Promoting health equity among racially and ethnically diverse adolescents a practical guide lisa bar
Promoting
Health Equity Among Racially and Ethnically Diverse Adolescents A Practical Guide Lisa Barkley
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Positive Mental Health Fighting Stigma and Promoting Resiliency for Children and Adolescents 1st Edition
Promoting Health Equity Among Racially and Ethnically Diverse Adolescents
A Practical Guide
Lisa Barkley
Maria Veronica Svetaz
Veenod L. Chulani
Editors
Promoting Health Equity Among Racially and Ethnically Diverse Adolescents
Lisa Barkley • Maria Veronica Svetaz
Veenod L. Chulani
Editors
Promoting Health Equity
Among Racially and Ethnically Diverse Adolescents
A Practical Guide
Editors
Lisa Barkley, MD, FAAFP, FSAHM, FACSM
Program Director, Family Medicine Residency
Vice-Chair, Department of Family Medicine
Charles R. Drew University of Medicine and Science
Los Angeles, CA, USA
Maria Veronica Svetaz, MD, MPH, FSAHM, FAAFP Medical Director, Faculty Department of Family and Community Medicine
Hennepin Healthcare Minneapolis, MN, USA
Assistant Professor, School of Medicine University of Minnesota Minneapolis, MN, USA
Veenod L. Chulani, MD, MSED, FSAHM Chief, Section of Adolescent Medicine Department of General Pediatrics and Adolescent Medicine Phoenix Children’s Hospital Phoenix, AZ, USA
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Preface
The adolescent population of the United States is becoming increasingly diverse as of the proportion of racial and ethnic minority adolescents grows to comprise a greater share of the population. While 54% of US adolescents were white in 2014, that proportion is projected to drop to 40% by 2050 as Hispanic and multiracial teens, in particular, come to represent a larger share of the population.
Why focus on racial and ethnic diversity? We acknowledge that there are multiple dimensions of diversity that are critical to adolescent health and well-being. In the United States and in many regions globally, however, race and ethnicity are visible differences that have been particularly impactful in setting the stage for inequitable social contexts and opportunities that represent the root causes of health disparities. Differences in access to health care, health-related behaviors, and health outcomes by race and ethnicity are well documented. Members of racial and ethnic minority groups, in general, have less access to health care, experience more serious health conditions, and have higher mortality rates than whites. These health disparities are linked to social determinants of health and well-being: social, economic, and environmental factors that are disproportionally distributed along the lines on race and ethnicity that require urgent attention to best promote health equity among diverse adolescent populations.
This publication, Promoting Health Equity Among Racially and Ethnically Diverse Adolescents: A Practical Guide, is born out of recognition that clinicians need to hone skills beyond the biomedical to address the multifaceted needs of youth across diverse cultures and communities and to effectively address the social structures, factors, norms, and drivers of inequity among these groups. Intended for use by clinicians working with diverse adolescent populations, it seeks to promote reflection on the roles they can play to promote heath equity for adolescents. It provides an overview of key health equity principles and clinical, teaching research skills and abilities to apply health equity to practice. Clinically oriented chapters provide guidance on approaches and strategies that clinicians can integrate in their encounters with diverse youth to identify and address the social, economic, and environmental factors that profoundly influence their health and well-being. Many of the chapters feature clinical vignettes, clinical pearls, and reflection questions to promote the application of concepts to practice.
In this book, the terms racial and ethnic minority adolescents, racially and ethnically diverse adolescents, and adolescents from nondominant racial and ethnic groups are used interchangeably. We have all struggled to find common terms to describe this population of youth in terms that do not themselves marginalize racial and ethnic groups. While racial and ethnic groups that were once considered minorities increasingly come to represent the majority in numbers, they remain marginalized and in the minority in their access to social and political capital. We recognize that terms are imperfect, and there is a need to continue to find new terms that best reflect their status and experiences in the prevailing social order.
Promoting health equity is a multidimensional concept that requires multiple strategies and partnerships to succeed and must include youth participation and collective action. Ginwright and Cammarota describe key principles to guide youth participation and activism, foremost of which is that Young People Are Agents of Change, Not Simple Subjects to Change. It is a perspective of young people that recognizes their capacity to produce knowledge to transform their world. Additionally, Young People Have Basic Rights. The category of youth as a socially distinct group of people fundamentally imposes a second-class status upon young people. Wyn and White submit that our concept of youth “in transition,” “becoming,” or “adults to be” all positions our focus on the future of what young people may become, ignoring the present-day reality of young people’s lives. By focusing entirely on the future, we fail to instill decision-making responsibilities on young people about issues that impact their lives in the present. A conceptual shift from youth as future citizens to present civic actors forces us to think more boldly about the nature of rights for youth and how to ensure these rights, including their right to civic representation and decision-making. While this publication reflects the contribution of leading experts in the field of adolescent health, it is critically important that readers engage youth as they develop and implement strategies, approaches, and interventions to promote health equity in their respective clinical settings
We hope that this publication will truly assist providers to develop the framework and competencies they need to promote health equity and serve as a practical guide for clinical training and practice.
We are humbled by the opportunity to work with so many of our colleagues to develop this book and are especially thankful for Dr. Michele Allen’s contribution to the initial steps in this book. We are grateful to the youth we serve and for the honor of representing their interests.
“Fair doesn’t mean giving every child the same thing, it means giving every child what they need.”
