Social Determinants of Hispanic/Latino Health Daniel Santibañez, MPH, RD Department of Public Health University of North Florida This is part 8 of an 8 part series of seminars on Hispanic Health Issues brought to you by the University of North Florida’s Dept. of Public Health, College of Health, a grant from AETNA, and the cooperation of the Duval County Health Department.

While education plays a valuable role… It is important not to “blame the victim” by focusing strictly on lifestyle choices Addressing the social and physical environment that influences behavioral choices is an essential element of a strategy to change behavioral patterns

It is important not to “blame the victim” by focusing strictly on lifestyle choices

Addressing the social and physical environment that influences behavioral choices is an essential element of a strategy to change behavioral patterns

SES is central to eliminating health disparities It is closely tied to health and longevity At all income levels, people with higher SES have better health than those at the level below them SES is also a strong force behind differences in health among racial and ethnic groups People die younger in societies with greater inequalities in income

It is closely tied to health and longevity

At all income levels, people with higher SES have better health than those at the level below them

SES is also a strong force behind differences in health among racial and ethnic groups

People die younger in societies with greater inequalities in income

Social Determinants of Health The socioeconomic and racial disparities in health in the United States today require public health professionals to critically examine the scope and focus of public health research and practice Healthy People 2010 Goals: Goal 1: Increase quality and years of healthy life Goal 2: Eliminate health disparities

The socioeconomic and racial disparities in health in the United States today require public health professionals to critically examine the scope and focus of public health research and practice

Social Determinants of Health Income inequality Social exclusion Job insecurity Poor working conditions Food insecurity Inadequate housing Language Access to care

Income inequality

Social exclusion

Job insecurity

Poor working conditions

Food insecurity

Inadequate housing

Language

Access to care

People affected by health disparities more frequently live in environments with: Toxic conditions Inadequate access to affordable nutritious food, places to play and exercise, effective transportation systems, and accurate, relevant health information Violence Joblessness, poverty Targeted marketing and excessive outlets for unhealthy products Community norms that do not support protective environments

Toxic conditions

Inadequate access to affordable nutritious food, places to play and exercise, effective transportation systems, and accurate, relevant health information

Violence

Joblessness, poverty

Targeted marketing and excessive outlets for unhealthy products

Community norms that do not support protective environments

Focusing only on individual responsibility for lifestyle changes ignores larger environmental factors that can work against the educational message For example, limited education may mean less exposure to info about risk, but the same people may live in neighborhoods with poor recreational facilities, fewer stores selling fresh produce, and more advertising for tobacco and alcohol

For example, limited education may mean less exposure to info about risk, but the same people may live in neighborhoods with poor recreational facilities, fewer stores selling fresh produce, and more advertising for tobacco and alcohol

Hispanic young people were exposed to more alcohol advertising in English-language media than non-Hispanic young people

Key Community Factors for Reducing Health Disparities Built Environment Factors Social Capital Factors Services and Institutions Structural Factors

Built Environment Factors

Social Capital Factors

Services and Institutions

Structural Factors

Built Environment Factors Activity-Promoting Environment Nutrition-Promoting Environment Housing Transportation Environment Quality Product Availability Aesthetic/Ambiance Number of play areas Supermarket access Housing quality and asthma Psychological stress

Activity-Promoting Environment

Nutrition-Promoting Environment

Housing

Transportation

Environment Quality

Product Availability

Aesthetic/Ambiance

Number of play areas

Supermarket access

Housing quality and asthma

Psychological stress

Social Capital Factors Social Cohesion and Trust Collective Efficacy Civic Participation and Engagement Social and Behavioral Norms Gender Norms Connections and trust Improved mental health and trauma outcomes Securing community resources Voting and volunteering Lower addiction rates and violence

Social Cohesion and Trust

Collective Efficacy

Civic Participation and Engagement

Social and Behavioral Norms

Gender Norms

Connections and trust

Improved mental health and trauma outcomes

Securing community resources

Voting and volunteering

Lower addiction rates and violence

Resilience and responses to stress affect health Researchers have found that people who experience discrimination are far more likely than others to develop HTN and other stress-induced health effects Biological effects of repeated stress affect immunity, health, and life expectancy Minority women and “kinwork” of family and friends

Researchers have found that people who experience discrimination are far more likely than others to develop HTN and other stress-induced health effects

Biological effects of repeated stress affect immunity, health, and life expectancy

Social Connections within a community are important Children are healthier in neighborhoods were adults talk to each other High levels of social support and a number of positive health benefits among Latinos Social networks enforce social sanctions and controls to diminish negative behaviors. Reduce incidence of crime, juvenile delinquency, and access to firearms within communities

Children are healthier in neighborhoods were adults talk to each other

High levels of social support and a number of positive health benefits among Latinos

