Occupation
Poverty
Parents’ social class
Ageing of populations
Poor governance
Socioeconomic context
and position
(entry-points and
interventions are common
to other areas of health)
MeasurementInterventionsMain entry-pointsSocial determinants and pathways
Priority public health
conditions level
Information on policies and structural
environment measures conducive
to healthy behavior, e.g. tobacco
cessation, consumption of fruits and
vegetables, reduce salt in processed
food, regular physical activity
Information on legislative and
regulatory frameworks to support
healthy behavior
Measurement of gaps in
implementation of policies and
legislative and regulatory frameworks
International trade agreements that promote availability and
affordability of healthy foods
International agreements on marketing of food to children
Use tobacco tax for promotion of health of the population
Develop urban infrastructures to facilitate physical activity
Government legislation and regulation, e.g. tobacco advertising and pricing
Voluntary agreement with industry, e.g. trans fats and salt in processed food
User-friendly food labeling to help customers to make healthy food choices
Strengthen positive and
counteract negative
health effects of
modernization
Community
infrastructure
development
Reduce affordability of
harmful products
Increase availability
of and accessibility to
healthy food
Poor living conditions in childhood
Community structures
Control over life and work
Attitudes towards health
Marketing
Television exposure
Psychosocial and work stress
Unemployment
High-deprivation neighborhoods
Availability of preventive health services
Health-related behaviors
Residence: urban/rural
Differential exposure
Access to employment opportunities,
poverty alleviation schemes and
education
Level of investment in interventions
that improve health (including
cardiovascular health) that lie outside
the health sector
Universal primary education
Programs to alleviate undernutrition in women of childbearing age and pregnant women
Tax-financed public services, including education and health
Multifaceted poverty reduction strategies at country level, including employment opportunities
Define, institutionalize,
protect and enforce
human rights
to education,
employment, living
conditions and health
Redistribution of power
and resources in
populations
Social status
Education
Occupation
Poverty
Parents’ social class
Ageing of populations
Poor governance
Socioeconomic context
and position
(entry-points and
interventions are common
to other areas of health)
Inequity and CVD
Equity, Social Determinants and Public Health Programmes. (2010). Edited by Erik Blas and Anand Sivasankara Kurup. WHO, WHO Press, 1211 Geneva 27, SwitzerlandISBN 978 92 4 156397
Risk Factors & Possible Policy Responses
Priority Public Health Conditions Level Socioeconomic Context & Position
Social Determinants and Pathways Social Status, Education, Occupation, Poverty, Parent’s Social class, Ageing of Population, Poor governance
Main Entry Points Define, institutionalize, protect and enforce human rights to education, employment, living
conditions and health; Redistribution of power and resources in populations
Interventions Universal primary education Programs to alleviate under nutrition in women of childbearing age and pregnant women Tax-financed public services, including education and health Multifaceted poverty reduction strategies at country level, including employment opportunities
Risk Factors & Possible Policy Responses
Priority Public Health Conditions Level Differential exposure
Social Determinants and Pathways Poor living conditions in childhood Community structures Control over life and work Marketing; Television exposure Psychosocial and work stress Unemployment High-deprivation neighborhoods; Residence: urban/rural Availability of preventive health services Health-related behaviors
Main Entry Points Strengthen positive and counteract negative health effects of modernization Community infrastructure development Reduce affordability of harmful products Increase availability of and accessibility to healthy food
Interventions International trade agreements that promote availability-affordability of healthy foods International agreements on marketing of food to children Use tobacco tax for promotion of health of the population Develop urban infrastructures to facilitate physical activity Government legislation and regulation, e.g. tobacco advertising &pricing Voluntary agreement with industry, e.g. trans fats and salt in processed food User-friendly food labelling to help customers to make healthy food choices
Priority Public Health Conditions Level Differential vulnerability Social Determinants and Pathways Access to education plus Access to welfare assistance Health care-seeking behaviors Co-morbidity Lack of social support Health care-seeking behaviors plus Accessibility of health services Under nutrition Physical inactivity Access to health education Gender Main Entry Points Subsidize healthy items to make healthy choices easy choices Compensate for lack of opportunities Empower people Interventions Provide healthy meals free or subsidized to schoolchildren Subsidize fruits and vegetables in worksite canteens and restaurants Facilitate a price structure of food commodities to promote health, e.g. lower price for low-fat milk Improve early case detection of individuals with diabetes and hypertension by targeting vulnerable groups, e.g.
