Promoting Health Intervention Strategies from Social and Behavioral Research (2000) / Chapter Skim
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Paper Contribution A: The Contribution of Social and Behavioral Research to an Understanding of the Distribution of Disease: A Multilevel Approach
Paper Contribution A: The Contribution of Social and Behavioral Research to an Understanding of the Distribution of Disease: A Multilevel Approach
Pages 37-80
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From page 37... ...
However, the premise of this paper is that these advances, in and of themselves, will not be able to accomplish these goals. Instead, we argue for a public health-based approach that incorporates knowledge across a multitude of levels, ranging from the pathobiology of disease to the social and economic policies that result in differential patterns of exposure of individuals and populations to risk factors and pathogenic environments.
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From page 38... ...
In what follows we will review selected information on variations in life expectancy and the occurrence of a number of major public health problems and discuss how such a multilevel approach provides critical perspectives on the causes of these variations and on opportunities to reduce them. Life Expectancy and Death Rates from All Causes Overall life expectancy at birth reached 76.5 years in the United States in 1997, with almost steady increases since 1950 (NCHS, 1999~.
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From page 39... ...
As might be expected from trends and differences in life expectancy, consideration of age-adjusted mortality rates from all causes also indicates substantial variation by gender, race/ethnicity, and time. Figure 2 (Hoyert et al., 1999)
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From page 40... ...
1 OOO $1 O 1°°° $1 51 COO 2$25 1 DO $1 41999 $241999 Family Income FIGURE 3 Life expectancy at age 45 by family income, race, and sex, United States, 1979-1989.
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From page 41... ...
The gradient between socioeconomic position and death rates is clearly seen for broad classes of causes of death, as shown in Figure 4 (NCHS, 1998~. The strong effects of socioeconomic position on mortality, coupled with substantial heterogeneity by race/ethnicity and geographic place in mortality rates and strong secular trends can lead to phenomena of major public health significance.
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From page 42... ...
Such a pursuit is in its infancy and represents a major challenge that will succeed only with a broad interdisciplinary vision accompanied by state-of-the-art thinking in multiple domains. In what follows we describe some general epidemiologic and demographic features of six major public health problems: low birthweight, childhood asthma, firearm-related deaths in adolescents and young adults, coronary heart disease, breast cancer, and osteoporosis.
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From page 43... ...
THE DISTRIBUTION OF DISEASESOME ILLUSTRATIVE EXAMPLES Low Birthweight Overall 43 An' Low birthweight, defined as a live birth less than 2,500 grams, is one of the most vexing problems facing the public health community in the United States. Low birthweight can result from babies being born prematurely and/or being born too small, and it is the major underlying cause of infant mortality and early childhood morbidity.
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From page 44... ...
[""""""':':':':':':'1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 ~ 1 1 t 1 1 White, non- Black, non- Hispanic Native Asian or Hispanic Hispanic Peoples Pacific Islander FIGURE 6 Low birthweight by education and race/ethnicity, United States, 1996. HisDanic Distribution by Race and Socioeconomic Position As alluded to above, the problem of low birthweight is not distributed randomly across population subgroups.
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From page 45... ...
Nevertheless, the differences in low birthweight across race/ethnic groups cannot be ignored and deserve more intensive investigation. Adding to the complexity of this picture is recent research showing that birthweights of Africanborn black women are more closely related to those of U.S.-born white women than to U.S.-born black women (David and Collins, 1997~.
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From page 46... ...
Casey Foundation, 1999~. Geographic Distribution Not unexpectedly, there also is considerable geographic variation in low birthweight across the United States.
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From page 47... ...
have shown how the extent of income inequality within a state is correlated with rates of low birthweight even after adjustment for the average incomes in the state (r = -065, p < .001~. As Paneth has argued, "The effects of poverty at the level of the individual, the family and the community need all to be taken account of, the context in which pregnancy occurs is larger than the womb" (1995, p.
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From page 48... ...
