1. 29/04/2011
Towards an Understanding of the Determinants of
Health in the Old Order Mennonites
By: Kathryn Fisher, PhD Candidate
Fisher
Dr. K. Bruce Newbold, Supervisor
Kathryn Fisher (PhD Candidate), McMaster University,
Dr. K. Bruce Newbold (Supervisor)
Topics
I. Why study Old Order Mennonites (OOMs) for insight into
health?
II. Study design
III. Selected results (general health status)
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2. 29/04/2011
I. Why study OOMs?
Social Determinants of Health (SDOH)
literature:
OOMs lifestyle may generate health benefits...may be
good (+) and bad (-):
+: highly religious, no smoking, low/no alcohol,
strong social support, high physical activity (esp.
men)
-: high parity, no OHIP, low education
g p y, ,
Example: ongoing research (2005-Present) indicates
higher physical fitness levels in Waterloo OOMs (and
Amish) children compared to urban children
I. Why study OOMs?
Epidemiological literature on chronic illness (e.g.,
Maziak, 2009, Pearce, 2004; Rose, 2001):
OOMs are a population isolate that differ from mainstream
populations on factors:
linked to chronic illness
stable rather than rapidly changing (e.g., patterns of mobility,
indoor existence, recreation, socialization, communication)
key: whether factors impact health + or –, studying
OOMs should more clearly highlight their influence
y g g
Example: U.S. research found overall cancer incidence for Old
Order Amish (similar to OOMs) to be 60% of rate in Ohio
general population, and 37% for tobacco-related cancers
(Westman et al., 2010)
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3. 29/04/2011
II. Study Design
Research question: Does the prevalence of chronic illness differ in
OOMs, and are differences in SDOH explanatory?
Comparative population:
non-OOM farmers living in the same location (eliminate influence
of physical environment, focus on lifestyle)
Study area: Waterloo, Ont. (home to 2/3 of Ontario OOMs)
Mixed Methods (Survey Interviews), Today ‘s focus:
(Survey, Interviews) s
Selected Survey results for general physical and mental health status
(SF-12) (not chronic conditions)
OOMs & non-OOMs Survey Participant Profile
(Sample, Age, Gender, Marital Status)
OOMs Non-OOMs
Sample Size 1171 344
Response Rate 60% 30-40% (estimate)
Mean age 43.40 57.76
% Females | % Males 58% | 42% 51% | 49%
% Married | % Single 64% | 33% 87% | 5%
OOMs survey group is younger, has more females and has
more singles (mostly young, 18-24 yr olds)
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OOMs Differ (Stat. Significantly) from non-OOMS on Almost all SDOH
(In Addition to Age, Gender & Marital Status)
SDOH OOMs versus non-OOMs (on average)
Income & Social Status - OOMs have lower incomes, no health insurance, but view their
income as equally adequate
Social Networks,
S i lN t k -OOMs more strongly rooted and value community more, non-
OOM t l t d d l it
Environments OOMs value natural environment more
- OOMs participate less, give and receive more support, and are
more trusting
- OOMs report higher social interaction and perceived support
Education, Literacy - 100% of OOMs <= Grade 8 vs. 11% of non-OOMs
Employment & Work -majority are farmers in both groups (by selection)
-both report high (& =) levels of control
Personal Health & Coping -OOMs report more difficulty coping and lower stress levels
- no smoking among OOMs or 90% of non-OOMS
- low/no alcohol among OOMs, 64% of OOMs drink
1/month+
OOMs Differ (Stat. Significantly) from non-OOMS on Almost all SDOH
(In Addition to Age, Gender & Marital Status)
SDOH OOMs versus non-OOMs (on average)
Healthy Childhood, Adult - OOMs report fewer childhood diseases
Biomarkers - OOMs are shorter (both genders)
- OOM women weigh more & men less
- OOM women have higher BMI’s
Health Service Use - OOMs report less use of traditional services
- 97%+ in both groups have access to family doctor
- OOMs use more chiropractors, nurse practitioners,
community clinics
Culture - OOMs report higher levels of “spirituality”
- 97% of OOM go to church 1/ k vs 48% of non-OOMs
f OOMs t h h 1/wk f OOM
- >93% in both groups report no discrimination
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5. 29/04/2011
Physical Health Results (Known as “PCS” in SF-12)
mean PCS scores for OOMs and non-OOMs do not differ
(statistically) => p y
y physical health the same
unexpected, since:
OOMs younger (PCS ↓with age)
OOMs have better mental health (see MCS later)
SF-12 instrument appears reliable and valid for use in the OOMs
(std. tests were done & suggest no issues)
Why isn’t PCS higher in the OOMs?
