University Place

Social and Ecological Factors that Influence Health

– Welcome everyone to Wednesday Nite @ the Lab. I’m Tom Zinnen. I work at the UW-Madison Biotechnology Center. I also work for the Division of Extension, Wisconsin 4-H. And on behalf of those folks and our other co-organizers, PBS Wisconsin, the Wisconsin Alumni Association, and the UW-Madison Science Alliance, thanks again for coming Wednesday Nite @ the Lab. We do this every Wednesday night, 50 times a year. Tonight, it’s my pleasure to introduce to you Eva Vivian. She’s a professor in the School of Pharmacy here. She was born in Chicago and went to Aquinas Dominican High School there. Then she went to Benedictine University to get her bachelor’s degree in biology and got her doctorate of pharmacy degree at the University of Illinois.

She came here to get a master’s in public health, at the School of Medicine and Public Health, and stayed to get a PhD from the School of Human Ecology in civil society and community research. Tonight, she’s gonna speak with us about social and ecological factors that influence health. Would you please join me in welcoming Eva Vivian to Wednesday Nite @ the Lab.

– Thank you, Tom, for that wonderful introduction. Today, I have the distinct pleasure of speaking to you about the social and ecological factors that influence health. Today, I will identify factors that influence the health and well-being of all persons, and identify needs and barriers that persons face that may inhibit their ability to lead a healthy lifestyle. And I’ll also describe how social and ecological and environmental conditions can negatively impact the health and well-being of those individuals that reside in under-resourced communities. I’d like to start off today by providing a slide that provides a picture of a conceptual model of the social determinants of health. And at the very core of this conceptual model are non-modifiable factors that influence our health, such as our age, sex, and genetic makeup. These are factors that clearly have an impact on our health, but they are things that we cannot change.

Right above those factors are lifestyle, individual lifestyle factors. And these are factors that we can actually modify. Things such as physical activity, healthy nutrition, alcohol consumption, and cigarette smoking. These factors are usually addressed at our annual visit with our healthcare provider. Unfortunately, all too often, the social and community networks that a person engages in are often overlooked. But we know that those individuals who have strong relationship with family, friends, and interact and work with their community on a regular basis are healthier than those individuals who are socially isolated. Living and working conditions clearly affect our health, and they are included in this conceptual model. Education, work environment, water and sanitation, housing, are all factors that play a role in our health. We know that if an individual is fortunate to obtain a good education, that they will go on and obtain a good job that affords them health insurance and allows them to obtain housing in a well-resourced community. While things such as physical activity and nutrition clearly impact health, how does poverty and education and employment influence health? I’d like to share a story about a boy named Jimmy.

Jimmy was recently hospitalized because he had a bad infection in his leg. And he obtained this infection while he was playing in a junkyard in his neighborhood. There was some sharp, jagged steel in the junkyard that he fell on. And as a result, he cut his leg and his leg became infected. You may wonder, well, why was Jimmy playing in a junkyard? It’s because Jimmy lives in a rather run-down neighborhood and the junkyard is the only place for children to play. And they often play in this junkyard and they’re unsupervised. Why would Jimmy’s family have to live in that type of neighborhood? Well, it’s because his father is unemployed and his mother is ill. Why is this father unemployed? And that is because his father does not have a good education and cannot obtain a job. But why? Unfortunately in our country, everyone does not have the same opportunities. And on this slide, we see examples of equality versus equity.

And these terms are frequently used interchangeably, but they actually have different meanings. Equality means sameness. And it means that everyone essentially gets the same thing. However, this only works if everyone has the same opportunities. In the cartoon, you see that there’s three boys of different heights. And they are all attempting to view a baseball game. Each boy has been provided with a box. So the tallest boy is able to view the baseball game with ease. The boy in the middle can now see the baseball game because he can stand on the box and it allows him to view the game. However, the shortest boy is unable to see the game in spite of having a box to stand on.

