When Zip Code Matters More Than Genetic Code: The Social Determinants of Health

Transcription

1 When Zip Code Matters More Than Genetic Code: The Social Determinants of Health Dave Steward, MD, MPH ABC-D Conference Illinois Chapter, American Academy of Pediatrics April 28, 2017 O Fallon, Illinois

2 DISCLOSURE I declare that neither I, nor my immediate family, have a financial interest or other relationship with any manufacturer/s of a commercial product/s or service/s which may be discussed at the conference.

3 What we ll do today Review some definitions Discuss general concepts about social determinants Talk about social determinants and children And, think about some new ideas

4 Social Determinants of Health A person s health and chances of becoming sick and dying early are greatly influenced by powerful social factors such as education, income, nutrition, housing, and neighborhoods. Robert Wood Johnson Foundation Commission to Build a Healthier America Issue Brief No. 7 December 2009 Your health is more affected by your zip code than by your genetic code. Tom Frieden

5 Place Matters Life expectancies by zip code in the Twin Cities

6 Place Matters Life expectancies along the El in Chicago Life Expectancy Differences Along The El in Chicago, IL

7 What is Health? Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

8 What are the Determinants of Health? The determinants of health are factors that contribute to a person's current state of health. These factors may be biological, socioeconomic, psychosocial, behavioral, or social in nature.

9 Biological: What are the Determinants of Health? Gender, age, inherited conditions, sporadic diseases, infectious diseases Socioeconomic: Education, income/wealth, violence, discrimination (race, gender, age, sexual identity), family structure, social connections Behavioral: Alcohol, drug use, unprotected sex, nutrition, physical activity, smoking Physical environment: Household conditions, crowding, neighborhood characteristics, geography Health services: Access to quality health care, health insurance, health literacy

10 What are the Social Determinants of Health? The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices

11 Biological: What are the Social Determinants of Health? Gender, age, inherited conditions, sporadic diseases, infectious diseases Socioeconomic: Education, income/wealth, violence, discrimination (race, gender, age, sexual identity), family structure, social connections Behavioral: Alcohol, drug use, unprotected sex, nutrition, physical activity, smoking Physical environment: Household conditions, crowding, neighborhood characteristics, geography Health services: Access to quality health care, health insurance, health literacy

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14 NACCHO: The National Aboriginal Community Controlled Health Organizations Australia

15 Portland State University Social Determinants of Health Initiative

16 Frieden TR. Am J Public Health 2010; 100(4):

17 What is Health Equity? Health Equity: Every person has the opportunity to attain his or her full health potential and no one is disadvantaged from achieving this potential because of social position or other socially determined CDC circumstances. CDC /02/7-tools-for-advancing-equity-in-education

18 Health Equity

19 What are Health Disparities? If a health outcome is seen in a greater or lesser extent between populations, there is disparity. Race or ethnicity, gender, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual s ability to achieve good health.

20 What is Downstate Illinois? Source: Garner K, Shen T, Steward D. Cancer in Downstate Illinois, Epidemiologic Report Series 14:02. Springfield, Ill.: Illinois Department of Public Health, September 2013

21 Another way to think about Disparities in Downstate Illinois

22 County Health Rankings and Roadmaps Collaboration among: Robert Wood Johnson Foundation, The University of Wisconsin Population Health Institute Community Catalyst Analyze health data to rank counties in a state The model: Health Outcomes and Health Factors

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24 Downstate Illinois Health Outcomes 2017 County Health Rankings Counties Downstate Upstate Top quartile (Rank 1-26) Second quartile (Rank 27-51) Third quartile (Rank 52-76) Fourth quartile (Rank ) 13/73 18% 13/29 45% 15/73 21% 10/29 34% 22/73 30% 3/29 10% 23/73 32% 3/29 10%

25 Premature Death Years of Potential Life Lost Before Age 75 per 100,000 population Location Rate US 7,700 Top 10% US counties 5,200 Illinois 6,300 DuPage County 4,100 Cook County 6,600 Sangamon County 7,200 Mason County 9,700 Gallatin County 10,600 Hardin County 11,600