Age Matters with PCS
Figure 1: PCS by Age (OOMs, non-OOMs)
60
50
40
PCS Score
30
20
10
0
18-24 25-34 35-44 45-54 55-64 65+
Age Group OOMs non-OOMs
PCS Declines with Age in Both Groups, is Higher in the non-OOMs for all but the Youngest
Age Group (?), and the Gap between the Groups Increases with Age
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Gender Also Matters with PCS
PCS of OOMs women lower (statistically) than OOMs men,
whereas non-OOMs women are same as men
recall that women are a higher proportion of the OOMs survey
group (58%) compared to non-OOMs (51%)
Do age/gender differences in PCS suggest:
physical demands of traditional (less mechanized) farming?
influence of social stressors (e.g., difficulty maintaining
agrarian lifestyle, hidden minority impacts)?
influence of other SDOH (see regressions)?
impact of high parity on women?
genetics (not measured in this study)?
Mental Health Results (Known as “MCS” in SF-12)
mean MCS scores do differ (stat. sign.) between OOMs and
non-OOMs => better mental health in the OOMs
MCS is relatively homogeneous in the OOMs, and varies
little with socio-demographic variables (e.g., age, income,
gender)
OOMs are:
less downhearted/blue
more calm/peaceful
l f l
more inclined to socialize regardless of health issues
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Age and MCS
Figure 2: MCS by Age (OOMs, non-OOMs)
60
50
40
MCS Score
30
20
10
0
18-24 25-34 35-44 45-54 55-64 65+
Age Group OOMs non-OOMs
Multiple Regressions for PCS and MCS
SDOH - independent variables in OLS regressions:
dependent variables: PCS & MCS
used same SDOH in all regressions
regarding the significant SDOH in regressions:
most reflect the general SDOH literature
some are the same in both groups, others are significant for one
group and not the other
many are intuitive given our knowledge about each group
help in understanding the differences in PCS and MCS
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PCS Regression Results: Coefficients for Significant SDOH
SDOH/Terms OOMs Non-OOMs
Coping 1.77*** 2.00***
# Childhood Diseases
Childh d Di -1.06***
1 06*** -1.25***
1 25***
BMI -.04* -.54***
Age -.27*** -.25***
Stress - -1.11***
Income Adequacy 2.05*** -
Marital Status -.28*** -
Perceived Social Support .22
22** -
Gender 1.03** -
Adjusted R-Square .41 .29
***<p≤.01, **.01<p≤.05, *.05<p≤.10
MCS Regressions Results: Coefficients for Significant SDOH
SDOH/Terms OOMs Non-OOMs
Coping 2.22*** 3.35***
Stress -1.62*** -.89***
Social Network Index (SNI) .11*** .11**
Social Capital (Reciprocity)
S lC l - -.37***
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Social Capital (Participation) - .23*
Control .16** -
Sense of Place (Rootedness)Ω -1.00*** -
Social Capital (Trust) .86*** -
# Childhood Diseases -.89*** -
BMI -.04**
04** -
Age .04*** -
Spirituality (DSES6 Score)ΩΩ -.10*** -
Adjusted R-Square .29 .22
***p≤.01, **.01<p≤.05, *.05<p≤.10
Ω-increase in rootedness is a decrease in sense of place (SoP)
ΩΩ-increase in DSES6 score is a decrease in spirituality
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Concluding Remarks
comparison of OOMs and non-OOMs:
mental health is higher in OOMs (overall, for women)
physical health is same (overall, each gender), declines
with age (b th groups), higher in non-OOMs (increasingly with age)
ith (both ) hi h i OOM (i i l ith )
comparison of genders within each group:
OOMs: women have lower physical health than men
non-OOMs: women have lower mental health than men
OLS regressions show:
importance of SDOH depends on health outcome and population
for PCS or MCS, some SDOH are important for both groups, and
others are important for one but not the other
studying a unique population (OOMs) highlights the role of SDOH
more clearly, and identifies new relationships (e.g., roots and MCS)
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