–Rick Lavoie
Los Angeles, CA, USA
Lisa Barkley, MD, FAAFP, FSAHM, FACSM Minneapolis, MN, USA
Veenod L. Chulani, MD, MSED, FSAHM
Maria Veronica Svetaz, MD, MPH, FSAHM, FAAFP Phoenix, AZ, USA
10 Bringing the Strength of Positive Youth Development to the Practice Setting
Kelly Bethea 11 The Patient Experience: Stereotype Threat in Medical Care
Sean M. Phelan, Sarah Atunah-Jay, and Michelle van Ryn
12 Intersecting Identities and Racial and Ethnic Minority in Lesbian, Gay, Bisexual, and Transgender (LGBT) Youth .
Veenod L. Chulani
13 Supporting Diverse Families During the Transition of Adolescence: Special Situations and Conundrums of Care .
Diego Garcia-Huidobro 14 Immigrant and Refugee Adolescent Care: Challenges and Opportunities
Roli Dwivedi, Mary O’Donnell, and Karen Jankowski 15 A Clinical Practice Model to Promote Health Equity for Adolescents and Young Adults
Contributors
Michele L. Allen, MD, MS Department of Family Medicine and Community Health, Program in Health Disparities Research, University of Minnesota, Minneapolis, MN, USA
Sarah Atunah-Jay, MD, MPH Division of Community Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
Lisa Barkley, MD, FAAFP, FSAHM, FACSM Program Director, Family Medicine Residency, Vice-Chair, Department of Family Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
Kelly Bethea, MD United States Health Organization, Department of Health Affairs, Mt. Laurel, NJ, USA
Suzanne Bring Independent Writer and Editor, Delray Beach, FL, USA
Veenod L. Chulani, MD, MSED, FSAHM Chief, Section of Adolescent Medicine, Department of General Pediatrics and Adolescent Medicine, Phoenix Children’s Hospital, Phoenix, AZ, USA
Roli Dwivedi, MD University of Minnesota, Department of Family Medicine and Community Health, Community-University Health Care Center (CUHCC), Minneapolis, MN, USA
Mychelle Farmer, MD Advancing Synergy, LLC, Baltimore, MD, USA
Diego Garcia-Huidobro, MD, PhD Department of Family Medicine, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
Rachel R. Hardeman, PhD, MPH Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
Karen Jankowski, MD University of Minnesota, Department of Family Medicine and Community Health, Community University Health Care Center, Minneapolis, MN, USA
Alden Matthew Landry, MD, MPH Office for Diversity Inclusion and Community Partnership, Harvard Medical School, Boston, MA, USA
Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Emergency Medicine, Boston, MA, USA
Richard M. Lee, PhD Department of Psychology, University of Minnesota, Minneapolis, MN, USA
Eduardo M. Medina, MD, MPH Park Nicollet Clinic, Family Medicine, Minneapolis, MN, USA
Diem Julie Nguyen, BA Department of Psychology, University of Minnesota, Minneapolis, MN, USA
Mary O’Donnell, RN, MSN, DNP Community-University Health Care Center/ University of Minnesota, Minneapolis, MN, USA
Lena Palacios, PhD Department of Gender, Women, and Sexuality Studies, University of Minnesota, Minneapolis, MN, USA
Sean M. Phelan, PhD, MPH Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
Jeffrey M. Ring, PhD Keck School of Medicine of the University of Southern California, Health Management Associates, Los Angeles, CA, USA
Camille A. Robinson, MD, MPH Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
Maria Veronica Svetaz, MD, MPH, FSAHM, FAAFP Medical Director, Faculty, Department of Family and Community Medicine, Hennepin Healthcare, Minneapolis, MN, USA
Assistant Professor, School of Medicine, University of Minnesota, Minneapolis, MN, USA
Lindsay A. Taliaferro, PhD, MPH Department of Population Health Sciences, College of Medicine, University of Central Florida, Orlando, FL, USA
Maria Trent, MD, MPH Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
Michelle van Ryn, PhD, MPH School of Nursing, Oregon Health and Science University, Portland, OR, USA
Melissa M. Vélez, BS Department of Psychology, University of Minnesota, Minneapolis, MN, USA
April K. Wilhelm, MD University of Minnesota, Department of Pediatrics, Division of General Pediatrics and Adolescent Health, Minneapolis, MN, USA
Chapter 1 Population Health and Health Equity for Adolescents
Lindsay A. Taliaferro and Lisa Barkley
Learning Objectives
By the end of this chapter, the reader will be able to:
• Define population health and the social-ecological model
• Define health equity
• Discuss how to apply a population health and social-ecological perspective in the care of adolescents to promote health equity
Clinical Vignette
Nicole is a 16-year-old African American female who you follow for obesity and hypertension. You are discussing her blood pressure, which is not under good control despite significant improvement related to diet and exercise. You prescribe a medication, discuss the risks and benefits, and agree on the plan. She seems motivated to start the medication. At your next visit, her blood pressure is unchanged. You ask about the medication, and she gives a bland response that she did not get the medication because it was too expensive and questions if she really needs a medication.
L. A. Taliaferro
Department of Population Health Sciences, College of Medicine, University of Central Florida, Orlando, FL, USA
e-mail: Lindsay.Taliaferro@ucf.edu
L. Barkley (*)
Program Director, Family Medicine Residency, Vice-Chair, Department of Family Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA e-mail: lisabarkley@cdrewu.edu
L. Barkley et al. (eds.), Promoting Health Equity Among Racially and Ethnically Diverse Adolescents, https://doi.org/10.1007/978-3-319-97205-3_1
L. A. Taliaferro and L. Barkley
Population Health
Researchers define population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” [1, p381]. The goals of population health involve maintaining the health of an entire population and reducing inequalities in health between groups [2]. Thus, the field focuses on health outcomes, patterns of health determinants, and policies and interventions that link health determinants and outcomes [1]. Population health extends beyond the traditional disease management approach to glean a thorough understanding of clinical and nonclinical characteristics of a population (e.g., economic and social conditions that affect health), including risks associated with these factors. Within the population health conceptual framework for clinical care, the patient remains central to the model and is surrounded by factors that impact his/her health, including organizational interventions, clinician interventions, and family and community resources [3]. Key processes associated with delivering components of population health involve assessing the health of specific populations; using these data to stratify patients into meaningful risk groups; delivering tailored, patient-centered interventions based on risk stratification; evaluating the impact of interventions; and implementing quality improvement measures based on evaluation data [3]. Some researchers note a difference between population health and the field of public health. Kindig and Stoddart suggest public health activities do not have as broad a mandate as population health over major determinants of health such as medical care, education, and income [1]. Thus, population health may be viewed as encompassing all determinants of health, such as public health interventions, as well as medical care, aspects of the social environment (income, education, employment, social support culture) and physical environment (urban design, clean air and water), genetics, and individual behavior [1]. Population health initiatives proactively identify health issues, diseases, or conditions that affect the targeted population and provide patient support and outreach to meet their needs.
