Using a Social Determinants of Health Paradigm to Improve Chronic Disease Management in Latino Communities

1. Using a Social Determinants of Health
Paradigm to Improve Chronic Disease
Management in Latino Communities
Sea Mar Community Health Centers
14th Annual Latino Health Forum
October 30, 2019
Julian Perez, MD
Sea Mar Community Health Centers

2. Today’s agenda
1. Review concept of Social Determinants of Health
2. Review evidence for Income Inequality being greatest
determinant of poor health outcomes in a population
3. Latest CDC chronic disease rate differences between Latin@s
and White population in USA
4. Birth weight and Mortality differences through economic
boom and busts and the political fallout
5. Closer look at US and WA chronic disease using GIS maps
6. Review a series of studies trying to uncover the mystery of the
Latin@ paradox
7. End with the sum evidence for theories for Latin@ resilience
and what we can and should be focused on in our clinics
8. Discussion

3. What makes Latin@ families healthy?
• Employment
• Community/Support system
• English fluency
• Immigration status
• Education/Literacy
• Environments “Place matters”
• Public health policies
• Diet
• Physical Activity
• Habits
• Genetics
• Preventative medicine
• Curative medicine

4. Healthy Sick Outcome
Symptoms Access
x x
Treatment
genetics 30% health care 10%
Societal determinants:
60% of health

6. “The gap”
What’s the evidence?
Is income important for health?
Is income inequality bad for our health?
Is income equality good for our health?

8. How rich is the USA?
(2017 World Bank data)
•#2 GDP = $17.7 trillion
•325 million population
•GNI per capita: $55,351
•Life expectancy at birth: 78.5 yrs
•Income inequality ranking: #1 (the highest)

10. Mexico

11. World Income Inequality: USA
20.2% in 2004 (peak 21.4% in 1928)

16. Take home #1
Sharing is good for
your health

19. Infant mortality #/1000 live births
CDC 2013-2015
•US Total 5.9
•US Non-Hispanic Whites 5
•US Hispanic/Latinas 5
•WA State Total 4.6
•WA State Non-Hispanic Whites 4.2
•WA State Hispanic/Latinas 4.6

20. US Low birth weights (under 2.5kg)
Non-Hispanic Whites
•1980: 5.69%
•1990: 5.61%
•------.Com boom----------
•2000: 6.60%
•2005: 7.29% (Recession)
•2010: 7.14%
•----------ACA-------------
•2014: 6.96%
•2015: 6.93%
•2016: 6.99%
Hispanic/Latin@s
•1980: 6.12%
•1990: 6.06%
•------.Com boom---------
•2000: 6.41%
•2005: 6.88% (Recession)
•2010: 6.97%
•----------ACA----------
•2014: 7.05%
•2015: 7.21%
•2016: 7.31%

21. WA State Low birth weights
Under 2.5kg. CDC
Non-Hispanic Whites
•2000-2002: 5.43%
•2011-2013: 5.66%
•2014-2016: 5.87%
Hispanic/Latin@s
•2000-2002: 5.31%
•2011-2013: 6.24%
•2014-2016: 6.20%

24. WA

25. Summary
•Income does correlate with longer life
•Inequality is a good predictor of poor
population health
•Higher income equity is associated with lower
mortality (longer life)

26. What makes Latin@s healthy?
•My Dad, “I married your mother”
•My Dad, “Low incomes make us eat at home
more”
•Me, “Mexican pride”
•My wife, “Telenovelas”
•Viejito, “Chile piquin”
•Aunt Rita, “Faith in God”
•Aunt Margie, “Close family”

27. What makes Immigrant families healthy?
• Immigration status
• Employment
• Community/Support system
• English fluency
• Education/Literacy
• Environments “Place matters”
• Public health policies
• Diet
• Physical Activity
• Habits
• Genetics
• Preventative medicine
• Curative medicine

