why health equity is critical for birth...
TRANSCRIPT
Why Health Equity is Critical for Birth Outcomes
July 19 2016
Marcella Nunez Smith MD MHS
Section of General Internal Medicine (YSM) Chronic Disease Epidemiology (YSPH) Robert Wood Johnson Foundation Clinical Scholars Program Global Health Leadership Institute Yale Center for Clinical Investigation
No conflicts
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Things I want to convince you are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
What Are Health Inequities
Health Inequity
Health inequities are avoidable inequalities in health between groups of people within countries and between countries These inequities arise from inequalities within and between societies Social and economic conditions and their effects on peoplersquos lives determine their risk of illness and the actions taken to prevent them becoming ill or treat illness when it occurs
WHO httpwwwwhointsocial_determinantsthecommissionfinalreportkey_conceptsen
We Are Not Achieving Our Health Potential US Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
RWJF 2013 Overcoming Obstacles to Health in 2013 and Beyond
US Health Disadvantage Cannot Be Explained By International Differences In Wealth
Source IMF World Economic Outlook (WEO) April 2015
Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
Source OECD Health Data 2011 World Bank and national sources for non-OECD countries
US spends $8000 per capita more than any other country
US Losing Ground on Child Mortality Compared to European Countries US Ranks 26 in Infant Mortality Rates
International Comparisons of Infant Mortality and Related Factors United States and Europe 2010 National Vital Statistics Reports Vol 63 No 5 September 24 2014 CDC
NIH Disparity Populations
Differences in the incidence prevalence mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States
CDC At-risk Populations
httpwwwcdcgovMinorityHealthindexhtml
IOM Vulnerable Populations
Subpopulations who because of shared social characteristics
Are exposed to contextual conditions that distinguish them from the rest of population
Have a higher mean distribution of risk exposure than the rest of the population characterized by a clustering of risks that conspire to foster disease
Experience stressful social disorganization as a normative reality of life
Schillinger D IOM Roundtable on Health Disparities 2010 Pearlin The Stress Process Revisited
2020 Topics and Objectives - Objectives A-Z
Select a topic area from the list below to get started
Each top c area includes an overview objectives and data md evidence based resources
Health Outcomes
o- C) -----Now Online -----Search the Healthy People 2020 Data
Overarching Goals
bull Attain high quality longer lives free of preventable disease disability injury and premature death
bull Achieve health equity eliminate disparities and improve the health of all groups
bull Create social and physical environments that promote good health for all
bull Promote quality of life healthy development and healthy behaviors across all life stages
er c Healthy People 2020 Objectives
If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
No conflicts
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Things I want to convince you are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
What Are Health Inequities
Health Inequity
Health inequities are avoidable inequalities in health between groups of people within countries and between countries These inequities arise from inequalities within and between societies Social and economic conditions and their effects on peoplersquos lives determine their risk of illness and the actions taken to prevent them becoming ill or treat illness when it occurs
WHO httpwwwwhointsocial_determinantsthecommissionfinalreportkey_conceptsen
We Are Not Achieving Our Health Potential US Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
RWJF 2013 Overcoming Obstacles to Health in 2013 and Beyond
US Health Disadvantage Cannot Be Explained By International Differences In Wealth
Source IMF World Economic Outlook (WEO) April 2015
Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
Source OECD Health Data 2011 World Bank and national sources for non-OECD countries
US spends $8000 per capita more than any other country
US Losing Ground on Child Mortality Compared to European Countries US Ranks 26 in Infant Mortality Rates
International Comparisons of Infant Mortality and Related Factors United States and Europe 2010 National Vital Statistics Reports Vol 63 No 5 September 24 2014 CDC
NIH Disparity Populations
Differences in the incidence prevalence mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States
CDC At-risk Populations
httpwwwcdcgovMinorityHealthindexhtml
IOM Vulnerable Populations
Subpopulations who because of shared social characteristics
Are exposed to contextual conditions that distinguish them from the rest of population
Have a higher mean distribution of risk exposure than the rest of the population characterized by a clustering of risks that conspire to foster disease
Experience stressful social disorganization as a normative reality of life
Schillinger D IOM Roundtable on Health Disparities 2010 Pearlin The Stress Process Revisited
2020 Topics and Objectives - Objectives A-Z
Select a topic area from the list below to get started
Each top c area includes an overview objectives and data md evidence based resources
Health Outcomes
o- C) -----Now Online -----Search the Healthy People 2020 Data
Overarching Goals
bull Attain high quality longer lives free of preventable disease disability injury and premature death
bull Achieve health equity eliminate disparities and improve the health of all groups
bull Create social and physical environments that promote good health for all
bull Promote quality of life healthy development and healthy behaviors across all life stages
er c Healthy People 2020 Objectives
If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Things I want to convince you are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
What Are Health Inequities
Health Inequity
Health inequities are avoidable inequalities in health between groups of people within countries and between countries These inequities arise from inequalities within and between societies Social and economic conditions and their effects on peoplersquos lives determine their risk of illness and the actions taken to prevent them becoming ill or treat illness when it occurs
WHO httpwwwwhointsocial_determinantsthecommissionfinalreportkey_conceptsen
We Are Not Achieving Our Health Potential US Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
RWJF 2013 Overcoming Obstacles to Health in 2013 and Beyond
US Health Disadvantage Cannot Be Explained By International Differences In Wealth
Source IMF World Economic Outlook (WEO) April 2015
Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
Source OECD Health Data 2011 World Bank and national sources for non-OECD countries
