BBH 302 Exam 3

Health Disparities in LGBTQI Populations: Tobacco and Other Substance Use

- A higher percentage of lesbian or gay or bisexual adults were current smokers or binge drinkers. Rates for all illicit drugs were markedly higher in gay, lesbian, or bisexual youth than in heterosexual youth. Increased substance use in LGBT populations has been speculated to result from chronic exposure to discrimination, victimization, and rejection in this population.

Health Disparities in LGBTQI Populations: Cancer

- Anal cancer is the number 1 cancer risk in MSM. HPV, a sexually-transmitted infection, increases the risk of anal cancer. - Lesbian women may be at an increased risk for breast cancer given lower birth rates and breastfeeding rates (protective factors), and increased smoking, obesity, and alcohol use (risk factors). - Lesbian/bisexual women had a higher rate of cervical cancer. It is likely that lesbian/bisexual women may have fewer cancer screening visits due to discrimination or fear of disclosure of sexual orientation. Women who reported disclosing their sexual orientation to their healthcare provider were more likely to receive a Pap smear. This provides some explanation for the increased risk of cervical cancer in lesbian and bisexual women.

Health Disparities in LGBTQI Populations Females

- Anxiety, depression, conduct disorder, suicidal thoughts/attempts, teen pregnancy, obesity, HIV/STIs, substance use, breast cancer, and sexual violence

Results from the Braveman article showed a consistent health-wealth gradient in all but which of the following racial/ethnic groups? A. Whites B. Hispanics C. Asians D. Blacks

- B. Hispanics

Vulnerabilities

- Children's Educational Attainment may be compromised - Disease and Illness may be increased because of these exposures, which then leads to further social stratification

SES and General Health Status

- Data shows a clear social gradient in health, using education as the social status indicator. A greater percentage of individuals with higher education rated themselves to be in excellent or very good health, compared to those with lower education. Similarly, a larger percentage of individuals with lower education rated themselves to be in fair or poor health, compared to those with higher education.

Unique Challenges to Health in Men and Women: Injury and Risky Behaviors

- Deaths from unintentional injuries were almost 75% higher in men than in women. This could partially be explained by higher risk-taking behaviors that are evident in males as young as teenage years.

Choose the potential explanations for cervical cancer disparities in lesbian and bisexual women.

- Discrimination, fear of sexual orientation disclosure, and fewer cancer screening visits

Further Ill Health

- Disease and Illness may then result from lack of preventative care, delaying care or not seeking care due to costs - Disability may result from the burden of disease

Leading cause of death in men

- Diseases of the heart

Leading cause of death in women

- Diseases of the heart

Top ten causes of death in women

- Diseases of the heart - Cancer - Chronic lower respiratory diseases - Cerebrovascular diseases - Alzheimer's Disease - Unintentional injuries - Diabetes - Influenza and pneumonia - Nephritis, nephrotic syndrome and nephrosis - Septicemia

Top ten causes of death in men

- Diseases of the heart - Cancer - Unintentional injuries - Chronic lower respiratory diseases - Cerebrovascular diseases - Diabetes - Suicide - Alzheimer's Disease - Influenza and pneumonia - Chronic liver disease and cirrhosis

Health Disparities in LGBTQI Populations Males

- Anxiety, depression, conduct disorder, suicidal thoughts/attempts, suicide, eating/body image disorders, HIV/STIs, substance use, anal cancer, and sexual violence

Cancer in males and females

- The incidence of cancer was highest in males - However, prevalence rates from cancer were higher in women. This is important, as it suggests that while men may be developing cancers at a faster rate than women, women may have been living with cancer for a longer period of time.

Sex Health Paradox:

- The observation that females have higher rates of morbidity but lower rates of mortality, compared to men.

Net Worth:

- an indicator of wealth that refers to cash flow and assets, minus liabilities/debts.

Review Terms

From Exam 1

Lesson 09

Health Disparities By Sex and Gender

Incomes:

Highest to Lowest: Asian, Whites, Hispanic/Latinos, Blacks

Education:

- Education is typically measured in terms of completion of (1) secondary education, which includes a high school degree, diploma, or general equivalency diploma (GED), (2) post-secondary education, which includes college and technical school degrees, and (3) advanced degrees, which include any degrees obtained after the undergraduate degree (e.g., M.D., Ph.D., M.S., etc.). The problem with using education as a measure of SES is that educational attainment does not perfectly correlate with job attainment, income, or prestige.

Further Social Stratification

- Family Income and Education may then be impacted, and the cycle repeats and continues

Mortality rates: Alzheimer's disease

- Females had an almost 50% higher rate than males

Which of the following is a potential biological explanation for women's greater life expectancy, compared to men?

