Aetna Presentation Social Determinants of Latino Health

Social Determinants of Hispanic/Latino Health

Daniel Santibañez, MPH, RDDepartment of Public HealthUniversity of North Florida

This is part 8 of an 8 part series of seminars on Hispanic Health Issues brought to you by the University of North Florida’s Dept. of Public Health, College of Health, a grant from AETNA, and the

cooperation of the Duval County Health Department.

Healthy People 2010

Health for All (2003)

While education plays a valuable role…

• It is important not to “blame the victim” by focusing strictly on lifestyle choices

• Addressing the social and physical environment that influences behavioral choices is an essential element of a strategy to change behavioral patterns

CDC (2002)

SES is central to eliminating health disparities• It is closely tied to health and longevity

• At all income levels, people with higher SES have better health than those at the level below them

• SES is also a strong force behind differences in health among racial and ethnic groups

• People die younger in societies with greater inequalities in income

Schulz et al. (2002); healthpeople.gov

Social Determinants of Health

• The socioeconomic and racial disparities in health in the United States today require public health professionals to critically examine the scope and focus of public health research and practice

Healthy People 2010 Goals:

Goal 1: Increase quality and years of healthy life

Goal 2: Eliminate health disparities

Farquhar et al. (2005)

Social Determinants of Health• Income inequality

• Social exclusion

• Job insecurity

• Poor working conditions

• Food insecurity

• Inadequate housing

• Language

• Access to care

Health for All Campaign (2003)

People affected by health disparities more frequently live in environments with:• Toxic conditions

• Inadequate access to affordable nutritious food, places to play and exercise, effective transportation systems, and accurate, relevant health information

• Violence

• Joblessness, poverty

• Targeted marketing and excessive outlets for unhealthy products

• Community norms that do not support protective environments


Focusing only on individual responsibility for lifestyle changes ignores larger environmental factors that can work against the educational

message

• For example, limited education may mean less exposure to info about risk, but the same people may live in neighborhoods with poor recreational facilities, fewer stores selling fresh produce, and more advertising for tobacco and alcohol

Hispanic young people were exposed to more alcohol

advertising in English-language media than non-Hispanic young

people


Key Community Factors for Reducing Health Disparities

• Built Environment Factors

• Social Capital Factors

• Services and Institutions

• Structural Factors


Built Environment Factors

• Activity-Promoting Environment

• Nutrition-Promoting Environment

• Housing

• Transportation

• Environment Quality

• Product Availability

• Aesthetic/Ambiance

• Number of play areas

• Supermarket access

• Housing quality and asthma

• Psychological stress


Social Capital Factors

• Social Cohesion and Trust

• Collective Efficacy

• Civic Participation and Engagement

• Social and Behavioral Norms

• Gender Norms

• Connections and trust

• Improved mental health and trauma outcomes

• Securing community resources

• Voting and volunteering

• Lower addiction rates and violence

CDC (2002)

Resilience and responses to stress affect health

• Researchers have found that people who experience discrimination are far more likely than others to develop HTN and other stress-induced health effects

• Biological effects of repeated stress affect immunity, health, and life expectancy

Minority women and “kinwork” of family and friends

Health for All (2003); Wilkenson (1999)

Social Connections within a community are important

• Children are healthier in neighborhoods were adults talk to each other

• High levels of social support and a number of positive health benefits among Latinos

Social networks enforce social sanctions and controls to diminish negative behaviors.

Reduce incidence of crime, juvenile delinquency, and access to firearms within communities

CDC (2002)

Residential Segregation

• Hispanics and Blacks are more likely than poor white families to live in areas of concentrated poverty

• Research has shown that living in neighborhoods where some residents have higher incomes and more education is healthier


Services and Institutions

• Public Health, Health, and Human Services

• Public Safety

• Education and Literacy

• Community-Based Organizations

• Cultural and Artistic Opportunities

• Availability and access to high quality services

• Community coalitions and perceived safety

• Community-based health promotion

• Gardens, murals, and music promote healing

CDC (2002)

Quality of health care can cause problems

• Research has found that higher SES does not protect minorities from poor health outcomes

Medical professionals should be trained to understand social causes in patients’ lives so that they can improve the quality of care

Improving Quality of Care

• Cultural competency training

• Recruiting minorities in healthcare

• Even w/insurance coverage and higher SES, disparities in prevention and screening exists

• Quality = Equity in health care

“Racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factors, such as patients’ insurance status and income, are controlled.”

