Moving Upstream:How Interventions that Address the Social

Determinants of Health can Improve Health

and Reduce Disparities

David R. Williams, PhD, MPHFlorence & Laura Norman Professor of Public Health

Professor of African & African American Studies and of Sociology

Harvard University

Reducing Inequalities Health Care

• Improve access to care and the quality of care– Give emphasis to the prevention of illness– Provide effective treatment– Develop incentives to reduce inequalities in the

quality of care

Care that Addresses the Social context

• Effective health care delivery must take the socio-economic context of the patient’s life seriously

• The health problems of vulnerable groups must be understood within the larger context of their lives

• The delivery of health services must address the many challenges that they face and take the characteristics and needs of vulnerable populations into account

• This will involve consideration of: the strengths of the client, the support and barriers in the client’s environment and the non-medical resources that may be mobilized to assist the client

Nurse Family Partnership• Nurses make prenatal and postnatal visits to pregnant

women.• Nurses enhance parents’ economic self-sufficiency by

addressing vision for future, subsequent pregnancies, educational and job opportunities.

• Three randomized control trials (Elmira, NY; Memphis, TN; Denver, CO)

• Improved prenatal behaviors, pregnancy outcomes, maternal employment, relationships with partner.

• Reduces child abuse and neglect, subsequent pregnancies, welfare and food stamp use

• $17,000 return to society for each family served

Olds 2002, Prevention Science

Service Delivery and Social Context

•244 low-income hypertensive patients, 80% black (matched on age, race, gender, and blood pressure history) were randomly assigned to:

• Routine Care: Routine hypertensive care from a physician.• Health Education Intervention: Routine care, plus weekly clinic meetings for

12 weeks run by a health professional.• Outreach Intervention: Routine care, plus home visits by lay health

workers*. Provided info on hypertension, discussed family difficulties, financial strain, employment opportunities, and, as appropriate, provided support, advice, referral, and direct assistance.

* Recruited from the local community, one month of training to address social and medical needs of persons with hypertension.

Source: Syme et al.

Service Delivery and Social Context: ResultsAfter seven months of follow-up, patients in the outreach group:

1. Were more likely to have their blood pressure controlled than patients in the other two groups.

2. Knew twice as much about blood pressure as patients in the other two groups. Those in the outreach group with more knowledge were more successful in blood pressure control.

3. Were more compliant with taking their hypertensive medication than patients in the health education intervention group. Moreover, good compliers in the outreach third group were twice as successful at controlling their blood pressure as good compliers in the health education group.

Source: Syme et al.

Needed Interventions

Policies to reduce inequalities in health must also address fundamental non-

medical determinants.

Moving Upstream

Effective Policies to reduce inequalities in health must address fundamental

non-medical determinants.

WHY?

WHY?

WHY?

Centrality of the Social Environment

An individual’s chances of getting sick are largely unrelated to the receipt of medical care

Where we live, learn, work, play and worship determine our opportunities and chances for being healthy

Social Policies can make it easier or harder to make healthy choices

Redefining Health Policy

Health Policies include policies in all sectors of society that affect opportunities to choose health, including, for example,

• Housing Policy

• Employment Policies

• Community Development Policies

• Income Support Policies

• Transportation Policies

• Environmental Policies

Neighborhood Change and Health

• The Moving to Opportunity Program randomized families with children in high poverty neighborhoods to move to less poor neighborhoods.

• It found, three years later, that there were improvements in the mental health of both parents and sons who moved to the low-poverty neighborhoods.

Leventhal and Brooks-Gunn, 2003

Yonkers Housing InterventionCity-wide de-concentration of public housing Half of public housing residents selected via a

lottery to move to better housing 2 years later, movers reported better overall

health, less substance abuse, neighborhood disorder and violence than those who stayed

Movers also reported greater satisfaction with public transportation, recreation facilities and medical care

Movers had higher rates of employment and lower welfare use

Fauth et al. Social Science and Medicine, 2004

Increased Income and Health

• A study conducted in the early 1970s found that mothers in the experimental income group who received expanded income support had infants with higher birth weight than that of mothers in the control group.

• Neither group experienced any experimental manipulation of health services.

• Improved nutrition, probably a result of the income manipulation, appeared to have been the key intervening factor.

Kehrer and Wolin, 1979

Income Change and Health

• A natural experiment assessed the impact of an income supplement on the mental health of American Indian children.

• It found that increased family income (because of the opening of a casino) was associated with declining rates of deviant and aggressive behavior.