The population of adolescents in the USA will look very different in the foreseeable future. By 2050, just 40% of US adolescents will be identified as non-Hispanic white [4], and the US adolescent population will become a “majority-minority” population or a “plurality” of racial and ethnic groups [5]. Healthcare providers will need to provide quality care that appropriately addresses needs of the diverse population of young people in this country. Applying a population health approach could help achieve the five objectives that promote responsive adolescent health services for all young people [6]:
1. Accessibility: policies and procedures ensure services are broadly accessible.
2. Acceptability: policies and procedures consider culture, relationships and the climate of engagement.
3. Appropriateness: health services fulfill the needs of all young people.
4. Effectiveness: health services reflect evidence-based standards of care and professional guidelines.
5. Equitability: policies and procedures do not restrict the provision of eligibility for services.
A population health perspective requires a consideration of health outcomes in relation to the occurrence and patterns of health determinants (conditions and factors that influence the health of populations over the life course) within the adolescent population, as well as the impact of policies and interventions at the individual and social levels on determinants associated with poor health outcomes [1]. The consideration of social influences on adolescent health is critical as the leading factors that influence health outcomes have been shown to be more dependent on social factors than on clinical care delivery. According to Sowada, environmental and social factors account for 55% and behavioral factors for 20% of the determinants of health vs. 20% for medical care and only 5% for genetic factors [44]. Since adolescence and young adulthood are phases of the life course where a large amount of social development occurs, it is especially critical to adolescent population health to address the social determinants of health.
The Social-Ecological Model
Population health applies a social-ecological perspective, which recognizes that health behaviors are part of, and often stem from, the larger social system or ecology of social influences on an individual. Further, this perspective recognizes that lasting changes in health require supportive changes in the whole system. The social-ecological model examines how the social environment, including interpersonal, organizational, community, and public policy factors, supports and maintains health and health behaviors [7]. This perspective includes five levels of influence on health-related behaviors and conditions:
1. Intrapersonal factors: knowledge, attitudes, and skills of the individual 2. Interpersonal relationships: family, friends, social networks
Promoting healthy/positive youth development requires an acknowledgement of how factors across adolescents’ social ecologies affect their health, behavior, and well-being. Applying a positive youth development approach involves an intentional process of recognizing and building positive strengths and maximizing potential by providing all youth with the support, relationships, experiences, resources, and opportunities needed to become successful and competent adults, rather than focusing on extinguishing maladaptive behaviors [8, 9]. Thus, efforts to promote healthy youth development should not solely focus on reducing risks but also on enhancing protective factors that promote resilience among young people [10]. Figure 1.1 presents a social-ecological model, with environmental resources and vulnerabilities clinicians should address during clinical visits with adolescents [11]. For adolescents, in particular, safe and supportive families and schools, as well as supportive prosocial peers, represent critical factors within their social environ-
-Academically engaged -Emotionally and physically safe
-Positive sense of self or self-efficacy
-Life and decision-making skills
-Physically and mentally healthy
A.
Fig. 1.1 A Social-Ecological Framework for Addressing Adolescent Health. (Originally printed in Blum et al. [11]. Reproduced with permission from Dr. Robert W. Blum)
ments that affect health behaviors and attainment of their full potential [12]. A positive youth development perspective emphasizes the potential of all young people, including those from disadvantaged backgrounds or with troubled histories [8]. Such an approach represents a promising strategy for creating health equity, as young people vulnerable to poor health may prefer this strength-based, solutionoriented approach [9].
L.
Taliaferro and L. Barkley
Overview of Social Determinants of Health and Health Disparities
Health during adolescence is shaped by social determinants of health and their interaction with risk and protective factors that affect engagement in health-related behaviors [13]. Social determinants of health represent conditions in the environments in which people live, learn, work, and play that affect health outcomes and risks [14]. Figure 1.2 presents examples of social determinants of health within individuals’ social and physical environments. Recognizing the important developmental period of adolescence, the US government created the new category “Adolescent Health” within their Healthy People document, with goals addressed in Healthy People 2020 [15]. The US Department of Health and Human Services (USDHHS) recognized that the leading causes of illness and death among this
Physicalenvironments
e.g. Air & water quality
e.g. Income
e.g.
Socialenvironments
e.g Diet Tobacco use
Drug/alcohol use
Sexual behaviours
Fig. 1.2 Social Determinants of Health. (Reproduced with permission from Marla Orenstein, M.Sc. Habitat Health Impact Consulting, http://www.habitatcorp.com)
L. A. Taliaferro and L. Barkley
population are preventable and caused by health-compromising behaviors (e.g., homicide, suicide, drinking and driving, substance use, risky sexual behavior). Further, applying a social-ecological perspective, USDHHS acknowledges that these behaviors are influenced at the individual, peer, family, school, community, and societal levels, and health outcomes are linked to multiple environmental determinants, including family, school, neighborhoods, and media exposure [15]. These external social determinants contribute to making certain adolescent populations vulnerable to high-risk behavior and poor health outcomes. Therefore, applying a positive youth development approach remains essential for addressing adolescent health-risk behaviors [15].
Negative social determinants preclude the development of positive health over time and lead to health disparities, i.e., differences in health that are not only unnecessary and avoidable but also unfair and unjust. Health disparities negatively affect groups of people who have systematically experienced greater social or economic obstacles to health [16]. These obstacles stem from characteristics historically linked to discrimination or exclusion such as race or ethnicity, religion, socioeconomic status, gender, mental health, sexual orientation, geographic location, or cognitive or physical disability. Where a health disparity exists, disadvantaged groups have worse health outcomes and systematically greater health risks than comparatively advantaged groups.
While the overall health of the US population has improved over the past several decades, health disparities among racial and ethnic groups have persisted. Racial/ ethnic minorities in the USA, including adolescents, receive lower-quality healthcare services and demonstrate worse health indicators than white Americans [17, 18]. Despite increased pediatric clinicians in the workforce, advances in medical care, and improved screening and detection of diseases, racial/ethnic minority youth continue to demonstrate multiple disparities, including those related to overall suboptimal health, overweight and obesity, asthma, oral health, mental health, substance use, and high-risk sexual behaviors that lead to STIs and pregnancy [19–24].
