in San Joaquin Valley Challenges and Opportunities John A Capitman State of the Valley Health Forum Hospital Council of Northern and Central California Saint Agnes Medical Center Fresno ID: 560823
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Understanding Health Equity in San Joaquin Valley:Challenges and OpportunitiesJohn A. CapitmanState of the Valley Health ForumHospital Council of Northern and Central California Saint Agnes Medical Center, FresnoJuly 14, 2016Slide2
This Work was Supported By2Slide3
OverviewSan Joaquin Valley Health Inequities: Recent FindingsAddressing Birth Outcome Disparities in FresnoCurrent Policy Discussions Addressing Health Equity3Slide4
Mortality and Place4Place Matters Report of the San Joaquin ValleyHigher poverty, premature mortality and hospital use than State.The premature death rate in the poorest zip codes is nearly double the rate in the most affluent.Premature mortality is highest in zip codes with higher % Latinos and higher povertySimilar findings for life expectancy. 21 years differences between zip codes.
Years of Potential Life Lost Before 65Slide5
Mortality and Race/Ethnicity5Slide6
SJV Health InequitiesThe San Joaquin Valley overall has higher levels of premature mortality, self-reported morbidity, and ED/inpatient use than California.While Whites in the most affluent neighborhoods have health and health care experiences similar to rest of state, people of color and poor neighborhood residents’ experiences are notably worse.The individual and neighborhood factors associated with unequal health differ across outcomes and the life course.6Slide7
Social Determinants of Health (SDOH)7Place, Economic and Social History. Individual and Structural Racism, Classism
Current & Cumulative Exposure to Living Conditions
, Resource
Access
, and Civic
Voice
I
nequities
Health
Inequities
by
Class
,
Race
/
Ethnicity
,
Gender
and
Age
Overall
Lower
S
urvival
and
Health
Individual H
ealth
B
ehavior and Service UseSlide8
Life Course Perspective and SDOH: Varied Person*Setting Impacts8PlaceLiving Conditions
Health Inequities
Respiratory Health
Individual
Behavior
Place
Living Conditions
Health Inequities
Birth Outcome
Individual
Behavior
Place
Living Conditions
Health Inequities
Longevity
Individual
Behavior
Children
Young Women
Elders
Population
Determinants of Health
Health OutcomeSlide9
Life Course Outcomes Shaped by Distinct Social Determinants9Slide10
Geographic Distribution: Health Outcomes10
No Indictors
ACSC Hospitalizations
Years of Life Lost
Premature Birth
1
At least two
indicators present
FRESNO
TULARE
KINGS
MADERA
LEGEND: Health Outcomes in Selected SJV Counties by Zip Code
1
Premature birth at census tract level. Health outcomes are predicted mean values after controlling
for individual- and community-level variables.
Geographic Distribution of Top Quintile of ACSC Hospitalizations, Years of Life Lost,
and Premature BirthSlide11
Premature BirthPremature birth < 37 gestational weeksCriteria for inclusion in analysisMother aged 15 - 40 who reside in the San Joaquin ValleyBirth between 2009 - 2013Health Outcome: Premature Birth11Slide12
SDOH: Premature BirthCommunity-level IndicatorsSig.Individual-level IndicatorsSig.
Non-Modifiable
Economic Opportunity
white
Ref
Particulate
Matter 2.5
African American
Latino
-
Housing
-
Asian/Pacific Islander
Civic
Life Opportunity
-
Other Race/Ethnicity
Education
-
Private
Insurance
Ref
Medi
-Cal
Other Insurance
Modifiable
Mother with 4-year
Degree
Smoke
Hypertension
WIC Services
Previous
Premature Birth
Inter-pregnancy
Period <33 M
12Slide13
Fresno County Pre Term Birth Collective Impact InitiativeThe Gates/Benioff/UCSF Pre Term Birth Initiative selected Fresno County as 1/3 Collective Impact Initiatives.A Fresno PTBi Steering Committee was formed in 2015 with diverse organizational and community leaders as well as women with lived experience of preterm birth, and a draft common agenda was developed with over 150 stakeholders.Fresno State became the Backbone Organization for the initiative in 2016.Sandra Flores just joined as Director this week.13Slide14
Focus areas and cross-cutting strategies14Deliver services and resources to women in their communities and neighborhoods to improve birth outcomes, address stress, and improve social and emotional support during pregnancy.Improve the coordination and integration of physical and behavioral healthcare, social services, and other support for women before, during, and after pregnancy Care and Support for Pregnant Women
Coordination of Care
for Women
Focus areas:
Cross-cutting strategies:
Changing policy
Providing
care and services informed by a strong understanding of and
responsive
to the customs and practices of different cultures
Delivering
services in the
community
Improving
education and economic life options for women
and men
(in collaboration with other initiatives focused on education/economic development)
Addressing the natural and built environment’s impact on women’s health
Deliver
primary, behavioral, reproductive health services, and health education
t
o
empower
girls, boys, women,
and men to
be
healthy before having
children
.