Residential Segregation Hispanics and Blacks are more likely than poor white families to live in areas of concentrated poverty Research has shown that living in neighborhoods where some residents have higher incomes and more education is healthier

Hispanics and Blacks are more likely than poor white families to live in areas of concentrated poverty

Research has shown that living in neighborhoods where some residents have higher incomes and more education is healthier

Services and Institutions Public Health, Health, and Human Services Public Safety Education and Literacy Community-Based Organizations Cultural and Artistic Opportunities Availability and access to high quality services Community coalitions and perceived safety Community-based health promotion Gardens, murals, and music promote healing

Public Health, Health, and Human Services

Public Safety

Education and Literacy

Community-Based Organizations

Cultural and Artistic Opportunities

Availability and access to high quality services

Community coalitions and perceived safety

Community-based health promotion

Gardens, murals, and music promote healing

Quality of health care can cause problems Research has found that higher SES does not protect minorities from poor health outcomes Medical professionals should be trained to understand social causes in patients’ lives so that they can improve the quality of care

Research has found that higher SES does not protect minorities from poor health outcomes

Improving Quality of Care Cultural competency training Recruiting minorities in healthcare Even w/insurance coverage and higher SES, disparities in prevention and screening exists Quality = Equity in health care “ Racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factors, such as patients’ insurance status and income, are controlled.” -Unequal Treatment, Institute of Medicine

Cultural competency training

Recruiting minorities in healthcare

Even w/insurance coverage and higher SES, disparities in prevention and screening exists

Quality = Equity in health care

Educational Opportunity Because the quality of schools is partially determined by community resources, people in poor communities get poor quality education As a result, they have fewer opportunities for good jobs and incomes. In addition, they face the effects of lowered expectations.

Because the quality of schools is partially determined by community resources, people in poor communities get poor quality education

Structural Factors Economic Capital Media and Marketing Ethnic, Racial, and Intergroup Relations Employment opportunities Adequate living wage Job training Local ownership of business and homes Access to loans Media perceptions

Economic Capital

Media and Marketing

Ethnic, Racial, and Intergroup Relations

Employment opportunities

Adequate living wage

Job training

Local ownership of business and homes

Access to loans

Media perceptions

Economic pressures exact a toll on minorities Hispanics, African-Americans, Native Americans and some Asian groups are more likely than other groups to be poor Poverty affects health by limiting access to needed resources Other elements of SES, including education, residence, and occupation, also affect people’s quality of life, including their health

Hispanics, African-Americans, Native Americans and some Asian groups are more likely than other groups to be poor

Poverty affects health by limiting access to needed resources

Other elements of SES, including education, residence, and occupation, also affect people’s quality of life, including their health

Occupational Opportunities Having to work more than one job, lacking health benefits, having little control over one’s schedule or pace of work, and being unable to take time off work when needed can cause chronic stress and damage self-esteem.

Having to work more than one job, lacking health benefits, having little control over one’s schedule or pace of work, and being unable to take time off work when needed can cause chronic stress and damage self-esteem.

Disparities go beyond SES To plan and develop interventions that will truly help the community, public health professionals must capture the contextual reality of racial and ethnic communities By understanding race and ethnicity in terms of community, we can grapple with their complexity and take note of the differences between poor communities It is a holistic approach that does not exclude poor people but rather looks at them within the communities where they live

To plan and develop interventions that will truly help the community, public health professionals must capture the contextual reality of racial and ethnic communities

By understanding race and ethnicity in terms of community, we can grapple with their complexity and take note of the differences between poor communities

It is a holistic approach that does not exclude poor people but rather looks at them within the communities where they live

Poder es Salud/ Power for Health Many public health practitioners and researchers have identified greater community involvement and increased social capital as ways to reduce inequities related to income, race, gender, ethnicity, and geographic location. A more empowered and competent community is a healthier community

Many public health practitioners and researchers have identified greater community involvement and increased social capital as ways to reduce inequities related to income, race, gender, ethnicity, and geographic location.

Poder es Salud/ Power for Health Social capital is characterized by a sense of trust, shared norms and values, and interconnectedness It has both an informal aspect related to social networks and a more formal aspect related to our social development programs Social cohesion, “civicness” and participation in society and governance

Social capital is characterized by a sense of trust, shared norms and values, and interconnectedness

It has both an informal aspect related to social networks and a more formal aspect related to our social development programs

Social cohesion, “civicness” and participation in society and governance

Poder es Salud/ Power for Health The project builds on existing social capital to expand ties between the African American and Latino communities and expand access to social and economic resources Community-based research works with existing units of identity that share an emotional connection, values and norms, common interests, and a commitment to meeting shared needs.