Equity means fairness. And it means that we afford the same opportunities to everyone. We have to have equity before we can really enjoy equality. And in this cartoon, we see the same three boys. However, the tallest boy does not receive a box because he’s tall enough to view the baseball game without a box. The boy in the middle receives one box. However, the shortest boy is given two boxes so that he can now view the game. So now we see how equity ensures equality. Now this can apply to health equity. Health equity means that every person has the same opportunities, resources, and supports needed to stay safe and healthy.

Socioeconomic status clearly is a central determinant of the distribution of resources within our society. An example is the Scholastic Aptitude Test, known as the SAT. And this is an exam that most high schools students take prior to applying to college. This test has recently been nicknamed the Student Affluence Test. And this slide provides an explanation of why this test has been given that nickname. On the x-axis, we have the annual household income of families. And on the y-axis, we have SAT score. And what we see is a comparison of SAT score based on family income. And it’s clear from this graph that as the annual household income increases, there’s a corresponding increase in student SAT scores. So students that are from families with high incomes tend to have higher SAT scores when compared to students from lower income families.

And this could probably be because students from higher income families are able to attend schools that prepare them for college. And they also have the resources to help them prepare for this important examination. There is clearly large racial and ethnic differences in socioeconomic status. For example, for every dollar of wealth that whites have, Asians have about 81 cents. Blacks have only 6 cents, and Latinos have only 7 cents. So it’s important to keep these things in mind when we attempt to make sense of racial disparities in health. Over the last year, we’ve all been socially isolated and dealing with the impact of the COVID-19 pandemic. And I’m sure that most of us have heard that this pandemic has dramatically impacted people of color. For example, on this slide, we see that Hispanic or Latinx individuals actually only make up 7% of the population in the state of Wisconsin, but accounted for over 11% of all COVID-19 cases. This slide provides a percent of the total population that received at least one vaccine dose based on race and ethnicity between the months of March and May.

And this accounts, this data is from 40 states. And what we see is that overall, Asians are leading in the percent of individuals who have actually received at least one dose of the COVID-19 vaccine. However, you’ll notice that Black Americans and Hispanic Americans have the lowest percentage of individuals that have been vaccinated, with Blacks still below 30%. So why are Blacks hesitant to be vaccinated? There are multiple reasons. And over the last few months, I’ve been involved in mobile vaccine clinics and I’ve had an opportunity to speak to many African Americans about their concerns about the vaccine. And one common concern that I hear from people is that there’s a concern about how quickly the vaccine was developed. And the fact that the previous administration seemed to be involved in getting the vaccine on the market as quickly as possible. Another very common concern is the long-term effects of this vaccine. Many people told me that they just wanted to wait and see what the outcome would be of receiving this vaccine. And there are some people that just mistrust the healthcare system.

Because of bad experiences in the past with the healthcare system, they really don’t trust healthcare providers’ messages. Then of course, there are historical reasons that can lead to mistrust. There are African Americans that still remember the Tuskegee experiment that was conducted in the mid 20th century, where Black men were denied treatment for syphilis so that researchers could actually study the long-term effects of syphilis on their neurological system. Then of course, Hispanics are also hesitant to be vaccinated. And often, many people express concern about sharing their personal information with the government. And there is some historical mistrust as well. In the 1940s, the United States Public Health Service used sex workers to expose prisoners in the Guatemalan jails with sexually transmitted diseases. And this hasn’t been forgotten, and many Latinx individuals remember this. In the 1950s, Puerto Rican women from low income communities were given experimental birth control pills without being told that they were enrolled in a clinical study. So these things break down the trust within a community and can contribute to vaccine hesitancy.

So I believe that the key to unlocking vaccine hesitancy is trusted messengers. I think it’s important as people from various communities become vaccinated, that they share with their families and friends their experience of being vaccinated. And I believe that as people who are hesitant see that their family and friends actually benefit from being vaccinated and do not endure any long-term side effects, that more and more people are likely to become vaccinated. However, healthcare providers should still make efforts to go into the community and deliver accurate information about the vaccine. There’s a significant amount of misinformation about the vaccine. And it’s our responsibility as healthcare providers to ensure that people in the community have accurate information so that they can make an informed decision about whether or not they should become vaccinated. It’s also very helpful when prominent figures such as politicians actually receive the vaccine. And I believe that that could increase trust as well. Now there are other conditions that disproportionately impact people of color. And one of those conditions is obesity.