Researchers suggest that an unequal distribution of health-damaging experiences results from a combination of poor social policies and programs, unfair economic arrangements, structural racism, and bad politics [14]. Racially and ethnically diverse adolescents are overrepresented in low SES communities as a result of many of these factors. Specific social determinants of health that may represent particular challenges for racial/ethnic minority and underserved adolescents include those related to economic factors, the built environment in which they live and attend school (i.e., neighborhood factors), quality education, zoning and land use, housing, and exposure to trauma [25]. Research has established a clear connection between low socioeconomic status (SES) and poor adolescent health outcomes [26]. Further, applying a life-course perspective, researchers have identified an association between childhood health and early-life SES and adult health outcomes [27–30]. The factors through which SES impacts adolescents’ health are complex and interactive across levels of their social ecologies. Still, understanding these complex relationships remains imperative for creating and implementing successful interventions and policies that will reduce health disparities [26].
Relationship Between Social Determinants of Health, Health Disparities,
and Health Equity
Addressing social determinants of health associated with health disparities among youth will help achieve the goal of promoting health equity among the adolescent population. Health equity refers to the absence of disparities in modifiable aspects of health, thus, some type of social injustice, among groups of people defined socially, economically, demographically, or geographically [31]. Health equity differs from health equality, as the former concerns fairness and the latter concerns sameness. Equality involves providing everyone with the same resources, without accounting for preexisting differences that may exist among groups. Equity ensures groups are provided tailored resources needed to help achieve health equality (see Fig. 1.3).
Achieving health equity requires going beyond a focus on the immediate causes of health or illness and addressing controllable and remediable aspects of health related to different social determinants across levels of an individual’s social ecology [32]. Structural determinants of health and conditions of daily life cause much of the health inequity between groups [14]. Thus, improving the conditions of daily life, such as circumstances in which people are born, grow, live, and work, and remediating the inequitable distribution of power, money, and resources should profoundly improve health equity among racial and ethnically diverse youth [14].
Clinical Applications of Population Health and Health Equity
Health disparities among adolescents can be eliminated [33, 34]. However, reducing racial/ethnic health disparities among youth requires interventions that address poverty and racism [25]. Structural changes in adolescents’ social environments often related to SES, such as improving access to quality healthcare services, education, employment, and high-quality housing and safe communities, likely represent the most effective interventions in improving adolescent health [12, 14].
Equity involves trying to understand and give people what they need to enjoy full, healthy lives. Equality, in contrast, aims to ensure that everyone gets the same things in order to enjoy full, healthy lives. Like equity, equality aims to promote fairness and justice, but it can only work if everyone starts from the same place and needs the same things
Fig. 1.3 Health Equity versus Health Equality. (Originally printed in The Annie E. Casey Foundation [47]. Reproduced with permission from The Annie E. Casey Foundation)
Equality Equity VS.
L. A. Taliaferro and L. Barkley
Adolescent health behaviors are strongly shaped by social, economic, and cultural factors beyond the influence of clinicians [12]. Yet, very often, adolescents will be engaged in healthcare settings, and providers must take every opportunity with individual youth to address the personal impacts from their social ecologies and advocate at system levels for policy and practice changes that can impact on the population health of adolescents.
First, healthcare providers must self-reflect to determine their own biases, stereotypes, and triggers. Continual self-assessment is a powerful skill for clinicians to master as it allows one to engage the adolescent at the stage at which they present and reduces the likelihood of biased judgment clouding clinical decision-making. Clinical decision-making is not only based on data and science; it includes interpreting information from patients and making judgments based on clinical experience. Often these decisions have to be made with limited information, when fatigued or under time pressures [46]. The Unequal Treatment report in 2002 by the Institute of Medicine provides considerable evidence that the race and ethnicity of patients influence medical decision-making and increase the likelihood of health disparities. Without self-reflection, it will be very easy for healthcare providers to overlook prejudice in their own behavior [46].
Healthcare providers can acknowledge and assess social determinants of health, including risk and protective factors associated with health-related behaviors, across adolescents’ social ecologies. An ecological or life-course perspective remains essential to understanding adolescents’ current health and potential health trajectories [11]. Clinicians are encouraged to address modifiable, proximal determinants of risk and protective factors related to health outcomes such as school connectedness and safety, family connectedness, neighborhood safety, access to resources and services, connections to prosocial peers, and adoption of health-promoting behaviors that will persist into adulthood [12, 45]. For example, when addressing physical inactivity and obesity among minority youth, clinicians should assess neighborhood safety and access to safe green spaces and grocery store options within an adolescent’s community [35, 36]; time spent watching television, as a measure of sedentary behavior and indirect measure of exposure to targeted marketing of unhealthful foods and beverages to minority youth [37, 38]; and the home food environment [39]. As discussed below, clinicians and administrators within clinical care settings are encouraged to routinely collect data on their patient populations with a goal of identifying, monitoring, and targeting common determinants of health and potential racial/ethnic disparities [21]. They can subsequently use these data to prioritize targets of intervention activities and inform the implementation of evidence-based strategies to address identified common determinants.
