UNC SOCI 172 Final

Population Health

Documentation and explanation of patterns and trends in certain geographic locations. Then translate these findings into action, often through policy and program

Social Demographics

Mortality

Population representativeness

Complex set of tools to collect accurate and representative data

Population Representativeness

What is true of the overall population and its subgroups

Life Expectancy at birth (e0)

Expected remaining years of life based on current population health

US Life Expectancy

78.6 years

Infant Mortality Rate

Number of infants who die before their first birthday

Key indicator of health for an area because it's society's most vulnerable group

(# of deaths/ # of live births in a year) * 1000

IMR in the US

6.00 (per 1000 live births)

Age-Adjusted Mortality Rates

Effectively weighs age- specific death rates

1. Choose standard population age distribution

2. Multiply each death rate by an age specific population proportion for standard population.

3. Sum totals in #2

Age-Specific Mortality Rate

Death rate for a certain age group based on current health

Cause-specific Mortality rate

Death rate for a certain cause

Life Course

Life changes due to social, economical, psychological, and health domains

Prevalence

Number of cases of a disease, of infected, or of persons with attribute present during a particular interval of time

*often age-adjusted

Incidence

New cases, onset during a period, expressed as a rate

Lexis Diagram

y-axis: age

x-axis: time

shows cross sectional data

shows health or that yea but doesn't show individual health over time

Age group

Looks at a certain age group in a certain time

Period

Addresses all age groups in one time group

*most common way to collect data

Cohort

Follows a group of people over time

Social Stratification

Who gets what and why

Systems of inequality

Social Context

Groups and institutions that structure the norms, behaviors, and health of people who are exposed to such influences

Vital Statistics Data

From National Center for home health statistics

Birth certificates and death certificates (numerator data)

Census Data

The permanent US population

Taken every 10 years

Provides denominator data for birth and death rates

Next one is April 1, 2020

2020 Census controversy

Citizenship question

Adding question is predicted to reduce participation

Less people counted means less funding for school, infrastructure, etc

Matters for Congress representation and redistricting for state government

Biomarkers

Data from biospecimens or physical measurements by trained and certified personnel following standard protocol

*Effective with survey data

*provides objective data

*Examples: blood, urine, sleep, cognitive function, saliva, heart function, and BP

*requires logistics, consent, ethics, money, and time

National Health: Interview Survey

telephone survey that asked about health and health behaviors

National Health and Nutrition Examination Survey

collected data through direct physical examinations, clinical and laboratory testing

Self-reported questionnaire

Cross-sectional

ADD Health

Follows a cohort over time of about 20,000 people

Questionnaire and physical exam

Also scan medications

Health and Retirement Study

Starts with a group of 50-51 year olds every other year and follows them until they die

Linked with medicare, death certificates, earning, and geographic data

Epidemiological Transition

Theory by Omaran

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

3 phases: Age of pestilence & famine, age of receding pandemics, and age of degenerative & man-made disease

e0 in the US 1870-37

Infectious Diseases

Caused by pathogens that can be spread

Age of Receding Pandemics

1870-1920

LE:37-54

Social/economical modernization, coincides with industrial revolution, increased personnel hygiene, little to do with modern medicine as infectious disease such as measles saw an extreme decline without vaccines

Age of Pestilence and Famine

Before 1870

LE: 20-40 with year to year fluctuation

Poor health, high infant mortality rate, horrible societal and environmental factors

Lack of clean water, food, medicine, and hygiene

Age of Degenerative & Man-made diseases

1920-1960

LE: 67.7 years

Chronic disease is now the main cause of death as people are now living long enough to experience them

Chronic Diseases

Non-communicable diseases

Deaths of Despair

these were suicide, drugs, and alcohol related deaths; reduced labor (people lost jobs) decreased /marriage and an increase in mental health problems; disproportionately affects low-income, non high school graduating whites (middle-aged; ages 45-54)

US Life Expectancy trend in the last 3 years has ________

declined

True or False

Smoking has caused more deaths than any other US epidemic in history

True

History of Smoking in the US

1950's: about 50% of US adults smoke; ads would use doctors and famous people

1960's: shift marketing to women and minorities (become sexy)

1990's: Joe Camel, more minorities, very fun, young people

2010: social media contracting ads, shift to low income and minorities

Current Tobacco Ads

2016

$8.7 bil on ads and promo

90% of money is used for price reduction for retailers

Smokeless tobaccos ads: $759.3 mil

Overall health and mortality trends from tobacco use

Current smokers (about 15%, 40 mil of US pop) are 2.3 more likely to die from all death causes than non smokers

