Determinants of Health
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
Columbia University School of Nursing M6920, Fall, 2001
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*
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
A Causal Model of Disease
Cause
Treatment
Disease
Cure
Columbia University School of Nursing M6920, Fall, 2001
A beginning complex model
DiseaseHealthCare
Need, Access
Cure, Care
OtherFactors
Evans & Stoddard
Columbia University School of Nursing M6920, Fall, 2001
Growing feedback model
DiseaseHealthCare
Growing care costs
Cure, Care
OtherFactors
Clinical epiEvaluationHS Research
Evans & Stoddard
Columbia University School of Nursing M6920, Fall, 2001
Four field model
DiseaseHealthCare
Growing care costs
Cure, Care
OtherFactors
Clinical epiEvaluationHS Research
Human Biology
EnvironmentLifestyle
Evans & Stoddard
Columbia University School of Nursing M6920, Fall, 2001
fieldmodelnurs10.gif
Evans & Stoddard
Columbia University School of Nursing M6920, Fall, 2001
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
care
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
Fundamental Causes
Low social status Low economic status Lack of environmental resources
Columbia University School of Nursing M6920, Fall, 2001
Groups recognized as vulnerable
Poor Groups subject to
• discrimination • intolerance • subordination • stigma
Politically marginalized, disenfranchised and denied human rights
Columbia University School of Nursing M6920, Fall, 2001
Specific Groups
Women Children Ethnic people of
color Immigrants
Gay, lesbian, bisexual, transgendered individuals
Homeless Elderly
Columbia University School of Nursing M6920, Fall, 2001
Income and health status
0%2%4%6%8%
10%12%14%16%18%
Gen
eral
hea
lth
Men
tal h
ealt
h
Ph
ysic
alp
erfo
rman
ce
Dis
abili
ty
High employmentgradeMiddle employmentgradeLow employment grade
Adapted from Breeze et al, AJPH 91:2, pg. 280
Columbia University School of Nursing M6920, Fall, 2001
Household income and health
0.00
%
5.00
%
10.00
%
15.00
%
20.00
%
25.00
%
Persons
with
perceived
fair or poor
health
status
>$50,000$35-49,900$25-34,900$15-24,900<$15,000
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
Median weekly earnings of women (by educational level)
$0.00
$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
1980
1998
Bureau of Labor Statistics
Columbia University School of Nursing M6920, Fall, 2001
Women’s 1998 median weekly earnings
$0.00
$100.00
$200.00
$300.00
$400.00
$500.00
$600.00
$700.00
No diploma HS Only AD BA or more
White
Black
Hispanic
Bureau of Labor Statistics
Columbia University School of Nursing M6920, Fall, 2001
Electricity (per megawatt) Northern California
$0$20$40$60$80
$100$120$140$160$180$200
Ma
y
Ju
ne
Ju
ly
Au
gu
st
Se
pte
mb
er
1999
2000
Columbia University School of Nursing M6920, Fall, 2001
Loss of systems in Russia
0
2000
4000
6000
8000
10000
12000
14000
16000
New HIV infections
1993
1994
1995
1996
1997
1998
1999
Columbia University School of Nursing M6920, Fall, 2001
Loss of systems in Russia
0
2
4
68
10
12
1416
18
20
Death rate from TB (per 100,000)
1991
1992
1993
1994
1995
1996
1997
1998
1999
US rate: below 1/100,000
Columbia University School of Nursing M6920, Fall, 2001
0
20
40
60
80
100
Total Lessthan 5years
5 to 9years
10 to 14years
15 to 19years
20 yearsand
more
1970 1980 1990 1997
Citizenship Rates by Length of Residence
Source: U.S. Bureau of the Census
%
Columbia University School of Nursing M6920, Fall, 2001
39.8
71.7
*
*
****
**
24.7
63.2
65.5 45.9
27.3
31.8
60.5
26.0
39.9
41.7
74.142.8
40.3
38.3
30.8
55.2
37.6
66.7
43.9
61.834.325.8
17.4
54.7
41.0
59.1
116.6
187.5
34.6
<5050-99
100+<5 cases
Rate per 100,00057.554.2
MARICTNJDEMDDC
115.8107.1113.2153.6119.8124.5324.8
80.6
183.5
Includes cases with unknown state of residence†
US rate =86.3N=21,515
*
*
1988 AIDS Rates (per 100,000 Black Population)
Columbia University School of Nursing M6920, Fall, 2001
0.2
< 44.1-12
0.6
1.8
13.5
3.3
1.8
1.41.9
3.20.8 0.2
0.0
0.00.2
0.1
0.3
0.0
0.00.0
0.2
0.6
0.3
0.0
0.0
Ra te p e r 100,000p o p ula tio n
14.2
> 12
0.8
1.7
0.7 3.3
0.1
0.3
VTN HM AR IC TN JD EM D
0.00.01.00.21.51.42.7
15.4
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.