The project builds on existing social capital to expand ties between the African American and Latino communities and expand access to social and economic resources

Poder es Salud/ Power for Health 3 core strategies to enhance community-level social capital: Community-based participatory research Popular education Community health workers

3 core strategies to enhance community-level social capital:

Community-based participatory research

Popular education

Community health workers

Poder es Salud/ Power for Health 3 African-Am faith based organizations A coalition of 5 evangelical congregations in the Latino community A geographically defined community consisting of 4 apartment complexes Steering committees formed

3 African-Am faith based organizations

A coalition of 5 evangelical congregations in the Latino community

A geographically defined community consisting of 4 apartment complexes

Poder es Salud/ Power for Health Public safety committee Community health fair Diabetes support and information group Homework club Photovoice Project Led residents to develop a campaign to remove trash and illegally-dumped materials from area

Public safety committee

Community health fair

Diabetes support and information group

Homework club

Photovoice Project

Led residents to develop a campaign to remove trash and illegally-dumped materials from area

Poder es Salud/ Power for Health Created a cooperative to provide members with insurance, small-business loans, and job opportunities In response to community members prioritizing 3 social determinants of health: Lack of health insurance Lack of self-employment and business knowledge Lack of jobs and employment security

Created a cooperative to provide members with insurance, small-business loans, and job opportunities

In response to community members prioritizing 3 social determinants of health:

Lack of health insurance

Lack of self-employment and business knowledge

Lack of jobs and employment security

Poder es Salud/ Power for Health Peace Campaign initiated and implemented to address the increase in gang violence and repeated police use of lethal force against unarmed citizens Peace Campaign Goals: Explore violence as a public health issue To build lasting relationships between young people and police officers To help youths learn nonviolent techniques that they can use with peers and adults

Peace Campaign initiated and implemented to address the increase in gang violence and repeated police use of lethal force against unarmed citizens

Peace Campaign Goals:

Explore violence as a public health issue

To build lasting relationships between young people and police officers

To help youths learn nonviolent techniques that they can use with peers and adults

Poder es Salud/ Power for Health Youth advisory council Youth gang task force Creation of a community-based initiative created to prevent crime and revitalize the community - Weed and Seed Included police cadets in the coalitions Peace Campaign has involved coalition members in design, implementation, and evaluation

Youth advisory council

Youth gang task force

Creation of a community-based initiative created to prevent crime and revitalize the community - Weed and Seed

Included police cadets in the coalitions

Community Action Model

“ No epidemic has even been resolved by attention to the affected individual” - Dr. George Albee

Migrant Farmworker Health There are over 3 million MSFW in the U.S. 81% foreign born 95% born in Mexico, 2% Latin America, 1% Asia, 1% other 80% Male and 84% Spanish-speaking Nearly ¾ of U.S. farmworkers earned less than $10,000 per year 3 out of 5 families had incomes below poverty level

There are over 3 million MSFW in the U.S.

81% foreign born

95% born in Mexico, 2% Latin America, 1% Asia, 1% other

80% Male and 84% Spanish-speaking

Nearly ¾ of U.S. farmworkers earned less than $10,000 per year

3 out of 5 families had incomes below poverty level

Migrant Farmworker Health The health needs of farmworkers have been ignored by the public health research community Most agricultural studies have focused on farm owners/operators

The health needs of farmworkers have been ignored by the public health research community

Most agricultural studies have focused on farm owners/operators

Migrant Farmworker Health Of the farmworkers who go to health clinics, at least 40% present with multiple and complex health problems including infectious and chronic diseases, making diagnosis and treatment that much more difficult

Of the farmworkers who go to health clinics, at least 40% present with multiple and complex health problems including infectious and chronic diseases, making diagnosis and treatment that much more difficult

Migrant Farmworker Health Dental Environmental/Occupational health Mental health and substance abuse Domestic violence Disaster relief Housing Child labor

Dental

Environmental/Occupational health

Mental health and substance abuse

Domestic violence

Disaster relief

Housing

Child labor

Migrant Farmworker Health The poor level of oral health for farmworkers was generally found to correspond with lack of access to information that could help prevent oral health problems and lack of access to preventive care and restorative services Dental disease ranks as one of the top 5 health problems for farmworkers aged 5-29 and among the top 20 health problems for all other ages presenting for care

The poor level of oral health for farmworkers was generally found to correspond with lack of access to information that could help prevent oral health problems and lack of access to preventive care and restorative services

Migrant Farmworker Health Environmental/Occupational health issues include: Disability and death Traumatic injuries Respiratory problems Dermatitis Infectious diseases Cancer Eye problems

Environmental/Occupational health issues include:

Disability and death Traumatic injuries

Respiratory problems

Dermatitis

Infectious diseases

Cancer

Eye problems

Migrant Farmworker Health Although there are field sanitation guidelines for farmworkers developed by OSHA, these are seldom enforced by OSHA or compiled with by employers Tuberculosis and parasitic diseases are attributable to deficient sanitation both at work and at residence sites, poor quality drinking water and failure to provide uncontaminated washing and drinking water

Although there are field sanitation guidelines for farmworkers developed by OSHA, these are seldom enforced by OSHA or compiled with by employers

Migrant Farmworker Health High levels of depression are associated with high acculturative stress, low self-esteem, discrimination, low religiosity, lower income, physical health problems, and lack of child care Because Mexican culture emphasizes familism , collectivist values, and affiliation, Mexican migrants may be particularly vulnerable to depression when they lack support from family and friends

High levels of depression are associated with high acculturative stress, low self-esteem, discrimination, low religiosity, lower income, physical health problems, and lack of child care

Mental Health Stressors: Language Unpredictable nature of work and housing Being away from family and friends Difficult workload and structure Socialization of children Lack of daycare and supervision Poverty and poor housing conditions Isolation and discrimination

Language

Unpredictable nature of work and housing

Being away from family and friends

Difficult workload and structure

Socialization of children

Lack of daycare and supervision

Poverty and poor housing conditions

Isolation and discrimination

Migrant Farmworker Health Approximately 13% drink 6 or 7 days a week an average of 21 drinks weekly Alcohol and drug abuse create safety and health hazards Social isolation is the primary risk factor for elevated alcohol consumption

Approximately 13% drink 6 or 7 days a week an average of 21 drinks weekly

Alcohol and drug abuse create safety and health hazards

Migrant Farmworker Health Estimated 20% of women experienced physical abuse and 10% reported forced sexual activity in one year Women whose partners used drugs and/or alcohol were 6 times more likely to be abused Research on domestic violence among this population continues to progress at a slow pace and much is still unknown

Estimated 20% of women experienced physical abuse and 10% reported forced sexual activity in one year

Women whose partners used drugs and/or alcohol were 6 times more likely to be abused

Migrant Farmworker Health When faced with a natural disaster, migrant community health centers find themselves restricted by emergency relief vehicles that are financially limited and unable to respond the needs of the areas that they serve The costs of serving this population are in many ways already extraordinary. Add to this situation a natural disaster, and most migrant health centers simply do not have the additional resources to adequately address these difficult circumstances

When faced with a natural disaster, migrant community health centers find themselves restricted by emergency relief vehicles that are financially limited and unable to respond the needs of the areas that they serve

Migrant Farmworker Health Overcrowded and substandard housing can contribute to the contraction and spread of disease, as well as injury through household accidents Many farmworkers crowd units to limit the cost impact of housing on their low incomes Although they toil to bring a bounteous harvest to our tables, farmworkers are often faced with some of the poorest living conditions in their communities

Overcrowded and substandard housing can contribute to the contraction and spread of disease, as well as injury through household accidents

Many farmworkers crowd units to limit the cost impact of housing on their low incomes

Migrant Farmworker Health Exposure to pesticides, transportation accidents, tractor rollovers, unguarded machinery, open irrigation ditches, and animals are among the serious hazards faced by child laborers Large numbers of youth are suffering fatal and non-fatal agricultural injuries Few legal protections exist to safeguard the health and well-being of young farmworkers.

Exposure to pesticides, transportation accidents, tractor rollovers, unguarded machinery, open irrigation ditches, and animals are among the serious hazards faced by child laborers

Large numbers of youth are suffering fatal and non-fatal agricultural injuries

Child Labor: 2 groups Unaccompanied and those who work alongside their parents Approx. 55,000 unaccompanied Of these, 44,000 are foreign-born males Median annual income $1,000 - $2,500 There is no limit under federal law to the number of hours per day or per week that children may work in agriculture. As a result, the hours worked are often long and affects health and education.

Unaccompanied and those who work alongside their parents

Approx. 55,000 unaccompanied

Of these, 44,000 are foreign-born males

Median annual income $1,000 - $2,500

Migrant Farmworker Outreach Over 100 migrant health centers, along with a dozen migrant “voucher” and other special programs exist Federally assisted migrant health services reach only about 15% - 20% of the nation’s MSFW population In migrant health, the challenge of making real breakthrough during the coming decade in improving access and reducing health disparities for MSFWs depends on investing adequately in lay health outreach

Over 100 migrant health centers, along with a dozen migrant “voucher” and other special programs exist

Federally assisted migrant health services reach only about 15% - 20% of the nation’s MSFW population

Questions ? Thank you Daniel Santibanez [email_address]

Questions ?

Thank you

Daniel Santibanez

[email_address]