Former smokers are 1.4 more likely to die from all death causes than non smokers

1964 Surgeon General's Report

First report to say smoking causes cancer and other issues

Cigarette ads and boxes now require labels and warnings

Started pressure and lawsuits on tobacco companies

Doesn't include other forms of tobacco

1998 Master Tobacco Settlement Agreement

5 largest tobacco companies were taken to court by 46 states (other 4 states sued alone)

5 key parts

1. Tobacco companies required to pay for healthcare of people sick due to cigarettes

2. Certain marketing strategies outlawed (ex: marketing to kids, billboards, and TV)

3. Money paid to Truth Campaign and research money

4. Had to admit they used deceptive ads overtime and knew that what they were selling was killing people

5. Restrictions on publicity, sponsorships, and free samples

Opioid Epidemic

Affects mostly white middle-aged men

Purdue Pharma

opioid production company, drugs have a high chance for addiction

Increase in availability and supply of prescription opioids since 1990s

FDA approved and direct marketing

Created oxycodone and directly marketed it to physicians for them to prescribe

Back to Sleep Campaign

Prevents babies from suffocating in their sleep ( Sudden Infant Death Syndrome)

Worked to educate parents, caregivers, and healthcare professionals

extremely successful

Obesity Epidemic

coincides with increases in cardiovascular diseases and levels of disability

May explain why 50 year old's levels of disability are increasing while it remains somewhat steady for the elderly

17% of kids were found obese in ~2016

The US outranks most other high income countries on BMI related overweight or obese with 63.9% of adults compared to an average 50% among all other countries

2018 SUPPORT for Patients and Communities Act

Almost unanimous support for bill in house and senate

Package screening for fentanyl

Increased funding for opioid prevention

Research to create more non addictive medications

Funding for states to buy back unused pills

National Strategy to Increase Life Expectancy Bill

2018

Referred to the House committee to vote

Not passed yet

Only modest amount of money involved ($10 million)

Little causation data to support bill

US International Standing on Population Health is among _____ of all high-income nations, except at ages ____

worst, 75+

We live _______ & ____ healthy lives than people in most high-income countries and spend the ____ on health care.

shorter, less, most

US health disadvantage began to emerge in ____; really took off ~____

1960,1980

Key explanations for US health disadvantage: Care? Behavior? Built Environment? Inequality? Policy?

Care: Lack of universal health insurance

Behavior: unhealthy eating, less physical activity,

Built Environment: marketing,

Inequality: economic, education, neighborhoods, wealth

Policy:

Income Inequality

the unequal distribution of household or individual income across the various participants in an economy

Since mid 70's productivity has continued to rise while wages have stayed relatively the same (people should be making almost double)

Regionally: New England is the best and the Southeast is the worst

Income Distribution

Right Skewed

Affordable Care Act (Obamacare)

law aimed at lowering the rate of people without health insurance

Wealth Inequality

the unequal distribution of assets within a population

Historically blacks were discouraged from homeownership

1/5 black households have (-) wealth due to debt

Median wealth Black: 11,030

White: 134,230

Why has economic inequality grown so fast?

Tax policy: Trump tax cuts, Regan tax cuts, graduated income tax redistributes resources; less money brought in by taxes means less money for funding programs

Decline of unions

Globalization and trade policy (NAFTA)

Possible Policies to reduce income inequality

Progressive tax based on net worth from automatic bank info

Increase minimum wage

Strengthen unions

Offer more generous social benefits

Medicare

Ages 65+

Care for the elderly

Medicaid

Aid the poor

Urban Penalty in Population Health (1850s to ~1950)

Mortality rates were higher in the cities because of pollution and bad hygiene (use of unclean water sources)

Rural Penalty in Population Health (~1950s to present)

Mortality rates are higher in the rural areas as heart disease and cancer lowered more slowly in the rural areas than in the city. The wealth and resources are distributed unevenly - more so prevalent in cities

Social Networks

a type of social context that characterizes structures of social interactions and relationships

Religious Context

Better population health and lower mortality among specific religious groups characterized by substantial norms of social control (especially Seventh Day Adventists and Church of Jesus Christ of Latter Day Saints)