Clinicians also might partner with community-based organizations, such as schools and social service agencies, to develop and implement initiatives that address health disparities [40]. Researchers found that successful interventions aimed at eliminating health disparities among minority youth involved culturally and linguistically sensitive community-based programs that included collaboration with participants from the target population [33]. Community and youth are crucial partners in eliminating inequities as they are living in the conditions that are influ-
encing the disparities – solutions that do not actively include community and youth voices will be incomplete. Overall, clinicians can help address health disparities and promote or enhance health equity among adolescents by [41]:
• Connecting families to resources and creating bridges to schools
• Enhancing the comprehensiveness of services offered
• Addressing family health during adolescent clinical visits
• Extending care outside the clinical setting into the community by partnering with key stakeholders
• Diagnosing disparities in their communities and practices
• Innovating new models to address social determinants of health
• Addressing health literacy in families
• Ensuring cultural competence and a culture of workplace equity
• Advocating with and on behalf of youth and families on issues that address the root causes of health disparities (e.g., quality healthcare, childcare, and education; safe housing; access to healthful food; family supports; and fair wages)
Administrators within clinical care settings are encouraged to routinely collect racial/ethnic data on youth by health systems, practices, and insurance with a goal of identifying, monitoring, and targeting racial/ethnic disparities within qualityimprovement efforts [21]. Researchers have identified several challenges associated with using quality improvement approaches to address pediatric health disparities and suggest these designing and implementing quality improvement interventions: (1) consider comparison groups (e.g., comparisons within specifically targeted high-risk populations), (2) use rigorous evaluation methods, (3) use evidence-based interventions that are appropriate in the current context, (4) directly engage the social determinants of health, and (5) leverage community resources to build collaborative networks and engage community members [42]. Specific recommendations for quality improvement programs based on a review of the research literature [40] include:
• Examining performance data by insurance status, race/ethnicity, language, and SES
• Measuring and improving health-related quality of life, development, and condition-specific targets
• Measuring and improving anticipatory guidance for early prevention of healthrisk behaviors and conditions, as well as promoting positive youth development
• Measuring and improving structural aspects of care that affect health outcomes and can reduce health disparities (e.g., elements of patient-centered medical homes)
• Incorporating families into interventions
• Using multidisciplinary teams with close tracking and follow-up of patients
• Integrating non-healthcare partners into interventions
• Culturally tailoring quality improvement
Providing holistic, culturally responsive, patient-centered care represents a focus of current healthcare delivery, and applying a population health perspective that
L. A. Taliaferro and L. Barkley
considers social determinants of health across levels of adolescents’ social ecologies will help ensure we get closer to reducing the gap and attain health equity for all adolescents [43].
Clinical Challenges
• Clinicians cannot directly modify many of patients’ social, economic, and cultural factors that influence population health indicators.
• Clinicians may experience difficulty applying a population health perspective in the care of individual patients.
Clinical Pearls
• Clinicians should triage for unmet social determinants and make timely referrals to key partners such as social workers, community health workers, and community-based social service organizations.
• Clinicians can acknowledge patients’ limited resources and meet them where they are related to addressing social and environmental resources that promote health.
• Clinicians should approach patients with an open, nonjudgmental attitude that seeks to understand the socio-ecological context to patient’s health choices and behaviors.
Reflection Questions
1. Identify two concepts you learned from this chapter that will help you in your clinical practice.
2. Define two strategies that will integrate these concepts into your care delivery.
3. How do the concepts in this chapter help you readdress the clinical vignette?
References
1. Kindig D, Stoddart G. What is population health? Am J Public Health. 2003;93:380–3.
2. Health Canada. Taking action on population health. Ottawa, Ontario: Health Canada; 1998.
3. Care Continuum Alliance. Implementation and evaluation: a population health guide for primary care models. Washington, DC: Care Continuum Alliance; 2013.
4. Office of Adolescent Health. The changing face of America’s adolescents [Internet]. [cited 2017 Mar 13]. Available from: https://www.hhs.gov/ash/oah/adolescent-health-topics/americas-adolescents/changing-face.html
5. Colby S, Ortman J. Projections of the size and composition of the U.S. population: 2014 to 2060. Washington, DC: U.S. Census Bureau. p. 2014.
6. National Research Council and Institute of Medicine. In: Lawrence RS, Appleton Gootman J, Sim LJ, editors. Adolescent health services: missing opportunities. Washington, DC: The National Academies Press; 2009.
7. Bronfenbrenner U. Ecological systems theory. In: Vasta R, editor. Six theories of child development: revised formulations and current issues. London: Jessica Kingsley Publishers; 1992. p. 187–249.
8. Damon W. What is positive youth development? Ann Am Acad Pol Soc Sci. 2004;591:13–24.
9. Resnick M. Healthy youth development: getting our priorities right. Med J Aust. 2005;183:398–400.
10. Taliaferro L, Borowsky I. Beyond prevention: promoting healthy youth development in primary care. Am J Prev Med. 2012;42:S117–S21.
11. Blum R, Bastos F, Kabiru C, Le L. Adolescent health in the 21st century. Lancet. 2012;379:1567–8.
12. Viner R, Ozer E, Denny S, Marmot M, Resnick M, Fatusi A, et al. Adolescence and the social determinants of health. Lancet. 2012;379:1641–52.
13. Sawyer S, Afifi R, Bearinger L, Blakemore S, Dick B, Ezeh A, et al. Adolescence: a foundation for future health. Lancet. 2012;379:1630–40.
14. Marmot M, Friel S, Bell R, Houweling T, Taylor S. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372:1661–9.
15. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2020 [Internet]. [cited 2017 Apr 10]. Available from: https://www. healthypeople.gov/2020/topics-objectives/topic/Adolescent-Health#49.
16. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2020 [Internet]. [cited 2017 Mar 15]. Available from: https://www. healthypeople.gov/2020/about/foundation-health-measures/Disparities.
17. Dykes D, White A. Culturally competent care pedagogy: what works? Clin Orthop Relat Res. 2011;459:1813–6.
18. Elster A, Jarosik J, VanGeest J, Fleming M. Racial and ethnic disparities in health care for adolescents: a systematic review of the literature. Arch Pediatr Adolesc Med. 2003;157:867–74.
19. Alegria M, Vallas M, Pumariega A. Racial and ethnic disparities in pediatric mental health. Child Adolesc Psychiatr Clin N Am. 2010;19:759–74.
20. Carlson D, McNulty T, Bellair P, Watts S. Neighborhoods and race/ethnic disparities in adolescent sexual risk behavior. J Youth Adolesc. 2014;43:1536–49.
21. Flores G, Lin H. Trends in racial/ethnic disparities in medical and oral health, access to care, and use of services in US children: has anything changed over the years? Int J Equity Health. 2013;12:1–16.
22. Kakade M, Duarte C, Liu X, Fuller C, Drucker E, Hoven C, et al. Adolescent substance use and other illegal behaviors and racial disparities in criminal justice system involvement: findings for a US national survey. Am J Public Health. 2012;102:1307–10.
