Shir ik i Kumanyika, PhD, MPH Pres ident , Amer ican Publ ic Heal th Associat ion P r o f e s s o r E m e r i t a , U n i ve r s i t y o f P e n n s y l v a n i a P e r e l m a n S c h o o l o f M e d i c i n e F o u n d e r a n d C h a i r , A f r i c a n A m e r i c a n C o l l a b o r a t i v e O b e s i t y R e s e a r c h N e t w o r k C o - C h a i r , P o l i c y a n d P r e v e n t i o n S e c t i o n , W o r l d O b e s i t y F e d e r a t i o n C U N Y F o r u m o n I m m i g r a t i o n a n d H e a l t h , N e w Yo r k C i t y , J u n e 3 , 2 0 1 5

PATHWAYS TO HEALTH FOR IMMIGRANTS TO THE UNITED STATES

Place of origin Socio-political history Socio-cultural background Reason for migration Health history Health status at arrival

Health insults Health behaviors Access to health services Appropriateness of health services Quality of health services

ADVERSE SITUATIONS POOR

HEALTH OUTCOMES

INFLUENCES ON HEALTH EQUITY

Immigration policies Other public policy Public health policy Health care policy

GOOD HEALTH

OUTCOMES

Source: The Newest New Yorkers, 2013 edition

• 37% of New Yorkers are immigrants • Nearly 6 in 10 are immigrants or children of immigrants

WHO ARE THE PEOPLE AND WHERE DID THEY COME FROM?

ADVERSE SITUATIONS

INFLUENCES ON HEALTH EQUITY

EXAMPLE: OBESITY

Associated with diabetes, heart disease, some cancers, mobility problems; discrimination

Requires life course perspective Sociocultural importance of food for immigrant

populations Sociocultural influences on food and physical

activity, e.g., preferences, gender-related roles and constraints

Generally increases with exposure to US environment

OBESITY PREVALENCE

Source: NYC Department of Health and Mental Hygiene. The Health of Immigrants in New York City, 2006

OBESITY AND DIABETES

Source: NYC Department of Health and Mental Hygiene. The Health of Immigrants in New York City, 2006

Influences on Obesity-related Health Inequities Applicability Situations Health Implications(Obesity)

All racial/ethnic minority populations

Racial/ethnic category • Cultural food preferences • Neighborhood access (segregation) • Targeted marketing of unhealthy foods • Mobility (freedom of movement)

Socioeconomic status; social position

• Neighborhood access (poverty) • Food purchasing power • Affordability of physical activity options • Transportation

Language/literacy • Access to nutrition information • Access to quality education

Cultural assets and protection • Buffering from aggressive promotion of unhealthy foods and beverages

Environmental context • Access to and affordability of healthy food and physical activity options

Structural empowerment and resilience

• Ability to benefit from new opportunities • Social capital and social support

Immigrant populations

Immigration experience • Disruption of social support systems; food insecurity

Residence or citizenship status • Access to federal nutrition and social welfare programs

MITIGATION: OBESITY- RELATED POLICY CONTEXT

Major focus of federal, state, and local policy

Embedded in social structure

More difficult to address in socio-economically disadvantaged

Environmental pathways involve multiple societal sectors and types of policies

FACTORS INTERNATIONAL

Development

Globalization of

markets

School Food & Activity

WORK/ SCHOOL/

HOME

Infections

Labour

Worksite Food & Activity

Leisure Activity/ Facilities

Agriculture/ Gardens/ Local markets

COMMUNITY/ LOCALITY

Health Care

System

Public Safety

Public Transport

Manufactured/ Imported Food

Sanitation

NATIONAL/ REGIONAL

Food & Nutrition

Urbanization

Education

Health O

I T Y

P R E V A L E

INDIVIDUAL

Energy Expenditure

POPULATION

%

OBESE

OR

UNDERWT Social Security

Transport

Family & Home

National perspective

Media & Culture

Food intake :

Nutrient density

Media programs

& advertising

Source: International Obesity Task Force [www.iotf.org] see Kumanyika S et al International Journal of Obesity 2002;26:425-36

Built environment Physical activity resources, facilities, and opportunities Food marketing environment Government nutrition assistance programs Endorsement, social support, and social capital for physical activity and healthy eating

Home food availability Food choices and feeding Electronic media use Physical activity opportunities Health care provider advice

Food choices and eating behaviors Electronic media use Involvement in physical activity Weight control behaviors Awareness and advocacy

Communities

Homes and families

People

Kumanyika S, Taylor WC, Grier SA, Lassiter V, Lancaster KJ, Morssink CB, Renzaho AM. Community energy balance: a framework for contextualizing cultural influences on high risk of obesity in ethnic minority populations. Prev Med. 2012 Nov;55(5):371-81.

OBESITY RELATED POLICY TARGETS

ADVERSE SITUATIONS

─ Health insults ─ Health behaviors ─ Low access to health services ─ Inappropriate health services ─ Poor quality of health services

Racism; Discrimination

Education; Income; Jobs Fair labor practices

Family and social support Neighborhood conditions Access to resources

Life course and intergenerational perspectives

Humane treatment Immigration reform

MITIGATION

─ Immigration policies ─ Other public policy ─ Public health policy ─ Health care policy

INFLUENCES ON HEALTH EQUITY