US spends $8000 per capita more than any other country
US Losing Ground on Child Mortality Compared to European Countries US Ranks 26 in Infant Mortality Rates
International Comparisons of Infant Mortality and Related Factors United States and Europe 2010 National Vital Statistics Reports Vol 63 No 5 September 24 2014 CDC
NIH Disparity Populations
Differences in the incidence prevalence mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States
CDC At-risk Populations
httpwwwcdcgovMinorityHealthindexhtml
IOM Vulnerable Populations
Subpopulations who because of shared social characteristics
Are exposed to contextual conditions that distinguish them from the rest of population
Have a higher mean distribution of risk exposure than the rest of the population characterized by a clustering of risks that conspire to foster disease
Experience stressful social disorganization as a normative reality of life
Schillinger D IOM Roundtable on Health Disparities 2010 Pearlin The Stress Process Revisited
2020 Topics and Objectives - Objectives A-Z
Select a topic area from the list below to get started
Each top c area includes an overview objectives and data md evidence based resources
Health Outcomes
o- C) -----Now Online -----Search the Healthy People 2020 Data
Overarching Goals
bull Attain high quality longer lives free of preventable disease disability injury and premature death
bull Achieve health equity eliminate disparities and improve the health of all groups
bull Create social and physical environments that promote good health for all
bull Promote quality of life healthy development and healthy behaviors across all life stages
er c Healthy People 2020 Objectives
If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Things I want to convince you are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
What Are Health Inequities
Health Inequity
Health inequities are avoidable inequalities in health between groups of people within countries and between countries These inequities arise from inequalities within and between societies Social and economic conditions and their effects on peoplersquos lives determine their risk of illness and the actions taken to prevent them becoming ill or treat illness when it occurs
WHO httpwwwwhointsocial_determinantsthecommissionfinalreportkey_conceptsen
We Are Not Achieving Our Health Potential US Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
RWJF 2013 Overcoming Obstacles to Health in 2013 and Beyond
US Health Disadvantage Cannot Be Explained By International Differences In Wealth
Source IMF World Economic Outlook (WEO) April 2015
Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
Source OECD Health Data 2011 World Bank and national sources for non-OECD countries
US spends $8000 per capita more than any other country
US Losing Ground on Child Mortality Compared to European Countries US Ranks 26 in Infant Mortality Rates
International Comparisons of Infant Mortality and Related Factors United States and Europe 2010 National Vital Statistics Reports Vol 63 No 5 September 24 2014 CDC
NIH Disparity Populations
Differences in the incidence prevalence mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States
CDC At-risk Populations
httpwwwcdcgovMinorityHealthindexhtml
IOM Vulnerable Populations
Subpopulations who because of shared social characteristics
Are exposed to contextual conditions that distinguish them from the rest of population
Have a higher mean distribution of risk exposure than the rest of the population characterized by a clustering of risks that conspire to foster disease
Experience stressful social disorganization as a normative reality of life
Schillinger D IOM Roundtable on Health Disparities 2010 Pearlin The Stress Process Revisited
2020 Topics and Objectives - Objectives A-Z
Select a topic area from the list below to get started
Each top c area includes an overview objectives and data md evidence based resources
Health Outcomes
o- C) -----Now Online -----Search the Healthy People 2020 Data
Overarching Goals
bull Attain high quality longer lives free of preventable disease disability injury and premature death
bull Achieve health equity eliminate disparities and improve the health of all groups
bull Create social and physical environments that promote good health for all
bull Promote quality of life healthy development and healthy behaviors across all life stages
er c Healthy People 2020 Objectives
If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
What Are Health Inequities
Health Inequity
Health inequities are avoidable inequalities in health between groups of people within countries and between countries These inequities arise from inequalities within and between societies Social and economic conditions and their effects on peoplersquos lives determine their risk of illness and the actions taken to prevent them becoming ill or treat illness when it occurs
WHO httpwwwwhointsocial_determinantsthecommissionfinalreportkey_conceptsen
We Are Not Achieving Our Health Potential US Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
RWJF 2013 Overcoming Obstacles to Health in 2013 and Beyond
US Health Disadvantage Cannot Be Explained By International Differences In Wealth
Source IMF World Economic Outlook (WEO) April 2015
Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
Source OECD Health Data 2011 World Bank and national sources for non-OECD countries
US spends $8000 per capita more than any other country
US Losing Ground on Child Mortality Compared to European Countries US Ranks 26 in Infant Mortality Rates
International Comparisons of Infant Mortality and Related Factors United States and Europe 2010 National Vital Statistics Reports Vol 63 No 5 September 24 2014 CDC
NIH Disparity Populations
Differences in the incidence prevalence mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States
CDC At-risk Populations
httpwwwcdcgovMinorityHealthindexhtml
IOM Vulnerable Populations
Subpopulations who because of shared social characteristics
Are exposed to contextual conditions that distinguish them from the rest of population
Have a higher mean distribution of risk exposure than the rest of the population characterized by a clustering of risks that conspire to foster disease
Experience stressful social disorganization as a normative reality of life
Schillinger D IOM Roundtable on Health Disparities 2010 Pearlin The Stress Process Revisited
2020 Topics and Objectives - Objectives A-Z
Select a topic area from the list below to get started
Each top c area includes an overview objectives and data md evidence based resources
Health Outcomes
o- C) -----Now Online -----Search the Healthy People 2020 Data
Overarching Goals
bull Attain high quality longer lives free of preventable disease disability injury and premature death
bull Achieve health equity eliminate disparities and improve the health of all groups
bull Create social and physical environments that promote good health for all
