addressing social determinants through community & system change by aida l. giachello, ph.d....

Addressing Social Determinants through Community & System Change

By

Aida L. Giachello, Ph.D.

Associate Professor & DirectorMidwest Latino Health Research, Training

and Policy CenterUniversity of Illinois at Chicago

[email protected] at the State Workshop on Latino Health,

Columbia, MD

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Objectives Briefly list selected health disparities

of Hispanics/Latinos (H/L) and the sources of the disparities

Share some strategies on how to address the health and social needs of the growing Hispanic/Latino population through community and system change

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Public Interest in Hispanic/Latino Health Disparities in Montgomery County & in Maryland

1. Dramatic population growth In 2006, 128,365 H/L lives in Montgomery

Country representing the 2nd largest minority in the County

MC has the largest concentration of H/L in MD

Most H/L are from Central America (44%), followed by South America (22.4%)

65% of H/L are foreign born

Interest in H/L Health Disparities issues…….

2. Mobilization of H/L groups and forming partnership with the Montgomery Dept of HHS and other sectors

Hispanic Health Initiatives BluePrints for Latino Health in

Montgomery County

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Public Interest in H/L health Disparities 3. Increased Research & DataNational Mortality Data:

1. Heart Disease (65+)2. Cancer (particularly

breast, cervical (45+) and lung (25-44) cancer)

3. Injuries-- leading cause of death: 24-44 yrs

4. Cerebrovascular diseases

5. Diabetes- 3rd cause of death for persons 45+

6. Homicide-- leading cause of death: 15-24 yrs

7. Pneumonia and influenza (65+)

8. Liver diseases (cirrhosis)

9. Pulmonary diseases

10.HIV/AIDS (25-64)11.Kidney failure

(65+)12.Maternal deaths

Interest in H/L Health Disparities issues…Res & Data…

Montgomery County HIV/AIDS

In 2005, H/L accounted for 1.6 times as many new HIV diagnoses as non H/L whites (MD Dept of PH, 2007).

Tuberculosis TB for H/L in Maryland is 3.5 times Foreign-born Latinos in Maryland is 12.5

higher than for the US

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Interest in H/L Health Disparities issues…Res & data...

Type 2 Diabetes Leading cause of death Latinos are diagnosed after the age of 38 New cases are emerging among children

and adolescents and young adults Diabetes complications serious problems

Diabetic end-stage renal disease among 55+ is 10%-20% higher than whites

Hypertensive end-stage renal disease rates is 1.5 to 5 times higher than whites

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Interest in H/L Health Disparities issues…Res & Data… Over-weight and obesity

In 2005, 3 out of 4 H/L 40 years of age were overweight (46%) or obese (30%)

Community Safety issues discourage physical activity

Limited income lead to limited access to healthy food options

Communities designated food dessert Occupation injuries & fatalities Social stress, violence, suicide/homicide, social

discrimination & anti-immigrant sentiment 8

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Hispanic/Latino Health Vary By

Age Socio-economic status Place of birth National origin Acculturation and assimilation “Push” and “pull” factors related to

immigration Neighborhood, place of employment, etc

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High acculturation impact negatively Latino Health

+Infant mortality +Low birth weight

babies +blood pressure +Obesity

+Teen pregnancy +Smoking +Alcohol use +Other drug use -breast-feeding

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TRUE SOURCES OF DISPARITIES

1. Poverty & Low SES• Neighborhoods and school segregation and neighborhood

quality• Poor neighborhood becomes market for tobacco, alcohol

and fast food Large families, average size of 3.96

44% have more than 4 members H/L has the lowest per capita income in Montgomery

Country ($20,165), representing 37.4% of whites ($53,926).

