Disparities Health in Multiethnic Populations
Lourdes Baezconde-Garbanati PhD MPH Baezconde-Garbanati, PhD, Department of Preventive Medicine Institute for Health Promotion and Disease Prevention Research November 12, 2009
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What I we will do today e ill toda
Overview of Minority population demographics and the growth of the population CONTEXT MATTERS Define health and health disparities Factors that influence health disparities Achieving Parity Explore possible solutions to eliminating health disparities Group Exercise p
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Projections of the U.S. Population 2000 to 2050
U.S. population will continue to grow, from 282.1 million in 2000 to 419.9 million in 2050.
However, the te of increase might be the slowest since the Depression of the 1930's as the size of the baby boom population continues to decline.
The nation s projected 49% population increase nation's during the next 50 years will be in sharp contrast to most European countries, whose populations are expected to decline by mid-century.
Source: U.S. Census Bureau, 2006. Partnership & Data Services Program, [e-mail]
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United States Population Projections 2000 to 2050
450,000 425,000 425 000 400,000 375,000 375 000 350,000 325,000 300,000 275,000 250,000
In Thousands
419,854 391,946 363,584
335,805 335 805 308,936 282,125 282 125 2000 2010 2020 2030 2040 2050
Source: U.S. Census Bureau, 2006. Partnership & Data Services Program, [e-mail]
White Alone Not Hispanic Population Percent of Total U.S. Population US
75 70 65 60 55 50 45 40 35
69.4 65.1 65 1 61.3 57.5 53.7 50.1 50 1
2050
2000
2010
2020
2030
2040
The Blacks/African Americans
Black or African Americans in the US are projected to rise from 35.8 million to 61.4 million in 2050 (71% growth).
A rate increase from 12.7% to 14.6%.
Source: U.S. Census Bureau, 2006. Partnership & Data Services Program, [e-mail] Jerry B Wong@census gov
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15 14.5 14 13.5 13 12.5 12 11.5
Black or African American Alone Population Percent of Total U.S. p Population
14.3 13.5 12.7 2000 13.1 13.9 13 9
14.6
2010
2020
2030
2040
2050
Asians/Pacific Islanders
Asian/Pacific Islanders will triple by 2050. The Asian alone population is p p A projected growth of 213%, from 10 7 million in 2000 to 33.4 10.7 33 4 million in 2050. API share of the nation's population nation s would double from 3.8% to 8%.
Source: U.S. Census Bureau, 2006. Partnership & Data Services Program, [e-mail]
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9 8 7 6 5 4 3 2 1 0
Asian Alone Population Percent of Total U.S. Population US
3.8
4.6
5.4
6.2 62
7.1
8
2000
2010
2020
2030
2040
2050
Hispanic/Latinos
Hispanic/Latinos will also triple by 2050. The growth will be from 35.6 million 35 6 to 102.6 million (increase of 188%). population share will nearly double from 12.6% to 24 4% 12 6% 24.4%.
