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1.
Milbank Q ; 102(2): 351-366, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38363858

RESUMO

Policy Points The structural determinants of health are 1) the written and unwritten rules that create, maintain, or eliminate durable and hierarchical patterns of advantage among socially constructed groups in the conditions that affect health, and 2) the manifestation of power relations in that people and groups with more power based on current social structures work-implicitly and explicitly-to maintain their advantage by reinforcing or modifying these rules. This theoretically grounded definition of structural determinants can support a shared analysis of the root causes of health inequities and an embrace of public health's role in shifting power relations and engaging politically, especially in its policy work. Shifting the balance of power relations between socially constructed groups differentiates interventions in the structural determinants of health from those in the social determinants of health.


Assuntos
Política , Determinantes Sociais da Saúde , Humanos , Política de Saúde , Saúde Pública , Poder Psicológico , Disparidades nos Níveis de Saúde , Estados Unidos
2.
Milbank Q ; 102(2): 503-516, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38240319

RESUMO

Policy Points White evangelical theology has an "antistructural" component. Counties with a high percentage of White evangelicals have higher mortality rates and more persons with fair/poor health. The potential influence of antistructural components in evangelical theology on decision making and resource allocation and, ultimately, the length and quality of life of community members presents a point of intervention for religious leaders and policymakers to improve population health. CONTEXT: Structural factors are important determinants of health. Because antistructuralism has been identified as a tenet of White evangelical theology, we explored if there is an association of the percentage of White evangelicals in a US county with two county health outcomes: premature mortality and percentage of fair/poor health. METHODS: Regression analysis was performed with data from 2022 County Health Rankings and the American Value Atlas from the Public Religion Research Institute. FINDINGS: Every percent of evangelicals in a county is associated with 4.01 more premature deaths per 100,000 population and 0.13% fair/poor health. After controlling for income, education, political ideology, and county school funding adequacy (a proxy for antistructuralism), the associations remain positive and significant. CONCLUSIONS: We hope these findings could inform dialogue and critical analysis among individuals of evangelical faith, particularly fundamental and Pentecostal subsets, regarding a belief system that is inclusive of individual dimensions and health-promoting structural policies like school funding, Medicaid expansion, and antipoverty programs. These findings also demonstrate the importance of considering cultural factors like religion and political ideology in population health outcomes research.


Assuntos
Política , Humanos , Estados Unidos , Disparidades nos Níveis de Saúde , Brancos
3.
Am J Public Health ; 113(10): 1106-1109, 2023 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-37672738
4.
Prev Chronic Dis ; 20: E23, 2023 04 06.
Artigo em Inglês | MEDLINE | ID: mdl-37023356

RESUMO

We describe updates to the University of Wisconsin Population Health Institute's methodology for a state health report card, first described in Preventing Chronic Disease in 2010, and the considerations that were weighed in making those updates. These methods have been used since 2006 to issue a periodic report entitled Health of Wisconsin Report Card. The report highlights Wisconsin's standing among other states and serves as an example for others seeking to measure and improve their population's health. For 2021, we revisited our approach with an increased emphasis on disparities and health equity, which required many choices about data, analysis, and reporting methods. In this article, we outline the decisions, rationale, and implications of several choices we made in assessing Wisconsin's health by answering several questions, among them: Who is the intended audience and which measures of length (eg, mortality rate, years of potential life lost) and quality of life (eg, self-reported health, quality-adjusted life years) are most relevant to them? Which subgroups should we report disparities about, and which metric is most easily understood? Should disparities be summarized with overall health or reported separately? Although these decisions are applicable to 1 state, the rationale for our choices could be applied to other states, communities, and nations. Consideration of the purpose, audience, and context for health and equity policy making is important in developing report cards and other tools that can improve the health of all people and places.