52% work in the Service or Construction industries

Factors affecting poverty rates

Low education Low earnings High

unemployment High poverty

among married couple families

High teen pregnancy

& parenthood High no. of

families headed by women

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Public Response to Health Disparities: Blaming the Victim

Don’t be poorDon’t be unemployedChange jobsChange neighborhoodetc

True Sources of Disparities: 2. Access to Care Barriers

No regular source of care—in MC Over 50% have no medical home)

Lack of health insurance (50-58%) [2005 and 2007 cancer study]

System barriers Limited bilingual and bicultural staff Long traveling time to go to healthcare

facility Lack/limited transportation

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True Source of Health Disparities…Access to

care… Systems- barriers

Lack of capacity of health care facilities

Long waiting time between calling for an appointment and the actual visit

Long waiting time once you get to doctor’s office

Lack of hours of services during evening or weekends

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Other Healthcare Systems-level barriers

•In managed care organizations, financial In managed care organizations, financial incentives to providers tend to limit incentives to providers tend to limit servicesservices• “ “Fragmentation” of services and poor Fragmentation” of services and poor coordinationcoordination

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True Source of Health Disparities…Access to care…System Barriers. Lack of interpreters– For example 1 out 5 have Gone Without Care

When Needed Due to Language Obstacles Poor pt-doctor communication NO interpreter services available

Only 1 out of 4 requests received interpreter in MC

1 of 6 failed to make an appt due to language barrier in MC

1 in 5 could not complete their phone calls in MC

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True Source of Health Disparities…Access to Care…

Low use of health and medical care Delays seeking care and using preventive

services Limited familiarity with the health care

system and low health literacy Uses home remedies and OTC Uses medication from their country of

origin Seek non professionals (e.g., faith healers)

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True Source of Disparities…Access to care…

Eligibility issues 1996 Immigration reform made eligibility

for public funder programs more restrictive for more immigrants

Concerns about deportation

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July 29 – August 6

Source: Kaiser Health Tracking Poll, Election 2008: August 2008

The Obama Plan Mandated coverage for kids Pay-or-play for employers New public plan offered No tax credits/changes Expansion of Medicaid/SCHIP Invest $10 B in HIT Cost: estimates range from

$50-110 B a year

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3. Sources of Health Disparities: Poor Quality of Medical Care

Most of the improvements in health in the last 100 years have been the results of improvement in public health, sanitation, nutrition and living conditions

Physicians and other health professionals are not familiarized with clinical guidelines for the management and control of chronic diseases

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•Racial and ethnic minorities and women receive poor care due to physicians’ biases and stereotypes

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3. Source of Health Disparities:Poor medical care…

Due to long history of race/ethnic and gender bias in the medical care system Mexican Americans received 38% fewer

medications (antiarrhythmics) than whites

Hispanics in a Los Angeles hospital ER, were least likely to receive no analgesia for their injuries

Source: Goldberg et al. 1992; Herholz et al. 1996; Blustein et al, 1995; Todd et al, 1993

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3. Source of Disparities: Poor Medical Care…Conclusions of IOM Report

“Across virtually every therapeutic intervention, ranging from high technology procedures to the most elementary forms of diagnostic and treatment interventions, minorities receive fewer procedures and poorer quality medical care than whites

Differences persist after controlling for health insurance, SES, stage and severity of disease, comobidity, and the type of medical facility”

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Disparities in the Clinical Encounter: The Core Paradox (Williams, 2004)

How could well-meaning and highly educated How could well-meaning and highly educated

health professionals, working in their usual health professionals, working in their usual

circumstances with diverse patient populations, circumstances with diverse patient populations,

create a pattern of care that appears to be create a pattern of care that appears to be

discriminatory?discriminatory?