23. Lau M, Lin H, Flores G. Racial/ethnic disparities in health and health care among U.S. adolescents. Health Serv Res. 2012;47:2031–59.
24. Rossen L, Makram T. Social determinants of disparities in weight among US children and adolescents. Ann Epidemiol. 2014;24:705–13.
25. Price J, McKinney M, Braun R. Social determinants of racial/ethnic health disparities in children and adolescents. Health Educ. 2011;43:2–12.
26. Schreier H, Chen E. Socioeconomic status and the health of youth: a multi-level, multi-domain approach to conceptualizing pathways. Psychol Bull. 2013;139:606–54.
27. Braveman P, Barclay C. Health disparities beginning in childhood: a life-course perspective. Pediatrics. 2009;124:S163–S75.
28. Haas S. Trajectories of functional health: the ‘long arm’ of childhood health and socioeconomic factors. Soc Sci Med. 2008;66:849–61.
29. Haas S, Rohlfsen L. Life course determinants of racial and ethnic disparities in functional health trajectories. Soc Sci Med. 2010;70:240–50.
30. Palloni A, Milesi C, White R, Turner A. Early childhood health, reproduction of economic inequalities and the persistence of health and mortality differentials. Soc Sci Med. 2009;68:1574–82.
31. World Health Organization. Equity [Internet]. [cited 2017 Mar 13]. Available from: http:// www.who.int/healthsystems/topics/equity/en/
32. Marmot M. Achieving health equity: from root causes to fair outcomes. Lancet. 2007;370:1153–63.
33. Flores G. Devising, implementing and evaluating interventions to eliminate health care disparities in minority children. Pediatrics. 2009;124:S214–S23.
34. Flores G, Olson L, Tomany-Korman S. Racial and ethnic disparities in early childhood health and health care. Pediatrics. 2005;115:e183–e93.
35. Alvarado S. Neighborhood disadvantage and obesity across childhood and adolescence: evidence from the NLSY children and young adult cohort (1986–2010). Soc Sci Res. 2016;57:80–98.
36. Singh G, Siahpush M, Kogan M. Neighborhood socioeconomic conditions, built environments, and childhood obesity. Health Aff. 2010;29:503–12.
37. Grier S, Kumanyika S. The context for choice: health implications of targeted food and beverage marketing to African Americans. Am J Public Health. 2008;98:1616–29.
38. Kramer K, Schwarte L, Lafleur M, Williams J. Targeted marketing of junk food to ethnic minority youth: fighting back with legal advocacy and community engagement. In: Williams J, Pasch K, Collins C, editors. Advances in communication research to reduce childhood obesity. New York: Springer; 2012. p. 389–405.
39. Larson N, Eisenberg M, Berge J, Arcan C, Neumark-Sztainer D. Ethnic/racial disparities in adolescents’ home food environments and linkages to dietary intake and weight status. Eat Behav. 2015;16:43–6.
40. Chin M, Alexander-Young M, Burnet D. Health care quality-improvement approaches to reducing child health disparities. Pediatrics. 2009;124:S224–S36.
41. Cheng T, Emmanuel M, Levy D, Jenkins R. Child health disparities: what can clinicians do? Pediatrics. 2015;136:961–8.
42. Lion K, Raphael J. Partnering health disparities research with quality improvement science in pediatrics. Pediatrics. 2015;135:354–61.
43. Zangerie C. Population health: the importance of social determinants. Nurs Manag. 2016;47:17–8.
44. Sowada BJ. A call to be whole: the fundamentals of health care reform. Westport: Greenwood Publishing Group; 2003.
45. Patton G, Sawyer S, Santelli J, et al. Our future: a lancet commission on adolescent health and wellbeing. Lancet. 2016;387:2423–78.
46. Institute of Medicine. Unequal treatment: what healthcare providers need to know about racial and ethnic disparities in health-care. Washington DC: National Academy of Sciences; 2002.
47. The Annie E. Casey Foundation. Race equity and inclusion action guide: 7 steps to advance and embed race equity and inclusion within your organization. Baltimore, MD: Author; 2014. Retrieved from www.aecf.org
L. A. Taliaferro and L. Barkley
Chapter 2 Social Determinants of Health for Racially and Ethnically Diverse Adolescents
April K. Wilhelm and Michele L. Allen
Learning Objectives
At the end of this chapter, the reader will be able to:
• Present the most used frameworks about social determinants of health.
• Discuss the impact on health of the most relevant social determinants of health.
• Understand the role of clinicians in addressing social determinants of health.
A. K. Wilhelm (*)
University of Minnesota, Department of Pediatrics, Division of General Pediatrics and Adolescent Health, Minneapolis, MN, USA
e-mail: awilhelm@umn.edu
M. L. Allen
Department of Family Medicine and Community Health, Program in Health Disparities Research, University of Minnesota, Minneapolis, MN, USA
L. Barkley et al. (eds.), Promoting Health Equity Among Racially and Ethnically Diverse Adolescents, https://doi.org/10.1007/978-3-319-97205-3_2
A. K. Wilhelm and M. L. Allen
Clinical Vignette
L.P. is a 15-year-old female patient established in your practice who has long struggled with poorly controlled asthma. She presents to your office today with her mother for an acute visit due to worsening cough and shortness of breath. You have tried multiple controller medications and have developed several asthma action plans, but L.P. continues to have several asthma exacerbations each year that require hospitalization. She narrowly avoided intubation last year after arriving at the emergency department in an ambulance. Today, L.P. and her mother report that she has been completely out of her controller medications for the past month. As part of your visit, you ask how things are going at home and learn that L.P. and her family are currently living in a basement apartment. On further probing, you discover that the apartment is in a neighborhood near a large freeway intersection and that recent water damage contributed to a mold infestation that the landlord has not yet addressed. L.P. and her family, due to their immigration status, are hesitant to pursue any legal action against the landlord out of fear of retaliation.