Assuntos
Equidade em Saúde , Qualidade de Vida , Humanos , Wisconsin/epidemiologia
5.
BMC Public Health ; 21(1): 1117, 2021 06 10.
Artigo em Inglês | MEDLINE | ID: mdl-34112114

RESUMO

BACKGROUND: Understanding current levels, as well as past and future trends, of the percentage of infants born at low birthweight (LBW) in the United States is imperative to improving the health of our nation. The purpose of this study, therefore, was to examine recent trends in percentage of LBW, both overall and by maternal race and education subgroups. Studying disparities in percentage of LBW by these subgroups can help to further understand the health needs of the population and can inform policies that can close race and class disparities in poor birth outcomes. METHODS: Trends of percentage of LBW in the U.S. from 2003 to 2018, both overall and by race/ethnicity, and from 2007 to 2018 by education and race by education subgroups were analyzed using CDC WONDER Natality data. Disparities were analyzed using between group variance methods. RESULTS: Percentage of LBW experienced a significant worsening in the most recent 5 years of data, negating nearly a decade of prior improvement. Stark differences were observed by race/ethnicity and by education, with all subgroups experiencing increasing rates in recent years. Disparities also worsened over the course of study. Most notably, all disparities increased significantly from 2014 to 2018, with annual changes near 2-5%. CONCLUSIONS: Recent reversals in progress in percentage of LBW, as well as increasing disparities particularly by race, are troubling. Future study is needed to continue monitoring these trends and analyzing these issues at additional levels. Targets must be set and solutions must be tailored to population subgroups to effectively make progress towards equitable birth outcomes and maternal health.


Assuntos
Recém-Nascido de Baixo Peso , Parto , Peso ao Nascer , Escolaridade , Etnicidade , Feminino , Humanos , Lactente , Recém-Nascido , Gravidez , Estados Unidos/epidemiologia
8.
Am J Public Health ; 110(12): 1735-1740, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33058710

RESUMO

Objectives. To quantify changes in US health care spending required to reach parity with high-resource nations by 2030 or 2040 and identify historical precedents for these changes.Methods. We analyzed multiple sources of historical and projected spending from 1970 through 2040. Parity was defined as the Organisation for Economic Co-operation and Development (OECD) median or 90th percentile for per capita health care spending.Results. Sustained annual declines of 7.0% and 3.3% would be required to reach the median of other high-resource nations by 2030 and 2040, respectively (3.2% and 1.3% to reach the 90th percentile). Such declines do not have historical precedent among US states or OECD nations.Conclusions. Traditional approaches to reducing health care spending will not enable the United States to achieve parity with high-resource nations; strategies to eliminate waste and reduce the demand for health care are essential.Public Health Implications. Excess spending reduces the ability of the United States to meet critical public health needs and affects the country's economic competitiveness. Rising health care spending has been identified as a threat to the nation's health. Public health can add voices, leadership, and expertise for reversing this course.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Países Desenvolvidos/economia , Produto Interno Bruto , Custos de Cuidados de Saúde/tendências , Humanos , National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division , Estados Unidos
9.
Health Equity ; 4(1): 446-462, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33111031

RESUMO

Purpose: Frameworks can be influential tools for advancing health and equity, guiding population health researchers and practitioners. We reviewed frameworks with graphic representations that address the drivers of both health and equity. Our purpose was to summarize and discuss graphic representations of population health and equity and their implications for research and practice. Methods: We identified publicly available frameworks that were scholarly or practice oriented and met defined inclusion and exclusion criteria. The identified frameworks were then described and coded based on their primary area of focus, key elements included, and drivers of health and equity specified. Results: The variation in purpose, concepts, drivers, underlying theory or scholarly evidence, and accompanying measures was highlighted. Graphic representations developed over the last 20 years exhibited some consistency in the drivers of health; however, there has been little uniformity in depicting the drivers of equity, disparities or interplay among the determinants of health, or transparency in underlying theories of change. Conclusion: We found that current tools do not offer consistency or conceptual clarity on what shapes health and equity. Some variation is expected as it is difficult for any framework to be all things to all people. However, keeping in mind the importance of audience and purpose, the field of population health research and practice should work toward greater clarity on the drivers of health and equity to better guide critical analysis, narrative development, and strategic actions needed to address structural and systemic issues perpetuating health inequities.