- Females' ability to bear children

CAPSES

- Given that capital is a part of each of these indicators, Oakes and Rossi refer to the combined measure as CAPSES (capital measures of SES).

Health Disparities in LGBTQI Populations: Childhood Abuse

- Higher rates of childhood physical and sexual abuse in LGBT men and women.

Tobacco and other substance use in men and women

- Higher smoking prevalence, illicit drug use, and alcohol use in men

Exposures

- Housing Quality, Safety and Access to Amenities, such as access to parks, walking paths, and full-service grocery stores - Opportunities for Healthy Behaviors - Preventative Care, which refers to parents' ability to cover the costs of preventative medical and dental care

Poverty descriptions:

- Hunger, Lack of shelter, Sick and unable to see a doctor, Not having access to school and not knowing how to read, Unemployment, Fear for the future, Powerlessness, lack of representation, Lack of freedom, Lack of education, Living one day at a time

Income:

- Income is typically a measure of household cash income, usually measured over the past year. While this is a good measure of SES that provides an estimate of the types of resources, goods, and services one can access, it is not a perfect measure.

Not having interpreters in areas in which there is a large prevalence of immigrants from China is an example of what type of racism?

- Institutionalized

SES and Health Behaviors

- Is it possible to explain SES disparities in health by certain health behaviors that are risk factors for disease? For smoking and sedentary or physical activity and for binge drinking behavior, there is a social gradient, with riskier behaviors being more prevalent in individuals at lower income levels.

Further Social Stratification

- Job Prestige and Income may be impacted, by limiting children's ability to secure a high-paying, high prestige job - Health Care Coverage may be reduced as a result of low-paying or part-time employment

Sexual Minority:

- Lesbian, Gay and Bisexual individuals

LGBTQI:

- Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex

Health Disparities in LGBTQI Populations: Mental Health Problems

- Lesbian, gay, and bisexual men and women reported higher levels of experiences with psychological distress. LGBT populations reported a greater deal of anxiety and depression disorders than heterosexual populations in youth, early/middle-adulthood, and later adulthood. LGBT youth also experienced higher levels of conduct disorders. Suicide is a major cause of death in LGBT populations. Transgender men and women have the highest rates of suicide of all sexual and gender minority groups.

Health Disparities in LGBTQI Populations: Intimate Partner Violence (IPV) and Sexual Violence (SV)

- Lesbian/Gay and bisexual women/men disproportionately experienced rape, physical violence, and stalking by an intimate partner at a higher rate than heterosexual women.

SES and Health Care Utilization

- Lower income individuals were more likely than higher income individuals to not receive medical care or delay seeking care due to cost. Individuals with lower education levels were more likely than those with higher education to be without health care coverage in the past year or the past 7-12 months, and the association shows a clear social gradient, with gradual increases in education level being associated with lower reports of a lack of health care coverage. It is likely that individuals living in poverty may not have employer-provided health care coverage, either due to part-time work, inadequate work or low-quality employment.

SES and Children's Health

- Male and female youth from households with parents who were more highly educated had the lowest prevalence of obesity. Obesity experts attribute this to a number of household factors, including the availability and provision of healthy foods, increased opportunities to be physically active, lower stress levels, among other things that are associated with higher levels of education. - The greatest prevalence of cavities was seen in children who were at the lowest poverty levels, and a similar pattern was seen for adults. - The greatest percent of children without contact (doctor) were from lower education and lower income households. - The impact of children's poor health can limit their ability to succeed in school, which may limit greater educational and employment potential in the future.

Mortality rates: Chronic lower respiratory diseases

- Males had a higher rate than females

Mortality rates: Diabetes

- Males had a higher rate than females

Mortality rates: Influenza and pneumonia

- Males had a higher rate than females

Mortality rates: Kidney-related diseases and conditions

- Males had a higher rate than females

Mortality rates: Chronic liver disease and cirrhosis

- Males had almost 2 times the rate of females

Mortality rates: Ischemic heart disease (a condition that often leads to heart attack)

- Males had almost 2 times the rate of females

Mortality rates: HIV

- Males had almost 3 times the rate of females

Mortality rates: Occupational injuries

- Males had more than 13 times the rate of females

Mortality rates: Motor vehicle-related injuries

- Males had more than 2 times the rate of females

Mortality rates: Poisoning

- Males had more than 2 times the rate of females

Mortality rates: Unintentional injuries

- Males had more than 2 times the rate of females

Mortality rates: Suicide

- Males had more than 3 times the rate of females

Mortality rates: Homicide

- Males had more than 4 times the rate of females

Mortality rates: Firearm-related injuries

- Males had more than 6 times the rate of females

Lesson 09 Summary

- Men and women are exposed to unique health risks that differentially impact health and disease outcomes. The Sex Health Paradox states that although women live longer than men, they have higher rates of morbidity in early life. The major take-home messages from this lesson include: - Women are living with chronic diseases for longer periods of time, which may explain why septicemia is a leading cause of death in women - Women and men have different stress coping styles, which may explain higher rates of suicide in men Women have higher mental illness diagnoses, however, rates may be underestimated/underreported in men - Women bear a greater burden of HIV in places where heterosexual contact is the main mode of transmission - There are some biological explanations for sex differences in health, but many explanations are social in nature