Religious Attendance and Health/Mortality in US

reater religious involvement=better health, denomination did not matter

56% higher probability of death if you said "never" for religious attendance

Religious social institutions have the power to exert social control and influence the health behavior and health of individuals in certain groups

Blacks who are not religiously involved have poorest health and highest rates of mortality

Some subgroups affected more than others. Lack of involvement among African Americans is strongly associated with poor health and high mortality perhaps bc of the institutional centrality of religion in the Black community. Lack of involvement among highly educated Americans may not be associated with poor health at all perhaps because the benefits of high educational attainment are so strong in the 21st century US

Emile Durkheim

Sociologist who thought natural desires of individuals for material wealth, pleasure status, and other "goods" can never be satisfied, only controlled

Also studied anomie and suicide: religion decreased suicide rate

Built Environment

he physical spaces we inhabit: how places are organized, quality and affordability/availability of housing, access to public transportation/parks/recreational facilities, the location of environmental waste, and what kind of consumer goods are marketed and sold

Places people at increased risk of poor health behaviors

US fares poorly internationally in relation to our heavier use of automobiles and much greater availability of firearms, but in air pollution US is not an outlier

Car culture, pollution, environmental taxes, lack of recreation, etc lead to lower health

How our cities, suburbs, and rural areas are organized

Difficult to measure and compare in a systematic way across countries, a key contributor to health inequalities by SES and race/ethnicity. Likely has something to do with obesity related causes of deaths/injuries

Spatial Context

the groups and institutions that structure the norms behaviors, and health of people who are exposed to such influences

Spatial differences because of the characteristics of people who live there (selection)

Social Context

the time, space, and social institutions that structure the norms and behavior of people who are exposed to them

Social contexts create opportunities for integration and support because they bring together romantic partners, friends etc.

Waite found that married individuals had better health due to the social support and pooling of economic resources (can have the opposite effect depending on the context of the relationship)

Have potential to regulate the behavior of individuals providing a form of social control that can influence harm

States, Counties, Neighborhoods & Population Health

For counties across the country, the life expectancy disparities are very high, vary by as much as 20 years from county to county

Increasing. Fairfax vs Boone

Most health-disadvantaged places are rural and/or located in the South

Counties with longer life expectancies tend to be urban and coastal

"At Least we aren't Arkansas"- this state performs poorly in almost all aspects of population health

Black neighborhoods vs white neighborhoods have different population health because of stress and discrimination and violence

NY health better than Minnesota

Possible reason: NY heavily taxes cigarettes

Social Integration

he overall level of involvement with informal social relationships (such as having a spouse) and with formal social relationship (such as those with religious institutions and volunteer organizations)

Coined by Durkheim

Other Definition: Social ties and support that are garnered from social contexts

Social Support

the emotionally sustaining qualities of relationships

Social Control

the idea that neighbors, colleagues, friends, etc restrict certain behaviors through the enforcement of social norms

School Contexts

a critical social context, only studied in Add Health

Schools that have strong norms against teen pregnancy exhibited substantially lower teen pregnancy rates compared with schools where the norm was less strong

Residential Segregation in US (by race and SES): explanations, trends

explanations, trends ; selection of disadvantaged people into different neighborhoods, towns, cities, etc ; less economic investing in these areas; perpetuation of poverty

Selection (e.g., into neighborhoods)

people sort themselves into neighborhoods, on aspects like gender, race, ethnicity, income, education, etc. its not random at all.

Housing=expensive; not everybody buys because wealth is passed through families... more accessible to those that have wealth

Factors that draw people to a place (both internal to individual and external- meaning characteristics of the place)

Causation (e.g., neighborhood "effects")

Place determines what someone is exposed to (violence/crime, access to healthy foods, quality housing, chemicals/pollution, social interaction, safety)

Property tax- more expensive to buy things in low income areas

Immense stress, few resources, violence

Ex: Richmond vs. Seattle

Social Class

Individuals' relationship to the means of production → workers and owners; economic based; relational. Marxist. Much more simple than SES

Workers (proletariat)

Owners (bourgeoisie)

Economic based

Socioeconomic Status

differences in individuals and groups in the possession of highly valued societal resources. (multidimensional, economic-, status-, and power- based, relational) much more hierarchical

Most important 4 measures = educational attainment, occupational status, income, and wealth

Absolute level of resources. Hierarchical

Dimensions of socioeconomic status

1) educational attainment - usually education in years and/or degrees; but does not measure the quality of the education (content and types of schools and instruction) some sociologists argue it is the best measure because typically it is determined earlier in one's lifetime, so disabilities or sickness are less likely to interfere

2) occupational status - usually the current job; difficult to measure because of the retired, incarcerated, students, or stay at home parents who do not have jobs

3) Income - personal, household, who gets included, is it hourly/weekly/monthly ?