Source: U.S. Census Bureau, 2006. Partnership & Data Services Program, [e-mail]
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115,000 105,000 105 000 95,000 85,000 75,000 65,000 , 55,000 45,000 , 35,000 25,000
Hispanic Population Projections 2000 to 2050
In Thousands
102,560
87,585 73,055 59,756 47,756 47 756 35,622
2000
2010
2020
2030
2040
2050
Percent of All Persons Below Poverty in the U.S. by Race/Ethnicity, 1994-2005
35 30
30.7
25
30.6 24.9
20
%
15 10 5 0
14.5
21.8 12.6
All Races White Black/African American Asian American Latino/Hispanic
19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05
Year
Source: U.S. Census Bureau, Current Population Survey, 1960 to 2005 Annual Social and Economic Supplements (Slide Courtesy of Pebbles Fagan, Tobacco Health Disparities Research Network)
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A Large Country of Hispanics
U.S. Hispanics are the 3rd largest Spanish-speaking population in the world At 41.3 million U S Hispanics represent 14% of the 41 3 million, U.S. total population
Top 5 Spanish-Speaking Populations Country Mexico Colombia United States Spain Argentina Population (Spanish- Speaking) 106,202,903 42,954,279 41,300,000 40,341,462 39,537,943
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Sources: Pearson Education 2005, US Census Bureau 2005.; Acento, 2006
Latinos Accounted for Half of the U.S. Population Growth since 2000
77% of f Hispanic s live in seven states: Arizona, Californi a, Florida, Illinois, Illinois New Jersey, New York and Texas
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Among national Share of Hispanic Audience Spanish-TV vs. English-TV
Spanish-language TV shares have maintained their growth while English-TV shares continue to decline
65% 60%
55%
54%
50%
46%
45%
40%
35%
92-93 93-94 94-95 95-96 96-97 97-98 98-99 99-00 00-01 01-02 02-03 03-04 Apr'04 May'04 Jun'04
Spanish-TV
English-TV
Source: NHTI STD 03-04 09/22/03-6/27/04, Applied same date span to previous seasons. Monday-Sunday 7:00-11:00pm (includes only advertiser-supported networks, cable, and independents; excludes, pay cable, pay-per-view and PBS). The Spanish-Language TV category includes viewing to all TF, TEL and UNI affiliates (including network cable outlets), plus any viewing to the following: 15 Spanish-language stations originating in Mexico, Spanish-language independent stations (i.e., those stations that are not affiliated with either TF, TEL or UNI) and viewing to Spanish-language cable networks.
Definition of Health
Before we can determine inequalities or disparities in health, we need to understand how we define health. Definition of health:
"Absence of disease" (Biomedical model) "Not just the absence of disease, but a state of complete physical, mental and social well-being." As defined by the World Health Organization y g
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Definition of Health
Definition of Health : "Health is a state of well-being and ll b i d capacity to function in the face of changing circumstances"
Institute
of Medicine,
1997
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Health is a Human Right H man
Good h lth is G d health i considered a "Human Right". u a g t We have a right to g health.
U ted at o s General United Nations Ge e a Assembly meets for the first time, Jan 10, 1946
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Health Disparities
When a disproportionate number of individuals in a specific p p p population have either higher risk, higher rates of disease (morbidity), or are dying more ( y), y g frequently from a specific disease ( (mortality) than the g y) general p p population.
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Achieving Parit Achie ing Parity
In Public Health our goal is not only to eliminate health disparities, but also to p , achieve parity for populations that have been left behind.
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Parity Parit
Parity goes beyond sameness or equality Begins with assumptions of "being in the red" d fi it and needing t b ild up. deficit d di to build Parity refers to bringing up a population group by providing the needed resources and services to help them thrive even in the face p of adversity
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Parity Parit
To achieve Parity we need multiethnic disadvantaged y g populations to obtain gains in: Education Access to information Access to health services Infrastructure building Reduction/elimination of system barriers Bringing resources to a community Making room for participation in decision making
Source: Parity Task Force (2000)
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Life E pectanc has Increased Expectancy
In the last century with advances in science and medical technology, lif t h l life expectancy has increased by at least 30 years in the general population. Its not just about the quantity of life that has increased, but also about the quality of life
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Life E pectanc Expectancy
But there are populations which have not obtained gains in the same way, g y, and are still lagging behind.
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Average A erage Life Expectancy at Birth E pectanc
For persons born 1988-1991 (18-21 years of age in 2009) average life expectancy:
Number in Years
Ethnic group Asian Hispanic White Black
Females 84.2 yrs 84 yrs 79.1 yrs 73.7 73 7 yrs
Males 78.4 yrs 76.4 76 4 yrs 72.6 yrs 64.8 64 8 yrs
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Inequalities Ineq alities
We must all share in both the extension of the quantity of life and the increases in the quality of life The U.S. Medical System has had its share of inequalities. Often we have not recognized the differences in p p people or how the system or society or specific y y p groups create disadvantages for some and not others. White Privilege
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Inequalities Ineq alities in Health Status Stat s
Health disparities exist for various groups in terms of morbidity or mortality in:
Infectious diseases Chronic diseases Vi l Violence
Domestic violence Street violence
Risk factors for various diseases Prevalence rates of specific illnesses
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An Unequal Burden of Disease Uneq al B rden
Some groups carry an unequal burden of death and/or disability related to specific diseases:
African American men and prostate cancer Hispanic/Latinas and Korean women and Cervical Cancer
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Unequal distrib tion Uneq al distribution of health
Health of Black Americans, Latinos and Asians and American Indians has not reached the levels of advances in medicine and technology made possible for most Americans. Much Americans f thi disparity i ti d t economic wellM h of this di it is tied to i ll being. However, poverty alone doesn't explain health disparities disparities.