And almost every socio-demographic group is affected by obesity. And on this slide, we have a graph that provides the age-adjusted prevalence of obesity among adults 20 years of age and older. And what I’d like to point out is that the green bars represent non-Hispanic Asians. And you’ll notice that for the total population as well as for men and women, that non-Hispanic Asians have the lowest prevalence of obesity in our country. But when we look at other groups in total, we see that Hispanics have the highest prevalence of obesity, which is represented by the olive-colored bar, followed by African Americans. Hispanic men have the highest prevalence of obesity among men in our country. However, the picture is different for women, and we see that non-Hispanic Black women have the highest prevalence of obesity among women, followed by Hispanic or Latino women. Now let’s look closely at the percentage of obese adults by race and ethnicity within our country and state. And what you notice on this chart is that the United States is represented by white bars and Wisconsin is represented by red bars. And it appears like Wisconsinites are heavier than most people in our country.

And that’s the case for all different racial and ethnic groups. We see, for example, that the percentage of obese white adults in the United States is about 30%. However, the percentage of obese whites within the state of Wisconsin is close to 33%. Obesity has been found to be associated with age and education. And what we have found is that obesity tends to decrease by level of education. So high school individuals are more likely to be obese when compared to someone with a college degree. Young adults are also less likely to be obese compared to middle-age adults. Which is something that we would expect, since our metabolic rate tends to decrease as we age. Now socioeconomic status also plays a role in obesity in our country. And studies have found that among men, obesity tended to be lower among the lowest and highest income groups.

However, this pattern was only seen among non-Hispanic white and Hispanic men. Obesity prevalence was actually higher among the highest income group among non-Hispanic Black men when compared to low income Black men. So higher income Black men tended to be heavier than lower income Black men. Now among women, the obesity prevalence was less among the highest income groups, which is something that you would expect when compared to the middle income and low income group. But this was the case for non-Hispanic white women, non-Hispanic Asian women, as well as Hispanic women. But when we looked at data for non-Hispanic Black women, we found that there was no difference in obesity prevalence based on income. So a high-income Black woman is just as likely to be obese as a low income Black woman. And this may account for why Black women have the highest prevalence of obesity in our country. But why is this the case? The number one cause of obesity among women of color, particularly Black women, has been identified as stress. Stress and obesity had been identified as partners in crime.

And we know that in addition to dealing with ongoing racism, many Black women have the responsibility of being the head of household as well as the primary breadwinner. And these things increase the stress in their life, which is often compensated for by unhealthy coping behaviors such as overeating. Stress has a striking pattern of accelerating aging, which results in an earlier onset of disease. And chronological age actually captures the duration to risk for various groups of color that are living in adverse living conditions. Now, Blacks actually experience greater physiological wear and tear, and are actually aging biologically faster than whites. Biological weathering is driven by the cumulative impact of repeated exposures to psychosocial and chemical stressors in the environment and work environment, as well as other environments as well. Now, compared to whites, Blacks experience higher level of stressors, greater clustering of stressors, and probably a greater duration and intensity of stressors. There was a study that was published in Human Nature in 2010. And this study actually looked at the racial differences in telomere length. Now telomeres are sequences of DNA at the end of a chromosome.

And the telomere length is viewed as an overall marker of biological aging. And this study reported that Black women had shorter telomeres than white women. So at the same chronological age, Black women had accelerated aging of about seven and a half years when compared to white women. This slide provides the United States life expectancy based on race and ethnicity. And we see that Asian Americans have the longest life expectancy in our country. However, African Americans have the shortest life expectancy. When we compare life expectancy for non-Hispanic Black and non-Hispanic white males in Wisconsin and the United States, what we find is that Black men have a average life expectancy of about 72 years in our country compared to 76 years for non-Hispanic white males. So there’s about a four-year difference in life expectancy nationally. However, Black men in the state of Wisconsin have a life expectancy of about 70 years of age compared to 78 years of age for white men within the state of Wisconsin. So there’s a significantly wider Black/white gap for males within our state.