4) Wealth - what people own (house, land, assets) minus debt

Douglas Massey & Social Stratification Theory

Individuals are organized into social categories, determined at birth; not equally likely that anyone can be equally mobile (socioeconomic stickiness), and this is less the case in recent years. Institutional processes differentially allocate resources to these categories

SES-Health Gradient

Higher SES is associated with better long term health and longevity; thorny issues of causality; life-course timing of SES-health relationship is not very well understood; differs across time, place, subgroup (Whites may benefit more from education or higher SES than Blacks or Latinos)

Some policies have helped to increasingly concentrate those with high SES in some areas and with lower SES in other geographic areas (highest level of socioeconomic segregation in the nation's history)

Lax zoning laws

Creation of municipal boundaries to maintain pockets of segregated affluence

Property tax increases in gentrifying areas

The concentration of affluence creates further inequality because funding for schools, parks, and other health-enhancing community resources can be spent on those with already high levels of SES

Scientific work on the causal effect of SES on health is difficult because generally researchers can't use experimental designs

We can use advanced statistical methods

Take advantage of natural experiments like changes in compulsory school laws

Produce better data sets to address causality

Fundamental Cause Theory

Link and Phelan. SES embodies individuals with a flexible array of (disposable) resources they can use at any time to prevent or mediate against disease risk; Inequalities in health persist over time despite radical changes in the diseases, risks, and interventions (mechanisms) that produce them. Fundamental causes are an enduring connection between a social factor and a wide range of health outcomes

Critics: suggests that there are strong correlations between measures of SES and measures of pop health that are actually due to a third set of factors that influence both SES and health

Genetic makeup, family background, infant and child health characteristics

Flexible Resources

Resources to use on an everyday basis that work to enhance health and protect against the risk of death; include knowledge, money, power, social connections; flexible because they can be used in a variety of ways. The key point here is that the flexible resources that embody SES do not simply influence health in one simple way; there are literally dozens and dozens of mechanisms at work that translate socioeconomic advantages and disadvantages into health; INDIRECT influence; access to health care is NOT a flexible resource

Whitehall Study

Mortality rates were graded by occupational status; those in the highest ranking positions exhibited the lowest mortality rates and those in the bottom ranked positions exhibited the highest. Remarkable because all employees were covered by the UK's universal health care program, so differences in access to care could not account for the occupational status disparities in mortality. Occupational status provides individuals with social networks and an enhanced sense of control over their lives; health measures like blood pressure didn't really account for the disparities

Income and Health: Causality

bi-directional relationship-- high income, better health. Low income, worse health. Worse health, not able to go to work thus lower income etc.

Increase in estimated LE gaps by income from 1930 to 1960

The widening of US distribution of income and wealth

De-unionization

Rise of the top executive compensation in US corporations

Changes in tax policies

Favoring high income and wealthy

Tax Cuts and Jobs Act (TCJA) signed by Trump in late 2017 - reduces taxes on US corporations, small businesses, wealthy estates, and high-earning individuals

Federal gov spending on income transfers (eg to the elderly, children, disabled, unemployed) is higher than ever and such funding has been redistributed away from the poorest people to those with higher incomes

Education and Health/Mortality

Educational attainment provides access to flexible resources: money, knowledge, power, prestige, social connections; Educational attainment most often utilized measure of socioeconomic status in US studies of population health; highly educated adults have greater access to technological, informational, and momentary resources than ever, resulting in more favorable population health patterns than ever before

Women with lowest level of education have the highest rates of low birth weight (9%) and prematurity (14%)

Interestingly, women with a graduate or professional degree exhibit slightly higher rates of low birth weight and prematurity than do women with a college degree, possibly bc rates of multiple births (who are more likely to be born early and/or small) have increased among women with high levels of education due to their greater use of fertility-enhancing treatments

IMR for women with less than a HS degree = 7.9

IMR for women with a college degree = 4.1

IMR for women with a graduate degree = 3.6

At the earliest ages, population health measures are strongly differentiated by (parents') SES

Least educated report higher levels of poor health

Significant reduction in odds of death for those with high school degrees

Life expectancy was estimated to be 9.6 years longer for highly educated (1 or more years of college) white women compared to low educated (0-4 years of schooling) white women. The educational disparity in life expectancy between the highest and lowest educated white men was smaller, at 3.2 years, but still sizable. Data limitations prevented calculation of educational disparities in life expectancy for non-white populations at the time.

