WHAT TO DO WITH SOCIAL DETERMINANTS OF HIV? Dula F. Pacquiao, EdD, RN, CTN-A, TNS Professor, Rutgers University School of Nursing Newark, NJ.

WHAT TO DO WITH SOCIAL DETERMINANTS OF HIV?

Dula F. Pacquiao, EdD, RN, CTN-A, TNSProfessor, Rutgers University School of NursingNewark, NJ

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OBJECTIVES

1. Describe social determinants of health in vulnerable populations affected by HIV.

2. Analyze evidence of the pathways by which social determinants create differential epidemiological vulnerability in population groups.

3. Evaluate current strategies and initiatives in HIV prevention and management using research evidence on social determinants of health.

HIV- RELATED HEALTH DISPARITIES

Despite prevention efforts, some groups of people are affected by HIV/AIDS, viral hepatitis, STDs, and TB more than other groups of people.

Differences may occur by gender, race or ethnicity, education, income, disability, geographic location and sexual orientation among others.

Social determinants of health like poverty, unequal access to health care, lack of education, stigma, and racism are linked to health disparities.

HIV-RELATED HEALTH DISPARITIES

Poorer communities have higher rates of HIV/AIDS Patients with low SES have lower rates of survival Patients without adequate insurance are less likely to

be on ART Substance abusers and minorities are more likely to

delay medical care Minorities continue to experience higher death rates ,

even after introduction of combination therapy Patients who are homeless or unstably housed do not

have regular source of care and less likely to receive or stay on ART

RACIAL/ETHNIC DISPARITIES IN TB: 2010 (CDC, 2013)

Compared with whites, TB rates were approximately: 7x higher among Hispanics 8x higher among Blacks 25 x higher among APIs

Compared with whites, the relative difference in TB rates was: 614% for Blacks 429% for APIs 286% for Hispanics 757% for AI/ANs

TB DISPARITIES BASED ON NATIVITY

1993-2010 TB cases among foreign-born increased from 29% to 60%.

2006–2010 59% of reported TB cases occurred among foreign-born. Relative difference in TB rates among foreign-born vs. US born

was 857% in 2006 and 1,031% in 2010.

2010: Among foreign-born, the relative difference in TB rates compared with whites was:

2,271% for APIs 1,771% for Blacks 836% for Hispanics

TB DISPARITIES BY EMPLOYMENT

TB cases among unemployed persons was 53% in 2006 and 59% in 2010.

Relative difference in reported TB cases among unemployed persons compared with those employed in fields other than health care was 74%, a change of 44.2% over time

Relative difference in reported TB cases among persons whose primary health-care provider for TB disease was a health department compared with persons whose primary health-care provider for TB disease was private/other providers was 217%, a change in the relative difference of 109% over time.

HEALTH DISPARITY (CDC, HRSA, DHHS)

A type of difference in health closely linked with social or economic disadvantage that negatively affect groups of people who have systematically experienced greater social or economic obstacles to health.

Obstacles stem from characteristics historically linked to discrimination or exclusion such as race or ethnicity, religion, socioeconomic status, gender, mental health, sexual orientation, or geographic

location.

INEQUALITY VS. INEQUITY (Sadana & Blas, 2013)

Health inequalities- differences in access to a range of promotional, preventive, curative, or palliative health services or differences in outcomes including disability, morbidity, and mortality spanning physical, mental, and social health.

Health inequities -differences in health that are judged to be avoidable, unfair, and unjust; often revealed through systematic patterns or gradients in access or outcomes across populations with different levels of underlying social advantage or disadvantage (wealth, power, prestige, or other markers of social stratification).

HEALTH DISPARITY AS A CHAIN OF EVENTS

1. Environment2. Access to, utilization of, and quality of

care3. Health status, or4. A particular health outcome deserving

scrutiny

(Carter-Pokras & Baquet, 2002)

ENVIRONMENT

Natural and Built environment Social environment

Linked with: SES (income, education, occupation)

(Babones, 2011) Race and ethnicity (Kawachi et al 2005) Social status (Marmot, 2006)

SOCIAL DETERMINANTS OF HEALTH (Marmot & Bell, 2009)

Life conditions that tend to be cumulative in their influence on health

Conditions where people are born, grow, live and work

ECOSOCIAL /EMBODIMENT THEORY (Krieger, 2011)

Humans embody their material and social world Health and disease in populations patterned by:

Societal arrangements of power, property, production, consumption and reproduction

Possibilities of the human body shaped by evolution, ecology, context and history.

These causal pathways create the cumulative interplay of exposure, susceptibility and resistance to diseases or illness.