When we compare the life expectancy for non-Hispanic Black and non Hispanic white females in Wisconsin and our country, what we find is that Black women in our country have a life expectancy of about 79 years and white women have a life expectancy of about 81 years. So that’s not a significant gap, only two years. However, within the state of Wisconsin, we find that Black women’s life expectancy is about 76 and a half years compared to 82 years for white women. So once again, the Black/white gap among females in the state of Wisconsin is significantly wider than the Black/white gap among U. S. females. So why does race still matter? And could racism be a critical missing piece of the puzzle to understand how racism impacts health? Now, there are several mechanisms that can explain how racism influences health. One is institutional discrimination. That can actually restrict socioeconomic attainment and group differences in socioeconomic status and health. Segregation can also create pathogenic residential conditions.

We know that residential segregation is associated with poverty. And poverty is usually associated with poor housing conditions. And discrimination results in an inability to obtain desirable goods and services. Now, racism has also been associated with internalized racism. And that internalized racism is when a marginalized group accepts society’s stereotypes or negative characterization of that particular group. And that can really adversely affect health. Racism can also create exposure to traditional discrimination such as unemployment. Often, these experiences of discrimination are overlooked by healthcare providers. And it’s very rare that a healthcare provider will ask a person of color, particularly of African-American, if they feel that they experience discrimination, and if so, do they feel that these acts actually impact their health? Now, once again, I would like to present the conceptual model of the social determinants of health. But you’ll notice that I included structural racism, which actually influences laws and policies that result in an uneven distribution of the social determinants of health.

For example, residential segregation, which came into existence in the mid 1800s and lasted for over a hundred years, still impacts our nation. And residential segregation resulted in poor housing for many people. So unfair laws and policies have actually impacted many of the determinants of health. The pervasiveness of discrimination cannot be ignored in our country. There are things that some people endure that others can’t understand because of something that is not part of their lived experience. For example, several Black mothers have shared with me that their young two and three-year old children had been suspended from preschool. We know that Black men are more likely to be targeted and pulled over by the police. The cost of bail is very restrictive and results in incarceration. We know that Blacks are more likely to be arrested for drug-related crimes. Something as simple as hailing a taxi can be a challenge in a major city, particularly if the taxi driver thinks that the passenger is going to ask him to take him to a very dangerous neighborhood.

Buying a home is a challenge for many people of color, particularly African-Americans where they feel that they may not be able to purchase a home in a nice neighborhood because of segregation. Purchasing a car can be a challenge. We know that African-Americans who may have the same down payment as their white counterpart will still be charged a higher interest rate. Renting an apartment is a challenge. Getting a job, receiving a promotion, obtaining insurance because insurance companies think that you’re high risk. Obtaining bank loans, seeking medical care. All of these things are affected by discrimination and impact the health of many Americans in our country. I’d like to share a study that was conducted here in the state of Wisconsin. Where pairs of young, well-groomed, well-spoken college men with identical resumes applied for 350 advertised entry-level jobs in Milwaukee, Wisconsin. Two teams were Black and two teams were white.

And in each team, one of the men was asked to state that he had served a 18-month prison sentence for cocaine possession. This study found that a white male with a felony record was more likely to receive a job than a Black male with no felony record. And this slide provides the results. And you can see that 17% of white males that reported that they had a felony record received a call back, compared to only 14 Black men with no criminal record. Place clearly matters. Segregation remains a legacy of racism. And segregation affects health in many ways. In the 171 largest cities in our nation, there’s that one city where whites live in equal conditions to those of Blacks. So the worst urban contexts in which whites reside is considerably better than the condition in which Black communities live. Wisconsin was recently identified as the most segregated state in our country.