Williams argues that it has to due with Williams argues that it has to due with

stereotypingstereotyping

Unconscious Discrimination When one holds a negative stereotype

about a group and meets someone who fits the stereotype s/he will discriminate against that individual

It is automatic and unconscious process It occurs even among persons who are not

prejudiced

“I am not racist: I know I don’t stereotype”

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Factors that Increase Stereotype Usage in Medical Care

Time Pressure Need for Quick Judgments High Cognitive demands Task Complexity Resource constraints Anger or Anxiety

Source: Williams, 2004; Van Ryan 2002

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Conclusions

Many sources are responsible for health disparities• Socioeconomic and environmental

conditions• Financial, linguistic, cultural and system

barriers to access to care; • Poor medical care as a result of Medical

Professional behaviors in clinical settings

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STRATEGIES & RECOMMENDATIONSFOR ACTION

To address the social determinants of health we must work at different levels:

Individual Empowerment of H/L

Family NeighborhoodMacro:

Health and other systems Other systems

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Long term institutional/structural changes

This calls for an improvement in the levels of education and income, and better distribution of resources and services for all Hispanics/Latinos

H/L health must be viewed within a broader societal context

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Stronger Government & Private Sector Commitment at all Levels

For Example: To eliminate health disparities, in addition to the

DHHS, you need to involve the Depts. of Education, housing, Commerce, Environmental Protection Agencies, etc.

You need Strong commitment from businesses, foundations, and many other key players

For example, MC DHHS should establish a multi-sectorial council across departments

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For Example: Structural Conditions Impacting Health

Type and location of employment within the economic structure (i.e., services industry)

Environmental and occupational hazards.

By not addressing the origins of the problems we are treating the most costly symptoms

We need to Recognize Health Inequities

Systematic and unjust distribution of social, economic, and environmental conditions needed for health Access to healthcare Employment Education Access to resources (e.g. grocery stores,

car seats) Housing Transportation Freedom from discrimination

Source: Whitehead M. et al

Social Determinants of Health: Socio-ecological Model

Source: Institute of Medicine, 2003

Social Determinants of Health

Social Determinants of Health:Refers to…

Life-enhancing resources, such as food supply, housing, economic and social relationships, transportation, education, and health care, whose distribution across populations effectively determines length and quality of life.

Source: James S., 2002

Adopt Population based approach including multiple determinants of Health For example:

Public Health Working with the Business Community Why should business care about diabetes

prevention and control? Loss productivity Increased health care expenditures Poorer quality of life for employees Consequences related to permanent

disability What can the food industry do?:

Educate its members, make available fruits and vegetables

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5. Adopt a Population-level Approach, including Multiple Determinants of Health…

Work with the school system to change the School Environment Changing School Environment Curbs Weight

Gain In Children, Study Shows (Apr. 7, 2008) Public Health Law Reform (federal, state,

local) Arkansas Act 1220, An Act to Combat

Childhood Obesity Act 1220 is now codified, in part, at Ark. Code Ann. 20-7-135 (2005)

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Population approach to address multiple determinants of health

New York - The Board of Health voted to make New York the nation’s first city to ban artery-clogging artificial trans fats at restaurants-- MSNBC News Services, Dec. 5, 2006

U. S. District Court for the Southern District of New York upheld the constitutionality of New York City’s calorie-posting requirement for restaurants of a certain size and type. Apr. 16, 2007)

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Develop & Sustain different partners

Role of the Workplace What can employers do

Employee risk assessments Employee education Health plan benefit design/disease

management vendors Environmental change (supportive

environment)

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Sustaining partnerships

Partnerships will require: Forging a common language and

understanding Exchange of information and data Learning together about effective

strategies for the workplace Recognizing efforts

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Increase accountabilityReview the regulatory authorities of DHHS agencies to

maximize effectiveness and collaboration across departments, and with other state and local health agencies

How can WIC be used to impact on the childhood obesity epidemic?

How can the DOT integrate health and physical activity goals into transportation planning?

What is the role of DOE in supporting implementation of K-12 Health Education Standards?

Is there a body that coordinates activities across agencies to address the obesity epidemic? Do we need one?

