SOCI 172 Final Exam

Population Health

(1) Documentation of Patterns and Trends

(2) Multi-level set of explanatory factors/determinants

(3) Use research to improve population health

(4) Geographic-specific orientation

Social Demographic Perspective on Population Health

Social-stratification; critical of overly-individualistic orientations to health; draws from demography (study of human populations) and sociology

Sociology

Focus on context: time, space, and systems of inequality (SES, race/ethnicity, etc.)

King-Stoddart (2003)

definition of population health - the health outcomes of a group of individuals, including the distribution of such outcomes within the group; measures = length of life, health related quality of life

Robert Wood Johnson Program

"Health and Society" - trained dozen of PhD students with a focus on population health

Key US trends:

(1) Health outcomes are worse than other wealthy countries

(2) Health disparities are very wide and are growing

(3) Spend far more on health care than any other country

Lexis Diagram

Shows Age-Period-Cohort relationship to illustrate population health

The National Longitudinal Study of Adolescent to Adult Health (Add Health)

One of most important US studies of population health over past two decades; followed more than 20,000 adolescents aged 12-19 from 1994-1995 to adulthood; now 37 years old; five waves; INTEGRATIVE APPROACH

Integrative Approach

bridging social/behavioral sciences with the biological sciences to understand population health; Harris (2010) encourages this approach in theory, research design, and data collection/analysis

Health (WHO definition)

a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity

Health Disparities

population-specific differences in the presence of disease, health outcomes or access to health care

Cohort Study

a particular form of longitudinal study that samples a group of people who share a defining characteristic, typically who experienced a common event in a selected period ex: birth, graduation

Add Health Cohort Aged from Adolescent to Adulthood trends (Harris)

1. Generally worsening health; rapid increases in obesity and smoking; no health insurance, less health care, not exercising, more STD, more asthma, more drug use/heavy drinking

2. Declines in suicide ideation, depression, violence, and few reports of poor health

3. Widening disparities

Measuring Population Health

Need: Valid, reliable, comprehensive and standard way of measuring/reporting population health; reflect temporal and spatial dimensions; reflect the population their intended to relfect/representative data; broad set of factors that influence population health

Five Key Applications to Measurement of Population Health

(1) Advocacy

(2) Accountability

(3) System Management

(4) Quality Improvement

(5) Research

Census Data from US Census Bureau

1. US Decennial Census Data - 4/1/2020; complete count, mandatory may law, multi-modal; denominator for birth and death rates

2. American Community Survey (ACS) data - large annual survey of US population; 3.5 million annual respondents; great understanding for small geographic areas

Vital Statistics Data from National Center for Health Statistics

1. Birth (Natality) Certificate Data - annual counts/characteristics of birth for every geographic area

2. Death (Mortality) Certificate Data - annual counts/characteristics of deaths for every geographic area

Period-Based (Cross-Sectional) Surveys from National Center for Health Statistics

Most common Data

1. National Health Interview Survey - THE nation's health survey; provides data on key self-reported population health measures; all ages, oversampled minority groups

2. National Health and Nutrition Examination Survey - annual health survey AND examination data; provides data on measured weight/height/waist, BP, cholesterol, glucose, etc.; expensive so only N of 5,000

Cohort-Based Longitudinal Surveys

1. Add Health

2. Health and Retirement Study- every-other-year health survey of US adults aged 50+; follow them until they die and add new people each time; oversampled minority groups; provides longitudinal survey AND exam data

Administrative Data

passive data collection on individuals and places; often not population based; confidentiality is an issue

ex: tax forms, hospital records, electronic medical records, cancer registries, medicare/medicaid, insurance claim records, other disease registries

Other forms of Population Health Data

1. Mapping data - graph depictions, links places in the world with what comes with them

2. Qualitative and Archival Data - focus groups, in-depth interviews, systematic observation, historical records

3. "Non-health" population surveys - cross-sectional and longitudinal

Age Specific Death Rates (ASDR)

# deaths X to X+4/mid-year population ages X to X+4 * 100,000

Infant Mortality Rate (IMR) Calculation

# deaths ages 0-364 days in yr/# live birth in yr * 1,000

Population Composition

Key population health measure

Since 1975, US population is: larger, older, more racially/ethnically diverse, more foreign-born, more suburban, more poverty for children/working ages, less poverty for older ages