Which is very surprising, because I actually expected a southern state to come in first place. But actually, it’s our state. And I believe that this could partly explain the health disparities that we see within our state. So how does segregation affect health? Segregation can actually determine socioeconomic status by affecting the quality of education and employment opportunities. As we saw in the case of Jimmy, Jimmy’s father was unemployed. And more than likely, Jimmy’s father grew up in a low income community with under-resourced schools that were unable to provide him with the education that he needed to be successful. Segregation also creates pathogenic neighborhood and housing conditions. Most residentially segregated communities are poverty-stricken. And those communities often lack grocery stores that carry fresh produce. But they probably have an abundance of fast food stores.

These neighborhoods are often crime-ridden, so people feel uncomfortable to walk in their neighborhood, for fear that they will be a victim of crime. So what happens is that the conditions linked to residential segregation result in unhealthy health practices, where people may consume fast food frequently because it’s readily available and they are unable to be physically active in their community. One study that was reported over 20 years ago found that if we eliminated segregation, we could completely erase Black/white differences in income, education, and unemployment. That’s incredible. And I also believe that if segregation could be eliminated, it would allow us as Americans to learn more about each other and recognize that we have more in common than our differences. Unequal treatment in the medical profession is a reality. Virtually across every therapeutic intervention, ranging from high technology procedures to the most elementary forms of diagnostic and treatment interventions, Black Indigenous People of Color receive fewer procedures and poorer quality medical care than whites. And this persists, even after differences in health insurance, social economic status, stage and severity of disease, and co-morbidities are taken into account. These situations exist even for Medicare patients and patients within the health– within the VA health system, where insurance coverage is not really an issue. This study published in JAMA actually looked at the percent of patients with a broken arm that received no anesthesia or pain medication.

And Hispanics are represented by the green bar. And we can see that 55% of Hispanic patients reported receiving no anesthesia for the pain associated with a broken arm or leg, compared to less than 30% of non-Hispanic whites, which is represented by the white bar. Now, 43% of Blacks reported receiving no pain medication, compared to only 26% of whites. So race does matter. Cultural racism does matter and it’s deeply embedded in our culture. And it’s important that each and every one of us is really reflective and really attempt to identify unconscious discrimination or bias. Because when someone holds a negative stereotype about a group and they meet someone who fits that stereotype, he or she will discriminate against that individual. So stereotype-linked bias results in automatic discrimination. And it’s usually unconscious. I’d like to share a story about a patient who was referred to me for diabetes self-care management.

She was a older woman, about 60 years of age. And when she presented to my clinic, she appeared to be in great pain. She explained that she had severe back pain. Of course, I felt uncomfortable trying to talk to her about diabetes self-care management while she was in such extreme pain. I asked her if she had received any pain medication from her primary care doctor. And she indicated that her doctor refused to give her another prescription. Her doctor happened to be at the clinic at the time, so I went to her doctor’s office and explained that the patient was in extreme pain. And the doctor informed me that at the patient’s last visit, that the patient was given a urine test, which came back negative. So the provider assumed that the patient was selling her drugs because she was not– Based on the negative urine test, she assumed that the patient was not taking her medication. I went back to my office and sat down with the patient and I asked the patient about the urine test.

I explained that her urine test came back negative, and I asked the patient if she could explain to me why that test came back negative. And the patient informed me that she was caring for her grandchildren on the day that she took the urine test. And when she cares for her grandchildren, she does not take her pain medication because she needs to be alert. Of course, I informed her doctor of that and that patient was provided with a prescription for her pain that day. So it’s very important that we not make assumptions about people and that we give everyone the benefit of the doubt by asking questions. Many African-Americans as well as other groups of color have a perceived threat of discrimination that can really impact their health as well. Discrimination, like other stressors, can impact health through both actual exposure as well as the threat of being exposed to discrimination. Experiences of discrimination are often a neglected psychosocial factor. All too often, when patients are monitored for blood pressure, they’re rarely asked if there’s something in their environment that can actually increase their stress and raise their blood pressure. Perceived discrimination can result in an elevated risk of diabetes, substance use, breast cancer, uterine fibroids, as well as coronary artery disease.