ECOSOCIAL/EMBODIMENT THEORY

Health disparities understood by examining the proximal pathway of embodiment stemming from social inequities (race, class, gender, economic and political) that create differences in health and biology.

Pathways of embodiment can occur in multi-level contexts of global, national and local communities or neighborhood, family and individual.

ALLOSTATIC LOAD (McEwen, 2008)

Acute stress produces responses that promote adaptation and survival through neural, cardiovascular, autonomic, immune and metabolic systems

vs. Chronic stress promotes and exacerbate

pathophysiology through the same systems that are dysregulated.

ALLOSTATIC LOAD OR OVERLOAD

Resulting wear and tear from too much stress, inefficient allostasis • Inability to turn off the stress response when not needed• Ineffective response to stress or not adapting to the

same stressor over time.• Changes in personal behaviors that aggravate allostatic

load as smoking, overeating, drinking, poor quality sleep, violence, risky sexual behaviors.

• Affects memory, attention, cognition, learning, fear and unlearned fears, anxiety, aggression

• Health effects: PTSD, HTN, obesity, Type 2 diabetes, cancer, mood disorders

Race/ethnicity

Residential location

Neighborhoodresources

CommunityStressors

StructuralFactors

EnvironmentalHazards and

pollutants

Community Stress Exposure

Internal DoseIndividual stressorsIndividual copingAppraisal process

Individual stress

BiologicallyEffective dose

Residential Segregation

Health effect(disparities)

Community-levelvulnerability

Individual-levelvulnerability

Stress Exposure Disease Framework ( Gee and Payne Sturges,2004)

WHAT IS HEALTH (WHO, HEALTH CANADA)

A capacity or resource rather than a state of being

Capacity of people to adapt to, respond to, or control life's challenges and changes" (Frankish et al., 1996). Being able to pursue one's goals, to acquire skills

and education, and to grow. Recognizes the range of social, economic and

physical environmental factors that contribute to health.

HEALTH (WHO, 1946)

HEALTH PROMOTION WITHIN PHC

Health promotion - the process of enabling people to increase control over, and to improve their health (WHO, 1986).

Enabling or empowering people to address factors that affect their health

Improvement of health rather than just maintenance of health built on a system focused on individuals and the communities where they live.

Health promotion is holistic and integrates mental, physical and social well-being.

POPULATION HEALTH

An approach to health that aims to: Improve the health of the entire population Reduce health inequities among population

groups.

Examines and acts upon the broad range of factors and conditions that have a strong influence on health.

CRITIQUE OF POPULATION-APPROACHES (Frohlich & Potvin, 2008)

Population at-risk – individuals with elevated risk for specific disease (biological risk)

versus Vulnerable populations – subgroup or subpopulations

at higher risk of risks because of shared social characteristics (social vulnerability; implications for chronic disease)

IMPLICATIONS OF ECOSOCIAL THEORY AND ALLOSTATIC LOAD

UPSTREAM DOWNSTREAM Improving education,

housing, minimum wage Occupational and

environmental safety Better zoning and land

use Fair taxation

Early detection of diseases

Disease-prevention education

Disease-based health care

Use of appropriate pharmaceutical agents to combat stress

POPULATION FOCUSED AND HEALTH-FOCUSED Address social determinants

Poverty Employment, sufficient wages

Residential and work environment Access to healthy, safe and affordable food Access to healthy, safe and affordable housing Access to healthy and safe environment Access to safe and quality schools

Combat stigma, marginalization and discrimination

POPULATION FOCUSED AND HEALTH-FOCUSED

Focus on communities and populations where they live, grow and work

Emphasize health promotion rather than disease-focused prevention alone

Focus on families/populations and communities rather than just individual patients

INITIATIVES ON SOCIAL DETERMINANTS Moving to Opportunity (Leventhal & Brooks-Gunn, 2003) Health in all policies (Avey, et al 2013) Primary health care (Chu & Selwyn, 2011) Project LEAD in Australia to combat racism (Ferdinand, et al

2013) Community engagement (Hardy, et al 2013). Community and academic partnership (Ramos, et al 2013) Health impact assessment of zoning (Thornton et al 2013) Protecting labor rights (Bhatia, et al., 2013) Binational collaboration for occupational safety (Flynn et

al., 2013)

LESSONS LEARNED Economic improvement

Employment Education Wages

Addressing work and residential environments Safety and quality Transportation Access to resources

Combating discrimination Multisectoral collaboration

Building social capital and social networks Policy and program development and evaluation Research and measurements on social determinants