3.1
The H ealthy People year 2000 objective is 4 .0 per 100,000 population.
3.3
0.8
(n=43)(n=7)(n=3)
2.72.2
6.0
Virg in Is.Puerto R ico 0.0
G uam 0.0 5.1
7.9 9.0
8.3
8.2
9.4
Columbia University School of Nursing M6920, Fall, 2001
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
<4
>4
(n=2,702)
(n=413)
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
Occupational Death, 1999
0
1
2
3
4
5
6
Fatal injuries per 100,000 workers
White
Black
Hispanic
HispanicFatalities Increasing1993 851996 1201999 200
Columbia University School of Nursing M6920, Fall, 2001
Children 2-4 years who have ever had tooth decay
29
21
10
0 5 10 15 20 25 30 35 40
Poor
Near Poor
Mid/High
Family Income
(%)
Columbia University School of Nursing M6920, Fall, 2001
Children Age 15 Who Have Untreated Tooth Decay
29
1815
0
5
10
15
20
25
30
35
40
< H.S. High School > H.S.Level of Education (Head of Household)
Source: NHANES III, 1988-94
(%)
Columbia University School of Nursing M6920, Fall, 2001
Children with a Preventive Dental Visit* in past year
9
2723
8
282322
56
48
0
10
20
30
40
50
60
70
Age <6 Age 6-11 Age 12-18
Poor Near Poor Mid/High
(%)
* includes prophylaxis, fluorides, or sealants
Source: Medical Expenditure Panel Survey, 1996
Columbia University School of Nursing M6920, Fall, 2001
Adults age 65+ With Complete Tooth Loss
39
26
13
0
10
20
30
40
50
< H.S. High School > H.S.
(%)
Level of Education
Columbia University School of Nursing M6920, Fall, 2001
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%
Columbia University School of Nursing M6920, Fall, 2001
Adults (35+) Who Reported Past Year Dental Visit
41
59
74
0102030405060708090
100
< H.S. High School > H.S.Level of Education
Source: NHIS 1997
Columbia University School of Nursing M6920, Fall, 2001
70%65-69.9%<65%Data unavailable
Dental Visits in Past Year, Age 35+: 1995-1998
HP 2000 Objective: 70%
Source: BRFSS 1995-1998
Columbia University School of Nursing M6920, Fall, 2001
Minorities Report Difficulty Getting Needed Health Care
19%
28%
38%
27% 30%
0%
10%
20%
30%
40%
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.
Columbia University School of Nursing M6920, Fall, 2001
Emergency Rooms Serve Uninsured New Yorkers and the Medicaid Population
30% 32%
47%
24% 25%
0%
10%
20%
30%
40%
50%
60%
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
Columbia University School of Nursing M6920, Fall, 2001
American Median Income
$0
$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.
1947
White
All Families
Black
FemaleHouseholder,No Husband
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
Medicare Beneficiaries Reporting Fair or Poor Health
29%
44%
36%
27%
20%
AllBeneficiaries
Less than100% ofPoverty
100-150% ofPoverty
150-200% ofPoverty
200% ofPoverty or
more
Income Relative to PovertySource: Urban Institute analysis of 1995 Medicare Current Beneficiary Survey.
Columbia University School of Nursing M6920, Fall, 2001
Model for research and practice
ResourceAvailability Relative
Risk
HealthStatus
ResearchPracticePolicy Analysis
Flaskerud