Life Expectancy at Birth (e0)

THE key measure used to gauge the overall health of a population; average # of years that a group of infants would live if the group were to experience the age-specific death rates present in the year of birth; use life-table

Infant Mortality Rate (IMR)

infant death - death of a live-born child before his or her first birthday; further classified as neonatal death (before 28th day of life) and post neonatal data (after 28th day before 1st birthday); indication of how society is taking care of their babies

Cause-Specific Mortality Rate

# of deaths that occur among individuals due to a SPECIFIC UNDERLYING CAUSE of death in a year per 100,000 people in the mid-year populations count in that same year

Underlying Cause of Death

the disease or injury that initiates the train of events leading directly to death or the circumstances of the accident or violence that produced the fatal injury; every death is attributed to one specific cause

Age-Adjusted Death Rates

AKA age-standardization; Used to compare two or more populations (different over place/time) with different age distributions; effectively negates the effect of age composition

Prevalence

# of cases of a disease, # of infected persons, or # of persons with some other attribute present during a particular interval of time; often age-adjusted and rate

Incidence

# of cases of a disease having their onset during a prescribed period of time; cohort studies are useful for measuring it; difficult because do not know when it began/population may change risk of disease over time

Epidemiologic Transition

long term sift in disease and cause of death patterns once dominated by infectious disease pandemics to one now characterized by the predominance of chronic disease and related causes of death

Infectious Diseases

those caused by pathogenic microorganisms; the diseases can spread directly or indirectly from person to person

Chronic Diseases

non-communicable diseases that are not spread from person to person; long duration and slow progressing; cardiovascular, cancer, chronic respiratory diseases, and diabetes

Age of Pestilence and Famine

Up until 1870; life expectancy 25-40; poor health and high mortality rates for infants, early childhood, and child bearing mothers; "long arm of childhood" health still poor and life short into adulthood; horrible social and environmental conditions; poor data/records

Age of Receding Pandemics

1870-1920

Life expectancy = 37-54 years

Due to "social and economic modernization" ex: increased economic strategy, housing, education, personal hygiene; modern medicine had little to do with decline in infectious diseases; introduction of clean water technology decreases mortality in major cities, mostly among infants/children

Age of Degenerative and Man Made Disease

1920/PreWWII/influenza epidemic-1960

Life expectancy = 69.7 in 1960

Chronic diseases began to dominate; not new diseases but now many people are living long enough to experience them; decades of exposure from birth to death so social and environmental conditions matter

HIV/AIDS

1981-1990s; prevention, programs, and treatment have improved since then; racial/ethnic minority and gay/bisexual men are at highest risk right now; decrease in prevalence because decrease risk behavior; federal government did not respond to disaster

Reduction in Heart Disease and Stroke Mortality

1960-2014

Science, public health campaigns, medicine to treat/alleviate symptoms, technological improvements; decrease in tobacco use

Reductions in Cancer Mortality

1980-present

1st in men because of smoking then in women

Tobacco - 1964 Surgeon General's Report, labels/warnings, tax increase, press on tobacco companies, smoking bans

Increases in Drug Poisoning and Suicide Mortality Rates

Tripling of drug poisoning death rates for men and women; increasing suicide mortality rates for both men and women; some evidence that deaths due to cirrhosis of the liver also increasing; trends may be especially bad for low-educated, middle-aged white adults in US

Increasing Prevalence of Obesity

Life course - not just middle aged and older adults; future impacts on health and health care costs

Increase in older adult activity limitations

does longer life mean an increase in healthier life? Not necessarily; more limitations reported recently

Case and Deanton

uncover rising midlife, all-cause mortality among middle-aged non-Hispanic white Americans between 1999-2013; mortality rates have increased by about 0.5% per year in US whites; US hispanics declined by about 2% and blacks by 2.6%

Cumulative disadvantage for relatively low-educated US white cohorts born after 1950

Explanations for Increase in Midlife Mortality:

Fewer good opportunities at time of labor market entry, less long term labor market stability, WEAK social/economic/health welfare system; reductions in martial patterns; reductions in belonging

Critical reports by NRC in international differences in health

1. Explaining Divergent Levels of Longevity in High-Income Countries (2011) - poor mortality rates among adults aged 50-74 due to cigarette smoking