bull Promote quality of life healthy development and healthy behaviors across all life stages
er c Healthy People 2020 Objectives
If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
What Are Health Inequities
Health Inequity
Health inequities are avoidable inequalities in health between groups of people within countries and between countries These inequities arise from inequalities within and between societies Social and economic conditions and their effects on peoplersquos lives determine their risk of illness and the actions taken to prevent them becoming ill or treat illness when it occurs
WHO httpwwwwhointsocial_determinantsthecommissionfinalreportkey_conceptsen
We Are Not Achieving Our Health Potential US Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
RWJF 2013 Overcoming Obstacles to Health in 2013 and Beyond
US Health Disadvantage Cannot Be Explained By International Differences In Wealth
Source IMF World Economic Outlook (WEO) April 2015
Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
Source OECD Health Data 2011 World Bank and national sources for non-OECD countries
US spends $8000 per capita more than any other country
US Losing Ground on Child Mortality Compared to European Countries US Ranks 26 in Infant Mortality Rates
International Comparisons of Infant Mortality and Related Factors United States and Europe 2010 National Vital Statistics Reports Vol 63 No 5 September 24 2014 CDC
NIH Disparity Populations
Differences in the incidence prevalence mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States
CDC At-risk Populations
httpwwwcdcgovMinorityHealthindexhtml
IOM Vulnerable Populations
Subpopulations who because of shared social characteristics
Are exposed to contextual conditions that distinguish them from the rest of population
Have a higher mean distribution of risk exposure than the rest of the population characterized by a clustering of risks that conspire to foster disease
Experience stressful social disorganization as a normative reality of life
Schillinger D IOM Roundtable on Health Disparities 2010 Pearlin The Stress Process Revisited
2020 Topics and Objectives - Objectives A-Z
Select a topic area from the list below to get started
Each top c area includes an overview objectives and data md evidence based resources
Health Outcomes
o- C) -----Now Online -----Search the Healthy People 2020 Data
Overarching Goals
bull Attain high quality longer lives free of preventable disease disability injury and premature death
bull Achieve health equity eliminate disparities and improve the health of all groups
bull Create social and physical environments that promote good health for all
bull Promote quality of life healthy development and healthy behaviors across all life stages
er c Healthy People 2020 Objectives
If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
We Are Not Achieving Our Health Potential US Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
RWJF 2013 Overcoming Obstacles to Health in 2013 and Beyond
US Health Disadvantage Cannot Be Explained By International Differences In Wealth
Source IMF World Economic Outlook (WEO) April 2015
Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
Source OECD Health Data 2011 World Bank and national sources for non-OECD countries
US spends $8000 per capita more than any other country
US Losing Ground on Child Mortality Compared to European Countries US Ranks 26 in Infant Mortality Rates
International Comparisons of Infant Mortality and Related Factors United States and Europe 2010 National Vital Statistics Reports Vol 63 No 5 September 24 2014 CDC
NIH Disparity Populations
Differences in the incidence prevalence mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States
CDC At-risk Populations
httpwwwcdcgovMinorityHealthindexhtml
IOM Vulnerable Populations
Subpopulations who because of shared social characteristics
Are exposed to contextual conditions that distinguish them from the rest of population
Have a higher mean distribution of risk exposure than the rest of the population characterized by a clustering of risks that conspire to foster disease
Experience stressful social disorganization as a normative reality of life
Schillinger D IOM Roundtable on Health Disparities 2010 Pearlin The Stress Process Revisited
2020 Topics and Objectives - Objectives A-Z
Select a topic area from the list below to get started
Each top c area includes an overview objectives and data md evidence based resources
Health Outcomes
o- C) -----Now Online -----Search the Healthy People 2020 Data
Overarching Goals
bull Attain high quality longer lives free of preventable disease disability injury and premature death
bull Achieve health equity eliminate disparities and improve the health of all groups
bull Create social and physical environments that promote good health for all
bull Promote quality of life healthy development and healthy behaviors across all life stages
er c Healthy People 2020 Objectives
If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
US Health Disadvantage Cannot Be Explained By International Differences In Wealth
Source IMF World Economic Outlook (WEO) April 2015
Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
Source OECD Health Data 2011 World Bank and national sources for non-OECD countries
US spends $8000 per capita more than any other country
US Losing Ground on Child Mortality Compared to European Countries US Ranks 26 in Infant Mortality Rates
International Comparisons of Infant Mortality and Related Factors United States and Europe 2010 National Vital Statistics Reports Vol 63 No 5 September 24 2014 CDC
NIH Disparity Populations
Differences in the incidence prevalence mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States
CDC At-risk Populations
httpwwwcdcgovMinorityHealthindexhtml
IOM Vulnerable Populations
Subpopulations who because of shared social characteristics
Are exposed to contextual conditions that distinguish them from the rest of population
Have a higher mean distribution of risk exposure than the rest of the population characterized by a clustering of risks that conspire to foster disease
Experience stressful social disorganization as a normative reality of life
Schillinger D IOM Roundtable on Health Disparities 2010 Pearlin The Stress Process Revisited
2020 Topics and Objectives - Objectives A-Z
Select a topic area from the list below to get started
Each top c area includes an overview objectives and data md evidence based resources
Health Outcomes
o- C) -----Now Online -----Search the Healthy People 2020 Data
Overarching Goals
bull Attain high quality longer lives free of preventable disease disability injury and premature death
bull Achieve health equity eliminate disparities and improve the health of all groups
bull Create social and physical environments that promote good health for all
bull Promote quality of life healthy development and healthy behaviors across all life stages
er c Healthy People 2020 Objectives
