NCHHSTP White Paper on Social Determinants of Health, 2010 - CDC

Establishing a Holistic Framework to Reduce Inequities in HIV, Viral Hepatitis, STDs, and Tuberculosis in the United States An NCHHSTP White Paper on Social Determinants of Health, 2010

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Suggested Citation: Centers for Disease Control and Prevention. Establishing a Holistic Framework to Reduce Inequities in HIV, Viral Hepatitis, STDs, and Tuberculosis in the United States. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; October 2010. The report is available at: www.cdc.gov/socialdeterminants

TABLE OF CONTENTS Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

A Systematic Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Social Determinants of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Vision for Change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Rationale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Theoretical Framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Applying the Framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

NCHHSTP Efforts to Address SDH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2011–2015 Priority Actions for Addressing SDH and HIV, Viral Hepatitis, STDs and TB Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Research and Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Health Communication and Marketing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Health Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Prevention Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Capacity Building. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Partnership Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Tracking Our Progress. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Activities for Partners to Consider. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Research and Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Capacity Building. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Summary.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 References.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Glossary Health disparity is a particular type of health difference that is closely linked with social or economic disadvantage. Health equity is the absence of systematic, unfair disparities in health (or determinants of health) among population groups in a social hierarchy or with different levels of social advantage or disadvantage. Health equity (U.S. Department of Health and Human Services [DHHS] definition) is attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities. Heath inequity is a difference or disparity in health outcomes that is systematic, unfair, and about which you can do something. Individual-level risk factors are characteristics of individuals that may explain health status or behavior (e.g., age, sex, marital status). Social determinants of health (SDH) are the complex, integrated, and overlapping social structures and economic systems that include the social environment, physical environment, and health services; structural and societal factors that are responsible for most health inequities. SDH are shaped by the distribution of money, power and resources at global, national, and local levels, which are themselves influenced by policy choices. Sources: U.S. Department of Health and Human Services. Healthy People 2020 Draft. 2009, U.S. Government Printing Office. Available at: http://www.healthypeople.gov/hp2020/advisory/PhaseI/glossary.htm Braveman, P. and S. Gruskin. Defining equity in health. Journal of Epidemiology and Community Health, 2003. 57(4): p. 254-258. World Health Organization. Closing the gap in a generation: Health equity through action on the social determinants of health. Report from the Commission on Social Determinants of Health. 2008. http://www.who.int/social_determinants/thecommission/finalreport/en/index.html

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EXECUTIVE SUMMARY In the United States, we have made great strides in reducing the incidence and improving the health outcomes of persons infected with the human immunodeficiency virus (HIV), viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB).1,2 Our success is a result of advances in surveillance; medical research; and prevention, diagnosis, and treatment. Nevertheless, today there are groups that carry a severe and disproportionate burden of our focus diseases. To address this imbalance, we must complement individuallevel interventions, intended to influence knowledge, attitudes, and behaviors, with new approaches that address the interpersonal, network, community, and societal influences of disease transmission and health.3 Evidence suggests that programs that comprehensively address health where we live, work, learn, and play can have greater impact on health outcomes at the population level than programs utilizing interventions aimed solely at individual behavior change.4,5 Social and personal differences should not hinder the opportunity for each of us to make healthy choices. As health begins at home, and is influenced by where we live, the jobs we hold, our knowledge of risk, and our support systems, it is critically important that our public health programs acknowledge and address these broader realities and contexts. This white paper outlines the strategic vision of the Centers for Disease Control and Prevention’s (CDC’s) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) for reducing health disparities and promoting health equity related to our conditions of interest. The purpose of the white paper is to advance a holistic approach to the design of our public health programs to advance the health of communities and increase their opportunities for healthy living. NCHHSTP is committed to promoting awareness, engagement, and action on the many factors that can affect the health of all of us; to addressing these factors in the policy, practice, and research activities of NCHHSTP; and to building partnerships on every level. This white paper extends and builds on the concepts found in the NCHHSTP social determinants of health (SDH) green paper and incorporates recommendations from the 2008 consultation on SDH.2,6 The term social determinants of health refers to the complex, integrated, and overlapping social structures and economic systems that include social and physical environments and health services. These determinants are shaped by the level of income, power, and resources at global, national, and local levels. They are also often influenced not only through personal choices, but through policy choices as well.5 NCHHSTP has adopted the conceptual framework of the World Health Organization’s Commission on Social Determinants of Health.5 This framework helps us to better analyze and understand the drivers of health and health inequities in the United States, determine priorities, and target and refocus our intervention efforts. This white paper outlines planned NCHHSTP activities and commitments for 2011–2015 to reduce health disparities related to HIV, viral hepatitis, STD, and TB infections, and promote health equity by addressing the SDH. Six focus areas are identified for priority actions: research and surveillance, communication, policy, programs, capacity building, and partnerships. NCHHSTP will monitor progress in these six areas with the intent of developing a more balanced portfolio that addresses the whole of health, i.e., all factors that can affect the health of a person, group, or community, and reduces health

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We must complement individual-level interventions with new approaches that address the interpersonal, network, community, and societal influences of health.

The white paper aims to advance a holistic approach to the design of our public health programs.

Social determinants of health refers to the complex, integrated, and overlapping social structures and economic systems that include social and physical environments and health services.

inequities, with the goal of accelerating reductions in disease incidence and reducing health disparities. Routine monitoring and a continuous feedback loop with our partners (including grantees) will allow us to assess progress and to identify processes and practices that are particularly effective in reducing disease transmission, improving health outcomes, and providing opportunities for better health for all. NCHHSTP encourages our partners, grantees, and other relevant stakeholders to join us in this journey to identify the best and most promising options, choices, and resources to ensure that our efforts are placed within a context of promoting good health in every community. This will require concerted, sustained, and coordinated action from many partners: it cannot be achieved by any agency acting alone. We ask our partners to serve as champions; to initiate conversations about the social and structural drivers of our epidemics and how to address them; to build local capacity through innovative strategic collaboration; and to incorporate a holistic view of health that begins in each community and with each individual.