Social determinants of health (SDH), defined by the World Health Organization (WHO) as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping” these conditions [1], are increasingly recognized as key factors influencing health that clinicians must address when providing high-quality, comprehensive health care for adolescent patients from racially and ethnically diverse backgrounds. Inequities in opportunities such as education, employment, safe neighborhoods, and physical health-promoting activities for youth from African-American, Native American, Asian, and Latino communities contribute to persistent health disparities [2–7]. By the year 2020, youth from diverse racial and ethnic groups are projected to represent more than half of the nation’s population under 18 years old [8]. These future decision-makers and drivers of our country’s economy represent an important target for initiatives aimed at improving US population-level health. This task requires redefining public health interventions and transforming how clinical services are provided to address social determinants that fall outside the traditional scope of clinical practice. An interdisciplinary approach to patient care that addresses key SDH holds the potential to address the underlying societal causes of health disparities for racially and ethnically diverse adolescents and their families.
Multiple conceptual frameworks describe categories of social factors comprising SDH and how these factors impact individuals and communities [9], including the WHO’s Commission on Social Determinants of Health conceptual framework [10] and the life-course model, which emphasizes the impact of youth’s life stages on adolescent development [11]. For the purposes of this chapter, we will focus on the action-oriented Healthy People 2020 Approach to Social Determinants of Health [12]. This “place-based” framework features five main categories of proximal social and physical determinants of health that are highly relevant for where youth live, work, study, and play in the USA: health and health care, economic stability, neighborhood and built environment, education, and social and community context (Fig. 2.1).
Structural Racism
Implicit and often referred to in the Health People 2020 model [10] is the profound impact of racism and discrimination toward adolescents from racially and ethnically diverse backgrounds. Youth’s everyday experiences with racism permeate each of the five categories of SDH. For instance, the longstanding history of institutionalized racism and historical trauma in the USA has contributed to tremendous inequities in the SDH that continue to negatively affect the health of many groups, largely along racial and ethnic lines [13–15]. As a result of historical and current discriminatory policies and practices in employment and the real estate and credit markets, youth of color disproportionately grow up in segregated and impoverished communities [16–19] compared to their white peers. Additionally, racial and ethnic minority youth and young adults in the USA routinely encounter interpersonal racism in the form of microaggressions [20, 21], which have been associated with increased risk of suicidal ideation in African-American young adults [22] and increased depressive symptoms among Latino and Asian-American adolescents [21].
Health and Health Care
Inequities in access to consistent high-quality medical and dental health care persist for many racial and ethnic minority youth [23–25]. Alternative care delivery models for primary care services such as home visits, school-based health
Neighborhood and built environment
Health and health care Economic stability
Education
Social and community context
SDOH
Fig. 2.1 The Healthy People 2020 figure (public domain)
A. K. Wilhelm and M. L. Allen
clinics, and adolescent-friendly clinical settings may be one way to bridge healthcare gaps among these populations [26–28]. Beyond access, the quality of clinical care provided may differ by race and ethnicity, as evidenced by studies demonstrating lower receipt of appropriate pain medications for black children presenting to emergency departments [29, 30]. Implicit racial biases toward blacks have been demonstrated among resident physicians [31] and have been correlated with pain medication prescribing patterns for African-American children [32]. These practices, whether implicit or not, directly conflict with the Hippocratic Oath pledged by clinicians when entering the profession and represent a serious issue that must be addressed across the health-care workforce. However, though consistent and equitable health care is important to promote well-being, inequities in health care explain only a portion of the differences in health outcomes observed along socioeconomic and racial/ethnic lines [33, 34].
Economic Stability
Foremost among these broader SDH are factors that contribute to economic stability, including poverty, parental unemployment, and food and housing insecurity. Childhood poverty, which disproportionately affects youth from racial and ethnic minority backgrounds, has been linked to poor health outcomes such as childhood obesity [35], mental illness [36], and increased allostatic load that may predispose youth to chronic diseases in later life [37]. More specifically, differences in housing quality and other material hardship among black and Hispanic youth [38] have been linked to observed racial disparities in asthma morbidity [39, 40] and increased mental health symptoms [41], while food insecurity limits access to adequate amounts and quality of healthy foods, increasing the risk of obesity [42]. The exact pathway by which poverty mediates health outcomes is not fully defined but includes differential access to resources and life opportunities such as education [43], erosion of social capital and cohesion [33, 44, 45], and increased psychological stress [46]. Another important consideration is how income inequality, or a family’s income relative to others in the broader community, impacts the health of young people [47]. In a developed country like the USA, large-scale material deprivation is relatively low, yet many pockets of significant poverty persist, exemplifying a type of relative income inequality linked to disparities in health outcomes and life expectancy even after adjustment for health-care access [44].
Neighborhood Environments
Compounding the impacts of the material hardship of poverty, low-income individuals are more likely to live in neighborhood environments that lack the infrastructure to support them in leading a healthy life [48]. This concept of “concentrated deprivation” in neighborhoods [49] is defined by the reduced availability of community resources such as local parks and green space [50] and limited access to
healthy food options close to home [51], as well as higher levels of exposure to crime, violence [52], and pollutants [53]. Residence in neighborhoods such as these, where racial and ethnic minority groups often build their homes, strongly predicts negative health outcomes [54]. The high levels of exposure to violence that many youth of color experience [52] in their neighborhoods promote fear, reduce opportunities for outdoor physical activity [55, 56], increase stress, and may have longterm individual-level health effects mediated by physiological epigenetic changes [57–59]. Additionally, youth from these groups are at disproportionate risk of living near both major highways or interstates [53, 60] and fast-food restaurants and convenience stores within food deserts [51, 61], phenomena that likely contribute to observed disparities in asthma rates [62] and childhood obesity [42, 63].