2. US Health in International Perspective - shorter lives, poorer health; self-rated health better than those of peers

2013 Report Implications

1. Start a National Conversation

2. Make people aware

3. Compare policies of other countries

Why does the US lag behind high-income peers: Explanation 1

3 Part US System (govt paid and provided; govt supported and private providers; employer-sponsored, private insurance, private providers) is disjointed and costly and inefficient; geared towards medicines, cures, and high-technology; much less toward prevention/primary care; NO UNIVERSAL ACCESS

Why does the US lag behind high-income peers: Explanation 2

Individual Health Behavior - 1. smoking: explains 50-75% of older adult mortality disadvantage

2. obesity (nutrition and physical activity)

3. alcohol and drug use: differentiating us more and more

4. others: drinking and driving, driving, lack of helmet/seat belt use, use of firearms, partial explanations

Why does the US lag behind high-income peers: Explanation 3

Social and Racial/Ethnic Inequality - US has highest level of income inequality and highest rate of poverty of any other high income country possibly due to material and social deprivation; long history of racism and profound population health consequences for minorities

Why does the US lag behind high-income peers: Explanation 4

Physical and Built Environment - difficult to conduct systematic research on; car culture, pollution, lack of recreation, lack of sidewalks/bike lanes, poor urban/rural planning, lack of healthy grocery stores/restaurants

Why does the US lag behind high-income peers: Explanation 5

Our Lack of Political Will as Reflected in our Policy Context - political process has not paid enough attention/cared enough about population health (social security and medicare are exceptions); ex: lack of childcare/early child education supporters; widely differing property taxes; declining investment in and performance of public schools; low income taxes; modest income support policies; low or no capital gains and inheritance taxes; weak labor and employment policies; CORPORATE AMERICA RUN AMOK: profit above else; weak labor and employment protection policies

Montez et. al

Large variation in life expectancy across US states (7.4yrs) than across high-income countries (4.7yrs); individuals and contexts are different in US states; Highest mortality in Nevada, Wyoming, Mississippi; Lowest mortality in Hawaii, North Midwest, Oregon, Utah

Multilevel, discrete time event history model

Used by Montez et al; statistical models that predict who lives and who dies over a 6-year period after answering the survey using state of residence as key variable and "multilevel: explanatory variables: (1) individual-level characteristics; (2) state-level characteristics

What explains state variation in women's mortality

1. Individual characteristics - demographic and socioeconomic characteristics; accounts for 30% state variation

2. State context AND individual characteristics - accounts for 62% state variation in mortality

3. Economic environment and social cohesion - most important characteristic accounting for differences between states

4. State contextual factors - more important for women than men; tobacco environment most important for men

Dwyer-Lindgren et al

County-level variation in life expectancy; 20-year difference between the healthiest and unhealthiest counties; geographic inequality in county-level mortality increased 1980-2014; 74% of county variation in mortality using county-level variables: socioeconomic/racial inequalities, behavioral/metabolic differences, some health care differences important

Neighborhoods

where we spend most of our time; have limited or no formal governance but still policy relevant; how are individuals sorted into them and how do neighborhoods affect those individuals?

Diez Roux and Mair

How do Neighborhood Environments Contribute to Health Inequalities?

Racial Segregation by race/ethnicity and SES; income and racial/ethnic segregation drive neighborhood physical and social environments

Residential segregation

the extend to which different racial/ethnic and socioeconomic groups share neighborhoods; examined using data from CENSUS TRACT that approximate neighborhoods; index of dissimilarity ranges from 0 to 100 and asked the evenness of distribution of people across neighborhoods

2 Classical Theoretical Paradigms

1. Marx-Social Class: Bourgeoisie (owners) exploit the proletariat (workers); capitalist society

2. Weber-Socioeconomic status: multidimensional hierarchy (class, status, party); modern approaches: education, occupation, income, wealth; holistic concept

Educational Attainment causally linked to mortality?