Health & Education
before Pregnancy
Improving quality of careSlide15
Race/Ethnicity and Infant Mortality in Fresno 15Slide16
Geographic Disparities in Infant Mortality in Fresno 16Slide17
First Five Fresno County:African American Infant Mortality InitiativeCommunity Recommendations For ActionForm a blue ribbon panel of health care, education and community leaders to improve the cultural appropriateness of health care for African American women and families. Pilot a Centering Pregnancy program for African American women to encourage social support, coordination of services and dissemination of accurate, timely health information prior to and following pregnancy. 17Slide18
Current Policy Discussions Addressing Health EquityVoter participation in under-resourced neighborhoods; creating opportunities to recognize shared fate across neighborhoodsHealth for All and similar initiatives to provide insurance coverage to undocumented and othersPromoting development of community perinatal wellness programs/integration of physical/behavioral health and human services.Air Quality, industrial policy, zoning and financing community revitalization and sustainable transportation18Slide19
1) SJV Institutional Context2)Conceptual Frameworks for Understanding Health InequalityAdditional Slides for Discussion19Slide20
SJV Institutional ContextHistorical Perspective:Valley communities have been segregated by R/E and social class since their earliest years.Iconic labor and environmental strugglesLocal governments consistently rejected housing, health, and educational investments in low income communities.Uneven voter registration and low participationLocal Health Department capacities20Slide21
Redlining in the SJVUrban Renewal Program and the Housing Act of 1949Fresno used Urban Renewal in 1950s to build Highway 99 isolating West Fresno, a historic immigrant neighborhoodLack of private sector investmentBanks refused loans to members of the “red” or “yellow” communityWith less investment and fewer middle class residents, urban areas and historic urban fringe settlements continued to decline as crime rates soared and school quality plummeted21
Source:
Abood
, M. (2014).
San Joaquin Valley Fair Housing and Equity Assessment.
Smart Valley Places.Slide22
SJV Health Department Revenue22Slide23
SJV Public Health Department Self-Assessment23Slide24
Conceptual Framework: Racism/Systemic Oppression as Root CauseRacial/ethnic, gender, and other health and well-being disparities are viewed as health inequities caused by racism/systemic oppressionNot attributable to genetics, behaviors or culturesAssociated with historical and current policies and practices that create and sustain inadequate living conditions, stymied life opportunities, structural inequalities, and discriminatory micro-aggressions24Source: National Collaborative for Health Equity, Community Strategies to End Racism and Support Racial Healing: The Place Matters Approach to Promoting Racial Equity, 2015Slide25
25Conceptual Framework: Racism/Systemic Oppression as Root CauseSource: National Collaborative for Health Equity, Community Strategies to End Racism and Support Racial Healing: The Place Matters Approach to Promoting Racial Equity, 2015Slide26
Adverse Birth Outcome Inequalities and Place: Modern Racism Examples26Expression of Modern RacismPersonal and Interpersonal Level Examples from White Community Meeting ParticipantsSystemic and Cultural Level Examples of Policies and Practices
Dysfunctional Rescue
“I
would never want to say to an African American woman that her risks are higher because of racism”
Programming for African
American fathers focused on “parenting skills” only. No education or employment help.
Blaming the Victim
“Higher
infant mortality for African American is due to risk behaviors.”
Termination of employment because mother misses work to go to NICU.
Avoidance
of contact
“Sorry
I missed the meeting. I just don’t know how to get around in that part of town”
Locating
health care in white community.
New public housing only in low-income neighborhoods
Denial
of Difference
“Women feels stress
during pregnancy but that doesn’t have anything to do with race”
Shifting funding for
public health to high risk pregnancies and away from Black Infant Health program.
Denial
of the significance of difference
“We are in a post-racial
society. Why don’t these people move?”
New
green space and rec’ programming funded by neighborhood tax levy.