The Differential Health of Women and Minorities

Transcription

1 The Differential Health of Women and Minorities CHS 150, November, 6, 2013 Marjorie Kagawa Singer, PhD, MA,MN,RN, FAAN UCLA Fielding School of Public Health and Asian American Studies

2 Minority Non-Minority Figure 1: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care* Clinical Appropriateness and Need Patient Preferences Difference The Operation of Healthcare Systems and the Legal and Regulatory Climate Discrimination: Biases and Prejudice, Stereotyping, and Uncertainty Disparity Populations with Equal Access to Health Care * Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, IOM, 2002

3 National Landmark Reports Highlighting Cancer Disparities Problem Pre

4 In 40 years of research to eliminate health disparities, we have made no progress. Leonard Syme, 2008 IOM Workshop Summary, 2012

5 Trends in Consumption of Five or More Recommended Vegetable and Fruit Servings for Cancer Prevention, Adults 18 and Older, US, Prevalence (%) Year Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Source: Behavioral Risk Factor Surveillance System CD-ROM ( , 1996, 1998) and Public Use Data Tape (2000, 2003), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 2008

6 The Economic Burden of Health Disparities in the United States U.S. spends $2.2 trillion (16% of GNP) on health care. Used 3 measures: 1) direct medical costs of health inequalities, 2) Indirect costs of health inequalities, 3) Costs of premature death. Found that between : The combined costs of health inequalities and premature death in the U.S. were $1.24 trillion Eliminating health disparities for minorities would have reduced direct medical care expenditures by $229.4 billion (30%) 30.6% of direct medical care expenditures for African Americans, Asian Americans, and Hispanics were excess costs due to health inequalities Eliminating health inequalities for minorities would have reduced health care costs by $1.24 trillion dollars. TA Laveist, DJ Gaskin, P Richard, Joint Center for Political and Economic Studies,

7 5 Leading Causes of Death, U.S., 2003, Female All races Cardiovascular Cancer Cerebrovascular Chronic lower respiratory White Cardiovascular Cancer Cerebrovascular Chronic lower respiratory Alzheimer s Alzheimer s Black Cardiovascular Cancer Cerebrovascular Diabetes Nephritis American Indian Asian or Pacific Islander Cardiovascular Cancer Accidents Diabetes Cerebrovascular Cancer Heart Cerebrovascular Accidents Diabetes Hispanic Cardiovascular Cancer Cerebrovascular Diabetes Accidents White, non- Hispanic Black, non- Hispanic Cardiovascular Cancer Cerebrovascular Chronic lower respiratory Alzheimer s Cardiovascular Cancer Cerebrovascular Diabetes Nephritis Heron, M. P., & Smith, B. L. (2007). Deaths: Leading causes for 2003 (No. DHHS Publication (PHS) ): National Center for Health Statistics.

8 Disease always occurs within a context of human circumstances, including economic status, social position, culture and environment.

9 Ecological Model of Health * Modified from McElroy and Townsend, 1996.

10 Culture Environment Economy Technology Religion/World View Language Social Structure Beliefs and Values

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12 California Demographics 2010 Population = 37,253,956 6% 1% 39% 13% 5% 0.4% 36% Black or African American (non-hispanic) American Indian & Alaska Native Asian Native Hawaiian & Other Pacific Islander Two or more races Hispanic or Latino Whites (non-hispanic)

13 Los Angeles County Demographics 2010 Population = 9,818,605 27% 9% 1% 13% 0.7% 4% 46% Black or African American (non-hispanic) American Indian & Alaska Native Asian Native Hawaiian & Other Pacific Islander Two or more races Hispanic or Latino Whites (non-hispanic)

14 Three Major Questions What populations have poor survival? What are the causes of disparities in survival? How can we eliminate disparities?

15 Four Major Answers Biases in our society due to: Racism Ageism Sexism Classism

16 Race Racial categories differ with different societies and nations. Fluid and situationally variable Contested by persons/populations involved

17 Cline Single trait genetic gradient over space and differing environments Example: skin color Site A Melanin in adjacent breeding populations Site N Environmental variation: UV radiation

18 Cline for skin color Jablonski, N and Chaplin, G.,California Academy of Sciences

19 Causes of Cancer & Other Chronic Diseases 5% due to genetics 95% due to: - lifestyle - environment - diet Culture forms lifestyle Therefore attention to cultural differences makes a great deal of difference in decreasing the unnecessary disease burden

20 Poverty and gender should NOT be an offense which is punishable by death. Harold Freeman, M.D., 2006

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22 California Hispanic Age 35+ Heart Disease Rate CDC 6/9/ 05 www\\\apps.ncd.cdc.gov

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27 TO BE JUDGED BY THE CONTENT OF THEIR CHARACTER.. Kian and Remee Horder