Education is a "fundamental cause of health and disease"; educational attainment facilitates access to important resources and is policy amenable; high preventability cause of death rates decrease with increasing education; major differences in US adult mortality rates by educational attainment; educational attainment strongly associated with preventable causes of death

Policy Interventions for Educational Attainment and Health

Investing in education - invest in children during the entire education process; empower teenagers with the opportunity to complete high school

11% in 2012 w/o high school degree

1. Target educational disparities in education - increase education levels for those who need it

2. improving overall population health - invest more at all levels for everyone

Advantages to education

jobs, income, healthy lifestyle, access to nutritious foods, parks and recreations, and school systems = RESOURCES

Fundamental Cause Theory

unequal distribution of risks and resources; wide variety of ways that social conditions affect health; deeply connected with inequality; social and economic disadvantages as fundamental cause of health

Four essential features of FCT

1. Influences multiple disease outcomes

2. Multiple risk factors - disadvantaged groups have higher mortality risk from chronic and communicable diseases; gradients evident in presence of risk and protective factors; preventable v. unpreventable causes of death

3. Involves access to flexible resources that can be critical to maintain health advantages - individual: knowledge, money, social connections, prestige, power, life skills; contextual: neighborhoods, work, schools, cities

4. Association reproduced over time via replacement of intervening mechanisms - ex: polio vaccine 1st given to president then slowly trickles up; new mechanisms come up

Life Course Pathway

potential life course processes encouraging reproduction of health disparities across generations: socioeconomic pathway, cognitive abilities, emerging health; strongest support for SES pathway because most associated with reproduction of health disparities, education attainment and income

Link and Phelan

education is a fundamental cause of health and mortality

Elizabeth Lawrence (2017)

Use of propensity score methods to account for selection into college degree attainment; uses 54 variables from adolescence in Add Health to best predict who gets a college degree and who does not by ~28 yrs old; takes into account an individual's PROPENSITY to get a degree; college degree attainment effect # of physical activities, sugary beverage and fast food consumption health behaviors

Overlapping mechanisms that Papel et all suggests might account for SES differences in health behavior

1. Background factors that affect education/health behavior*

2. stress of deprivation/inequality*

3. class distinction/culture*

4. future discounting among low SES

5. Access to information*

6. Agency; self-determination

7. aids for healthy behavior

8. community opportunities

9. social support/social cohesion/peer influences*

*strongest evidence

Chetty et al

Association between Income and Life Expectancy in the United States; data: income - 1.4 billion deidentified tax records, mortality - social security administration death records, contextual factor - access to health care, stress, race/ethnicity, etc.; objectives: calculate PERIOD LE (specific death rate used from specific period) at age 40, measure association between income and life expectancy

National Levels of LE by income

higher income associated with greater longevity (14.6yr difference between men, 10 year gap between women); inequality widening over time; the gender gap in LE is not the same for individuals at each income levels

Local Area Variation in LE by income

made easier with zip codes since able to get very local and not use state level; LE for low-income individuals varied substantially (men: low in Nevada, Indiana, OK; high in CA, NY, VT); NV, OK, HI - lowest LE for high income, UT, DC, VT highest for high income

What explains local area variation in life expectancy?

Health behaviors and area-specific characteristics: health behaviors, access to health care, income inequality and unemployment, fraction immigrants, fraction college graduates, government expenditures

Number of African Americans that die prematurely each year

60,000 - 100,000; equivalent to airliner full going down each day

What do racial disparities in health reveal and reflect?

Basic social inequality; racism is fundamental to that inequality

Race and Ethnicity

socially constructed categories of identity created through social processes; passed down through history embedded in institutions and learned through interactions with others; imposed on use while we also self identify with them; change over time and place and with experience

Ethnic groups

defined as common ancestral origin and cultural traits such as religion, language, and customs, culturally based

Race groups

defined by biological features such as skin tone, hair color, and facial features

Major race groups

White, Black, Asian, Native Hawaiian and Pacific Islander and American Indian Alaskan Native

Race/Ethnicity of US population in 2015

NH White - 61.8%

Hispanic - 17.5%

NH Black - 12.2%

NH Asian - 5.5%

NH AIAN - 0.8%

NH HPI - 0.3%

NH 2 or more races - 1.8%

Why are questions evolving for census?