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SES: A Key Determinant of Heath Socioeconomic Status (SES) is usually measured by income education and income, education, occupation
Source: David Williams Chicago 2003 Williams, Chicago,
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Although SES is a powerful predictor of h lth di t f health
There are other powerful predictors:
Genetics Work environments (exposure to carcinogens) g ) Life style issues (smoking) Access to health information and services Access to health insurance
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Determinants of Health
Large g p in mortality between those with a high g gap y g and a low SES.
Source: David Williams, Chicago, 2003
This gap is sometimes larger than the difference that exist between a smoker and a non-smoker, , or even among some racial/ethnic groups with different SES.
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SES and Race
Differences are seen in levels of education, income, professional status, and wealth. Education and income are generally more strongly associated with health status than race.
Source: The IOM report on Health Disparities 2003 Disparities,
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Education A key determinant of health
The death rate among Americans who have not graduated from high school is g g two to three times higher than for those who have graduated from college. g g
Source: David Williams (2003)
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Unequal distribution of health
We would still see disparities among p g people of color even if we eliminated negative socioeconomic conditions. (IOM report, 2003) WHY?
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What accounts in part for p disparities?
Systemic barriers and issues Discrimination Socioeconomic status Geography
for example number of clinics in rural areas
Access to resources and care Distribution of resources
number of ethnic doctors who speak more than g g one language in various areas
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Some Factors that Affect Health and Well-being
Economic factors Education Employment Language g g Social Networks Poverty Housing Insurance status Access to care Availability of care y Population characteristics Acceptability of care Geography ( g p y (rural versus urban)
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Problem of Disparities
Many times disparities are the result of a flawed system Lack of health care choices Lack of insurance coverage Lack of screening and early detection Availability of drug therapies for all Lack of cultural sensitivity Lack of language and cultural proficiency when dealing with clients of groups different from ones own
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Environmental Factors Working Conditions
Emergency crews respond to 9/11 Utah Mine, 2007
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Overpopulation p p Living in overcrowded conditions
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Lack of Rapid Response p p People in the Streets after Katrina
New Orleans After Katrina Photo by J. Bartlett
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Resolving Ineq alities Resol ing Inequalities
Need to acknowledge there is still racism, sexism and discrimination in this country
Women earn less than men for the same job There is ethnic profiling Police response in Beverly Hills and Santa Monica is 3 minutes; Response for L A averages 20 L.A. minutes
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A comprehensive solution is needed that is multi-factorial in nature lif i li
What we can change h Cultural solutions Economic (changing cultural solutions norms) (elevating wealth and economic status, minimum wage) Systemic changes (bilingual/bicultur (bili l/bi lt al personnel) increasing Availability of Resources Social solutions (improving the context of peoples lives) Eliminating Discrimination Reducing Stress Controlling diseases Compliance with medical treatments Increasing Literacy levels l l Geography Educational (investing in educational opportunities) "Burden of Support" ( pp (DHB, , 1999) Social and political will
Reducing the Providing Access Technology divide (health care gy ( reform) Achieving Cultural Competence can not change Genetics Language Translations
Working on the Dr-Patient communication Eliminating Violence
Age
Phenotype
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focus on multiple and complex determinants of health f lti l d l d t i t f h lth
ECONOMIC Income, its distribution and social status/income inequality i l t t /i i lit Employment/Unemployment and underemployment, job security Working d living W ki and li i conditions diti Contributions of the current economic climate SOCIAL Social networks/social support/social safety net/Social exclusion and inclusion Gender, Sexual Orientation Information Technology -Use of virtual social networks ENVIRONMENTAL Availability and Acceptability of Cessation services C ti i Education, literacy in materials Physical environments conducive to quitting Gene-environment interactions Specific targeting of tobacco Industry of particular populations CULTURAL Personal health practices and coping strategies to q p g g quit/ stay y quit POLITICAL Public Policy
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Transdisciplinary efforts can help in the elimination of disparities
Epidemiology Community Health H lth Sciences
Behavioral Sciences
Preventive Medicine
Anthropology A th l
Public Health
TD Research
Environ Health Sciences
Communication
Sociology
Technology
Public P bli Policy
Bioethics
Genetics
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What promises to eliminate health p disparities?
