Determinants of Health

Determinants of Health

M6920September 11, 2001

Columbia University School of Nursing M6920, Fall, 2001

Health

is a state of complete physical, mental and social well-being and

not merely the absence of disease or injury*

Includes capacity to function individually and within a social system.

World HealthOrganization


Cause of Death % of Deaths Ratio Male toFemale

Ratio Black toWhite

Heart Disease 31.4 1.6 1.5Malignancy 23.3 1.4 1.3Cerebrovascular Dis. 6.9 1.2 1.8COPD 4.7 1.5 0.8Injuries/Adverse Effects 4.1 2.4 1.2Pneumonia/Influenza 3.7 1.5 1.4Diabetes Mellitus 2.7 1.2 2.4Suicide 1.3 4.2 0.6Nephritis 1.1 1.5 2.6Chronic Liver Disease 1.1 2.3 1.2

*2,314,245 deaths, 445 less than in 1996

1997 Deaths*


Real Causes of Death, 1990

Tobacco 400,000 Diet/Activity Patterns 300,000 Alcohol 100,000 Microbial Agents 90,000 Toxic Agents 60,000 Firearms 35,000 Sexual Behavior 30,000 Motor Vehicles 25,000 Drug Use 20,000

McGinnis &Foege


Deaths in New York CityWeek of September 1

AllAges

>65 45-64 25-44 1-24 <1

1,076 742 212 90 16 16

Pneumonia & Influenza: 43


A Causal Model of Disease

Cause

Treatment

Disease

Cure


A beginning complex model

DiseaseHealthCare

Need, Access

Cure, Care

OtherFactors

Evans & Stoddard


Growing feedback model

DiseaseHealthCare

Growing care costs

Cure, Care

OtherFactors

Clinical epiEvaluationHS Research

Evans & Stoddard


Four field model

DiseaseHealthCare

Growing care costs

Cure, Care

OtherFactors

Clinical epiEvaluationHS Research

Human Biology

EnvironmentLifestyle

Evans & Stoddard


fieldmodelnurs10.gif

Evans & Stoddard


Leading Health Indicators, HP2010

Physical activity Overweight and

obesity Tobacco use Substance abuse Responsible

sexual behavior

Mental health Injury and

violence Environmental

quality Immunization Access to health

care


Vulnerable Populations

Social groups that have • an increased relative risk or • increased susceptibility to adverse

health outcomes Evidenced by

• increased comparative morbidity• premature mortality and• diminished quality of life


Fundamental Causes

Low social status Low economic status Lack of environmental resources


Groups recognized as vulnerable

Poor Groups subject to

• discrimination • intolerance • subordination • stigma

Politically marginalized, disenfranchised and denied human rights


Specific Groups

Women Children Ethnic people of

color Immigrants

Gay, lesbian, bisexual, transgendered individuals

Homeless Elderly


Income and health status

0%2%4%6%8%

10%12%14%16%18%

Gen

eral

hea

lth

Men

tal h

ealt

h

Ph

ysic

alp

erfo

rman

ce

Dis

abili

ty

High employmentgradeMiddle employmentgradeLow employment grade

Adapted from Breeze et al, AJPH 91:2, pg. 280


Household income and health

0.00

%

5.00

%

10.00

%

15.00

%

20.00

%

25.00

%

Persons

with

perceived

fair or poor

health

status

>$50,000$35-49,900$25-34,900$15-24,900<$15,000


Housing: HOPWA

June 2000 NYC has 43,000 adult/adolescent people/AIDS (up 12,000 in 2 years)

Assistance has shifted from new housing to rental assistance

FY99 City Budget: 199.6 Million Spent: 141.6 Million


Urban waste disposal

Queens generates 3,300 tons of trash EVERY DAY

Fresh Kills landfill • opened in 1948 • capacity to ~2025• closed April, 2001

Cost $838.3 million in 2000


Median weekly earnings of women (by educational level)

$0.00

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

$700.00

$800.00

No diploma HS Only Some College BA or more

1980

1998

Bureau of Labor Statistics


Women’s 1998 median weekly earnings

$0.00

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

$700.00

No diploma HS Only AD BA or more

White

Black

Hispanic

Bureau of Labor Statistics


Electricity (per megawatt) Northern California

$0$20$40$60$80

$100$120$140$160$180$200

Ma

y

Ju

ne

Ju

ly

Au

gu

st

Se

pte

mb

er

1999

2000


Loss of systems in Russia

0

2000

4000

6000

8000

10000

12000

14000

16000

New HIV infections

1993

1994

1995

1996

1997

1998

1999


Loss of systems in Russia

0

2

4

68

10

12

1416

18

20

Death rate from TB (per 100,000)

1991

1992

1993

1994

1995

1996

1997

1998

1999

US rate: below 1/100,000


0

20

40

60

80

100

Total Lessthan 5years

5 to 9years

10 to 14years

15 to 19years

20 yearsand

more

1970 1980 1990 1997

Citizenship Rates by Length of Residence

Source: U.S. Bureau of the Census

%


39.8

71.7

*

*

****

**

24.7

63.2

65.5 45.9

27.3

31.8

60.5

26.0

39.9

41.7

74.142.8

40.3

38.3

30.8

55.2

37.6

66.7

43.9

61.834.325.8

17.4

54.7

41.0

59.1

116.6

187.5

34.6

<5050-99

100+<5 cases

Rate per 100,00057.554.2

MARICTNJDEMDDC

115.8107.1113.2153.6119.8124.5324.8

80.6

183.5

Includes cases with unknown state of residence†

US rate =86.3N=21,515

*

*

1988 AIDS Rates (per 100,000 Black Population)


0.2

< 44.1-12

0.6

1.8

13.5

3.3

1.8

1.41.9

3.20.8 0.2

0.0

0.00.2

0.1

0.3

0.0

0.00.0

0.2

0.6

0.3

0.0

0.0

Ra te p e r 100,000p o p ula tio n

14.2

> 12

0.8

1.7

0.7 3.3

0.1

0.3

VTN HM AR IC TN JD EM D

0.00.01.00.21.51.42.7

15.4

Primary and secondary syphilis - Rates for women by state:United States and outlying areas, 1997