If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
Source OECD Health Data 2011 World Bank and national sources for non-OECD countries
US spends $8000 per capita more than any other country
US Losing Ground on Child Mortality Compared to European Countries US Ranks 26 in Infant Mortality Rates
International Comparisons of Infant Mortality and Related Factors United States and Europe 2010 National Vital Statistics Reports Vol 63 No 5 September 24 2014 CDC
NIH Disparity Populations
Differences in the incidence prevalence mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States
CDC At-risk Populations
httpwwwcdcgovMinorityHealthindexhtml
IOM Vulnerable Populations
Subpopulations who because of shared social characteristics
Are exposed to contextual conditions that distinguish them from the rest of population
Have a higher mean distribution of risk exposure than the rest of the population characterized by a clustering of risks that conspire to foster disease
Experience stressful social disorganization as a normative reality of life
Schillinger D IOM Roundtable on Health Disparities 2010 Pearlin The Stress Process Revisited
2020 Topics and Objectives - Objectives A-Z
Select a topic area from the list below to get started
Each top c area includes an overview objectives and data md evidence based resources
Health Outcomes
o- C) -----Now Online -----Search the Healthy People 2020 Data
Overarching Goals
bull Attain high quality longer lives free of preventable disease disability injury and premature death
bull Achieve health equity eliminate disparities and improve the health of all groups
bull Create social and physical environments that promote good health for all
bull Promote quality of life healthy development and healthy behaviors across all life stages
er c Healthy People 2020 Objectives
If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
US Losing Ground on Child Mortality Compared to European Countries US Ranks 26 in Infant Mortality Rates
International Comparisons of Infant Mortality and Related Factors United States and Europe 2010 National Vital Statistics Reports Vol 63 No 5 September 24 2014 CDC
NIH Disparity Populations
Differences in the incidence prevalence mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States
CDC At-risk Populations
httpwwwcdcgovMinorityHealthindexhtml
IOM Vulnerable Populations
Subpopulations who because of shared social characteristics
Are exposed to contextual conditions that distinguish them from the rest of population
Have a higher mean distribution of risk exposure than the rest of the population characterized by a clustering of risks that conspire to foster disease
Experience stressful social disorganization as a normative reality of life
Schillinger D IOM Roundtable on Health Disparities 2010 Pearlin The Stress Process Revisited
2020 Topics and Objectives - Objectives A-Z
Select a topic area from the list below to get started
Each top c area includes an overview objectives and data md evidence based resources
Health Outcomes
o- C) -----Now Online -----Search the Healthy People 2020 Data
Overarching Goals
bull Attain high quality longer lives free of preventable disease disability injury and premature death
bull Achieve health equity eliminate disparities and improve the health of all groups
bull Create social and physical environments that promote good health for all
bull Promote quality of life healthy development and healthy behaviors across all life stages
er c Healthy People 2020 Objectives
If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
NIH Disparity Populations
Differences in the incidence prevalence mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States
CDC At-risk Populations
httpwwwcdcgovMinorityHealthindexhtml
IOM Vulnerable Populations
Subpopulations who because of shared social characteristics
Are exposed to contextual conditions that distinguish them from the rest of population
Have a higher mean distribution of risk exposure than the rest of the population characterized by a clustering of risks that conspire to foster disease
Experience stressful social disorganization as a normative reality of life
Schillinger D IOM Roundtable on Health Disparities 2010 Pearlin The Stress Process Revisited
2020 Topics and Objectives - Objectives A-Z
Select a topic area from the list below to get started
Each top c area includes an overview objectives and data md evidence based resources
Health Outcomes
o- C) -----Now Online -----Search the Healthy People 2020 Data
Overarching Goals
bull Attain high quality longer lives free of preventable disease disability injury and premature death
bull Achieve health equity eliminate disparities and improve the health of all groups
bull Create social and physical environments that promote good health for all
bull Promote quality of life healthy development and healthy behaviors across all life stages
er c Healthy People 2020 Objectives
If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
CDC At-risk Populations
httpwwwcdcgovMinorityHealthindexhtml
IOM Vulnerable Populations
Subpopulations who because of shared social characteristics
Are exposed to contextual conditions that distinguish them from the rest of population
Have a higher mean distribution of risk exposure than the rest of the population characterized by a clustering of risks that conspire to foster disease
Experience stressful social disorganization as a normative reality of life
Schillinger D IOM Roundtable on Health Disparities 2010 Pearlin The Stress Process Revisited
2020 Topics and Objectives - Objectives A-Z
Select a topic area from the list below to get started
Each top c area includes an overview objectives and data md evidence based resources
Health Outcomes
o- C) -----Now Online -----Search the Healthy People 2020 Data
Overarching Goals
bull Attain high quality longer lives free of preventable disease disability injury and premature death
bull Achieve health equity eliminate disparities and improve the health of all groups
bull Create social and physical environments that promote good health for all
bull Promote quality of life healthy development and healthy behaviors across all life stages
er c Healthy People 2020 Objectives
If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
IOM Vulnerable Populations
Subpopulations who because of shared social characteristics
Are exposed to contextual conditions that distinguish them from the rest of population
Have a higher mean distribution of risk exposure than the rest of the population characterized by a clustering of risks that conspire to foster disease
Experience stressful social disorganization as a normative reality of life
Schillinger D IOM Roundtable on Health Disparities 2010 Pearlin The Stress Process Revisited
2020 Topics and Objectives - Objectives A-Z
Select a topic area from the list below to get started
Each top c area includes an overview objectives and data md evidence based resources
Health Outcomes