29. U.S. Chronic Disease Rates
CDC 2013-2016
Non-Hispanic Whites
• HTN 46% (48%M, 43%F)
• DM 9.6% (2% undiagnosed)
• DM A1c >9 = 16.6%
• Obesity 38% (M 37%,F 39%)
• Kids Ob 14.7%
• Asthma under 18 y/o: 7.1%
• Uninsured 7.3%
• Health “Fair/Poor” 7.6%
• Depression 3.7% (2.9% ‘90)
Hispanic/Latin@s
• HTN 54% (60%M, 50%F)
• DM 17% (4.7% undiagnosed)
• DM A1c >9 = 30%
• Obesity 45% (M 41%,F 48%)
• Kids Ob 23.6%
• Asthma under 18 y/o: 6.7%
• Uninsured 19.6%
• Health “Fair/Poor” 12.4%
• Depression 3.7% (5% ’90)

36. Hispanic/Latin@ Population%
CDC 2013-2017

37. WA Less than HS 25+ y/o
CDC. 2013-2017

38. WA Poverty all ages. CDC 2016

39. WA Uninsured% Under 65 y/o
CDC 2016

40. Unemployment 16+y/o. CDC 2017

41. Hispanic/Latin@ Population%
CDC 2013-2017

42. Inactivity% WA 20+ y/o. CDC 2015

43. Obesity% WA 20+ y/o. CDC 2015

44. Diabetes% WA 20+ y/o. CDC 2015

45. HTN Medicare hospitalizations.
Latin@s. CDC 2014-2016

46. HTN Medicare hospitalizations Non-
Hispanic Whites. CDC 2014-2016

47. BP higher in undocumented Latin@s
J Urban Health. 2017 Dec;94(6):764-775. doi: 10.1007/s11524-017-0197-3
Legal Status, Time in the USA,
and the Well-Being of Latinos
in Los Angeles.
Young MT1, Pebley AR2.
Author information
1
University of California, Los Angeles, Los Angeles, CA, USA.
mariaelena@ucla.edu.
2
University of California, Los Angeles, Los Angeles, CA, USA.

48. Diabetes disparities. CDC 2017

49. Diabetes disparities. CDC 2017

50. SOURCE: NCHS, Health, United States, 2017, Figure 8. Data from the National Health Interview Survey (NHIS).
Current asthma among children. CDC 2006-
2016

51. Depression equal, but antidepressant
use is lower in Undocumented Latin@s
Ann Epidemiol. 2019 Sep;37:17-23.e3. doi:
10.1016/j.annepidem.2019.07.007. Epub 2019 Jul 12.
Association between immigration
status and anxiety, depression, and use
of anxiolytic and antidepressant
medications in the Hispanic
Community Health Study/Study of
Latinos.
Ross J1, Hua S2, Perreira KM3, Hanna DB2, Castañeda SF4, Gallo
LC5, Penedo FJ6, Tarraf W7, Hernandez R8, Vega Potler N2, Talavera
GA4, Daviglus ML6, Gonzalez F 2nd3, Kaplan RC2, Smoller-Wassertheil S2.

52. U.S. Causes of Death. CDC 2017
Non-Hispanic Whites
1. Heart disease 23.3%
2. Cancer 21.4%
3. Chronic Lung disease 6.4%
4. Unintentional injuries 5.8%
5. Stroke 5%
6. Alzheimers 4.7%
7. Diabetes 2.5%
8. Influenza/PNA 2%
9. Suicide 1.7%
14. HTN/ESRD 1.1%
Homicide #20 at 0.3%
Hispanic/Latinos
1. Cancer 20.6%
2. Heart disease 20%
3. Unintentional injuries 8.5%
4. Stroke 5.5%
5. Diabetes 4.7%
6. Alzheimers 3.7%
7. Cirrhosis 3.2%
8. Chronic Lung disease 2.8%
9. Suicide 2%
14. HTN/ESRD 1.4%
Homicide #12 at 1.6%

53. Life expectancy at birth, by sex and race
and Hispanic origin
NOTES: Life expectancy data by Hispanic origin were available starting in 2006 and were corrected to address racial
and ethnic misclassification. Life expectancy estimates for 2016 are based on preliminary Medicare data.
SOURCE: NCHS, Health, United States, 2017, Figure 1. Data from the National Vital Statistics System (NVSS),
Mortality.