-Unequal Treatment, Institute of Medicine

CDC (2002)

Educational Opportunity

• Because the quality of schools is partially determined by community resources, people in poor communities get poor quality education

As a result, they have fewer opportunities for good jobs and incomes.

In addition, they face the effects of lowered expectations.


Structural Factors

• Economic Capital

• Media and Marketing

• Ethnic, Racial, and Intergroup Relations

• Employment opportunities

• Adequate living wage

• Job training

• Local ownership of business and homes

• Access to loans

• Media perceptions

CDC (2002)

Economic pressures exact a toll on minorities• Hispanics, African-Americans, Native

Americans and some Asian groups are more likely than other groups to be poor

• Poverty affects health by limiting access to needed resources

• Other elements of SES, including education, residence, and occupation, also affect people’s quality of life, including their health

CDC (2002)

Occupational Opportunities

• Having to work more than one job, lacking health benefits, having little control over one’s schedule or pace of work, and being unable to take time off work when needed can cause chronic stress and damage self-esteem.

CDC (2002)

Disparities go beyond SES• To plan and develop interventions that will

truly help the community, public health professionals must capture the contextual reality of racial and ethnic communities

• By understanding race and ethnicity in terms of community, we can grapple with their complexity and take note of the differences between poor communities

• It is a holistic approach that does not exclude poor people but rather looks at them within the communities where they live

Farquhar et al (2005)

Poder es Salud/Power for Health

• Many public health practitioners and researchers have identified greater community involvementcommunity involvement and increased social capitalsocial capital as ways to reduce inequities related to income, race, gender, ethnicity, and geographic location.

A more empowered and competent community is a healthier community

Farquhar et al (2005); Hancock (2000)


• Social capitalSocial capital is characterized by a sense of trust, shared norms and values, and interconnectedness

• It has both an informal aspect related to social networks and a more formal aspect related to our social development programs

• Social cohesion, “civicness” and participation in society and governance



• The project builds on existing social capital to expand ties between the African American and Latino communities and expand access to social and economic resources

Community-based research works with existing units of identity that share an emotional

connection, values and norms, common interests, and a commitment to meeting shared needs.



• 3 core strategies to enhance community-level social capital:

– Community-based participatory research

– Popular education

– Community health workers



• 3 African-Am faith based organizations

• A coalition of 5 evangelical congregations in the Latino community

• A geographically defined community consisting of 4 apartment complexes

Steering committees formed



• Public safety committee

• Community health fair

• Diabetes support and information group

• Homework club

• Photovoice Project– Led residents to develop a campaign to

remove trash and illegally-dumped materials from area



• Created a cooperative to provide members with insurance, small-business loans, and job opportunities

In response to community members prioritizing 3 social determinants of health:

•Lack of health insurance

•Lack of self-employment and business knowledge

•Lack of jobs and employment security



• Peace Campaign initiated and implemented to address the increase in gang violence and repeated police use of lethal force against unarmed citizens

Peace Campaign Goals:

•Explore violence as a public health issue

•To build lasting relationships between young people and police officers

•To help youths learn nonviolent techniques that they can use with peers and adults



• Youth advisory council

• Youth gang task force

• Creation of a community-based initiative created to prevent crime and revitalize the community - Weed and Seed

• Included police cadets in the coalitions

Peace Campaign has involved coalition members in design, implementation, and evaluation

Community Action Model


“No epidemic has even been resolved by attention to the affected individual”

- Dr. George Albee

National Center for Farmworker Health

Migrant Farmworker Health

• There are over 3 million MSFW in the U.S.