o- C) -----Now Online -----Search the Healthy People 2020 Data
Overarching Goals
bull Attain high quality longer lives free of preventable disease disability injury and premature death
bull Achieve health equity eliminate disparities and improve the health of all groups
bull Create social and physical environments that promote good health for all
bull Promote quality of life healthy development and healthy behaviors across all life stages
er c Healthy People 2020 Objectives
If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
2020 Topics and Objectives - Objectives A-Z
Select a topic area from the list below to get started
Each top c area includes an overview objectives and data md evidence based resources
Health Outcomes
o- C) -----Now Online -----Search the Healthy People 2020 Data
Overarching Goals
bull Attain high quality longer lives free of preventable disease disability injury and premature death
bull Achieve health equity eliminate disparities and improve the health of all groups
bull Create social and physical environments that promote good health for all
bull Promote quality of life healthy development and healthy behaviors across all life stages
er c Healthy People 2020 Objectives
If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
THINK 11
CULTURAL -HEALTH ~
National CLAS Standards
(updated 2010)
t fQMH Unequal
Treatment
1986 2000 _ ___ 2002 -~- 2007
OMH established (Heckler Report)
t fQMH
NCMHD established
(NIMHD 2010)
Heath Equality Index (HEI) established
El HUMAN RIGllTS CA M PA I GN
o
NIMHD
~middot~ NATIONAL ~ _I~bull Q UALI TY FORUM - NQF Healthcare
Disparities amp Cultural
Competency
er c
2009 ______ _ 2010 ------- 2012 ---- 2013
ACA enacted NIH advances LGBTI research
ampRCC
Milestones in federal research fundingand prioritization
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Infant Mortality Rates for Mothers Age 20 + By RaceEthnicity and Education 2001-2013
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
But how do health disparities arise
Differences in healthcare quality Differences in healthcare access Differences in life opportunities exposures stressors and
other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
But how do health disparities arise
Differences in healthcare quality
Adapted from Camara Jones MD PhD
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Healthcare disparities persist most disparities not improving across quality measures
Number amp percentage of quality measures for which disparities related to race ethnicity and income were improving not changing or worsening through 2012
Improving No Change Worsening 100
80
60
40
20
0 9
76
13
13
126
9
16
109
5
17
97
9
4
55
5
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=98) (n=148) White (n=130) (n=123) (n=64)
2014 National Healthcare Quality amp Disparities Reports AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
But how do health disparities arise
Differences in healthcare access
Adapted from Camara Jones MD PhD
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Through 2012 across access measures most disparities did not improve
Improving No Change Worsening 100
80
60
40
20
0 1
1
17
2
19
6
13
2
4
13
1
3
7
Poor vs High Black vs White Hispanic vs Asian vs White AIAN vs White Income (n=19) (n=21) White (n=21) (n=18) (n=10)
2014 National Healthcare Quality amp Disparities Report AHRQ httpwwwahrqgovresearchfindingsnhqrdrnhqdr14indexhtml
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
But how do health disparities arise
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status
Adapted from Camara Jones MD PhD
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Do you think racism againct blacks is or is not widespread in the US
bull Yes is No is not
19 )1
42
National adults lon-H ispanic whites Blacks Hispanics
Do you think racial discrimination againct blach is a major factor a minor factor or
not a factor in [RA1VDOM ORDER]
lh-ed on national adulh-
bull Major fuctor bull Minor factor bull Not a fuctor
39
26 28 L9 18
Black_ education leveJs Blacks income levelltgt
er c Most Americans ldquoRacism is widespreadrdquo
USA TodayGallup poll 2008
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Sexual Orientation amp Discrimination Seen as Serious Problem in US
USA TodayGallup poll 2012
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Unequal Treatment
Across all therapeutic interventions from high tech procedures to elementary diagnostics amp treatments racialethnic minorities receive fewer procedures amp poorer quality medical care than whites
Differences persist after differences in health insurance SES disease stage amp severity co-morbidity amp type of medical facility are taken into account
They persist in Medicare amp VA Health System where differences in SES amp insurance are minimized
Institute of Medicine 2003
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Excess Medical Expenditures Due To Health Inequities
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Patient Demographics Influence Physician Decisions
bull Chief complaint chest pain
bull n = 720 physicians
bull 8 actors representing all possible combinations of age gender and black-white race performed same ldquoscriptrdquo same objective data (eg EKG biomarkers)
bull Women and blacks were less likely to be referred for cardiac catheterization than men and whites
bull Black women least likely to be referred
Schulman KA et al NEJM 1999 340 618-626
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Ethnicity and Analgesia
Chart review n=139 patients with isolated long-bone fracture at UCLA Emergency Department (ED)
bull All patients 15-55 yrs within 6 hours of ER visit no alcohol intoxication
bull 55 of Hispanics received no analgesic compared to 26 of whites
bull Simultaneous adjustment sex primary language insurance occupational injury time of presentation total time in ED fracture reduction amp hospital admission
bull Hispanic ethnicity strongest predictor of no analgesia
bull Hispanics 75 times more likely than whites to receive no analgesia
Todd et al 1993
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Societal conte t for healthcare deliveryImplicit and E xxplicit Bias
Explicit bias
Beliefs amp attitudes people know they hold
Can control deliberatelystrategically
Can be overwritten with experiencechange in values
Amenable to self-reflective practice
Self-reports of bias uncommon among physicians
Unintentional activation
Outside personal awareness
Overlearned associations
Less controllable responses (eg nonverbal subtle cues)
Implicit bias
Explicit and implicit bias only weakly correlated but each independently associated with discriminatory behavior
Steele CM Am Psychol 199752 613-629 Fiske ST Cuddy AJC Glick P Xu J J Pers Soc Psychol 200282 878-902
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Implicit Attitudes Testing (IAT) data on physician race and gender
IAT implicit amp explicit attitudes about race (Jan 04 ndash May 06) Context
