1 Overview of Conceptual Frameworks of Health and Health Disparities Anita L. Stewart, Ph.D. University of California, San Francisco Institute for Health.

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Overview of Conceptual Frameworks

of Health and Health Disparities

Anita L. Stewart, Ph.D.University of California, San Francisco

Institute for Health & AgingCenter for Aging in Diverse Communities

April 5, 2005

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Health Disparities Research

Document health disparities Identify determinants of health

disparities Understand pathways or mechanisms

for disparities

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Types of Diverse Groups

Health disparities research focuses on health differences across diverse race/ethnic groups

A sizeable amount of research has examined differences in health across levels of socioeconomic status (SES):– Low income vs. others– Low education vs. others

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Racial/ethnic and SES Disparities Observed in Virtually All Health Domains

Premature mortality including infant mortality Morbidity

– Chronic disease (heart disease, diabetes, cancer)– Communicable disease (TB)– Low birth weight

Physiological and anthropometric risk factors – Hypertension– Obesity/overweight

Functional limitations, disability Self-rated health

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Purpose of Conceptual Frameworks

For research to identify determinants of health disparities and understand pathways:– Ground research in theory and knowledge

– Help identify key variables in developing research questions

– Guide the selection of measures

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Population vs. Health Services Research Frameworks

Population science

– Determinants of health in a population Health services research

– How health care affects outcomes

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Population-Based Approaches

Samples– Population-based– Population subgroups

» by age, ethnicity» community members

Disciplines– Social epidemiology– Public health– Sociology– Psychology

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Social Epidemiology

…studies the social distribution and social determinants of states of health (p. 6)

Determinants:– Socioeconomic position– Discrimination– Working conditions– Social integration, social networks– Health behaviors– Physical and social environments

Berkman LF and Kawachi I, Social Epidemiology, Oxford, 2000.

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Population-Based Determinants of Health

Medical care accounts for only 10% of the variance in health

But… medical care may have a greater impact on the health of vulnerable groups than on their counterparts (Williams and Collins)

Williams DR and Collins C, Ann Rev Sociol 1993;21:349-86

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Geneticpredisposition

30%

Health care

10%

Population Based Determinants of Premature Mortality

Behavior 40%

Social circumstances15%

Environmental exposure 5%

McGinnis JM, et al. Health Affairs, April 2002, p. 83

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Multiple Levels of Influence on Health

Individual– physiological, biological factors– behaviors, attitudes, beliefs

Family– size, structure, support, beliefs

Neighborhood or community– resources, transportation, – toxins, aesthetics, crime/poverty

Social support, social networks

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Multiple Levels of Influence on Health

Cultural group, ethnic identity– shared beliefs, values, behaviors

Occupation or workplace – occupational hazards, toxins, safety, working

conditions Health care

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Multi-level Determinants of Health

Psychosocial - social support, compliance, coping

Lifestyle - exercise, diet, alcohol, smoking, sexual behavior, illicit drug use

Health care

Sociodemographics - age, race, ethnicity, education, income

Physical environment

Social environment

Health

Psychological - beliefs, attitudes,personality

Contextual Individual-level

Organizational,institutional

Economic resources

Societal, political e.g., Larry Green,Dan Stokols

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Health care



Social environment

Health




Economic resources


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Conceptual Frameworks of Determinants: Social Support/Networks

Berkman LF and Glass T, Social integration, social networks, social support, and health, in Social Epidemiology, ch 7, p. 143.

Socialstructuralconditions

(macro)

Social networks (mezzo)

Psycho-social

mechanisms (micro)

Pathways

•Culture•Socio economic factors

•Network structure•Frequency of contact

•Social support•Social influence•Access to resources

•Health behaviors•Psychological•Physiologic

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Health care



Social environment

Health




Economic resources


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Multi-level (Ecological) Determinants of Health Behavior


Health care



Social environment

HealthBehavior

Psychological - beliefs, attitudes



Economic resources

Community resources

Emmons, K Health behavior in a social context, in Social Epidemiology, 2000, ch. 11.Policy

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Health care



Social environment

Health




Economic resources


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The Role of Socioeconomic Status (SES)

Because minority status and SES are usually confounded– SES has been a key hypothesis for observed

race/ethnic health disparities

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Socioeconomic Status: Underlying Constructs

SES is multidimensional Prestige

– Social stratification, social class– Relative social standing– Occupation

Resources– Education– Income, wealth, assets– Poverty, material deprivation

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Research on SES and Health Most researchers studying racial/ethnic

differences in health “adjust” for SES Many studies find that race/ethnicity remains a

significant determinant of health after controlling for SES– What else is going on?

