Targeting Health Disparities: A Model Linking Upstream Determinants To Downstream Interventions

Abstract

Certain social/environmental factors put some groups at extraordinary risk for adverse health outcomes, creating health disparities. We present a downward causal model, originating at the population level and ending at disease, with psychological and behavioral responses linking the two. This approach identifies how specific social environments "get under the skin" to cause disease, illustrated with the disparity in mortality from aggressive premenopausal breast cancer suffered by black women. Broadening our lens to consider the entire chain of causal factors, spanning multiple levels and interacting across the life span, heightens our ability to craft specific interventions to address group differences in health. [Health Affairs 27, no. 2 (2008): 339-349; 10.1377/hlthaff.27.2.339] H e a lt h d i s pa r i t i e s o c c u r by r ac e , ethnicity, sex, socioeconomic status, and sexual orientation, with inequities in screening, incidence, treatment, and mortality across a number of diseases and conditions, including cancer, diabetes, cardiovascular disease, infant mortality, and HIV/AIDS. A black/white gap in mortality from common cancer sites has been noted since 1975, for instance, when cancer data were first collected systematically by race and ethnicity. In 1975, black women experienced 39.2 more deaths per 100,000 population from breast cancer than white women. By 2004, that gap had increased to 44.1 excess deaths per 100,000. During the same time period, breast cancer mortality rates among white women decreased from 31.8 to 23.8 per 100,000. Mortality rates

Characteristics of Mammography Facility Locations and Stage of Breast Cancer at Diagnosis in Chicago

“…Ongoing research has begun to elucidate biochemical mechanisms underlying an association between stress and cancer progression. [49][50][51] Contrary to our findings on homicide, we found no relationship between stage at diagnosis and the number of robberies, aggravated assaults, or sexual assaults. There are several potential explanations, methodological and theoretical, for these seemingly contradictory results.…”

Grand Challenges for Social Work

“…Community-based prevention strategies, developed principally by social work prevention scientists, offer some of our most promising vehicles for successfully meeting this national priority (Hawkins, Kosterman, Catalano, Hill, & Abbott, 2005). Likewise, creating an affordable, high-quality health care system accessible to all will require combating the "upstream" social determinants of health that produce inequity (Gehlert et al, 2008), instituting effective community-based health and behavioral health promotion strategies, and creating culturally and locally tailored care-coordination practices (Andrews, Darnell, McBride, & Gehlert, 2013)-all strong focal points of the profession. The sustainability of the nation's health care reform and the nation's health may rest as much on the shoulders of social workers as in the hands of primary care doctors.…”

Relationship Between Operational Characteristics of Small Non-Community Drinking Water Systems and Adverse Water Quality Incidents in Southern Ontario, Canada

“…According to Murphy et al (2015), both owners and operators should receive water system training so that they can have a better understanding of the challenges for the provision of safe drinking water. Upstream determinants are fundamental parts of the social environment where individual differences in expression of feelings, thoughts and activities are shaped (Gehlert et al, 2008). The focus on operator training can be a viable intervention to address upstream behavioral determinants.…”

“…The operator training in SDWSs can be considered an upstream behavioural determinant (Gehlert et al, 2008;Williams et al, 2008) within the context of environmental and societal factors. Dreibelbis et al (2013) argue that behaviour change underpins enhanced water safety practices at individual, community and structural levels.…”