1. People can be double counted because of two part question

2. No separate category for Middle Easterns and North Africans

3. Can't simply choose preferred identity

4. Why have to answer race question if identify as Hispanic

Proposed single question for census 2020

Combined question with write-in area or check boxes; different categories with further detailed categories to choose from

Add Health experimentation with race/ethnicity questioning

"of the race/ethnicity categories you selected, please pick the one which you most strongly IDENTIFY"; allow respondents to easily summarize their primary identity; gives researchers easy to work with variable to use in analysis

Nativity

country of birth; summarized as foreign-born or US born; foreign-born = 1. specific country of origin; 2. age of immigration; 2013 - 13.1% of population was foreign-born

Racism

an ideology of a group inferiorly used to justify the unequal treatment of racial minorities by individuals and institutions; systematic restriction of access to society's goods, including work and fair pay, equal housing, quality schools, etc.; through exploitation and exclusion, policies/laws that have disparate impact; includes prejudice and discrimination; much more than individual treatment of one another

Racial residential segregation

key way that racism is revealed and enacted

Unnatural Causes: Bad Sugar

Example of racism and population health; diversion of river water disrupted Pima's agricultural sector and customary ways, leading to poverty and the influx of cheap unhealthy foods resulting in increase in diabetes among population

Phelan and Link Fundamental Cause Definition

Fundamental cause embodies a set of flexible resources, and a superior set of resources generates superior results on some outcome. Level of resources varies across social groups and groups with better resources have better outcomes; allow to influence outcomes due to flexibility of resources through multiple pathways; circumstances/mechanisms may change but power of flexible resources maintains the connection between fundamental cause and outcome

Fundamental Cause Implication

inequalities in health cannot be permanently eliminated by addressing proximate risk factors for diseases and death, and long-term reduction/elimination of health inequalities must address the root cause of those inequalities; must target flexible resources

P-L 3 sets of fundamental associations

1. Racism is a fundamental cause of racial differences in SES

2. SES is a fundamental cause of inequalities in health and mortality

3. Racism is a fundamental cause of racial differences in health/mortality independent of SES

1. Racism is a fundamental cause of racial differences in SES

Well documented black-white disparities in education, WEALTH, occupational category, home ownership, % poverty, median income; racism (both institutional and individual) works to create/maintain gaps; pervaded by stereotypes, ideas, etc. that reproduce SES disparities; mechanisms change

2017 Proposed Tax Reform

-cut corporate tax rate from 20% to 35%

-reduce number of individual tax brackets from 7 to 3

-rate for lowest income families would increase from 10 to 12%

-other two rates would be 25% and 35%

-eliminate the estate tax

-eliminate the Alternative Minimum tax (high income earners)

-double the standard deduction while eliminating specific deductions

3. Racism is Fundamental Cause Independent of SES

1. Prestige - honor attached to a person or social status and distributed unequally in a social group

2. power - intended and successful control of others

3. Neighborhood and beneficial social connections - ex: individual social networks of high SES people, bargaining power of neighborhood groups

4. Freedom - the ability to control one's own life circumstances and actions

How does racism affect health

accumulation of stress; access to, utilization of, and quality of health care; neighborhood effects: recreation, nutrition, substances, safety, environment

What to do/how to do fix the racism-health problem

1. Break association between race and SES

2. Break the association between race and non-SES resources

Do so by read, listen, better understand racism; vote; change minds and hearts; critically examine and reform our institutions

Unnatural Causes: When the Bough Breaks

How wide/narrow are racial/ethnic disparities in infant mortality, both for populations as a whole and when focusing on specifically on "low risk" child bearing women - college educated, married ages 25-34; policy and practice relevant question

B-W differences in prematurity

Distal: institutionalized and interpersonal racism

social: SES, social environment

Potential mechanisms: acute, chronic, and early life stress; preconception health

Proximate Determinants: Vascular Dysfunction, Inflammation and infection, HPA dysfunction (physiological responses to social stress)

Differences in low risk women

"low risk" US born black women exhibit odds of infant mortality 2.6 times higher than low risk white women, as a result of higher prematurity compared with whites; disparities amongst low risk women are pervasive across regions of the country; exceptional socioeconomic, school, neighborhood, stress, and health disadvantages for blacks compared to whites in young adulthood and adolescence

Markides and Coriel (1986)

Hispanic or Epidemiologic Paradox - "health status of Hispanics in SW US was comparable to health status of non-Hispanic whites and was considerably better than the health of African Americans whom they were most similar socioeconomically"; first paper to state paradox

Percent foreign born 1960 to 2017

1960: 4.7% foreign born; 2017: 14%; changes due to change/diversification of laws