Largest ever education disparities in health

the association between education and health has become increasingly strong since the 1980s, with widening disparities in many health outcomes across this period of time. Zajacova and Lawrence point to growing geographic segregation between rich and poor, the mass incarceration of low SES individuals, the loss of manufacturing jobs, and increasing psychological despair among the low educated as possible explanations for the widening educational disparities in health in recent decades.

Biggest disparities between white men, then white women, and then Black men

White men: highly educated men tend to occupy particularly advantaged social and economic positions in American society, this easily translates into good health

White women: potential advantages are diminished by the processes of gender discrimination that play out in the labor force

Black men: shallow educational disparities in pop health reflects inequality in schooling opportunities and discrimination in the labor force

At age 25, women with a college degree or graduate degree are expected to live, on average, an additional 62 years (a total of 87 years) while women without a HS degree are expected to live, on average, an additional 50 years (a total of 75 years). This is a 12 year difference.

For men, those with a college degree or graduate degree are expected to live, on average, an additional 57-60 years (a total of 82-85 years) while men without a HS degree are expected to live, on average, an additional 44 years (a total of 69 years). This is a 13-16 year difference!!!

Key explanations for educational differences in health/mortality

The wider disparities for men compared with women is most likely because highly educated men tend to occupy particularly advantaged social and economic positions in American society - positions that are also especially good for their health. The shallower education gradient in population health for African Americans most likely reflects both inequality in schooling opportunities and discrimination in the labor force, processes which result in lower pay and less access to key social networks for highly educated African Americans compared with Whites.

Quality of Education and Health (we don't know much)

Mortality rates drop significantly for those that have a high school degree vs those that do not.

Education quality is difficult to define/classify/control for

Childhood Socioeconomic Advantage/Disadvantage

The body doesn't forget

Children in poverty 8x higher to have poor health and also more likely to have physical limitations than children living in more affluent family

Socioeconomic upward mobility: less than a generation ago and less than in most countries

less than a generation ago and less than in most countries; Decreasing SES mobility among US young/middle adults since 1970s, especially those who ended up in a relatively high position; not impossible for low SES children to become high SES adults and it helps to be born into a high SES family.

Race

Race: the social grouping of people into categories based on perceived or real biological and cultural differences → initially to justify unequal treatment of POC

There is more genetic variation within race than there is across them...

Ethnicity

social grouping of people into categories based on perceived or real common ancestral origin and cultural traits

Only 2 ethnicities listed on US Surveys, Hispanic and non-Hispanic

Race, Education, and Population Health

Education adds a significant amount of years to both minority populations and whites. The biggest benefit comes from a high school degree, but with college, Masters, PhD, etc. each higher level adds more to a person's life expectancy

The increase in life expectancy is for all race groups, but benefits whites more than hispanics and african americans.

Excess deaths among Black Americans (~200 per day)

Between 60,000 and 100,000 premature deaths (earlier than they would have if they faced the same risk of death as white americans) = jumbo jet airliner every day year after year

Immigrant Selectivity

Immigrant Selectivity: Immigration of especially healthy individuals and emigration of especially unhealthy individuals

Racism

a social system that systematically restricts access to society's goods (work, housing, school) etc. to members of socially constructed racial/ethnic minority groups through the exploitation, exclusion, policies/laws that have disparate impact

Other definition: an ideology of group inferiority used to justify the unequal treatment of racial minorities (ie discrimination) by individuals and institutions

Systematic restriction of access to society's goods to members of racial and ethnic minority groups through exploitation and exclusion

Nativity

Distinction between persons who are born outside the country in which they live and persons who are living in the country in which they are born

David Williams

Says to break the association between race and SES; break the association between race and non-SES resources; both of these involve ridding society of racism and providing equity in flexible resources to people in all groups; Comprehensive reforms emphasizing structural interventions - segregation, wealth, income, criminal justice, political representation, healthcare; Programs to reduce implicit bias; Address discrimination in organizations, hiring, prejudicial attitudes; Research needs: build political will, decrease societal inertia, increase empathy, raise public awareness of societal benefits of racial equity