Can we eliminate tobacco use in public housing 45

Advocate & Support Health Care reform and Single-payer System

Health care is a right and not a privilege

Sooner or later we must have a national solution

Without health we cannot work, we cannot take care of our families, and we cannot be productive citizens

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Need for close monitoring of Managed-care Networks

Concerns exist with Access to specialists and/or

hospitalization Marketing strategies Limited support services and follow-up Possible violations of patients’ rights Assure that Health insurance

plans/managed care cover preventive services according to guidances

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•

Improve H/L Access and use of Health and mental health services &

Advocate for better quality of health/medical care, mental health & Human services

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Develop and implement Creative Public Health Solutions and Models

Example:Racial and Ethnic Approaches

to Community Health (REACH) 2010, a CDC Initiative

& Center of Excellence for the Elimination of Disparities

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REACH 2010: Building partnerships

Calls for community mobilization and system change

Encourage coalition building and establishing partners with non-traditional sectors Chamber of Commerce, food industry Faith communities etc

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Increase data and Research on Hispanics/Latinos

Issues Health data systems are poorly equipped to

provide information on the health status of Hispanic groups (GAO Report, 1992)

Insufficient Identifiers for subgroups Incompleteness Ethics (informed consent is often violated) Managed-care systems do not collect data

on demographic and socioeconomic characteristics of participants enrolled in the plans

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Community Participatory Action Research Model & Action Planning

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UIC – CSDCAC Phase I: Participatory Action Research & Coalition Building Model

CommunityDialogue

Coalition Formation

Capacity-Building

(Training)

Assessment, Data

Collection &Analysis

Disseminationof findings &CommunityConsultation

Evaluation

Process

ProblemDefinition

CommunityInvolvement

Strengthening

Orientation

EstablishingCom. Action

coalition

Community Organizing &

Coalition-building

Topic area 101 &

201

APPLIEDResearch Methods

TelephoneSurvey

Focus Groups

Analyses of Epidemiological

Data

ResourceSurvey &

Community. mapping

CommunityForums/Town

Meetings

Formationsof

Committees

FinalizeACTION PLAN

(logic Model)

ValuesGoals &

Objectives

Strategies

Activities

1 2 3 4 Giachello, 2003) 6

Strengths & limitations

ResourcesNeeded

SEM level Activity/ Target Effects Intermediate Outcomes

Long-term Outcomes

Political/ Economic System

Health-Social Service System

Organiza-tional

Community/ Interpersonal

Capacity-Building

Workshops

Develop Policy

Agenda

Influence Power-brokers

Practice Change

>Access minority clients

Policy Change

>Resources at Local

Level

Trainers Trained

Change in Local Norms

Training deliveredin Comm.

Cross-organiza-

tional policy change

<Socio-economic Barriers to Health

EquityStrengthen Coalition

Involve non-

health sectors

Obesi-ty

Reduc tion

CEED@Chicago Model: Systemic Links Across Socio-ecological Levels

ECP 2-20-09

TRAINING & TECHNICAL ASSISTANCE

CEED REACH-US HEALTHY EATING & PHYSICAL ACTIVITY PROGRAM

MULTI-SECTORAL PARTNERSHIPSPUBLIC POLICY

INITIATIVES

EMPLOYERS

PARK DISTRICT

GROCERY STORES

PROFESSIONALORGANIZATIONS

e.g. ADA

FAITH COMMUNITY

RESTAURANTSCDOHWIC

FOOD INSPECTION

MEDIA

CBOs

CHAMBER OF COMMERCE

SCHOOLS

APPOINTED & ELECTEDOFFICIALS

NEIGHBORHOODBLOCK CLUBS

Create Capacity and Engage in Workforce Development by Training Community Residents as Health Promoters

Changes Hb A1c Wave I

16.5

14.7

12.4

11.8

10

11

12

13

14

15

16

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Class #1 Class #12 6 Months after class #12 12 Months after class #12

Time of Intervention

HbA

1c3

Ran

ge

Hb A1c

Effectiveness of Health Promoter as diabetes educators

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Integration of Health in Human Services delivery

Establishing Health Promotion & Wellness Center in the community managed by Health Promoters These centers have walking clubs, and

engages in policy and advocacy activities in addition to health education and support