28 California Age 35+ Heart Disease Rates by Ethnicity v. U.S. CDC 6/9/ 05 www\\\apps.ncd.cdc.gov Race/Ethnicity Population Heart Disease - Rate Total Pop 12,576, AI/AN 105, AAPI 1,899, Blacks 1,023, Hispanics 3,450, WHITES 9,

29 Age-Adjusted Death Rates for Diseases of the Heart* Among Women, by Race/Ethnicity, Average annual deaths per 100,000 women, age adjusted to 1940 U.S. standard population, International Classification of Diseases, 9th Rev., codes , 402, and Source: Journal of Women s Health and Gender-Based Medicine, Vol. 10, No. 8, pp

30 Major Causes of Death in the U.S. Women have higher rates than Men for CVD and Diabetes *All data are age adjusted to 2000 total U.S. population. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993; 270:

31 Underlying Causes of Most Chronic Diseases 35% -65% Lifestyle choices *All data are age adjusted to 2000 total U.S. population. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993; 270:

32 Smoking Rates Among Ethnic Populations and Gender Native American (40.8%). Caucasian American (23.1%). African American (20.8%). Among Youth Males: 19.1% Females 20.7% Hispanic American (12.3%). Asian/Pacific Islanders (7.1%). 7/nhsda983.htm#E10E29

33 Cancer Incidence Trends California, Rate per 100, Asian/Pacific Islander Hispanic Black Non-Hispanic White S. Kwong, 2004

34 Female Breast Cancer Trends California, S. Kwong, Rate per 100,000 Chinese Filipino Japanese 120 Korean South Asian Vietnamese

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36 Our future: Black, White and Asian

37 Ethnic Minorities in the U.S. Behavior is influenced by: Cultural Beliefs Minority Status

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39 Relationship with Husbands of Chinese-, Japanese- & European-American Breast Cancer Survivors Theme 2: Nature of marital relationship A. Mutual emotional give and take B. Harmony and Intimacy C. Communication D. Role expectations Same for the 3 groups Harmony rather than intimacy predominates Non-Verbal Inshin denshin in Japanese and Zhih Yi in Chinese Wife s role clearly differentiated as emotional nurturer and husband as source of security Intimacy predominates v. harmony Direct and verbal communication is valued Ability to be dependent on husband Kagawa-Singer and Wellisch, 2002 Psycho-Oncology

40 Relationship with Husbands of Chinese-, Japanese- & European-American Breast Cancer Survivors Theme 3: Sources of dissonance: Meeting needs A. Empathy Expectations of wives not met by husbands B. Recognition of individuality C. Perceived types of support from H D. Sources of support for W Invalidation of individuality cut a little slack but abandoned to own resources No time out from ongoing stress in relationship Pragmatic problem-solving assistance and tangible aid driving, housecleaning, also reassurance and calm Friends/coworkers (3) Daughters/ Family (husband) (6) Kagawa-Singer and Wellisch, 2002 Psycho-Oncology Husbands (15)

41 Comparison of Physician Discussion, Decision-making and Disclosure at End of Life after adjustment * Odds Ratio (95% Confidence interval) Japanesespeaking Englishspeaking Japanese Americans Japanese Americans Japanese living in Japan Discuss end-of-life with a physician 0.73 (0.41, 1.31) 1.10 (0.62, 1.94) 1.0 Group decision-making model 1.11 (0.70, 1.74) 0.63 (0.41, 0.97) 1.0 Terminal prognosis disclosure to the patient using words 8.79 (5.42, 14.3) 2.80 (1.79, 4.37) 1.0 Terminal prognosis disclosure to the family using words 2.01 (1.05, 3.88) 1.03 (0.58, 1.83) 1.0 Matsumura, et al. 2000

42 PATH For Women Survivors and THRIVERS!!

43 Leading Causes of Death for Asian Males and Females, California, Male Female 1 Cancer Cancer 2 Heart Disease Heart Disease 3 4 Cerebrovascular Disease Chronic Lower Respiratory Disease Cerebrovascular Disease Influenza & Pneumonia 5 Accidents Diabetes

44 Five Most Frequently Diagnosed Cancers Among Asian/Pacific Islanders, Rank Male Female 1 Prostate Breast 2 Lung & Bronchus Colon & Rectum 3 Colon & Rectum Lung & Bronchus 4 Liver Uterus 5 Stomach Thyroid