26 Teen Births Number of Births per 1000 female population aged Location Rate US 24 Top 10% US Counties 17 Illinois 30 Monroe/DuPage 12 Jackson County 25 Effingham County 33 Cook County 36 St. Clair County 42 Peoria County 44 Macon County 49 Jefferson County 52 Alexander County 75

27 Children in Poverty Percent of children <18yrs in poverty Location Rate US 20% Top 10% US Counties 12% Illinois 19% Monroe County 6% Kendall County 7% Effingham County 14% Sangamon County 23% Cook County 24% St. Clair County 26% Jackson County 30% Alexander County 52%

28 Low Birthweight Percentage of live births with low birthweight (< grams) Location Rate US 8% Top 10% US Counties 6% Illinois 8% Bureau County 5% Cook County 9% Sangamon County 9% Macon County 10% Mason County 11% Pulaski/Alexander Counties 11%

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31 Life Expectancy related to Educational Attainment Age Males Years of Education Females Years of Education Both Sexes Combined Years of Education National Research Council (US) Panel on Understanding Divergent Trends in Longevity in High-Income Countries; Crimmins EM, Preston SH, Cohen B, editors. Washington (DC): National Academies Press (US); 2011.

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33 Life Expectancy related to Gender and Race Racial differences in life expectancy at age 50 for U.S. men and women, National Research Council (US) Panel on Understanding Divergent Trends in Longevity in High-Income Countries; Crimmins EM, Preston SH, Cohen B, editors. Washington (DC): National Academies Press (US); 2011.

34 Percent Smokers Association of Smoking Rates with Income and Education Illinois, 2009 By Household Income By Educational Level

35 When Zip Code Matters More Than Genetic Code: The Social Determinants of Health

36 Nicholas J Spencer, Clare M Blackburn, and Janet M Read BMJ Open. 2015; 5(9): e007062

37 Health Care, Family, and Community Factors among Children Aged 2-8 Years with Mental, Behavioral, and Developmental Disorders in Urban and Rural Areas National Survey of Children s Health, US, Across Urban and Rural locations, Children with MBDD and their families are more likely than those without MBDD to: Have no medical home Have financial difficulties Have at least one parent with fair or poor mental health Live in neighborhoods in poor condition, and with little social support Robinson, Holbrook, Bitsko, et al MMWR Surveil Summary 2017;66:1-11

38 Health Care, Family, and Community Factors among Children Aged 2-8 years with Mental, Behavioral, and Developmental Disorders in Urban and Rural Areas National Survey of Children s Health, US, % Neighborhood Unsafe % Neighborhood in Poor Condition Rural Urban % Neighborhood with Limited Amenities % with Financial Difficulties % Parent with Fair/Poor Mental Health % No Medical Home Robinson, Holbrook, Bitsko, et al MMWR Surveil Summary 2017;66: Percent

39 Three New Ways of Thinking

40 Out of Sight, Out of Mind Behavioral and Developmental Care for Rural Children Kelleher KJ and W Gardner. N Engl J Med : New options to extend specialized care in rural areas: School based services Existing community organizations Expanded services at FQHCs and rural clinics Telehealth Collaborative care arrangements Alternative providers Peer providers

41 The Old Social History Marital Status Employment Hobbies/interests Who lives in the household Habits: smoking, alcohol, drugs

42 The New Social History? From the Upstream Risk Screening Tool Education Employment Social Connection and Isolation Physical Activity Immigration Financial Strain Housing Insecurity Food Insecurity Dietary Pattern Transportation Exposure to Violence Stress Civic Engagement

43 New Genetics: Can your zip code alter your genetic code?!? Epigenetics: environment causing heritable traits. Mechanisms uncertain:?methylation of histones (the Scaffold for DNA) DNA sequence is unchanged; gene expression is changed. Example: Mice exposed to stress after a strong odor produce offspring and 2 nd generation mice with inherited stress reaction to the same odor

44 What we ll do today Review some definitions Discuss general concepts about social determinants Talk about social determinants and children And, think about some new ideas

45 Thank you. Questions/Comments? Dave Steward, MD, MPH ABC-D Conference Illinois Chapter, American Academy of Pediatrics April 28, 2017 O Fallon, Illinois