N ote: The to ta l ra te of prim ary and secondary syph ilis fo r w om en in the U nited S tates and outly ing areas (includ ing G uam , Puerto R ico, and Virg in Is lands) w as 2.9 per 100,000 popula tion.

3.1

The H ealthy People year 2000 objective is 4 .0 per 100,000 population.

3.3

0.8

(n=43)(n=7)(n=3)

2.72.2

6.0

Virg in Is.Puerto R ico 0.0

G uam 0.0 5.1

7.9 9.0

8.3

8.2

9.4


Primary and secondary syphilis - Counties with rates above and counties withrates below the Healthy People year 2000 objective: United States, 1997

R ate per 100,000population

<4

>4

(n=2,702)

(n=413)


Infant Mortality in Minnesota

1978/82 1989/93 African-American 22.6 16.5 American Indian 13.9 16.2 Asian 9.7 6.2 White 10.2 6.4


Occupational Death, 1999

0

1

2

3

4

5

6

Fatal injuries per 100,000 workers

White

Black

Hispanic

HispanicFatalities Increasing1993 851996 1201999 200


Children 2-4 years who have ever had tooth decay

29

21

10

0 5 10 15 20 25 30 35 40

Poor

Near Poor

Mid/High

Family Income

(%)


Children Age 15 Who Have Untreated Tooth Decay

29

1815

0

5

10

15

20

25

30

35

40

< H.S. High School > H.S.Level of Education (Head of Household)

Source: NHANES III, 1988-94

(%)


Children with a Preventive Dental Visit* in past year

9

2723

8

282322

56

48

0

10

20

30

40

50

60

70

Age <6 Age 6-11 Age 12-18

Poor Near Poor Mid/High

(%)

* includes prophylaxis, fluorides, or sealants

Source: Medical Expenditure Panel Survey, 1996


Adults age 65+ With Complete Tooth Loss

39

26

13

0

10

20

30

40

50

< H.S. High School > H.S.

(%)

Level of Education


20%21-25.9%

35%Data unavailable

Total Tooth Loss, Age 65+, 1995-1998

HP 2000 Objective: 20%

Source: BRFSS 1995-1998

26-34.9%


Adults (35+) Who Reported Past Year Dental Visit

41

59

74

0102030405060708090

100

< H.S. High School > H.S.Level of Education

Source: NHIS 1997


70%65-69.9%<65%Data unavailable

Dental Visits in Past Year, Age 35+: 1995-1998

HP 2000 Objective: 70%

Source: BRFSS 1995-1998


Minorities Report Difficulty Getting Needed Health Care

19%

28%

38%

27% 30%

0%

10%

20%

30%

40%

White Black Hispanic AsianAmerican

Other*

Adults Ages 18-64

Source: The Commonwealth Fund Survey of Health Care in New York City, 1997Louis Harris and Associates, Inc.

*Other includes Native American or Alaska native, mixed race, some other race, or not sure.


Emergency Rooms Serve Uninsured New Yorkers and the Medicaid Population

30% 32%

47%

24% 25%

0%

10%

20%

30%

40%

50%

60%

Total Uninsured Medicaid Medicare Private

Source: The Commonwealth Fund Survey of Health Care in New York City, 1997Louis Harris and Associates, Inc.

Adults age 18 or older


American Median Income

$0

$10,000

$20,000

$30,000

$40,000

$50,000

1950 '60 '70 '80 '90 1997

Source: United States Census Bureau issued in Statistical Abstract of the United States

In constant 1997 dollars.

1947

White

All Families

Black

FemaleHouseholder,No Husband


2000 Poverty Guidelines

1 $ 8,3502 11,2503 14,1504 17,0505 19,9506 22,850Each additional Add $2,900

Size of Family Income Guideline


The Low-Wage Factor of High-Tech

333318,000Receptionists

292333,000Nursing aides

273370,000Teacher aides

314378,000Home health aides

481404,000Truck drivers

299408,000Retail sales

697411,000Registered nurses

965467,000General managers

891520,000Systems analyst

$247530,000Cashiers

Weekly pay

Number of jobs expected to be added by 2006

Occupations adding the most jobs

Poverty line for a family of four is $308 a week (1996)Source: Bureau of Labor Statistics


Medicare Beneficiaries Reporting Fair or Poor Health

29%

44%

36%

27%

20%

AllBeneficiaries

Less than100% ofPoverty

100-150% ofPoverty

150-200% ofPoverty

200% ofPoverty or

more

Income Relative to PovertySource: Urban Institute analysis of 1995 Medicare Current Beneficiary Survey.


Model for research and practice

ResourceAvailability Relative

Risk

HealthStatus

ResearchPracticePolicy Analysis

Flaskerud

Determinants of Health

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