• 81% foreign born

• 95% born in Mexico, 2% Latin America, 1% Asia, 1% other

• 80% Male and 84% Spanish-speaking

• Nearly ¾ of U.S. farmworkers earned less than $10,000 per year

• 3 out of 5 families had incomes below poverty level

Catholic Migrant Farmworker Network


• The health needs of farmworkers have been ignored by the public health research community

• Most agricultural studies have focused on farm owners/operators



• Of the farmworkers who go to health clinics, at least 40% present with multiple and complex health problems including infectious and chronic diseases, making diagnosis and treatment that much more difficult


• Dental

• Environmental/Occupational health

• Mental health and substance abuse

• Domestic violence

• Disaster relief

• Housing

• Child labor

National Center for Farmworker Health (2001)


• The poor level of oral health for farmworkers was generally found to correspond with lack of access to information that could help prevent oral health problems and lack of access to preventive care and restorative services

Dental disease ranks as one of the top 5 health problems for farmworkers aged 5-29 and

among the top 20 health problems for all other ages presenting for care



• Environmental/Occupational health issues include:

– Disability and death Traumatic injuries– Respiratory problems– Dermatitis– Infectious diseases– Cancer– Eye problems



• Although there are field sanitation guidelines for farmworkers developed by OSHA, these are seldom enforced by OSHA or compiled with by employers

Tuberculosis and parasitic diseases are attributable to deficient sanitation both at work and at residence sites, poor quality

drinking water and failure to provide uncontaminated washing and drinking water



• High levels of depression are associated with high acculturative stress, low self-esteem, discrimination, low religiosity, lower income, physical health problems, and lack of child care

Because Mexican culture emphasizes familism, collectivist values, and affiliation, Mexican migrants may be particularly vulnerable to

depression when they lack support from family and friends


Mental Health Stressors:• Language

• Unpredictable nature of work and housing

• Being away from family and friends

• Difficult workload and structure

• Socialization of children

• Lack of daycare and supervision

• Poverty and poor housing conditions

• Isolation and discrimination



• Approximately 13% drink 6 or 7 days a week an average of 21 drinks weekly

• Alcohol and drug abuse create safety and health hazards

Social isolation is the primary risk factor for elevated alcohol consumption



• Estimated 20% of women experienced physical abuse and 10% reported forced sexual activity in one year

• Women whose partners used drugs and/or alcohol were 6 times more likely to be abused

Research on domestic violence among this population continues to progress at a slow pace

and much is still unknown



• When faced with a natural disaster, migrant community health centers find themselves restricted by emergency relief vehicles that are financially limited and unable to respond the needs of the areas that they serve

The costs of serving this population are in many ways already extraordinary. Add to this situation

a natural disaster, and most migrant health centers simply do not have the additional

resources to adequately address these difficult circumstances



• Overcrowded and substandard housing can contribute to the contraction and spread of disease, as well as injury through household accidents

• Many farmworkers crowd units to limit the cost impact of housing on their low incomes

Although they toil to bring a bounteous harvest to our tables, farmworkers are often faced with some of the poorest living conditions in their

communities



• Exposure to pesticides, transportation accidents, tractor rollovers, unguarded machinery, open irrigation ditches, and animals are among the serious hazards faced by child laborers

• Large numbers of youth are suffering fatal and non-fatal agricultural injuries

Few legal protections exist to safeguard the health and well-being of young farmworkers.


Child Labor: 2 groups

• Unaccompanied and those who work alongside their parents

• Approx. 55,000 unaccompanied

• Of these, 44,000 are foreign-born males

• Median annual income $1,000 - $2,500

There is no limit under federal law to the number of hours per day or per week that children may

work in agriculture. As a result, the hours worked are often long and affects health and education.


Migrant Farmworker Outreach

• Over 100 migrant health centers, along with a dozen migrant “voucher” and other special programs exist

• Federally assisted migrant health services reach only about 15% - 20% of the nation’s MSFW population

In migrant health, the challenge of making real breakthrough during the coming decade in improving

access and reducing health disparities for MSFWs depends on investing adequately in lay health

outreach

Questions?

Thank you

Daniel [email protected]

Aetna Presentation Social Determinants of Latino Health

Health & Medicine

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