Sample n = 404277 subset of n = 2535 MDs
Result
White MDs explicit amp implicit preferences for Whites over Blacks gt 50 stronger for implicit than explicit bias
Black MDs explicit preference for Blacks over Whites no implicit racial preference
Conclusion Implicit preference for white
Physiciansrsquo implicit and explicit Americans is strong among white attitudes about race by MD race males amp weaker among females ethnicity and gender
Sabin JA Nosek BA Greenwald AF Rivara FP (2009) J Health Care Poor Underserved
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Implicit bias is associated with differences in healthcare delivery and quality of care
Explore relationship between genetic counselorsrsquo implicit racial attitudes amp their communication during simulated counseling sessions
Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result Pro-White bias displayed lt positive affect use lt emotionally responsive communication with minority SC
lt verbal dominance with white SC
Genetic Counselorsrsquo Implicit Implicit bias associated with Racial Attitudes and Their negative communication amp may Relationship to Communication contribute to racial disparities in
genetic services care
Conclusio n
Schaa et al Health Psych 2015 Vol 34 No 2
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Physician implicit amp explicit bias have differing effects on patient experiences
Role of physician explicit amp implicit biases in shaping physician amp patient reactions in racially discordant medical interactions
Context
Sample n = 150 Black patients n = 15 MDs 3 White 12 Asian or South Asian
Result Black patients less positive reactions to MDs with low explicit but high implicit race bias than low explicitimplicit bias or high explicitimplicit bias
Aversive Racism and Medical Interactions with Black Patients Conclusio
n Patients respond more negatively
A Field Study to aversive racism
Penner et al J Exp Soc Psychol 2010 March 1 46(2)
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
Associations of cliniciansrsquo implicit attitudes about race with visit communication amp patient ratings of care
Context
Sample n = 40 primary care physicians n = 269 patients urban community-based practices
Result Black patients bias gt clinician verbal dominance lt patient positive affect poorer interpersonal care
Racecompliance stereotyping longer visits slower speech lt patient-centeredness
The Associations of Cliniciansrsquo White patients bias gt clinician verbal dominance Implicit Attitudes About Race better ratings of interpersonal care With Medical Visit
Racecompliance stereotyping shorter visits faster Communication and Patient speech gt patient-centeredness Ratings of Interpersonal Care
Cooper et al Am J Public Health May 2012 Vol 102 No 5
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Physician-to-patient talk time ratios associated with discrimination amp lower adherence
Non-Black MD implicit bias amp Black patientsrsquo past discrimination affect physician-patient talk time ratio
Relationship between ratio amp adherence Context
Sample n = 112 low-income Black patients n = 14 non-Black MDs
Result
Non-black MDs gt implicit bias = larger talk time ratios
Black patients gt discrimination = smaller talk time ratios
Smaller talk time ratios associated with less adherence
Racial Attitudes Physician-Conclusio
n
Greater patient talk time Patient Talk Time Ratio andassociated with high levels of past Adherence in Racially Discordant discrimination amp low levels of trust Medical Interactions
Hagiwara et al Soc Sci Med 2013 June 87
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
Overall Quality
RacialEthnic Disparities
httpnhqrnetahrqgovinhqrdrstateselect
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Integrating disparity populations in patient-reported quality of care metrics
Patient reported experiencesof discrimination in care tool
GOAL develop test amp implement a standardized measurement approach for patient-reported healthcare discrimination
YCCI
NCI R21
NCI R01
AIM used QUAL interviews to create taxonomy of patient-reported healthcare discrimination experiences
AIM developed item bank amp tested through cognitive interviews amp focus groups
AIM field test item bank with hospital consortium across multiple states
PI Nunez-Smith M R21 CA134980- 1R01CA169103
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
Health and health-related behaviors are shaped by conditions in homes workplaces amp neighborhoods and opportunities in education and income across generations
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
What Are The Social Determinants of Health
Image 2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Social determinants of health the circumstances in which people are born grow live work and age and the systems put in place to deal with illness
These circumstances are shaped by a wider set of forces economics social policies and politics
Income and education are the essential drivers of health status
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Social Disparities Contribute to Increased Deaths in the US
There were an estimated 28 million ldquoexcessrdquo deaths in US in 2000
245000 were attributable to low education
176000 were attributable to racial segregation
162000 were attributable to low social support
133000 were attributable to individual-level poverty
119000 were attributable to income inequality
Woolf and Braveman Health Affairs 30 no10 (2011) 1852-1859
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
United States Social Factors Affecting Adult Health
Federal Poverty Levels 2015
$11770 for individuals $15930 for a family of 2 $20090 for a family of 3 $24250 for a family of 4
2009 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2007 American Community Survey
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg Data 2008 Geolytics Neighborhood Changes database
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Parentrsquos Income Can Affect Childrsquos Health Throughout Life
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
How Education Can Influence Health By Shaping Employment Opportunities amp Income
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
Overcoming Obstacles to Health RWJF Commission 2009
Data National Health Interview Survey 2001ndash2005
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Data CDC Behavioral Risk Factor Surveillance System Survey Data 2008ndash10
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Neighborhood As A Geographic Determinant of Health Influence of Community-Level Factors on Health
Income influences community options and communities affect health
Overcoming Obstacles to Health in 2013 and Beyond RWJF Commission
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Mapping Life Spans A Short Distance to Large Health Disparities Washington DC
Red Line Union Station Washington to Shady Grove Montgomery County MD 17 metro stops 30 miles 9 year life span difference