................ ~~Overall <18 18-44 45-64 652 Male Female FIGURE 10 Asthma prevalence rate by age, and sex, United States, 1995.
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From page 49... ...
In fact, even black children living in zip codes where the median income was greater than $40,000 per year are much more likely to be hospitalized for asthma than white children living in the poorest income areas. Understanding what these race/ethnic and socioeconomic differences reflect is a complex task, but it is possible that residential environments for black children are poorer quality, at 60 55 50 OQ 45 lo lo Q lo: 40 · White · Black · Other ~4'~ 20 _ ~ / l l l l l l 1980 1981-1983 1984-1986 1987-1989 1990-1992 1993-1994 FIGURE 11 Asthma prevalence trends by year and race/ethnicity, United States, 1980-1994.
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From page 50... ...
, and important environmental differences may exist in levels of inflammatory bioallergens between the residential areas occupied by blacks and whites. Trends Prevalence, emergency department treatment, and mortality rates for asthma have all increased in the last 20 years (NHLBI, 1999~.
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From page 51... ...
The American Lung Association estimates that the direct health care costs for asthma in the United States are almost $10 billion, with inpatient hospital care being the largest single expenditure. Indirect costs related to both loss of work and missed school days may add up to more than $ 1 billion annually.
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From page 52... ...
................................... Females FIGURE 14 Death rates per 100,000 for fireamn-related injuries among persons age 1524 by sex and race/ethnicity, United States, 1996.
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From page 53... ...
(NCHS, 1998~. Among males, in 1996 the lowest rates were among Asian Pacific Islanders (19.6 per 100,000 population)
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From page 54... ...
On average, death rates from firearm-related injuries were 7.1 (median, 5.8) times higher among blacks than for whites, but the rates of relative disadvantage ranged from 2.4-fold in Texas and 2.7-fold in North Carolina to 12.1-fold in Illinois and 14.6-fold in Massachusetts.
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From page 55... ...
Coronary heart disease, which accounts for two-thirds of all heart disease deaths, alone accounted for more than 2 million hospital stays in 1995, with an average length of stay of 5.3 days, and almost 10 million physician visits (NHLBI, 1998~. Distribution by Race and Sex There is considerable variation in rates of death from cardiovascular disease (CVD)
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From page 56... ...
Figure 17 shows the inverse association between family income level and heart disease death rates for 25- to 64-year-old non-Hispanic whites and African-Americans. Those in families with incomes less than $10,000 had death rates that are 2.4- to 2.8-fold higher than those with family income greater than $15,000 in 1979-1989.
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From page 57... ...
For example, the average annual percentage decline in age-adjusted coronary heart disease death rates for white males and females was greater than for black males and females from 1980 to 1996. In some periods the differences were substantial the annual percentage decline for males was 50% greater (-3.6% versus -2.4%)
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From page 58... ...
11- 92 (13) FIGURE 18 Geographic distribution of age-adjusted mortality rates from ischemic heart disease among persons age 24-75, by state, United States, 1996.
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From page 59... ...
However, lung cancer mortality rates are higher than breast cancer mortality rates in women overall (American Cancer Society, 1995) , and three times as many women will experience heart disease as breast cancer in their lifetime.
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From page 60... ...
The mortality rate among African American women over all ages is 31.2 per 100,000 population, compared to 26 per 100,000 population for white women (American Cancer Society, 1995~. Mortality rates among other racial or ethnic groups, such as those shown in Figure 19, are less than 20 per 100,000 population (Perkins et al., 1995~.
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From page 61... ...
It has been suggested that the observed increase in breast cancer incidence was partially due to the increased prevalence of risk factors for breast cancer, particularly reproductive factors, such as later age at first birth and smaller family sizes than in previous generations (American Cancer Society, 1995~. Until relatively recently, trends in incidence of breast cancer were similar for white women and African American women.
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From page 62... ...