54. Mortality Ages 45-54
Case, A. and A. Deaton (2017)

55. 2016
Election
swing
• Best predictor
was combined
measure of low
exercise, heavy
EtOH, diabetes,
obesity, low life
expectancy =
worse health
made worse by
income inequality

56. “Hispanic Paradox”
Resiliency

57. Potential Life Years Lost
CDC 2016
Non-Hispanic Whites
• Total 6715
• Heart Disease 888
• Cancer 1251
• Accidents 1430
– Overdose 756
• Suicide 492
Hispanic/Latin@s
• Total 4926
• Heart Disease 574
• Cancer 900
• Accidents 914
– Overdose 402
• Suicide 239

58. Are Latin@s healthier because we
use more healthcare services?
Non-Hispanic Whites
• Medicaid beneficiaries 36%
• Medicaid payments/
beneficiary: $6691
• Medicare beneficiaries 75.6%
• Medicare payments/
beneficiary: $17,367
Is the healthcare system…
Hispanic/Latin@s
• Medicaid beneficiaries 17.4%
• Medicaid payments/
beneficiary: $2958
• Medicare beneficiaries 9.1%
• Medicare payments/
beneficiary: $18,651
bad for your health?

59. Do healthy behaviors decline with
greater acculturation?
Implications for the Latino
mortality paradox.
Soc Sci Med. 2005 Sep;61(6):1243-55. Epub 2005 Mar 3.
Abraído-Lanza AF1, Chao MT, Flórez KR.
Department of Sociomedical Sciences, Mailman School of Public
Health, Columbia University, 722 West 168 Street, 5th floor, New
York, NY 10032, USA. aabraido@columbia.edu

60. Do Healthy behaviors in Latino
populations decline w/
acculturation
Behaviors studied
• Smoking lower
• Alcohol use lower
• Leisure exercise lower
• BMI higher
Controlling for SES, age,
acculturation associated with
• Smoking up
• Alcohol use up
• BMI up
• Leisure exercise up

62. Race/Ethnic Differences in Adult
Mortality: The Role of Perceived
Stress and Health Behaviors
Patrick M. Krueger,
1
Jarron M. Saint
Onge,
2
and Virginia W. Chang
3,4,5
Soc Sci Med. 2011 Nov; 73(9):
10.1016/j.socscimed.2011.08.007.
Published online 2011 Aug 26. doi: 10.1016/j.socscimed.2011.08.007
PMCID: PMC3816937
NIHMSID: NIHMS322231
PMID: 21920655

64. Tobacco cigarette smoking
CDC 2014-2016, age & SES
Non-Hispanic Whites
• Total: 17.2%
• 18-24 y/o: 16.5%
• 25-34 y/o: 19.6%
• 35-44 y/o: 20.7%
• 45-64 y/o: 19%
• 65+ y/o: 7.8%
• Below 100% Pov: 37%
• 100-199%: 28%
• 200-399%: 18.6%
• 400+%: 8.8%
Hispanic/Latin@s
• Total: 7.3%
• 18-24 y/o: 5%
• 25-34 y/o: 6%
• 35-44 y/o: 8.3%
• 45-64 y/o: 9.5%
• 65+ y/o: 5%
• Below 100% Pov: 10%
• 100-199%: 7%
• 200-399%: 6%
• 400+%: 5.6%

65. Current smoking, stress, and
mortality by race/ethnicity

66. Alcohol consumption and mortality
by race/ethnicity

67. Alcohol use. CDC 2002-2016
Non-Hispanic Whites
• 2002 55%
• 2015 57%
• 2016 56%
• Binging 2016 25.4%
• Heavy 2016 7.2%
Hispanic/Latin@s
• 2002 42.8%
• 2015 42.4%
• 2016 42.5%
• Binging 2016 24.9%
• Heavy 2016 4.5%

68. Sleep hours and mortality by
race/ethnicity

69. Physical inactivity and Mortality by
Race/Ethnicity

70. Racial, Ethnic, and Gender
Differences in Physical Activity
J Hum Cap. 2013 Winter; 7(4): 378–410.
Henry Saffer, Dhaval Dave, Michael Grossman,
and Leigh Ann Leung

71. The Association Between Family
Social Network Size and Healthy
Lifestyle Factors: Results from the
Hispanic Community Health
Study/Study of Latinos (HCHS/SOL)
Rosenda Murillo et al. Journal of Behavioral
Medicine. pp1-11. 2019, July

72. Resiliency in the face of disadvantage:
do Hispanic cultural characteristics
protect health outcomes?
Gallo LC1, Penedo FJ, Espinosa de los
Monteros K, Arguelles W.
J Pers. 2009 Dec;77(6):1707-46. doi:
10.1111/j.1467-6494.2009.00598.x.
Epub 2009 Sep 30.