12.
Am J Public Health ; 109(5): 714-718, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30896992

RESUMO

OBJECTIVES: To address shortcomings of previous research exploring trends in racial, educational, and race by educational disparities in infant mortality rates (IMRs) by using nonlinear methods to compare improvement within and between disparity domains. METHODS: We used joinpoint regression modeling to perform a cross-sectional analysis of IMR trends from linked birth and death certificates in Wisconsin between 1999 and 2016. RESULTS: In the race and education domains, IMR decreased by 1.9% per year for infants of White mothers and 1.1% per year for infants of less-educated mothers. Further analysis showed these IMR reductions to be among infants of White mothers with more education (-0.6%/year) and Black mothers with less education (-2.0%/year). CONCLUSIONS: As previously reported, gaps in IMR by race and education in Wisconsin appear to be closing; however, only the change by education is statistically significant. Evidence suggests the racial divide in IMR might soon widen after years of progress in reducing IMR among infants of Black mothers. Public Health Implications. Those advancing strategies to address IMR disparities should pursue data and methods that provide the most accurate and refined information about the challenges that persist and progress that has been realized.


Assuntos
Mortalidade Infantil/tendências , Estatísticas Vitais , Negro ou Afro-Americano/estatística & dados numéricos , Estudos Transversais , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , População Branca/estatística & dados numéricos , Wisconsin
14.
J Urban Health ; 96(2): 149-158, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30506135

RESUMO

The purpose of this study was to better understand residential segregation and child/youth health by examining the relationship between a measure of Black-White residential segregation, the index of dissimilarity, and a suite of child and youth health measures in 235 U.S. metropolitan statistical areas (MSAs). MSAs are urban areas with a population of 50,000 or more and adjacent communities that share a high degree of economic and social integration. MSAs are defined by the Office of Management and Budget. Health-related measures included child mortality (CDC WONDER), teen births (NCHS natality data), children in poverty (SAIPE program), and disconnected youth (Measure of America). Simple linear regression and two-level hierarchical linear regression models, controlling for income, total population, % Black, and census region, examined the association between segregation and Black health, White health, and Black-White disparities in health. As segregation increased, Black children and youth had worse health across all four measures, regardless of MSA total and Black population size. White children and youth in small MSAs with large Black populations had worse levels of disconnected youth and teen births with increasing segregation, but no associations were found for White children and youth in other MSAs. Segregation worsened Black-White health disparities across all four measures, regardless of MSA total and Black population size. Segregation adversely affects the health of Black children in all MSAs and White children in smaller MSAs with large Black populations, and these effects are seen in measures that span all of childhood. Residential segregation may be an important target to consider in efforts to improve neighborhood conditions that influence the health of families and children.


Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Pobreza/estatística & dados numéricos , Características de Residência/estatística & dados numéricos , Saúde da População Urbana/estatística & dados numéricos , População Urbana/estatística & dados numéricos , População Branca/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Análise de Regressão , Segregação Social , Fatores Socioeconômicos , Estados Unidos
15.
Health Aff (Millwood) ; 37(4): 579-584, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29608349

RESUMO

Health investments, defined as formal expenditures to either produce or care for health, in the US are extremely inefficient and have yet to unlock the country's full potential for equitable health and well-being. A major reason for such poor performance is that the US health investment portfolio is out of balance, with too much spent on certain aspects of health care and not enough spent to ensure social, economic, and environmental conditions that are vital to maintaining health and well-being. This commentary summarizes the evidence for this assertion, along with the opportunities and challenges involved in rebalancing investments in ways that would improve overall population health, reduce health gaps, and help build a culture of health for all Americans.


Assuntos
Eficiência Organizacional , Equidade em Saúde , Gastos em Saúde , Investimentos em Saúde , Humanos
16.
Int J Equity Health ; 17(1): 25, 2018 02 17.
Artigo em Inglês | MEDLINE | ID: mdl-29452592