Orange Line Metro Center Washington to East Falls Church Arlington County VA 9 metro stops 10 miles 8 year life span difference
Green Line Gallery Place Washington to Greenbelt Prince Georges County MD 11 metro stops 17 miles 3 year life span difference
Blue Line Foggy Bottom Washington to Springfield-Franconia Fairfax County VA 10 metro stops 12 miles 9 year life span difference
2008 Robert Johnson Wood Foundation wwwcommissiononhealthorg
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Health Disparities In Local Communities Too New Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
bull 7 in 10 overweight or obese in New Haven 6 in 10 in CT and 65 in 10 in US
bull Higher levels of asthma diabetes heart disease amp stroke than in CT overall and US
bull Higher levels of cigarette smoking
bull Neighborhood safety an issue
bull 67 feel unsafe walking at night 33 feel unsafe walking at day
2012 New Haven Health Survey CARE httpcareyaleeduresources446_148336_CAREOverallFindingspdf
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Geography Also Mediates Access To Quality Healthcare Services
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Multiple Levels of Discrimination Permeate the Social Environment
Levels of Racism The Allegory of A Gardenerrsquos Tale
Jones CP American Journal of Public Health 2000 Vol 908 1212-1215
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Racial microagressions
Sue D W et al MayndashJun 2007 Amer Psychologist Vol 62 No 4
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
Infants of US Born Black mothers African-born Black mothers and US-born White mothers born in Illinois Context
Sample n =43322 (US-born Blacks) Subset of 90503
Result The infants of US-born Blacks had a lower mean birth weight (3089g) compared to those of African-Born Blacks (3333g) and US-Born Whites (3446g)
Conclusio n
Genetics SES and other risk factors do not account for
Lower Birth Weight Among USshy differences in mean birth weights born Blacks between white and black women
born in the US David Richard J and James W Collins Jr Differing birth weight among infants of US-born blacks African-born blacks and US-born whites New England Journal of Medicine 33717 (1997) 1209-1214
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Self-Reported Discrimination Contributes to Low Birth Rate
Self-Reported Experiences of Racial Discrimination Between Blacks and Whites (the CARDIA study)
Context
Sample n = 352
Result
Unadjusted odds ratio among Black vs White women was 254 (95 CI = 133 485) for preterm birth and was 424 (95CI = 131 1367) for low birth weight
Adjusted odds ratios for gt=3 vs 0 experiences of racial discrimination was unchanged for preterm birth and low birth weight
Conclusio n
Self-reported experiences of racial Self-Reported Discrimination discrimination may contribute to Contributes to Existing Disparities poor birth outcomes among Blacks
Mustillo Sarah et al Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries the CARDIA Study American Journal of Public Health 9412 (2004) 2125-2131
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Active Coping Attenuates Negative Effects of Discrimination
Different coping mechanisms and their effect on the relationship of discrimination and preterm low birth weight infants
Context
Sample n = 160 cases 117 controls
Result
The odds ratio is 25 (12 52) for preterm low birth weight infants given past-year exposure to high vs lowmedium levels of perceived racial discrimination
Active coping especially ldquoworking harder to prove them wrongrdquo and getting violent decreased this odds ratio Passive coping increases this odds ratio by seven
Conclusio n
Some coping behaviors can change Active Coping Attenuates the effects of discrimination on Negative Effects of birth outcomes Discrimination Rankin Kristin M Richard J David and James W Collins Jr African American womens exposure to interpersonal racial discrimination in public settings and preterm birth the effect of coping behaviors Ethnicity and Disease 213 (2011) 370
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
Discrimination experienced by pregnant persons perceived to be Arabs as a result of September 11
Context
Sample n = 1547375 subset of n = 15064 Arabic Named
Result
Arabic-Named women giving birth between October 2001 and March 2002 are 34 more likely to have a low birth weight infant than during the pre-911 period
The risk is 125 higher if the Infantrsquos given name is ethnically distinctive
Conclusio n
Arabic-named women with a stronger ethnic identity experience Discrimination in Arabic-Named a greater contextual effect from Women discrimination
Lauderdale Diane S Birth outcomes for Arabic-named women in California before and after September 11 Demography 431 (2006) 185-201
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
What are the dimensions of interventions to reduce and eliminate disparity
Differences in healthcare quality Health services delivery
Differences in healthcare access Social determinants of health
Differences in life opportunities exposures stressors and other contextual factors that differences in underlying health status Social determinants of equity
Adapted from Camara Jones MD PhD
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Todayrsquos Outline
Disparity Populations and Research Funding Priorities
Root Causes of Stubborn Health Disparities
Levers for Change
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Understanding the equity impact of policies at your organizations and the organizations serving your clients
Health impact assessment (HIA) has become an essential tool in the development of healthier public policies
Health Equity Impact Assessments (HEIA) are endorsed by WHO amp embeds equity in organizationsrsquo decision-making
HEIA is flexible and practical assessment tool that can be used to identify unintended potential impacts of a policy program or initiative on vulnerable or marginalized groups
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
STEP 1 Scoping Identify potentially affected vulnerable or marginalized populations
STEP 2 Potential Impacts Use available data and evidence to assess unintended impacts of the planned policy program initiative on vulnerable or marginalized groups
STEP 3 Mitigation Develop evidence-based recommendations to minimize or eliminate negative impacts and maximize positive impacts on vulnerable groups
STEP 4 Monitoring Determine how the rollout of the initiative will be monitored to determine its impacts on vulnerable or marginalized populations
STEP 5 Dissemination Share results and recommendations from the HEIA with diverse stakeholder groups in cyclic process
httpwwwhealthgovoncaenproprogramsheiadocswork bookpdf
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
What can I dohellip
Offer to lead a HEIA team at your organization