73. Hispanic cultural characteristics
Gallo
Allocentrism – needs of the many over the
individual – may lead to higher level of social
cohesiveness and community support
Simpatia – drive toward pleasant, non-
confrontational social interactions, perhaps
fostering socially desirable patterns and responses
– leading to better social relationships

74. Hispanic cultural characteristics
Gallo
Familialism –strong attachments to the nuclear and
extended family emphasized
Power distance/Personal space – amount of
physical space deemed appropriate for
interpersonal interactions. Hispanics are more
comfortable with close distances
Gender roles – machismo (male dominance) vs.
marianismo (female submissiveness) defined in
1973 as being characterized by female passivity,
dependence, self-sacrifice, and placing family
needs first

75. Hispanic cultural characteristics
Gallo
Religiousness – 94% of Hispanics had a religious
affiliation in 2003 and is associated w/ lower
smoking rates and lower mental health illnesses
and also predicts higher life satisfaction, lower
substance abuse rates and higher health seeking
behaviors for those that do have substance use
problems. Down to 83% in 2012 vs. 80% in general
population
Fatalism – believing that ones fate or destiny is
beyond one’s control

77. Ask different questions
Ask better questions

78. Levels of Intervention: Clinic
STATE/NATIONAL
SYSTEMS
COMMUNITY
CLINIC
INDIVIDUAL
UPSTREAM
DOWNSTREAM

79. Patient case: Azucar
• 45 y/o F, 10+ yrs poorly controlled IDDM
• Transferred to me for “non-compliance”
• SDOH screen
Assets Deficits
Employed Unstable housing
Had food Mexican Immigrant woman
Had emergency contact Uninsured, Undocumented
Good health-seeking behavior Non-English speaker
Trust in doctors Can’t read/write

80. Azucar’s Treatment Plan
• Can’t read – was not refrigerating insulin x 10 yr
– Referred to Goodwill for ESL and literacy
• Cheaper insulin
• Low-literacy health education materials
• EMR: SDOH Diagnoses added to problem list – makes
them active problems to be worked on consistently
• HbA1c 14+ down to 8+ in 6 months. Stable.
How do you begin to NOT ONLY treat Azucar with
SDOH lenses, but how to you treat her entire
community?

81. The 3 “Ms”:
Mission, Masses, Methods
Changing the paradigm of your clinic
operations

83. Maria Luisa Ortiz
Women’s Cooperative
Mulukuku, Nicaragua
• OB/Gyn care, Casa Materna
• Medical, Psych, Social
• Mobile clinics
• Dental, Pharmacy
• Political participation
• Traditional medicine
• Legal, Remediations
• Radio/Communication
• Refuge, shelter, self defense
• School based gardens
• Microlending project

84. Sea Mar’s SDOH Approach

85. Increased Risk
Poverty
Poor housing quality
Environmental exposures
Poor nutrition/ food insecurity
Safety concerns
Decreased Access
Language or cultural barriers
Geographical barriers
Inadequate health insurance
Lack of benefits
Development
of illness
Severity of
illness
Healthcare
Policy
& Advocacy
Health disparities & vulnerable populations

87. Uncoupling Poverty and Poor Health
Improve provider
ability to identify
social determinants
of health
Enhanced
family health
& wellbeing
Family
Empowerment
Medical-Legal
Collaboration
Enhanced
patient health
& wellbeing
Access to
legal
assistance