Integrating health promoters in primary care settings

Integrate health promotion programs in social services organizations

Examination of the impact of recent social & health Policies

Welfare Reform on health status and on access to health care

Immigration Reform Children’s Health Insurance Program

(CHIP) Affirmative Action Child Care Legislation Medicaid and Medicare Managed-Care Medicare Prescription Drug Plan

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Increase Latino representation in health and human services Professions

Between 60% to 75% of Latinos never go to college

Those that do go, less than 10 will graduate 90% of our students are in urban public

schools which suffer from a limited tax base School segregation has increased for

Hispanics/Latinos Only 3% of all teachers in US are Hispanics

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increase/encourage H/L leadership development

This calls for vision passion Commitment team work Knowledge and skills Willing to lead and seeking opportunities to

lead Risk taking Perseverance

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Achieve Cultural Competency in the health care system

At the individual levelOrganizational level

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Cultural Competency at the Institutional Level

Refers to practices, norms, value and policies (written or not) in the health care delivery system that either respond or do not respond to the needs of racial and ethnic minority (or no- minority) groups, or other diverse populations (e.g., the poor, women, gay and lesbians, people with special needs, etc)

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Cultural Competency strategies at the Institutional/Organizational level of the health care Delivery System

Steps Commitment from the top

organization leadership (e.g., board of directors/Bd of Trustees, President/CEO, Medical Director, etc) Commitment must be reflected in

budget allocation Recruitment of H/L in policy

decision-making positions

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Steps to achieve CC in the health care system (2) Establishment of a Community

Advisory Committee to the Agency They can also contribute to

identifying problems and the solutions

Conduct an assessment of needs and assets Within the institution/organization Target communities/catchments'

areas

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Steps to achieve CC in the health care system (3)

From the community assessment of needs and assets data develop policies & programs

Suggested Policies and practices Board of Directors/bd of Trustees

Recruitment of minorities in board Given minorities leadership roles Establishment of a policy on cultural diversity etc

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Steps to achieve CC in the health care system (4)Suggested Policies…..

Personnel When positions are open, qualified H/L

should be recruited with appropriate salary compensation Hire Executive Recruiters to assist, if needed Establish community personnel committee Promote jobs in ethnic media Use informal minorities network

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Suggested Policies….. Research & Data

inclusion of ethnic identifiers partnership with Universities On-going analyses of agency’s data On-going collection of data (e.g., pt.

Satisfaction surveys) Development and dissemination of reports

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Marketing of programs & services Assess channel of health information used

by H/L Provide contracts to H/L media Develop bilingual educational materials

(e.g., program brochures, newsletters) for population with low levels of health literacy

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Plan and implement cultural, gender and educational-appropriate Diversity Training Form a planning committee with members

of staff at different levels Assure to conduct training with

administrative staff (particularly middle management staff and supervisors)

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Suggested Policies….. Cultural Diversity Training….

Focus on one racial/ethnic group at a time Assure that training has group/individual

self-assessment exercises and activities Provide a forum for honest discussion and

ventilation of problems, concerns and identification of solutions

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Suggested Policies…..Cultural Diversity Training….

Provide multiple training sessions so everyone can attend, including administrators

Recognize that CC is an on-going process Identify minority vendors as trainers

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Suggested Policies…..Cultural Diversity Training….

You need to have realistic expectations. Things at times have to get worse before they get better. Be careful with firms that assures that they can sensitize everyone in one-two training session

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Suggested Policies….. Establish translation services

Establish a telephone hotline for non-English speaking persons calling in

Develop an interpreter/translation system with trained individuals who knows the medical terminologies

Hire minority vendor for translation of materials Establish patient navigator programs Integrate trained health promoters as educators and

to conduct outreach, home visits and follow up with professional backup

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Suggested Policies….. Establish translation services….