Costello et al. 2003

New Hope Random Experiment Families in poverty in Milwaukee, WI receive

intervention that provides work support and earnings supplements to raise total income above poverty

Five year evaluation showed multiple positive effects on children aged 6-16, especially boys: Better study skills, school-related measures and

positive social behaviors Higher school engagement, future expectations and

lower aggression

Huston, et al. Developmental Psychology, 2005

Conditional Cash Transfer Programs

Mexico’s PROGRESA (now Oportunidades) established in 1997

Low income families, randomized at the community, level receive additional cash conditional on children’s school attendance, preventive care visits and participation in health information sessions

Compared to controls, the intervention group had decreased illness rates, child stunting, BMI and improvements in endurance, language development, memory, and height for age

Additional cash is key determinant of program success

Rawlings & Rubin, 2005; Paxson & Shady, 2007; Fernand et al. 2008

Health Effects of Civil Rights Policy• Civil Rights policies narrowed black-white economic gap

• Black women had larger gains in life expectancy during 1965 - 74 than other groups (3 times as large as those in the decade before)

• Between 1968 and 1978, black males and females, aged 35-74, had larger absolute and relative declines in mortality than whites

• Black women born 1967 - 69 had lower risk factor rates as adults and were less likely to have infants with low-birth weight and low APGAR scores than those born 1961- 63

• Desegregation of Southern hospitals enabled 5,000 to 7,000 additional Black babies to survive infancy between 1965 to 1975

Kaplan et al. 2008; Cooper et al. 1981; Almond & Chay, 2006; Almond et al. 2006

Median Family Income of Blacks per $1 of Whites

0.54

0.55

0.56

0.57

0.58

0.59

0.6

0.61

0.62

Cents

1978 1980 1982 1984 1986 1988 1990 1992 1994 1996

Year

Source: Economic Report of the President, 1998

U.S. Life Expectancy at Birth, 1984-1992

75.3 75.3 75.4 75.6 75.6 75.9 76.1 76.3 76.5

69.5 69.3 69.1 69.1 68.9 68.8 69.1 69.3 69.6

60

65

70

75

80

1984 1985 1986 1987 1988 1989 1990 1991 1992

Year

Lif

e E

xpec

ten

cy (

Yea

r)

White Black

NCHS, 1995

Policy Matters

Investments in early childhood programs in the U.S. have been

shown to have decisive beneficial effects

The High/Scope Perry Preschool Study to

Age 40Larry Schweinhart

High/Scope Educational Research Foundation

www.highscope.org

High/Scope Perry Preschool 123 young African-American children, living in poverty

and at risk of school failure.

Randomly assigned to initially similar program and no-

program groups.

4 teachers with bachelors’ degrees held a daily class of 20-

25 three- and four-year-olds and made weekly home visits.

Children participated in their own education by planning,

doing, and reviewing their own activities.

Results at Age 40 Those who received the program had better academic

performance (more likely to graduate from high school)

Program recipients did better economically (higher

employment, annual income, savings & home ownership)

The group who received high-quality early education had

fewer arrests for violent, property and drug crimes

The program was cost effective: A return to society of $17

for every dollar invested in early education_____________________________________________________________________Schweinhart & Montie, 2005

Source: UNICEF (United Nations Children’s Fund), 2000

% Children Child Poverty (%)

Country 1 Parent HH

1 Parent Other

Spain 2 32 12

Italy 3 22 20

Mexico 4 28 26

France 8 26 6

Ireland 8 48 14

Germany 10 51 6

United States 19 55 16

United Kingdom 20 46 13

Sweden 21 7 2

Source: UNICEF (United Nations’ Children’s Fund), 2000

Child Poverty RatesCountry Before Taxes After Taxes

Netherlands 16.0 7.7

Spain 21.1 12.3

Sweden 23.4 2.6

Canada 24.6 15.5

Italy 24.6 20.5

United States 26.7 22.4

Australia 28.1 12.6

France 28.7 7.9

United Kingdom 36.1 19.8

Poland 44.4 15.4

Research Opportunities: Multiple Levels

• What interventions really work to reduce inequalities in health? How can we make them cost-effective?

• Which community-based interventions show the greatest promise?

• How can we more actively support individuals, families, and communities to make choices that promote health?

• Are there specific interventions targeted at the broader, social, political and economic determinants of health that would have larger health enhancing effects on disadvantaged (socioeconomic and racial/ethnic) populations than their higher status peers?

• How can we best build on the strengths and capacities of disadvantaged populations?

Conclusions -I

1. Health officials and organizations cannot improve health by themselves

2. Improving health and reducing inequalities in health is not just about more health programs, it is about a new path to health

3. All policy that affects health is health policy

4. Health officials need to work collaboratively with other sectors of society to initiate and support social policies that promote health and reduce inequalities and health

Conclusions -II

1. Inequalities in health are created by larger inequalities in society.

2. SES and racial/ethnic disparities in health reflect the successful implementation of social policies.

3. Eliminating them requires political will for and a commitment to new strategies to improve living and working conditions.

4. Our great need is to begin in a systematic and comprehensive manner, to use all of the current knowledge that we have.

5. Now is the time