deprived neighbourhoods, slum dwellers Improve population access to health promotion by targeting vulnerable groups in health education programmes Combine poverty reduction strategies with incentives for utilization of preventive services, e.g. conditional cash
transfers, vouchers Provide social insurance and fee exemptions for basic preventive and curative health interventions Education and employment opportunities for women
Inequity and CVD (cont’d)
Access to essential medicines and
basic technologies in primary health
care
Levels of population coverage related
to essential CVD interventions
Support for smoking cessation
for high-risk groups among low
socioeconomic segments of the
population
Increase awareness among providers of ethical norms and patient rights
Provide universal access to a package of essential CVD interventions through a primary health care approach
Provide incentives within public and private health systems
to increase equity in outcomes, e.g. fees and bonuses for
disadvantaged groups
Provide dedicated services for particular groups, e.g. smoking
cessation programs for people in deprived neighborhoods
Medical procedures
Provider practices:
compensate for
differential outcomes
Cost of appropriate care
Differential utilization by patients
Prescription practices not based on evidence
Poor adherence
Discriminating services
Poor access to essential medicines
Frequent recurrences and hospitalizations
Life stress and social isolation
Lack of education
Comorbidity
Differential health care
outcomes
MeasurementInterventionsMain entry-pointsSocial determinants and pathways
Priority public health
conditions level
Social and economic effects of health
outcomes
Access to cardiac rehabilitation
Policies for linking health and social
welfare
Policies and environments in worksites to reduce differential
consequences
Increase access of services for people with specific health conditions, e.g. cardiac rehabilitation
Improve referral links to social welfare and health education services
Social and physical
access
Lower survival and worse outcomes
Loss of employment
Social and financial consequences
Lack of access to welfare assistance
Heavy health expenditure
Lack of safety nets
Differential consequences
Access to media, e.g. print, radio
and television and health education
programs broadcast through these
media
Affordability of fruits, vegetables and
low-fat food items
Population coverage of screening and
early detection of high-risk groups
Access to treatment and follow-up
including to essential drugs, basic
technologies and special interventions,
e.g. bypass surgery
Provide healthy meals free or subsidized to schoolchildren
Subsidize fruits and vegetables in worksite canteens and restaurants
Facilitate a price structure of food commodities to promote health, e.g. lower price for low-fat milk
Improve early case detection of individuals with diabetes and
hypertension by targeting vulnerable groups, e.g. deprived
neighborhoods, slum dwellers Improve population access to health promotion by targeting vulnerable groups in health education programs Combine poverty reduction strategies with incentives for utilization of preventive services, e.g. conditional cash transfers, vouchers Provide social insurance and fee exemptions for basic preventive and curative health interventions
Education and employment opportunities for women
Subsidize healthy
items to make healthy
choices easy choices
Compensate for lack of
opportunities
Empower people
Access to education
Comorbidity
Lack of social support
Access to welfare assistance
Health care-seeking behaviors
Accessibility of health services
Undernutrition
Physical inactivity
Access to health education
Gender
Differential vulnerability
Access to essential medicines and
basic technologies in primary health
care
Levels of population coverage related
to essential CVD interventions
Support for smoking cessation
for high-risk groups among low
socioeconomic segments of the
population
Increase awareness among providers of ethical norms and patient rights
Provide universal access to a package of essential CVD interventions through a primary health care approach
Provide incentives within public and private health systems
to increase equity in outcomes, e.g. fees and bonuses for
disadvantaged groups
Provide dedicated services for particular groups, e.g. smoking
cessation programs for people in deprived neighborhoods
Medical procedures
Provider practices:
compensate for
differential outcomes
Cost of appropriate care
Differential utilization by patients
Prescription practices not based on evidence
Poor adherence
Discriminating services
Poor access to essential medicines
Frequent recurrences and hospitalizations
Life stress and social isolation
Lack of education
Comorbidity
Differential health care
outcomes
MeasurementInterventionsMain entry-pointsSocial determinants and pathways
Priority public health
conditions level
Social and economic effects of health
outcomes
Access to cardiac rehabilitation
Policies for linking health and social
welfare
Policies and environments in worksites to reduce differential
consequences
Increase access of services for people with specific health conditions, e.g. cardiac rehabilitation
Improve referral links to social welfare and health education services
Social and physical
access
Lower survival and worse outcomes
Loss of employment
Social and financial consequences
Lack of access to welfare assistance
Heavy health expenditure
Lack of safety nets
Differential consequences
Access to media, e.g. print, radio
and television and health education
programs broadcast through these
media
Affordability of fruits, vegetables and
low-fat food items
Population coverage of screening and
early detection of high-risk groups
Access to treatment and follow-up
including to essential drugs, basic
technologies and special interventions,
e.g. bypass surgery
Provide healthy meals free or subsidized to schoolchildren
Subsidize fruits and vegetables in worksite canteens and restaurants
Facilitate a price structure of food commodities to promote health, e.g. lower price for low-fat milk
Improve early case detection of individuals with diabetes and
hypertension by targeting vulnerable groups, e.g. deprived
neighborhoods, slum dwellers Improve population access to health promotion by targeting vulnerable groups in health education programs Combine poverty reduction strategies with incentives for utilization of preventive services, e.g. conditional cash transfers, vouchers Provide social insurance and fee exemptions for basic preventive and curative health interventions
Education and employment opportunities for women
Subsidize healthy
items to make healthy
choices easy choices
Compensate for lack of
opportunities
Empower people
Access to education
Comorbidity
Lack of social support
Access to welfare assistance
Health care-seeking behaviors
Accessibility of health services
Undernutrition
Physical inactivity
Access to health education
Gender
Differential vulnerability
Statement of Intent to Pursue Health Equity Strategies The ODH is committed to the elimination of health inequities. All applicant agencies must submit a statement which outlines the intent of this
application to address health disparities. This statement should not exceed 1 ½ pages and must:
(1) explain the extent in which health disparities are manifested within the health status (e.g., morbidity and/or mortality) or health system (e.g., accessibility, availability, affordability, appropriateness of health services) focus of this application;
(2) identify specific group(s) who experience a disproportionate burden for the disease or health condition addressed by this application; and
(3) identify specific social and environmental conditions which lead to health disparities (social determinants).
This statement must be supported by data. The following section will provide a basic framework and links to information to
understand health equity concepts. This information will also help in the preparation of this statement as well as respond to other portions of this application.
Options for Action-Grants
Questions & Answers
Miscellaneous slides