Need to focus on how SES affects health– Whether the SES-health relationship varies by

race/ethnicity

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Complex Mechanisms by Which SES Affects Health

Education

EnvironmentHealth Care

Health behaviorsSocial capitalChronic stress

Psychological resourcesHealth care

HealthIncome Occupation

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Lifecourse Issues

Hypothesis: health disparities are due to the accumulation over one’s lifetime of stresses/adverse conditions

Specific research– Childhood levels of SES and cumulative

disadvantageous economic circumstances are associated with poor health in mid-life

– Lifetime experiences of discrimination due to race/ethnicity adversely affect health

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Framework: Socioeconomic Status Over the Lifecourse and Health

Lynch J and Kaplan G, Social Epidemiology, Berkman and Kawachi (eds), Oxford, 2000 (Ch 2, p. 28)

Socioeconomic Position

Birth Childhood Adulthood Old Age

Low birth weightGrowth retardation

Smoking,diet, exercise

Job stressInadequate

medical care

Intrauterineconditions

Education,environment

Work conditions,income

Income,assets

Atherosclerosis CVD Reducedfunction

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Example of Lifecourse Research

“Compared with middle- and high-income children, low-income children are disproportionately exposed to more adverse social and physical environmental conditions.” (Evans, 2004, p. 88)

Cumulative rather than singular exposure is critical…

Evans GW, The environment of childhood poverty,Amer Psychol, 2004:59:77-

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Health Services Research

Conceptual frameworks guide research in how health care affects outcomes

Health care is “the total societal effort, whether public or private, to provide, organize, and finance services that promote the health status of individuals and the community”

p. 477, Cooper LA et al., JGIM, 2002;17:477-486

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Health Services Research Frameworks

Study samples– Patients – Health plan members– Providers

Classic frameworks – Donabedian– Aday and Anderson

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Donabedian’s Structure-Process-Outcome Paradigm for Assessing Outcomes of Care

Patient outcomes

Structure of care

•Structure - features of a system of care•Process – what is done for patients

•Technical care - knowledge and judgment skills •Interpersonal care - the way care is provided

Donabedian A. Quality Review Bulletin, 1992, p. 356

Process of care:-technical care-interpersonal

care

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Donabedian’s Structure-Process-Outcome Paradigm

Patient outcomes

Structure of care


care

•Quality of care is indicated when outcomes can be attributed to antecedent processes of care

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Ultimate outcomes- health

Structure of care


care

Intermediateoutcomes:

- compliance- knowledge

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Structure of care


care



Providercharacteristics

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Examples of Research - How Structure of Care Affects Health Disparities

If systems provide medical interpreters, do patients with limited English proficiency have better health outcomes?

If systems offer a broad choice of minority providers, do minority patients have better health outcomes?

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Examples of Research Questions - How Technical Processes Affect Health Disparities

Are treatments less effective for racial/ethnic minorities than for whites?

Are appropriate diagnostic procedures used less often for minorities than for whites?

Are optimal treatments provided less often for racial/ethnic minorities than for whites?– e.g., pain medication in emergency departments

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Examples of Research Questions - How Interpersonal Processes Affect Health Disparities

Effects on health of differences in:– Communication

– Elicitation of patient concerns

– Respectfulness

– Perceived discrimination

– Participatory decision making

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Extensive Disparities in Health Care: Summarized in Two Major Reports

Unequal Treatment (IOM) 2003 National Healthcare Disparities Report

(AHRQ for DHHS) – 2003, 2004

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Unequal Treatment Requested by Congress to assess

differences in healthcare received by U.S. racial/ethnic minorities and non-minorities

Focused on – healthcare systems and their legal and

regulatory climate – provider discrimination

Institute of Medicine, Unequal treatment: Confronting racial and ethnic disparities in healthcare, National Academy Press, 2003

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Unequal Treatment: Summary Racial/ethnic minorities receive lower quality

of care then non-minorities Disparities occur in the context of broad

historic and contemporary social/economic inequality, including discrimination

Sources are complex– involve systems, administrative processes, utilization

managers, healthcare professionals, and patients A comprehensive, multi-level strategy is

needed to eliminate these disparities

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National Healthcare Disparities Report

Issued by DHHS through the Agency for Healthcare Research and Quality– Annual report to Congress on racial, ethnic,

socioeconomic, and geographic disparities Institute of Medicine provided technical

guidance – Guidance for the National Healthcare

Disparities Report, Swift (ed), Institute of Medicine, National Academies Press, 2002

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Conceptual Framework for National Healthcare Disparities Report

