C A N P A N N U A L C O N F E R E N C E

J A N E T H I L D E B R A N D , F N P - B C

Social Determinants of Health: Looking Upstream for Answers

Shadows of Healthcare

Objectives

Assess the role of cultural, social and political influences to health and disease

Review key issues concerning poverty and social inequity in America

Analyze nursing science in the context of translating findings to enhance the health of individuals and communities

C U L T U R A L , S O C I A L A N D P O L I T I C A L I N F L U E N C E S T O H E A L T H A N D D I S E A S E

Vulnerable Populations

http://www.slate.com/blogs/behold/2014/07/17/brenda_ann_kenneally_documents_life_below_the_poverty_line_in_troy_york.html

Lia Lee

Language Barriers

Cultural Beliefs

Health literacy

Social norms

Past experiences

Rural environment

Adherence

The Cambodian Culture

Khmer Rouge Dictatorship from 1975 – 1979

Massive social trauma

Killed over 2 million Cambodians

Suffered human rights violations

Torture/Rape

Enslaved – worked in the rice fields

Starvation

Reinforced an environment of mistrust

Friends would turn on each other

Children would turn on parents

Families would turn on each other

The Cambodian Culture

Suffered human rights violations

Radically change their lifestyle

Loss of religious freedom

Mass graves

Buddhist ceremonial burial

Forced to move from homes – loss of land

Highest refugee population in Long Beach, CA

Marshall Islands

The Marshallese Culture

Located between Hawaii and Australia

US nuclear weapons testing from 1946 – 1958

Total destruction of natural food source

Fruits & vegetables & fish

US supplements

Canned foods – high fat and high salt

Compact of Free Association allowed the Marshallese to migrate to US without a visa

The Marshallese Culture

Mostly concentrated in Arkansas & Hawaii

Collectivist culture

Strong distrust of US health care

Shame and stigma of diabetes

Cultural insensitivity from providers

Loss of land

Massive social trauma

Alaskan Native & Native American

Health issues

Alternative Healing Practices

Shaman healers

Herbal remedies

Association of American Indian Physicians (aaip.org)

Isolation/Loss of history

Massive social trauma

Enslaved

Experienced radical change in lifestyle

White – Latino

Latino Origin

Numerous cultures clumped into broad term

Various dialects within this population

Numerous cultural beliefs

Alternative healing practices

Curanderos – Healers

Massage therapist

Spiritual emphasis

External locus of control

White – Non-Latino

Numerous cultures clumped into broad term

Genetic/Chronic Diseases

Loss of land

Enslaved

Massive social trauma

Radically changed their lifestyle

Black

Numerous cultures clumped into broad term

Genetic/Prevalent diseases

Enslaved

Forced to move from rural to urban

Massive social trauma

Experienced radical change to lifestyle

Risk Patterns – Social Histories

Enslaved

Land taken away

Forced to move from rural to urban region

Radically changed their lifestyle

Massive social change

Review Key Issues Concerning

Poverty and Social Inequity in America

Poverty & Social Inequalities

http://www.huffingtonpost.com/2013/09/17/poverty-america-census_n_3940812.html

Poverty

West Migrant Farm Worker

Working children

Midwest Industrialization

Migration of laborers

South Industrialization

East Displaced laborers

Union formation

Drug experimentation

Poverty

Lyndon B. Johnson

“Our aim is not only to relieve the symptoms of poverty, but to cure it and, above all, to prevent it.“

Social Security Amendments of 1965

Food Stamp Act of 1964

Expansion of AFDC

Job Corps, Vista Program, Office of Economic Opportunity

Title I program – target for impoverished students –No Child Left Behind Act

Poverty

Recession of 2008 & 2012

Healthy Families

TANF

SNAP

Food pantries

Homeless

Statistical Data Sources

Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care

HHS Action Plan to Reduce Racial and Ethnic Health Disparities

2013 National Healthcare Quality Report – AHRQ US Department of Health and Human Services

Unequal Treatment

Healthcare systems

Poor cultural match between minority patients and their providers

Language barriers – use of family members

Lack of continuity in care

In-patient to outpatient transition

Services are geographically separated

Reimbursement

Limited trauma units & tertiary NICU

Increase liability costs

Unequal Treatment

Providers of care – clinical encounter

Diagnoses influenced by race

Chest pain – cardiac or emotional anxiety

Categorization of ethnicities – stereotyping

Referral to drug rehabilitation – success or failure

Self-fulfilling prophecy

Expectations based on stereotypes

Bring own biases, beliefs, cultural experiences

Unequal Treatment

Patient

Genetic differences

Poor historian

Unable to explain symptoms

Health literacy – medical terminology

Mistrust in the healthcare system

Misconceptions in the recommendations

Religious beliefs and practices

Cultural beliefs and practices

Poor adherence to medications or recommendations

A N A L Y Z E N U R S I N G S C I E N C E I N T H E C O N T E X T O F T R A N S L A T I N G F I N D I N G S T O E N H A N C E T H E H E A L T H O F

