A model for understanding disparities in health and health

care

Scott Commins &

Dr. Raymond Greenberg

Figure 1 - Survival of males to the age of 65 in Harlem, Bangladesh, and among U.S. Whites in 1980(NEJM, 1990; 174).

Figure 2 - Life expectancy (in years) at birth

by race and sex, United States, 1998.(Source: Health, United States, 2000)

WhiteMale

BlackMale

BlackFemale

Lif

e e

xp

ecta

ncy

at

bir

th (

years

)

WhiteFemale

60

65

70

75

80

75

68

80

75

Life Expectancy

RACE

Cause of Death

Figure 3 - Age-adjusted death rates from all causes by race and sex,

United States, 1998.(Source: National Vital Statistics Reports 2000;

48 (11): 63)

WhiteMale

BlackMale

BlackFemale

Death

s p

er

100,0

00

pers

on

s

WhiteFemale

250

500

750

1000

562

885

355

541

Figure 4 - Age-adjusted death rates from heart disease by race and sex,

United States, 1998.(Source: Natl. Vital Stat. Rep. 2000; 48 (11): 63)

WhiteMale

BlackMale

BlackFemale

Death

s p

er

100,0

00

pers

on

s

WhiteFemale

50

100

150

200

250

162

232

88

147

50

Figure 5 - Age-adjusted death rates from

cancer by race and sex, United States, 1998.

(Source: Natl. Vital Stat. Rep. 2000; 48 (11): 63)

WhiteMale

BlackMale

BlackFemale

Death

s p

er

100,0

00

pers

on

s

WhiteFemale

0

75

150

225

144

208

104129

0

Figure 6 - Age-adjusted death rates from

stroke by race and sex, United States, 1998.

(Source: Natl. Vital Stat. Rep. 2000; 48 (11): 64)

WhiteMale

BlackMale

BlackFemale

Death

s p

er

100,0

00

pers

on

s

WhiteFemale

0

10

20

30

40

50

25

47

22

37

0

Figure 7 - Age-adjusted death rates from diabetes mellitus by race and sex, United States, 1998.

(Source: Natl. Vital Stat. Rep. 2000; 48 (11): 63)

WhiteMale

BlackMale

BlackFemale

Death

s p

er

100,0

00

pers

on

s

WhiteFemale

0

10

20

30

14

29

11

29

0

Figure 8 - Age-adjusted death rates from hypertension by race and sex,

United States, 1998.(Source: Natl. Vital Stat. Rep. 2000; 48 (11): 63)

WhiteMale

BlackMale

BlackFemale

Death

s p

er

100,0

00

pers

on

s

WhiteFemale

0

5

10

2

8

2

7

0

II. What is it about race?

• Understanding the basics:

Do racial differences existin socioeconomic

indicators?

Figure 9 - People living in poverty by race,

United States, 1999.(Source: US Census Bureau)

White Black0

10

20

30%

in P

over

ty

8

24

0

Figure 10 - Educational attainment of adults

25 years or older by race, United States, 2000.

(Source: US Census Bureau)

< H SGrad

H SGrad

SomeCollege

CollegeGrad +

0

10

20

30

40BlackWhite

21

12

35 34

27 26

17

28

%

0

Figure 11 - Quintiles of household income by race,

United States, 1999.(Source: US Census Bureau)

I II III IV V0

50

100

150

BlackWhite

Inco

me

inThousa

nds

of D

ollar

s

0

III. Do the differences in SES

indicators affect health?• Proposing a model:

How do we examine the cause(s) of disparities in health?

SubstandardLiving

Conditions

Unemployment

PoorNutrition

Risk-PromotingLifestyle

DiminishedAccess to

Health Care

Poverty/Lower SES

Figure 12 - Percentage of persons under age

65 years with private medical insurance

by income, United States, 1997.(Source: Health, United States, 2000)

% of Poverty Level<100100-149150-199200+

Pri

vate

Med

ical

Insu

ran

ce (

%)

0

25

50

75

100

24

42

64

88

0

Figure 13 - Percentage of persons under

age 65 years with private medical insurance by race, United States,

1997.(Source: Health, United States, 2000)

White Black

Pri

vate

Med

ical

In

su

ran

ce (

%)

0

25

50

75 74

56

0

Figure 14 - Percentage of persons 18 years

or older with 2 or more emergency room

visits in the past year, United States, 1998.

(Source: Health, United States, 2000)

Poor NearPoor

Non-Poor

Pers

on

s w

ith

tw

oor

more

ER

vis

its/y

ear

(%)

0

5

10

1513

10

5

0

Figure 15 - Percentage of children less than

18 years old with no usual source of health care, United States, 1997-98.