And often, perceived discrimination within the healthcare system can result in delays in a patient seeking help. Often, patients begin to mistrust the healthcare system, therefore they won’t adhere to treatment regimens. And discrimination actually is a significant contributor to the disparities that we see in health in the state of Wisconsin, as well as nationally. Macro-stressors also impact health. For example, large-scale societal events such as natural disasters can be stressful for individuals. I recall Hurricane Katrina. Just watching on television the number of African-Americans that were stranded and were unable to evacuate was very stressful, not just for the residents of New Orleans, but for those of us who had to watch this on television. Major negative race-related events can also be macro-stressors. For example, the video of George Floyd’s death was very stressful for many people across our country. Also, research has found that historical trauma and traumatic events that actually occurred over a hundred years ago can cross over generations and impact the physical and mental health of many individuals.

And we found this particularly among Native Americans, where incidents that occurred over a hundred years ago can still impact current generations. Now September 11th terrorist attacks were a clear example of how non-race related stressors can actually be racialized in ways that can generate racial, ethnic discrimination. It’s well-documented that there was an increase in discrimination and harassment of Arab Americans after 9/11/2001. And Arab-American women in the state of California actually had an increase in low birth weights six months following 9/11, particularly when compared with birth weights prior to September 11th. And what was interesting is other women in the state of California had no changes in birth weight outcomes, before or after September 11th. So this is an example of how discrimination can impact the health of people immediately after an incident. Anxiety and depression spiked for Black as well as Asian Americans after the police killing of George Floyd. We know that after the pandemic hit, that many Asian Americans were discriminated against. And what we see on this slide is that at the time of the release of the video of George Floyd’s killing that anxiety and depression spiked among African Americans. And actually, there was a spike found among Asian Americans as well.

So what do we do to dismantle institutional racism? What’s very important is that we have to acknowledge that racism exists. And that disparities in one societal domain are not independent of those in other domains. And that racism is a set of dynamically related components of subsystems. And it is impossible to come up with remedies for disparities if we fail to acknowledge and address the interdependence across domains. For example, when we look at racism as a system, we know that all of these systems are impacted by racism: school segregation, residential segregation, the criminal justice system are all impacted by racism. But then there is an interdependence. For example, residential segregation will influence school segregation. Both schools and racially segregated communities are in fact segregated. This impacts the education that students receive at that school. And as a result, can impact their ability to obtain a job later in life.

So how do we reduce disparities? It’s important that we raise public and provider awareness of racial and ethnic disparities in care. Expanding insurance coverage is also vital. Improving the capacity and number of providers in underserved communities is important. And increasing the awareness of interventions that will actually work to decrease disparities is also vital. So one way to reduce disparities is to support disparity reducing policies. Many policies actually promote disparities. So supporting disparity reducing policy interventions that are targeted at education in early childhood are also important. We should support urban planning and community development. Support housing; many low income housing apartment buildings are placed in undesirable areas of major cities. We should ban those policies and ensure that those individuals can live in safe communities, where they have access to resources that will help them be successful.

Also, support policies that will enable people to seek good education and employment. The cost effectiveness of these interventions will actually result in long-term outcomes that are very favorable for our country. So in conclusion, racism in its multiple forms is a major risk factor for health. And there is a need to increase research attention to understand its potential effects. There’s an urgent need to have effective efforts to mitigate the pathogenic effects of racism and develop optimal strategies to create a political will and support to dismantle societal structures and things that actually promote racism and hate and incivility. It has been a pleasure to talk to you today about these issues. I am very hopeful for our country. And I’m sure that each and every one of you will take into consideration the things that I presented today. And I know that going forward, we can make our state and our country a better place to live. And with that, I would like to close with a quote from the late Robert F.

Kennedy, who stated that, “Each time a man stands for an idea, “or acts to improve the lot of others, “or strikes out against injustice, “he sends forth a tiny ripple of hope. “And those ripples build a current “that can knock down the mightiest walls of oppression and resistance. ” Thank you.