Follow up to diagnosis Advances in medical care Greater G t access to t technology Improved prevention efforts Improved early detection d t ti Being prepared for emergency situations Availability, accessibility, affordability and y acceptability of treatments Increased compliance Consideration of culture and language Consideration of h lth C id ti f health belief systems Elimination of institutional racism
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Eliminating Health Disparities
Institutional changes Understanding culture and the impact of cultural b li f on h lth d i i lt l beliefs health decisions Addressing cultural competency Improved services I d i Strengthening health service system Ensuring better access Encouraging public and/or organizational policies that help eliminate disparities
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Other factors to consider
Health literacy of populations Literacy levels overall of populations Cultural and linguistic differences between providers and patients/clients Media advocacy Collaboration and partnership building Working with community based service agencies Building trust Giving back to communities Engaging p y makers g g g policy Including communities in decision making
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Other factors to consider
Community violence (ranging from gang warfare to war situations that sometimes are continued in the U.S.) Feeding the hungry (Food security) Respecting human rights
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Preparedness at all levels for emergencies p g Individual and systemic level
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Engaging Communities in their Own g g g Health
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Policy and Advocacy y y Implications
Promote healthy behaviors Engage employers to provide greater employee protections Reduce smoking Increase physical activity Proper nutrition Provide programs to p p p g prepare communities to face disasters Target interventions to reach particular populations
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Policy Polic and Ad ocac Advocacy
Encourage health promoting habits Fight discrimination g Build capacity Build infrastructure Pass Health Care Reform that makes sense! Develop "pipeline" of bilingual/bicultural providers
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Take Action: Meeting with first Hispanic US Surgeon General g
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Partnerships working together on policy p g g p y initiatives to prevent tobacco disparities
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Closing Remarks
Understand your population and its health disparities Transdisciplinary efforts Translation helps drive a broader agenda Revitalize our social and political will via advocacy Mentor students and junior faculty Train advocates in our communities Work towards achieving parity Experience a resurgence of our social learning (how do cultural values play a role?) lt l l l l ?) We are at a time of an intellectual and social transformation We Institute for Health Promotion & of opportunities are at the crossroad Disease Prevention Research 39 57 Aim for a new vision for health justice in the U.S.
Be inspired! Do Your Part!
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Nelson Mandela
"I have cherished the ideal of a democratic and free society in y which all persons live together in harmony and with equal opportunities. pp It is an ideal which I hope to live for and to achieve But if achieve. needs be, it is an ideal for which I am prepared to die".
Nelson Mandela's statements before a court in South Africa during Apartheid. He then went on to lead All South Africans.
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Sources: So rces:
Baezconde-Garbanati and Cruz, 2009 lectures. HP 420 Gender and Ethnic Minority Health, USC, IPR David Williams Institute of Medicine Williams, Medicine, 2003 Acento, Acento 2006 Google Images, 2008-2009
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Sources
U.S. Census Bureau Partnership & Data Services Program 15350 Sherman Way, Suite 300 Van Nuys, C 91406 V N Ca
( [phone] ) [phone] toll free
L.A. Regional Website: www.census.gov/losangeles [e-mail] [e-mail]
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