Components of Health Care Quality

Consumer Perspectives on health care needs:

Safety Effectiveness Patient centered-

ness

Timeliness

Staying healthy

Getting better

Living with illness or disability

Coping with the end of life

Equity

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National Healthcare Disparities Reports

2003 report:– http://www.qualitytools.ahrq.gov/

disparitiesreport/download_report.aspx 2004 report

– 2004 National Healthcare Disparities Report, USDHHS, AHRQ publication number 05-0014, December, 2004

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Key Findings: NHDR

Inequality in health care quality exists Differential access may lead to inequalities Opportunities to provide preventive care

often missed Knowledge of why disparities exist is limited Improvement is possible Data limitations hinder improvement efforts

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How Population “Variables” Affect Process and Outcomes of Care


Structure of care:

-providercharacteristics


care



Patient characteristicsEnvironment

Neighborhood resources

Family support

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The Structure-Process-Outcome Paradigm: Adding Access to Care

Patient healthoutcomes- clinical

- individual

Structure of care


care

Access to care

Aday LA and Anderson RM – Major contributors to access issues

Access to a system of care

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Defining Access to Care

Typical Definitions– Availability of health care providers in area

– Availability of health insurance/being uninsured» Type of health insurance (public versus private)» Quality of health insurance coverage

– Utilization of (appropriate) services

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IOM’s Definition of Access

“ the timely use of personal health services to achieve the best possible health outcomes”

IOM, Access to health care in America: A model for monitoring access, National Academy Press, 1993

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Within a System – Access to …

Providers of same race/ethnicity Providers who speak preferred language Timely care

– Someone to talk to by phone

– Waiting time for appointments

– Waiting time in office

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Framework for Studying Access

Potential Access – StructureCharacteristics of health

delivery systemAvailabilityOrganization

Potential Access – ProcessCharacteristics of population at riskPredisposing

EnablingNeed

Realized Access – ObjectiveUtilization of services

Realized Access – SubjectiveConsumer satisfaction

Aday LA, Anderson R, and Fleming GV. Health care in the U.S.: Equitable for whom? London: Sage, 1980

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The Behavioral Model for Vulnerable Populations: Access to Care Model

Population Characteristics

Predisposing Enabling Need Health behavior Outcomes

Gelberg L, et al., Health Serv Res 2002, 34:1273

Vulnerable populations: “at risk of poor physical, psychological,or social health”

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Conceptual Models for Health Services Research Interventions

Adapted IOM model of access to care– Incorporated elements relevant to eliminating

disparities in health care Focused on 2 types of interventions:

– Improving access to effective care

– Reducing barriers to healthy lifestyles

Cooper LA et al., JGIM, 2002;17:477-486

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Barriers to & Mediators of Equitable Health Care for Racial/Ethnic Groups: Modified IOM Model

•Personal/family•Structural•Financial

•Visits•Procedures

•Quality of providers•Appropriateness of care•Efficacy of treatment•Patient adherence

• Health status• Equity of services• Patient views of care

Barriers Use of Services Mediators Outcomes

Cooper LA et al., JGIM, 2002;17:477-486

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The Behavioral Model for Vulnerable Populations: Traditional Domains



DemographicsHealth beliefsSocial structure - ethnicity - education - social networks

Personal/family resources- insurance, incomeCommunity resources- residence, region

Perceived healthEvaluated health-general population conditions

Personal health practices- diet, exercise, tobaccoUse of health services- ambulatory, inpatient

HealthSatisfaction -general -technical -interpersonal

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The Behavioral Model for Vulnerable Populations: Vulnerable Domains



DemographicsHealth beliefsSocial structure-acculturation-literacy

Personal/family resources- competing needs, hunger- transportationCommunity resources-crime rates

Perceived healthEvaluated health-vulnerable population conditions

Personal practices- food sources- hygiene- unsafe sex

HealthSatisfaction-general-technical-interpersonal

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The Behavioral Model for Vulnerable Populations: Vulnerable Domains



DemographicsHealth beliefsSocial structure-acculturation-literacy

Personal/family resources- competing needs, hunger- transportationCommunity resources-crime rates

Perceived healthEvaluated health-vulnerable population conditions

Personal practices- food sources- hygiene- unsafe sex

HealthSatisfaction-general-technical-interpersonal

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Summary Numerous frameworks

– Health services and population science Worth reviewing in designing health disparities

research– Reflect theories and research from many disciplines

1 Overview of Conceptual Frameworks of Health and Health Disparities Anita L. Stewart, Ph.D. University of California, San Francisco Institute for Health.

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