(Source: Health, United States, 2000)

Poor NearPoor

Non-Poor

Ch

ild

ren

wit

h n

ou

su

al sou

rce o

fh

ealt

h c

are

(%

)

0

5

10

1512

10

4

0

SubstandardLiving

Conditions

Unemployment

PoorNutrition

Risk-PromotingLifestyle

DiminishedAccess to

Health Care

Poverty/Lower SES

Figure 16 - Percentage of children 1-5 years

old with blood lead levels 10 ug/dl by family income, United States,

1991-94.(Source: NHANES III, 1996)

Ch

ild

ren

wit

h h

igh

blo

od

lead

levels

(%

)

Low Middle High0

5

108

21

0

Figure 17 - Percentage of persons with blood lead levels 10 ug/dl by family income, United States,

1991-94.(Source: NHANES III, 1996)

Pers

on

s w

ith

hig

h b

lood

lead

levels

(%

)

Low Middle High0

3

65

2

1

0

SubstandardLiving

Conditions

Unemployment

PoorNutritio

n

Risk-PromotingLifestyle

DiminishedAccess to

Health Care

Poverty/Lower SES

Figure 18 - Percentage of children age 16

years or less with food insufficiency by

family income, United States, 1988-94.

(Source: NHANES III, 1996)

Ch

ild

ren

wit

hfo

od

in

su

fficie

ncy

(%

)

Low Middle High00

10

2016

20

Figure 19 - Percentage of children 6-16 years old with iron deficiency by family income, United States, 1988-

94.(Source: NHANES III, 1996)

Ch

ild

ren

wit

hir

on

defi

cie

ncy (

%)

Low Middle High0

5

10

6

3

1

0

SubstandardLiving

Conditions

Unemployment

PoorNutrition

Risk-PromotingLifestyle

DiminishedAccess to

Health Care

Poverty/Lower SES

Figure 20 - Unemployment rate of civilian labor force age 20 years or

older by race and sex, United States, July,

2001.(Source: Bureau of Labor Stats., July, 2001)

WhiteMale

BlackMale

BlackFemale

Perc

en

t u

nem

plo

yed

WhiteFemale

0

5

10

3.4

8.9

3.5

7.0

SubstandardLiving

Conditions

Unemployment

PoorNutrition

Risk-PromotingLifestyle

DiminishedAccess to

Health Care

Poverty/Lower SES

Figure 21 - Prevalence of cigarette smoking

among white males 25 years or older by

educational attainment, United States, 1998.

(Source: Health, United States, 2000)

< H SGrad

H SGrad

College Grad +

Pre

vale

nce o

fcig

are

tte

sm

okin

g (

%)

SomeCollege

0

10

20

30

40 3732

25

11

0

Figure 22 - Prevalence of cigarette smoking among adults by employment

status, South Carolina, 1995-96.(Source: SC Prevention Adult Household

Telephone Survey, 1995-96)

0

10

20

30

4033

22

Unemployed Employed

Pre

vale

nce o

f cig

are

tte s

mokin

g(%

)

Figure 23 - Prevalence of cigarette smoking

among persons 25 years or older by race and sex, United States, 1998.

(Source: Health, United States, 2000)

15

20

25

30

35

25

30

22 23

WhiteMale

BlackMale

BlackFemale

Pre

vale

nce o

fcig

are

tte

sm

okin

g (

%)

WhiteFemale

15

Figure 24 - Prevalence of obesity by race and sex, United States, 1988-94.

(Source: Health, United States, 2000)

WhiteMale

BlackMale

BlackFemale

Pre

vale

nce

of

ob

esit

y (

%)

WhiteFemale

10

20

30

40

20 2124

38

10

SubstandardLiving

Conditions

Unemployment

PoorNutrition

Risk-PromotingLifestyle

DiminishedAccess to

Health Care

Poverty/Lower SES

An Illustrative Example:Childhood Lead

Toxicity

IV. Employing the Model

Good Health Care?

You memorized the high lead threshold and used proper medical intervention, but have you addressed the underlying issues?

Probably not, because doing so requires identification of the contributing factors and intervening on numerous levels...

Contributing Factors• Unhealthy environment -

Increased risk of exposure to lead-based paint

• Parental education - Lack of knowledge regarding hazards

• Access to care - Poor screening results in delayed

detection and treatment

Public Health Perspective

• Treating the lead poisoning alone may not besufficient for this child

• Treating this child alone may not be sufficientfor the community