88. Collaboration: Sea Mar/NW Justice
Project offices in WA State

89. Possible protective factors
Non-Hispanic Whites
• Tobacco smoke 15%
• Breastfeeding 78%
• Fertility rate 58.8/1000 (‘16)
• Medicare Living alone 28.8%
• Medicare living w/ kids: 8%
• Suicide rate climbing
• Opioid epidemic worse
Hispanic/Latin@s
• Tobacco smoke 7%
• Breastfeeding 85%
• Fertility rate 70.6/1000 (’16)
• Medicare Living alone 25.3%
• Medicare living w/ kids: 18%
• Religiosity 83%

90. Building resilience in the Latino
community
Evidence
• Lowest tobacco use
• Highest breast feeding
• Highest fertility rates
• Multigenerational families
• Lower incomes
• Lower education
Thoughts
• Not advertised to
• Secure bond to mothers
• Nuclear family Incentive for
healthy individual habits.
• Kids, parents, abuel@s living
together gives benefit to
health?
• Is it protective vs. inactivity
and eating processed foods?
• Low SES universally seen as
deficit to good health

91. Don’t Forget Strengths & Assets!
• Community
• Family
• Faith
• Less US intervention
• Cultural pride
• Multilingual
• Self or family with US citizenship
• SDOH-6: “Do you have someone to call in case
of an emergency?”

92. Sea Mar CHC
clinic-based programs

93. Sea Mar Clinic Zumba classes

94. Sea Mar CHC community programs

95. Organize & Advocate
• Clinic-based organizing
• Promotor@s de Salud
• Direct actions/
Marches
• Latino Legislative Day

98. Summary: “Everyone should have
enough, and No one should have
too much”
• The gap between the rich and the poor is the
best determinant of health (income inequality)
• Predi$tribution of wealth is the best way to
solve this (equity of social/political policy)
• Politics and health are in continuum
• We need Healthcare Activists to organize and
educate ourselves, our patients, our
communities to participate in our Democracy

99. Discussion?

100. Great. So what do I do now?
This is your moment of truth!

101. Levels of Intervention: Individual
STATE/NATIONAL
SYSTEMS
COMMUNITY
CLINIC
INDIVIDUAL
UPSTREAM
DOWNSTREAM

103. There is plenty of money. It’s just
not where it needs to be.

104. In case you wanted to know where
it is…

105. Defining Equality vs Equity

106. Why is Maria in the clinic?

107. Levels of Intervention: Community
STATE/NATIONAL
SYSTEMS
COMMUNITY
CLINIC
INDIVIDUAL
UPSTREAM
DOWNSTREAM

108. Community Medicine
Gun violence: public health problem
Community building: the pill
A case study of the South Park Violence
Prevention Collaborative

109. Health
Mapping
Where is our
neighborhood
healthy?
Where is our
neighborhood
unhealthy?

110. Socioeconomic factor
component (rank 1-3):
Percent Below 200%
Poverty Level by
ZIP code
Poverty

111. Sensitive populations
component (rank 1-3):
Percent Foreign Born
by
ZIP code
Immigration status

112. Pollution
Environmental
exposures component
(Rank 1-10):
Annual Average Diesel
Particulate Matter in
human breathing zone
(ug/m3), by ZIP code

113. Public health factors
component
(Rank 1-5):
Childhood asthma
hospitalization
rate per 100,000 by
ZIP code
Asthma

114. Seattle
Cumulative
Impact
Analysis
Results

115. Georgetown/South Park disparities
Indicator Georgetown/
South Park
Census
tracts 109
and 112
Laurelhurst
Census
tracts 4100
and 4200
Seattle King County
Life expectancy at birth
(years)
73.3* 86.4* 81.5 81.5
Heart disease death rate
per 100,000
202.9# 89.6* 138.4 137.8
Source: Public Health Seattle & King County
*p=0.05 from both KC and Seattle average
#p= 0.05 for KC average only

116. +
Cumulative Effects - Imagine
+ +
+ +++++
+

117. OR
(Fill in Chronic Disease)
+ ++++
++
+

119. What are community health
issues?
Anna Schulman, Antioch University, 2012

120. Reality check...the “Aha moment”

121. South Park Action Agenda
•Youth Development – Teen programs
•Community Engagement - organizing
•Public Safety – Neighbor-Police relationship
•Business development – Jobs, Vibrancy
•Transportation – prevents stagnancy
•Physical Environment – Sliver by the River
•South Park Plaza – “3rd place”