Reach out to organizations serving your clients and offer to serve on committees that shape policy to bring an HEIA perspective
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Clinical and Socio-demographic Complexity
NQF sets standards to endorse healthcare measures and fosters healthcare improvements
Expert committees comprised of stakeholders (patients providers payers) evaluate measures for NQF endorsement
Recommends measures for use in payment amp public reporting programs
Identifies and accelerates quality improvement priorities
2014 National Quality Forum Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors httpwwwqualityforumorgProject_PagesRisk_Adjustment_and_SESaspxt=2amps=ampp=1|
NQF-endorsed measures are evidence-based and valid
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
What can I dohellip
Draft public comments on policies that affect Healthy Start and Healthy Start clients
Seek other opportunities to contribute to local regional and national policy conversations
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
Policy Research
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Pediatric cohorts
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
DHHS
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Part 1 Overview Information
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Leading the Way in Research partnerships
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
What can I dohellip
Identify knowledge gaps and inform funding priorities
Establish robust partnerships with researchers and others to lead innovative and relevant research agendas
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
Things yoursquore convinced are truehellip
1) Federal funding priorities are directly relevant to addressing persistent health disparities in birth outcomes
2) Addressing healthcare delivery social determinants of health and social determinants of equity in parallel is key for success
3) Healthy Start is well-positioned to lead local regional and national movements to advance critical policy and research change
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-
THANK YOU
Learn more about the Equity Research and Innovation Center (ERIC)
httpericyaleedu
- Why Health Equity is Critical for Birth Outcomes
- No conflicts
- Todayrsquos Outline
- Things I want to convince you are truehellip
- Todayrsquos Outline
- What Are Health Inequities
- We Are Not Achieving Our Health PotentialUS Life Expectancy Worsens Rank Dropping From 15 In 1980 To 27 In 2009
- US Health Disadvantage Cannot Be Explained By International Differences In Wealth
- Despite Spending Most Money on Health in the World US Lives Are Shorter by Nearly 5 Years Than Expected
- US Losing Ground on Child MortalityCompared to European CountriesUS Ranks 26 in Infant Mortality Rates
- NIH Disparity Populations
- CDC At-risk Populations
- IOM Vulnerable Populations
- Healthy People 2020 Objectives
- If we donrsquot collect data on ldquordquoitrdquo and if we donrsquot incentivize to fix ldquoitrdquo ldquoitrdquo wont change13
- Milestones in federal research funding and prioritization
- Infant Mortality Rates for Mothers Age 20 +By RaceEthnicity and Education 2001-2013
- Todayrsquos Outline
- But how do health disparities arise
- But how do health disparities arise
- Healthcare disparities persist most disparities not improving across quality measures
- But how do health disparities arise
- Through 2012 across access measures most disparities did not improve
- But how do health disparities arise
- Most Americans ldquoRacism is widespreadrdquo
- Sexual Orientation amp DiscriminationSeen as Serious Problem in US
- What are the dimensions of interventions to reduce and eliminate disparity
- What are the dimensions of interventions to reduce and eliminate disparity
- Unequal Treatment
- Excess Medical Expenditures Due To Health Inequities
- Patient DemographicsInfluence Physician Decisions
- Ethnicity and Analgesia
- Implicit and Explicit Bias
- Implicit Attitudes Testing (IAT) data on physician race and gender
- Implicit bias is associated with differences in healthcare delivery and quality of care
- Physician implicit amp explicit bias have differing effects on patient experiences
- Clinician implicit bias amp stereotyping associated with poor communication amp ratings of care
- Physician-to-patient talk time ratios associated with discrimination amp lower adherence
- QUALITY DISPARITIES Overall quality (top map) and racialethnic disparities (bottom map) varied widely across states and often not in the same direction
- Integrating disparity populations in patient-reported quality of care metrics
- What are the dimensions of interventions to reduce and eliminate disparity
- What Are Other Key Factors Shape Health While Medical Care amp Behaviors Influence Health Social Factors Play Crucial Roles As Well
- What Are The Social Determinants of Health
- Social Disparities Contribute to Increased Deaths in the US
- United StatesSocial Factors Affecting Adult Health
- Shrinking Middle Class And Growing Poverty Means Good Health Is Increasingly Out Of Reach For Many
- Parentrsquos Income Can Affect Childrsquos Health Throughout Life
- How Education Can Influence Health By Shaping Employment Opportunities amp Income
- Self-Reported Health Varies By RaceEthnicity Even At Same Levels Of Income
- Health Also Varies Across Racial or Ethnic Groups At Same Level of Education
- Neighborhood As A Geographic Determinant of HealthInfluence of Community-Level Factors on Health
- Mapping Life SpansA Short Distance to Large Health DisparitiesWashington DC
- Health Disparities In Local Communities TooNew Haven Residents In 6 Neighborhoods Reported Poorer Health Compared To CT amp The US
- Geography Also Mediates Access To Quality Healthcare Services
- What are the dimensions of interventions to reduce and eliminate disparity
- Multiple Levels of Discrimination Permeate the Social Environment
- Racial microagressions
- Lower Birth Weight among US Born Blacks Unexplained by ldquousual suspectsrdquo
- Self-Reported Discrimination Contributes to Low Birth Rate
- Active Coping Attenuates Negative Effects of Discrimination
- Discrimination in Arabic-Named Women Data on post-911 Birth Outcomes in Arabic-Named Women
- What are the dimensions of interventions to reduce and eliminate disparity
- Todayrsquos Outline
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Understanding the equity impact of policies at your organizations and the organizations serving your clients
- ldquoEquity Impactrdquo of Service Delivery Policiesndash Health Equity Impact Assessment framework
- What can I dohellip
- Clinical and Socio-demographic Complexity
- What can I dohellip
- Healthy Start and Systematic Levers of Change to Address Health Disparities in Birth Outcomes
- Pediatric cohorts
- DHHS
- Part 1 Overview Information
- Leading the Way in Research partnerships
- What can I dohellip
- Things yoursquore convinced are truehellip
- THANK YOU
-