Determinants of Health

transcript

M6920September 11, 2001

Columbia University School of Nursing M6920, Fall, 2001

Health

is a state of complete physical, mental and social well-being and

not merely the absence of disease or injury*

Includes capacity to function individually and within a social system.

World HealthOrganization

Cause of Death % of Deaths Ratio Male toFemale

Ratio Black toWhite

Heart Disease 31.4 1.6 1.5Malignancy 23.3 1.4 1.3Cerebrovascular Dis. 6.9 1.2 1.8COPD 4.7 1.5 0.8Injuries/Adverse Effects 4.1 2.4 1.2Pneumonia/Influenza 3.7 1.5 1.4Diabetes Mellitus 2.7 1.2 2.4Suicide 1.3 4.2 0.6Nephritis 1.1 1.5 2.6Chronic Liver Disease 1.1 2.3 1.2

*2,314,245 deaths, 445 less than in 1996

1997 Deaths*

Real Causes of Death, 1990

Tobacco 400,000 Diet/Activity Patterns 300,000 Alcohol 100,000 Microbial Agents 90,000 Toxic Agents 60,000 Firearms 35,000 Sexual Behavior 30,000 Motor Vehicles 25,000 Drug Use 20,000

McGinnis &Foege

Deaths in New York CityWeek of September 1

AllAges

>65 45-64 25-44 1-24 <1

1,076 742 212 90 16 16

Pneumonia & Influenza: 43

A Causal Model of Disease

Treatment

Disease

A beginning complex model

DiseaseHealthCare

Need, Access

Cure, Care

OtherFactors

Evans & Stoddard

Growing feedback model

DiseaseHealthCare

Growing care costs

Cure, Care

OtherFactors

Clinical epiEvaluationHS Research

Evans & Stoddard

Four field model

DiseaseHealthCare

Growing care costs

Cure, Care

OtherFactors

Clinical epiEvaluationHS Research

Human Biology

EnvironmentLifestyle

Evans & Stoddard

fieldmodelnurs10.gif

Evans & Stoddard

Leading Health Indicators, HP2010

Physical activity Overweight and

obesity Tobacco use Substance abuse Responsible

sexual behavior

Mental health Injury and

violence Environmental

quality Immunization Access to health

Vulnerable Populations

Social groups that have • an increased relative risk or • increased susceptibility to adverse

health outcomes Evidenced by

• increased comparative morbidity• premature mortality and• diminished quality of life

Fundamental Causes

Low social status Low economic status Lack of environmental resources

Groups recognized as vulnerable

Poor Groups subject to

• discrimination • intolerance • subordination • stigma

Politically marginalized, disenfranchised and denied human rights

Specific Groups

Women Children Ethnic people of

color Immigrants

Gay, lesbian, bisexual, transgendered individuals

Homeless Elderly

Income and health status

0%2%4%6%8%

10%12%14%16%18%

High employmentgradeMiddle employmentgradeLow employment grade

Adapted from Breeze et al, AJPH 91:2, pg. 280

Household income and health

Persons

perceived

fair or poor

health

status

>$50,000$35-49,900$25-34,900$15-24,900<$15,000

Housing: HOPWA

June 2000 NYC has 43,000 adult/adolescent people/AIDS (up 12,000 in 2 years)

Assistance has shifted from new housing to rental assistance

FY99 City Budget: 199.6 Million Spent: 141.6 Million

Urban waste disposal

Queens generates 3,300 tons of trash EVERY DAY

Fresh Kills landfill • opened in 1948 • capacity to ~2025• closed April, 2001

Cost $838.3 million in 2000

Median weekly earnings of women (by educational level)

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

$700.00

$800.00

No diploma HS Only Some College BA or more

Bureau of Labor Statistics

Women’s 1998 median weekly earnings

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

$700.00

No diploma HS Only AD BA or more

Hispanic

Bureau of Labor Statistics

Electricity (per megawatt) Northern California

$0$20$40$60$80

$100$120$140$160$180$200

Loss of systems in Russia

New HIV infections

Loss of systems in Russia

Death rate from TB (per 100,000)

US rate: below 1/100,000

Total Lessthan 5years

5 to 9years

10 to 14years

15 to 19years

20 yearsand

1970 1980 1990 1997

Citizenship Rates by Length of Residence

Source: U.S. Bureau of the Census

65.5 45.9

74.142.8

61.834.325.8

<5050-99

100+<5 cases

Rate per 100,00057.554.2

MARICTNJDEMDDC

115.8107.1113.2153.6119.8124.5324.8

Includes cases with unknown state of residence†

US rate =86.3N=21,515

1988 AIDS Rates (per 100,000 Black Population)

< 44.1-12

1.41.9

3.20.8 0.2

0.00.2

0.00.0

Ra te p e r 100,000p o p ula tio n

0.7 3.3

VTN HM AR IC TN JD EM D

0.00.01.00.21.51.42.7

Primary and secondary syphilis - Rates for women by state:United States and outlying areas, 1997

N ote: The to ta l ra te of prim ary and secondary syph ilis fo r w om en in the U nited S tates and outly ing areas (includ ing G uam , Puerto R ico, and Virg in Is lands) w as 2.9 per 100,000 popula tion.