Education
A young person’s neighborhood and overall economic position also directly influences their educational opportunities [17, 64], which represent one of the most influential factors in shaping future income and health outcomes [65]. Lifetime educational attainment is protective against youth health risk behaviors [66, 67] and has an outsized effect on long-term health outcomes [68] and mortality compared to other common prevention targets like smoking cessation and blood pressure control [69]. However, schools with predominantly racial and ethnic minority student populations struggle to maintain a workforce of highly qualified teachers [70] and adequate financial resources [71] to meet students’ educational needs. These phenomena correlate with the increasing concentration of poverty and persistent segregation of neighborhoods and schools among communities of color [72]. In this context, racial and ethnic minority American youth are less likely to graduate from high school [73] and to enroll in higher education compared with their white peers [74]. Immigrant youth often face the additional hurdle of learning to speak and read in the English language [75] within school systems where teachers lack adequate preparation and resources to meet their increasingly diverse student body’s needs [76–78]. Disparities in these youth’s school experiences, including lower rates of connectedness to their teachers and schools compared with white youth [79, 80], also contribute to the persistent achievement gap. Furthermore, striking differences in school disciplinary practices and policies exist in US school systems, disproportionately affecting racial and ethnic minority youth and contributing to the school-to-prison pipeline [81]; lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth of color may be particularly targeted by school disciplinary actions [82].
Social and Community Context
A strong sense of connectedness to family, school, and community is associated with adolescent well-being [83]. Families play a key supportive role for youth [84]. Parent-child connectedness is associated with lower rates of suicidal ideation [85]
A. K. Wilhelm and M. L. Allen
and reduced health risk behaviors in adolescents [86]; however, parenting practices such as over-monitoring that stem from experiences of vicarious trauma and internalized racism may offset some of these benefits [87]. In the larger social and community context, youth connectedness is both shaped by the other SDH categories and influences the impact these SDHs have on health outcomes. Studies in adults have demonstrated that communities with higher levels of social cohesion, or a strong sense of belonging and trust, experience lower lifetime levels of chronic disease [88, 89]. Neighborhoods with higher collective efficacy reflecting a community’s connectedness and shared expectations [90] may also protect against depression and anxiety symptoms in adolescents [91] and promote overall general health in children [92].
However, the places where youth from racial and ethnic minority backgrounds live do not always reflect this ideal. Poverty, experiences of racism, high rates of housing turnover, and other related forces have undermined the social cohesion and connectedness of many communities, reducing their capacity to promote youth well-being [90]. Longstanding policies of institutional racism, for example, as manifested by residential segregation and redlining (i.e., a practice whereby institutions refuse or limit access to home loans, mortgages, or other financial capital among individuals within certain geographic, often inner-city, areas), have contributed to the concentration of poverty and limited resources in communities of color [15, 16]. Parental incarceration, a phenomenon that disproportionately affects youth of color [93], is also linked to higher levels of behavioral issues in childhood [94] and increased risk of physical and mental health issues in young adults [95]. In this context, a community’s assets are often weakened by these and other disruptive forces [90], adding further complexity to this already “wicked problem” [96].
A Role for Clinicians in Addressing SDH
Several physician specialty groups have initiatives highlighting the importance of addressing SDH within a clinical context in recent years, including the American Academy of Pediatrics [97] and the American Academy of Family Physicians [98]. However, impacting youth and their family’s social determinants in a meaningful way will likely require thinking outside the typical clinic visit to integrate lifecourse-specific care across disciplines [99] and build the context of strong partnerships with other social service sectors who are well-equipped to attend to these needs [99, 100]. Health-care providers can play a key role in beginning to build practice and care models that target SDH in their own clinical spaces. To accomplish this, though, we must raise provider awareness of the fundamental ways in which the SDHs impact health outcomes among their patients through reforms in health professional training and continuing education programs.
A first step for providers to address SDH in clinical settings is identifying adolescent patient and family experiences and needs. Tested solutions include systematic screening during clinic visits [101–104] and presentation of integrated data
from geographic, public health, and clinical sources to providers at the appropriate time [101, 105]. For example, questions about food security, housing overcrowding and instability, and perceived safety in the community [106] could be incorporated into an adolescent HEADDS assessment [107] or completed by a parent in the waiting room during a well-child visit [104]. Systematic approaches for assessing SDH in both adult [102] and pediatric [103] primary care settings have been associated with increased referrals for social and psychological needs and increased receipt of community-based resources. Protocolized tools such as preformatted letters to utility services may help providers increase their capacity to address SDH during clinic visits [108]. Other promising methods include geographic information systems (GIS) data, which links geographic, social determinant, public health, and clinical data to highlight population patterns and aid in developing targeted interventions [105]. GIS models have been used in health disparities research to investigate complex problems such as asthma disparities in urban areas [109, 110] and to evaluate other metrics of neighborhood resources such as access to green space [50] and prevalence of food deserts [51, 111], information that can be used to advocate for program and policy interventions to reduce the prevalence of adolescent obesity and asthma in a community. Increasingly GIS data is emerging as a clinical tool that, when integrated with the electronic health record, can provide contextualized information about a patient’s neighborhood (e.g., prevalence of incarceration, proximity to a community center or park, and distance to a supermarket) that can ultimately be used to design interventions that meet the needs of individual patients or the community [112, 113] in ways that are also likely relevant for adolescents. Ultimately, adopting a systematic SDH screening and tracking approach such as questionnaires completed during well visits that flag action items for the provider [103], or implementing an electronic health record that utilizes pop-up messages or care management checklists that incorporate SDH checklists to prompt action [101], will help providers and clinics to consistently and efficiently discuss these issues with patients and to identify and address their needs.
Cross-sectoral, highly integrated services, ranging from colocation of multiple service providers to partnerships with social services and larger community initiatives, are key to effectively addressing identified community and individual SDH needs at multiple levels within a primary care context [104]. Colocation of providers such as mental health therapists, social workers, and dentists [99, 100, 108] as well as services such as Women, Infants, and Children (WIC) programs and pharmacies, often in the context of a medical home, breaks down professional silos and facilitates patient access to needed services [114]. Medical-legal partnerships also exemplify how collaboration augments a clinic’s capacity to address SDHs such as housing issues, access to public benefits, and issues related to incarceration [26, 115]. Increasingly, though, moving outside the walls of the clinic through collaborative community interventions has emerged as another tool for clinicians to focus more on upstream social determinants. The San Diego Healthy Weight Collaborative, a partnership between public elementary schools, a primary care residency training program, and community organizations, is one example that demonstrates the potential of such collaborations to impact SDHs at a population level [116]. The
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