RESUMO

BACKGROUND: The purpose was to develop and test a population health measure that combines mean health outcomes and inequalities into a single GDP-like metric to help policymakers measure population health performance on both dimensions in one metric. METHODS: The Population Health Performance Index is a weighted average of a mean index and an inequality index according to the user's inequality aversion. We deploy this methodology for two combinations of health outcome and disparity domain: infant mortality by race and unhealthy days by education. RESULTS: The PHPI is bounded between 0 and 1, and is comprised of a weighted average of two separate indices: a mean index and an inequality index, with 1 representing the ideal state of no ill health and no inequality and 0 representing the worst state in the U.S. PHPI values across states (neutral 50:50 weighting) vary between 0.60 (Massachusetts) to 0.17 (Delaware) for infant mortality by race and between 0.65 (North Dakota) to 0.00 (West Virginia) for unhealthy days by education. For some states, the choice of inequality aversion significantly impacts their PHPI value and state rank. CONCLUSIONS: Mean and inequality health outcomes can be combined into a single Population Health Performance Index for use by public and private policy makers, like the GDP is used as a summary metric to measure economic output. The index can allow for varying degrees of inequality aversion, an individual's or jurisdiction's value choice that can substantially impact the value of this new summary population health metric.


Assuntos
Disparidades nos Níveis de Saúde , Inquéritos Epidemiológicos/estatística & dados numéricos , Saúde da População/estatística & dados numéricos , Fatores Socioeconômicos , Humanos , Lactente , Mortalidade Infantil , Massachusetts , Grupos Raciais , Estados Unidos
17.
Environ Sci Pollut Res Int ; 25(9): 8735-8746, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29327189

RESUMO

Trichloroethylene (TCE) is a highly effective industrial degreasing agent and known carcinogen. It was frequently buried improperly in landfills and has subsequently become one of the most common groundwater and soil contaminants in the USA. A common strategy to remediate TCE-contaminated sites and to prevent movement of the TCE plumes into waterways is to construct biowalls which consist of biomaterials and amendments to enhance biodegradation. This approach was chosen to contain a TCE plume emanating from a closed landfill in Maryland. However, predicting the effectiveness of biowalls is often site specific. Therefore, we conducted an extensive series of batch reactor studies at 12 °C as opposed to the typical room temperature to examine biowall fill-material combinations including the effects of zero-valent iron (ZVI) and glycerol amendments. No detectable TCE was observed after several months in the laboratory study when using the unamended 4:3 mulch-to-compost combination. In the constructed biowall, this mixture reduced the upstream TCE concentration by approximately 90% and generated ethylene downstream, an indication of successful reductive dechlorination. However, the more toxic degradation product vinyl chloride (VC) was also detected downstream at levels approximately ten times greater than the maximum contaminant level. This indicates that incomplete degradation also occurred. In the laboratory, ZVI reduced VC formation. A hazard quotient was calculated for the landfill site with and without the biowall. The addition of the biowall decreased the hazard quotient by 88%.


Assuntos
Reatores Biológicos , Água Subterrânea/química , Folhas de Planta/química , Tricloroetileno/análise , Instalações de Eliminação de Resíduos , Poluentes Químicos da Água/análise , Adsorção , Biodegradação Ambiental , Glicerol/química , Ferro/química , Cloreto de Vinil/análise
18.
Am J Public Health ; 108(1): 87-92, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29161064

RESUMO

OBJECTIVES: To quantify the improvement in US life expectancy required to reach parity with high-resource nations by 2030, to document historical precedent of this rate, and to discuss the plausibility of achieving this rate in the United States. METHODS: We performed a demographic analysis of secondary data in 5-year periods from 1985 to 2015. RESULTS: To achieve the United Nations projected mortality estimates for Western Europe in 2030, the US life expectancy must grow at 0.32% a year between 2016 and 2030. This rate has precedent, even in low-mortality populations. Over 204 country-periods examined, nearly half exhibited life-expectancy growth greater than 0.32%. Of the 51 US states observed, 8.2% of state-periods demonstrated life-expectancy growth that exceeded the 0.32% target. CONCLUSIONS: Achieving necessary growth in life expectancy over the next 15 years despite historical precedent will be challenging. Much all-cause mortality is structured decades earlier and, at present, older-age mortality reductions in the United States are decelerating. Addressing mortality decline at all ages will require enhanced political will and a strong commitment to equity improvement in the US population.


Assuntos
Demografia/estatística & dados numéricos , Expectativa de Vida/tendências , National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division , Causas de Morte , Europa (Continente)/epidemiologia , Feminino , Humanos , Masculino , Mortalidade , Estados Unidos/epidemiologia
19.
JAMA ; 317(20): 2133-2134, 2017 05 23.
Artigo em Inglês | MEDLINE | ID: mdl-28535230
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