122. Levels of Intervention: Systems
STATE/NATIONAL
SYSTEMS
COMMUNITY
CLINIC
INDIVIDUAL
UPSTREAM
DOWNSTREAM

130. http://datatools.urban.org/Features/mortgage
s-by-race/#5/38.000/-96.500

132. Income inequality vs. Upward
mobility: the American Dream

133. Take Home #3
Politics and health are in
continuum

134. Levels of Intervention:
State/National
STATE/NATIONAL
SYSTEMS
COMMUNITY
CLINIC
INDIVIDUAL
UPSTREAM
DOWNSTREAM

135. US Life Expectancy 1960-2017
3 straight years drop – why?

136. US Life Expectancy 2014-16
US Age Specific Death Rates 2015-16
Washington Post 171221

138. Drug, alcohol & suicide mortality men, women ages 45-54
Case, A. and A. Deaton (2017)

139. State/National
Interventions
• $15 minimum wage
• Paid paternity/maternity leave
• Immigration reform – keep families together
• Equitable wealth distribution = Predi$tribution
• Education (Pre-K education, subsidized/free higher
education)
• Access to affordable health care
• Prison reform, Re-enfranchisement
• Increased funding for public transportation
• Democratic process – power to the people!

140. 2018 Access to Democracy Package
Signed by Gov. Inslee on March 19, 2018
July 1, 2019 voters can register at age 16 and
will be added to list of registered voters when
they turn 18.
Automatic voter registration when driver’s
license or enhanced ID granted
High school civics classes need to educate
students about their rights!

142. CO2 in atmosphere – Yellowstone

143. We’ve passed +1 degree C

144. California drought (reported 2012)

145. Mass conflict/climate migration

146. Who will control the wealthiest,
most powerful nation in 2020?

147. Convince yourselves?
Income
• Maria’s Diabetes is a
symptom of an unbalanced
society. Her true disease is
poverty, so I have to treat
poverty.
• Not quite – the real issue is
that a few people have too
much $$/power. The real
disease: Addiction to
control.
Immigration
• We need immigration
reform so she can get a
bone marrow transplant
• Not quite – US empire
needs to end. Extractive
economy must end.
Colonial habits must end or
we will continue to have
economic refugees like her
with other expensive
diseases.

148. Convince yourselves?
Healthcare (Ill care) system
• Cannot read or write – this
was why her insulin was not
refrigerated and she was
hyperglycemic for 10 yrs.
Teach her to read.
Document illiteracy in ICD-
10 code so we can get
funding to address SDOH.
• Now - We need to end a for-
profit healthcare system.
Organize, Politics
• Before: Fight for $15/hr
(redi$tribute wealth)
• Now: Maximum wage!
(Predi$tribute wealth)
• Women leadership – better
for our health?

149. What is possible!

150. Where can you take action?
STATE/NATIONAL
SYSTEMS
COMMUNITY
CLINIC
INDIVIDUAL
UPSTREAM
DOWNSTREAM

151. Clinical Best Practices
•Support academic excellence
–ROR
–Library card, age appropriate kits
•Support Spanish literacy
–Bilingual preschools
–Visits in Spanish
•Support value of hard work
–Total minutes of exercise/wk massive w/ labor jobs. Very
protective vs. cardiovascular death
•Support exercise (150min/wk; 350min/wk)
•7-8 hrs sleep/night adults

152. Not using next slides

153. CVDz Deaths 2014-2016
Latin@s in WA State (M/F 35+)

154. CVDz Deaths 2014-2016 (M/F 35+)
Non-Hisp Whites in WA State

155. CHF Medicare hospitalizations
Latin@s. CDC 2014-2016

156. CHF Medicare hospitalizations.
CDC 2014-2016 Non-Hisp Whites

157. CAD Deaths Latin@s (M/F 35+)
CDC 2014-2016

158. CAD Deaths Non-Hisp Whites
(M/F 35+) CDC 2014-2016

159. World Wealth Inequality: USA
38.6% in 2004 (peak 47.8% in 1928)

167. US Years lived w/ Disability, 2016