I N D I V I D U A L S A N D C O M M U N I T I E S

Enhance the Health of Individuals and Communities

http://www.specialolympics.org/RegionsPages/content.aspx?id=37368

GoalCreate social and physical environments

that promote good health for all

Healthy People 2020

Lesbian, Gay, Bisexual and Transgender Health

Older Adults

Sleep health

Social Determinants of Health

Social Determinants of Health

http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health

EnvironmentalMeasures

Policy

Community Awareness & Action

School & Work Support

Clinical Expertise & Systems

Family

Self-CareManagement

Adapted from Managing Chronic Disease Website

Health Belief Model

Perceived susceptibility

Perceived benefits

Perceived barriers

Perceived self-efficacy

Perceived severity of

disease

Cues to Action

IndividualBehaviors

Stress

McEwen & Gianaros (2011)

Stress

Acute time-limited stressors Laboratory challenges

Brief naturalistic stressors Confronting a real-life short-term challenge

Stressful event sequences A focal event such as natural disaster or loss of spouse

Chronic stressors Pervades a person’s life; forcing restructuring of one’s social role or

identity Traumatic injury or chronic disease

Distant stressors Traumatic experiences that occurred in the past Potential to continuously modify immune system due to long lasting

cognitive and emotional sequelae

Allostatic Load

Definition: an imbalance in systems that promote adaptation (McEwen)

3 types of physiological responses that make up allostatic load

Lack of adaptation or habituation

Prolonged response due to shut-down

Chronic activity and failure to shut off

Inadequate response that leads to hyperactivity

Failure to respond to challenge

Recommendations

Affordable Care Act

Signed into law on March 23, 2010 and upheld by Supreme

Court on June 28, 2012.

Details on website HHS.gov:

http://www.hhs.gov/healthcare/about-the-law/index.html

Improve fragmentation of health care

Improve gaps in research – clinical guidelines

Report cards to evaluate quality of care services

Recommendations

Providers

Structural competence

Evidence-based practice

Ethno-pharmacology

Disease prevention

Cultural Humility

Focus on clinical case

Know your biomedical biases

Nursing Science – Areas of Research

Translate research into practice Healthy lifestyles

Supportive networks Diet & exercise promotion

Employers Encourage healthy lifestyles

Governmental Policies Education, housing, minimum wage Occupational health and safety Environmental pollution

Communities Community Centers Senior Centers

Social Justice

Structural violence Political

Premature suffering and

Institutional violence

Marginalization

Exclusion

Public Health

Racial disparities Impact on health

Don’t just treat – get involved

Dis

ea

se

Community

Evaluation

L

i

t

e

r

a

c

y

Chronic

Hypertension

Women

Intervention

D

i

a

b

e

t

e

s

Asthma

Ca

re

Health

Ma

na

ge

me

nt

Families

Ac

tio

ns

O

u

t

c

o

m

e

s

Disparities

Environment

Poverty

Symptoms

Assessment

Social

Patient

Program

Children

Adults

Heart

Imp

ac

t

Factors

Elderly

Treatment

Data

Services

Medical

Illness

Imp

ro

ve

Assist

Required

Affordable

Act

Behavior

Food

Age

Prevention

Promotion

EthnicityCulture

Challenges

United

Medical

Group

Skills

Self-managementDesigns

Rates

Alternative

Public

Policy

Support

EMR

Evidence

Practice

Indicators

Cli

nic

al

Guidelines

Communication

WICTANF

Costs

Medications

National

Depression

Cancer

Pr

ov

ide

rs

Process

Life

Primary

Prevention

Determinants

Cultural Humility

References

Abramsky, S. (2013). The American Way of Poverty How the other half still lives. New York: National Books.

Affordable Care Act (ND). Retrieved from http://www.hhs.gov/healthcare/about-the-law/index.html

Braveman, P. A., Heck, K., Egerter, S., Marchi, K. S., Dominguez, T. P., Cubbin, C., . . . Curtis, M. (2015). The role of socioeconomic factors in Black-White disparities in preterm birth. Am J Public Health, 105(4), 694-702. doi:10.2105/ajph.2014.302008

Centers for Disease Control and Prevention. (ND). Retrieved from http://www.cdc.gov/

Hallgren, E. A., McElfish, P. A., & Rubon-Chutaro, J. (2015). Barriers and opportunities: a community-based participatory research study of health beliefs related to diabetes in a US Marshallese community. Diabetes Educ, 41(1), 86-94. doi:10.1177/0145721714559131

Harrington, M. (1963). The Other America: Poverty in the United States. Maryland: Penguin Books

Healthy People 2020. (ND). Retrieved from http://www.healthypeople.gov/

L. (2000). Heaven Becomes Hell. New Haven, Connecticut: Yale University Southeast Asia Studies.

Merriam-Webster (ND). Retrieved from http://www.merriam-webster.com

Mollica, R. F. (2009). Healing Invisible Wounds Paths to Hope and Recovery in a Violent World. Nashville, TN: Vanderbilt University Press.

Strutz, K. L., Hogan, V. K., Siega-Riz, A. M., Suchindran, C. M., Halpern, C. T., & Hussey, J. M. (2014). Preconception stress, birth weight, and birth weight disparities among US women. Am J Public Health, 104(8), e125-132. doi:10.2105/ajph.2014.301904

Weltin, A. M., & Lavin, R. P. (2012). The effect of a community garden on HgA1c in diabetics of Marshallese descent. J Community Health Nurs, 29(1), 12-24. doi:10.1080/07370016.2012.645724