Use ATT interpreter telephone line, only if bilingual interpreters are not available

Do not use bilingual staff with other assignments Do not use bilingual children, other

relatives, neighbors or friend, due to ethical issues (e.g., violation of confidentiality)

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Suggested Policies….. Establish translation services….

Train or hire interpreters who knows the medical terminologies

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Suggested Policies….. Develop benefit package for target

communities. E.g. : Support and attend cultural events Support and attend community

organizations benefits Provide scholarships in health career

development (e.g., nursing) for local residents

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Suggested Policies….. Have staff to sit in board of directors of

CBOs Provide job opportunities to local

residents, including training and recruitment of community health workers or health promoters

Provide uncompensated care for poor families

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Suggested Policies….. Engage in Effective outreach and community

education strategies Use health promoters Organize or participate in health fairs and other

community educational events Obtain bilingual education, low literacy materials and

have them available for physicians and other health professionals in direct services delivery

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Suggested Policies….. Use minority vendors for diverse services

within your institution, particularly in you are working or serving racial/ethnic minorities

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Suggested Policies….. Develop services delivery policies related

to: appointment system Walk-ins Cost (e.g., sliding scale) Translation services providing uncompensated emergency care

to those in needs

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Suggested Policies….. Develop services delivery policies….

Make the doctor office, clinic or hospital user-friendly places Have decorations that reflects the patients

preference Have staff trained in customer services

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Engaging in Cultural Competency practices at the individual level

Greet people with smile, hand-shaking, look at persons eyes. If he/she looks puzzle, approach the person and see I they need assistance

You need to do your homework about the specific racial/ethnic population being served

It requires knowledge on culture & environmental

conditions

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Engaging in Cultural Competency practices at the individual level

Developing awareness/sensitivity A deep understanding not only

at the intellectual level but at an emotional level “empathy”

Developing cultural competency- the skills to use the cultural knowledge and sensitivity in an effective manner in working with diverse populations

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Engaging in Cultural Competency practices at the individual level (2)….. Engaging in cultural assessment. Find

out: Gender roles Place of birth Language proficiency (fluency) Immigration history and experience # of years in US, as measure of acculturation # of years of schooling (literacy) Family composition Language Lifestyle practices Health practices (use of home remedies)

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Engaging in Cultural Competency practices at the individual level (3)….. Cultural assessment…

Religion/spirituality Socioeconomic status,

poverty/resources Gender role Urban/rural origin Social support systems/networks Community participation/civil

engagement Previous experience with the health

delivery system

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Engaging in Cultural Competency practices at the individual level (4)…..

Physicians and other providers should greet the person (s)

Establish contact with a smile and looking at person’s eyes. Use a word in Spanish: Buenos Dias/Tardes. It

relaxes the patient. Do not try to learn Spanish during the encounter

If you are looking at the medical records—inform the person what you found (most pts do not know their diagnosis or results of lab test and other results

Explain what will happen doing the clinic visit

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Engaging in Cultural Competency practices at the individual level (5)…..

Involve the family Treat patients/clients with

Respeto (respect)—a internal Latino value where the elderly, professionals, and persons in position of authority are treated with respect and dignity

Personalismo—person-to-person contact where the professional demonstrate interest for the patient (and his family) well-being while maintaining a professional image

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Engaging in Cultural Competency practices at the individual level (6)….

Listen attentively to the situational context surrounding pt. clinical condition

Explore the fear related to doctor visits and health conditions

Give patient specific referrals, when needed

Be aware of barriers to seeking & using services (e.g., lack of health insurance, inconveniences in obtaining care, etc.)

Conclusion

There is a sense of urgency to intervene now in developing and implementing strategies that will improve the health and well-being of H/L and to implement effective strategies

To eliminate social and health disparities we must commit to an agenda of social action

THANK YOU!

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addressing social determinants through community & system change by aida l. giachello, ph.d....

Documents

md slide

foreign born slide

montgomery country

rd cause of death

times higher

montgomery dept of hhs

social determinants

social needs