45 Top 5 Cancer Sites Ethnicity API API Asian Ind Asian Ind Chinese Chinese Filipino Filipino Gender Male Female Male Female Male Female Male Female 1 Lung* Lung* Lung* Breast Lung* Lung* Lung* Lung 2 Colorectum Breast Prostate Lung* Liver* Colorectum Prostate Breast 3 Liver* Colorectum Pancreas Colorectum Colorectum Breast Colorectum Colorectum 4 Prostate Pancreas Leukemia Ovary Stomach Stomach Liver* Pancreas 5 Stomach Stomach Liver* Pancreas Prostate Liver* Non-Hodgkin Ovary Ethnicity Japanese Japanese Korean Korean Vietnamese Vietnamese Gender Male Female Male Female Male Female 1 Lung* Lung* Lung* Lung* Lung* Lung* 2 Colorectum Breast Stomach Stomach Liver* Liver* 3 Stomach Colorectum Liver* Liver* Stomach Colorectum 4 Prostate Pancreas Colorectum Colorectum Colorectum Breast 5 Pancreas Stomach Pancreas Pancreas Leukemia Stomach Ethnicity Nat. Hawai Nat. Hawai Samoan Samoan White White Gender Male Female Male Female Male Female 1 Lung* Lung* Lung* Lung* Lung* Lung* 2 Colorectum Breast Stomach Breast Prostate Breast 3 Prostate Pancreas Colorectum Stomach Colorectum Colorectum Chu, Stomach Colorectum Liver* Ovary Pancreas Ovary 5 Pancreas Stomach Prostate Endomet. Non-Hodgkin Pancreas

46 Kaiser Key Health Indicators by Race/Ethnicity and State, 2009 Infant Mortality (per 1,000 live births) All White African American U.S Hispanic California New York

47 Kaiser Key Health Indicators by Race/Ethnicity and State, 2009 Diabetes-Related Mortality Rate (deaths/100,000) All White African American Other U.S California New York

48 Kaiser Key Health Indicators by Race/Ethnicity and State, 2009 Annual AIDS cases (per 100,000 population) All White African American Hispanic Asian NHOPI AI/ AN U.S CA NY 29l

49 White Black Native American Mexican Puerto Rican Cuban Other Hispanic Chinese Japanese Korean Vietnamese Cambodian Thai Laotian Filipino Asian Indian Other Asian Hawaiian Guamanian Samoan Other Islander Age-Adjusted Death Rates Due to All Causes, California

50 Percent of All Cancers Five Cancers contributing to overall cancer incidence burden in males by race/ethnicity and geography Chinese Males 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Colon (5) Esophagus (6) Liver (12) Stomach (20) Lung (26) Stomach (7) Colon (8) Nasopharynx (9) Liver (11) Lung (24) Rectum (5) Liver (8) Colon (10) Prostate (16) Lung (18) China Hong Kong/ Singapore US Chinese Geographic Region

51 Percentage Below Poverty 1999 Poverty Status in Asian Americans 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% US Total 12.38% 17.69% NHOPI Source: Census 2000 Asian Alone 12.60% Asian Indian 9.75% Cambodian 29.28% Chinese 13.50% Filipino 6.25% Hmong 37.78% Population Japanese 18.50% 16.46% 16.05% 14.77% 14.35% 9.72% Korean Laotian Pakistani Thai Vietnamese

52 Prostate Cancer Five-Year Average Annual Age-Adjusted Incidence Rates per 100,000, California, Rate per 100,000 S. Kwong, Chinese Filipino Japanese Korean South Asian Vietnamese

53 Lung and Bronchus Cancer Five-Year Average Annual Age-Adjusted Mortality Rates per 100,000, California, Rate per 100,000 Male Female 55.3 S. Kwong, Chinese Filipino Japanese Korean South Asian Vietnamese

54 incidence rates of breast cancer for all stages combined (Table 1), Differences African between Americans have and higher Cancer rates of regional- Mortality and Rates distant-stage disease. Similar variations by race and ethnicity are seen for the other cancer sites. Table TABLE 6. Treatment One measure of the quality of cancer treatment is five-year survival for patients with the same stage at diagnosis. African Americans have lower stagespecific survival than Whites for many cancers. 35 The poorer survival appears to result more from disparities in access to care White Total API Chinese Filipino Japanese Nat. Haw. AI/AN Hispanic Chu, K. 2004

55 Cancer Disparities by Race/Ethnicity and Socioeconomic Status CA: A Cancer Journal for Clinicians Volume 54, Issue 2, pages 78-93, 31 DEC 2008 DOI: /canjclin

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58 Our Challenge in Public Health Overwhelmingly, social inequalities in society determine the largest portion of health disparities (IOM & Institute of Medicine, 2012). Social inequalities directly impact the morbidity and mortality of marginalized populations within and between groups (IOM & Institute of Medicine, 2012), and are defined as power imbalances related to overt and covert discrimination due to race, class, gender, age, sexual orientation, or disability

59 The Question I leave with YOU Of all the forms of inequality, injustice in health care is the most shocking and inhumane. Martin Luther King Jr. If not you, then who? If not now, then when?