We ask our partners to serve as champions of a social determinants approach.

Tuberculosis Treatment in the U.S. Homeless Population Hospitalization for tuberculosis is most common for persons who are homeless and have HIV infection or no insurance. Lack of access to early medical care coupled with other conditions (e.g., substance abuse) contributes to TB hospitalization. Establishing and utilizing special treatment-housing centers to provide homeless persons with TB with continuous shelter and food during treatment saves hospitalization costs. CDC and partners have recommended these treatment-housing centers since 1992. These centers show similar or even higher TB treatment completion rates as hospitalization.

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INTRODUCTION Background Some population groups continue to be disproportionately affected by human immunodeficiency virus (HIV), viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB): the rate of chlamydial infection is disproportionately higher among females compared to the rate among males; HIV disproportionately affects men who have sex with men (MSM); syphilis rates are higher in males (especially MSM) than females; gonorrhea rates among females have been slightly higher than rates among males (except for blacks whose rates are higher in males); TB is more prevalent among foreign-born persons, U.S.-born blacks, American Indians, and U.S.-born homeless individuals; the rate of hepatitis B remains highest among blacks and males (especially MSM); and Asian American and Pacific Islanders comprise half of individuals living with chronic hepatitis B in the United States.7 Such disparities are unfair, pose a significant cost to society in terms of health care needs and lost productivity, and are avoidable.8 They are also counter to health as a human right.9 So why are these disparities getting worse?10-16

Disparities are unfair, pose a significant cost to society and are avoidable.

Social determinants, which are complex, integrated, and overlapping social structures and economic systems,17-21 are linked to lack of opportunity and to a lack of resources to protect, improve, and maintain health.22-24 Structural and societal factors such as social and physical environments, and availability, cost of, and access to health services, create pathways or barriers to good health. These factors are affected by the distribution of power and resources, all of which can be addressed through policy. For example, studies have shown that HIV-infected persons with low literacy levels had less general knowledge of their disease and disease management and were more likely to be non-adherent to treatment than those with higher literacy.25,26 Studies also show that black MSM at lower income levels are more likely to engage in sexual behaviors that put them at greater risk for acquiring STDs, compared to black MSM with higher income levels.27,28 Another study found that heterosexual men and women in 23 major U.S. cities living below the poverty line were twice as likely to have HIV infection (2.4%) as those living above it (1.2%), and other social determinants of health (SDH)—including homelessness, unemployment, and low education level—were independently associated with HIV infection.29Another study shows that although the burden of hepatitis C infection is greater among some racial and ethnic groups, mortality is highly correlated to the individual’s socioeconomic condition.30 In addition, income was shown to be an important predictor of a lack of health insurance among persons with HIV and, consequently, may be a reason why they are less likely to receive treatment.31 Environmental factors, such as housing conditions, social networks, and social support are also key drivers for infection with HIV, viral hepatitis, STDs, and TB. For example, a study among housed and homeless persons with HIV infection found that homeless persons had poorer health status, were less adherent to medication regimens, were more likely to be uninsured, and were more likely to have been hospitalized.32, 33 Social networks also play a role in fueling the spread of HIV infection and other STDs and have been shown to negatively influence adherence to TB drug therapy.34-38 Similarities in living conditions are often found among groups with disproportionately high levels of disease.

Environmental factors, such as housing conditions, social networks, and social support are also key drivers for infection with HIV, viral hepatitis, STDs, and TB.

Many of the current approaches to prevention and disease control are focused on individual behavioral risk factors. It is urgent, that these be supplemented to address underlying

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We need to go beyond controlling disease on the individual level to addressing social determinants of health.

factors, such as poverty, unequal access to health care, incarceration, lack of education, stigma, homophobia, sexism, and racism. We need to go beyond controlling disease on the individual level and address other contributors to disease, including the social and environmental determinants of health.39, 40 The DHHS Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 recommends using a health in all policies approach to address social determinants of population health.39, 41 Health in all policies is a comprehensive approach where all parts of government work toward common goals to achieve improved health for all and reduce health inequities. Toward this aim, in 2008, the World Health Organization’s (WHO’s) Commission on Social Determinants of Health called on all governments to address SDH by taking the following steps: “improve the conditions of daily life;” “tackle the inequitable distribution of power, money, and resources;” and “measure and understand the problem and assess the impact of action.”5 CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has adopted the WHO framework on SDH to serve as a guide for its activities.

Health in all policies is a comprehensive approach where diverse government agencies work toward common goals to achieve improved health for all.

The recently released United States National HIV/AIDS Strategy (NHAS)42 has identified “Reducing HIV-Related Disparities and Health Inequities” as one of its three main overarching goals. The strategy acknowledges that disparities in HIV prevention and care persist among racial/ethnic minorities, as well as among sexual minorities. While working to improve access to prevention and care services for all Americans, the NHAS calls for the following steps to help reduce inequities across groups: reduce HIV-related mortality in communities at high risk for HIV infection; adopt community-level approaches to reduce HIV infection in high-risk communities; and reduce stigma and discrimination against people living with HIV.

Addressing Poverty and HIV/AIDS among Young Low-income African American Women Poverty can increase risk behaviors for HIV and sexually transmitted infections (STI) acquisition. To address this social determinant of health, CDC and others conducted a study to identify components of a microenterprise intervention (i.e., a small, often unregistered, business with very few [