The H ealthy People year 2000 objective is 4 .0 per 100,000 population.

(n=43)(n=7)(n=3)

2.72.2

Virg in Is.Puerto R ico 0.0

G uam 0.0 5.1

7.9 9.0

Primary and secondary syphilis - Counties with rates above and counties withrates below the Healthy People year 2000 objective: United States, 1997

R ate per 100,000population

(n=2,702)

(n=413)

Infant Mortality in Minnesota

1978/82 1989/93 African-American 22.6 16.5 American Indian 13.9 16.2 Asian 9.7 6.2 White 10.2 6.4

Occupational Death, 1999

Fatal injuries per 100,000 workers

Hispanic

HispanicFatalities Increasing1993 851996 1201999 200

Children 2-4 years who have ever had tooth decay

0 5 10 15 20 25 30 35 40

Near Poor

Mid/High

Family Income

Children Age 15 Who Have Untreated Tooth Decay

< H.S. High School > H.S.Level of Education (Head of Household)

Source: NHANES III, 1988-94

Children with a Preventive Dental Visit* in past year

282322

Age <6 Age 6-11 Age 12-18

Poor Near Poor Mid/High

* includes prophylaxis, fluorides, or sealants

Source: Medical Expenditure Panel Survey, 1996

Adults age 65+ With Complete Tooth Loss

< H.S. High School > H.S.

Level of Education

20%21-25.9%

35%Data unavailable

Total Tooth Loss, Age 65+, 1995-1998

HP 2000 Objective: 20%

Source: BRFSS 1995-1998

26-34.9%

Adults (35+) Who Reported Past Year Dental Visit

0102030405060708090

< H.S. High School > H.S.Level of Education

Source: NHIS 1997

70%65-69.9%<65%Data unavailable

Dental Visits in Past Year, Age 35+: 1995-1998

HP 2000 Objective: 70%

Source: BRFSS 1995-1998

Minorities Report Difficulty Getting Needed Health Care

27% 30%

White Black Hispanic AsianAmerican

Other*

Adults Ages 18-64

Source: The Commonwealth Fund Survey of Health Care in New York City, 1997Louis Harris and Associates, Inc.

*Other includes Native American or Alaska native, mixed race, some other race, or not sure.

Emergency Rooms Serve Uninsured New Yorkers and the Medicaid Population

30% 32%

24% 25%

Total Uninsured Medicaid Medicare Private

Source: The Commonwealth Fund Survey of Health Care in New York City, 1997Louis Harris and Associates, Inc.

Adults age 18 or older

American Median Income

$10,000

$20,000

$30,000

$40,000

$50,000

1950 '60 '70 '80 '90 1997

Source: United States Census Bureau issued in Statistical Abstract of the United States

In constant 1997 dollars.

All Families

FemaleHouseholder,No Husband

2000 Poverty Guidelines

1 $ 8,3502 11,2503 14,1504 17,0505 19,9506 22,850Each additional Add $2,900

Size of Family Income Guideline

The Low-Wage Factor of High-Tech

333318,000Receptionists

292333,000Nursing aides

273370,000Teacher aides

314378,000Home health aides

481404,000Truck drivers

299408,000Retail sales

697411,000Registered nurses

965467,000General managers

891520,000Systems analyst

$247530,000Cashiers

Weekly pay

Number of jobs expected to be added by 2006

Occupations adding the most jobs

Poverty line for a family of four is $308 a week (1996)Source: Bureau of Labor Statistics

Medicare Beneficiaries Reporting Fair or Poor Health

AllBeneficiaries

Less than100% ofPoverty

100-150% ofPoverty

150-200% ofPoverty

200% ofPoverty or

Income Relative to PovertySource: Urban Institute analysis of 1995 Medicare Current Beneficiary Survey.

Model for research and practice

ResourceAvailability Relative

HealthStatus

ResearchPracticePolicy Analysis

Flaskerud

Determinants of Health

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