Recently, it was determined that regional differences in reproductive risk factors (e.g., low parity, late age at first birth) , many of which are associated with a more advantaged socioeconomic position, accounted for the high incidence rates of breast cancer in the Bay area (Robbing et al., 1997~.
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From page 63... ...
, indeed, vertebral fractures historically have been considered a defining clinical feature of osteoporosis (Albright et al., 1941~. Recent estimates indicate that the age-adjusted incidence of vertebral fracture is more than twice as high as the incidence of hip fracture in women (18 per 1,000 person-years versus 6.2 per 1,000 person-years, respectively)
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From page 64... ...
decrease in femoral bone density is equivalent to a 14-year age increase in risk of hip fracture (Melton et al., 1993~. Bone density decreases greatly with age, especially among women, making age one of the strongest risk factors for osteoporosis.
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From page 65... ...
Several of the risk factors for fracture (e.g., alcohol abuse, cigarette smoking, physical inactivity) are known to vary by socioeconomic position, with greater prevalence of these behavioral or life-style factors
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From page 66... ...
among poorer persons. One study reported that hip fracture incidence rates in elderly white women in the United States are higher in regions with greater poverty (Jacobsen et al., 1990~.
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From page 67... ...
Interestingly, however, regional variations in alcohol consumption, cigarette smoking, obesity, physical activity, or Scandinavian heritage did not account for the observed geographic patterns. The findings suggest that unobserved or unmeasured environmental characteristics and/or individual risk factors are contributing to the geographic variation in hip fracture rates.
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From page 68... ...
The changes in economic status of individuals and the communities they live in could conceivably lead to better health among pregnant women and women of childbearing age, thereby leading to a reduced risk of low birthweight. Increased SEP also
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69 an.
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From page 70... ...
The most obvious relates to access to health insurance and state-of-the-art medical care. To the extent that there is no consensus regarding the need for universal access, then we can expect to see substantial variations by SEP and race/ethnicity in low birthweight and the diagnosis and treatment of asthma, as well as screening, treatment, and outcomes of CVD, breast cancer, and osteoporosis.
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From page 71... ...
The school environment also can support factors related to increased risk of later development of breast cancer, through both dietary and reproductive risk factors. School-related factors also may contribute to patterns of bullying, gang formation, and violence that may lead to firearm-related injuries.
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From page 72... ...
, and resolution of violence that can lead to firearm-related deaths. Living conditions, reflected in the quality of housing and residential environments, may be associated with low birthweight, asthma, cardiovascular disease, and osteoporosis and the risk of hip fracture.
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From page 73... ...
These states can have indirect impacts on low birthweight, breast cancer, cardiovascular disease, and osteoporosis via their influence on access to and use of preventive and curative services, their impact on social relations, and, possibly, through the influence of psychological states on neuroendocrine and immune pathways. CONCLUSIONS We have briefly outlined the heterogeneity in prevalence, distribution, and trends for life expectancy and a number of important public health problems.
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From page 74... ...
Evidence of increasing coronary heart disease mortality among black men of lower social class. Annals of Epidemiology 1999; 464 2171.
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From page 75... ...
Hip fractures in the elderly: A worldwide projection. Osteoporosis International.
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From page 76... ...
MEDOS Study Group. The apparent incidence of hip fracture in Europe: A study of national register sources.
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From page 77... ...
Looker AC, Orwoll ES, Johnston CC, Jr., Lindsay RL, Wahner HW, Dunn WL, Calvo MS, Harris TB, and Heyse SP. Prevalence of low femoral bone density in older U.S.
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From page 78... ...
Secular trends in the incidence of hip fractures. Calcified Tissue International 1987; 41 :57-64.
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From page 79... ...
Mendall MA, Carrington D, et al. Association of Helicobacter pylori and Chlamydia pneumonias infections with coronary heart disease and cardiovascular risk factors.
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From page 80... ...
Decreased incidence of hip fracture in Hispanics, Asians, and blacks: California hospital discharge data. American Journal of Public Health 1988; 78:1482-1483.
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