Unique Challenges to Health in Men and Women: HIV/AIDS

- Men bear the greatest burden of HIV in the U.S.. The primary mode of transmission is through male-to-male sexual contact. Sexual risk appears to be greater for adolescent females than males. -

Unique Challenges to Health in Men and Women: Physical Activity and Inactivity

- More men than women reported higher levels of leisure time physical activity.. More women reported being sedentary or inactive.

Health Care Utilization:

- More women than men reported expenses for health care and prescription medicine.

The Whitehall Study

- Name of the landmark study that showed that there was a social gradient in health?

Standard of Living or Living Standard is an important measure of living and housing conditions that has clear implications for health.

- Number of people per room -Absence of or shared amenities - Access to transportation - Possession of consumer goods

Occupation:

- Occupation typically serves as a good indicator of several factors that are important to health, including (1) education and income, (2) occupational prestige, (3) occupational class, a term more typically used in Europe, (4) work content, and (5) access to health care coverage, sick leave, and vacation time. When occupation is ranked based on associated income and education levels, there is a clear social gradient in health; lower occupation levels relate to lower education and income. Steenland and colleagues (2004) showed that all-cause mortality rates progressively increased with lower occupation level. A similar relationship was seen based on occupational prestige; individual who ranked their jobs as higher in prestige, or social ranking, were less likely to rate themselves as being in fair/poor health than those who ranked their jobs as lower in prestige.

Using HIV in men who have sex with men as an example, match the description to the area of the model to which it applies.

- Primary prevention: Condom use - Secondary prevention: Mobile clinics that provide free HIV testing - Tertiary prevention: Anti-retroviral treatment - Moving away from the cliff: Adding education on risks associated with anal sex to all U.S. education system

Using cardiovascular disease as an example, match the description to the area of the model to which it applies.

- Primary prevention: Eating a healthy diet - Secondary prevention: Community clinic that provides free blood pressure screenings - Tertiary prevention: Bypass surgery after a heart attack - Moving away from the cliff: Policies that mandate that all populations have access to fresh foods and physical activity opportunities

Measures of Socioeconomic Status (SES):

- Reflecting "one's access to collectively desired resources, be they material goods, money, power, friendship networks, healthcare, leisure time, or educational opportunities." The most commonly measured indicators include: Income Education Occupation

Health Disparities in LGBTQI Populations: Cardiovascular Disease (CVD), Hypertension, and Stroke

- Sexual minority women were at higher risk for CVD than heterosexual women. Lesbian and bisexual women were more likely than heterosexual women to receive a cancer diagnosis. The higher risk of obesity in lesbian women and bisexual men and women may place LGBT populations at higher risk for a number of related outcomes, including CVD, hypertension, stroke, and diabetes.

Difference:

- Something that can be attributed to simple differences in biology. For example, the prevalence of breast cancer is markedly higher in women than in men.

Pathways to Poor Health Framework.

- The DIRECT route follows the lower pathway. When an individual experiences discrimination, harassment, or victimization because of some personal characteristic, there is a direct, immediate impact on health. In the example of a biological response, heart rate increases along with blood pressure, one may begin to sweat, and the body mounts a fight or flight response. Prolonged activation of these responses (in the presence of chronic exposure to discrimination) can impact poor health outcomes such as hypertension, cardiovascular disease, and hypertension. Similarly, discrimination could result in an emotional response (e.g., anxiety or depression), which can lead to unhealthy behaviors (e.g., substance use, poor dietary patterns, etc.) which can ultimately lead to a poor health outcome. - The INDIRECT pathway to poor health is the upper pathway, which works through health care experiences and quality. Thinking back to Camara Jones' levels of racism, discrimination may be unintended or intended. Health care providers may intentionally refuse to treat a person on the basis of some characteristic or may not provide the highest quality care, which may lead to poor health outcomes. Take, for example, a physician who is not familiar with the anal Pap smear used to screen men for anal cancer, a screening tool which is highly recommended for men who have sex with men. Discrimination may be a result of medical institutions refusing to purchase screening kits because of a perception of low need. Thus, screenings are not completed, which may result in a higher prevalence of anal cancer in men attending that medical institution.

The Need to Disentangle Race from SES

- The findings reviewed in this lesson thus far show a clear social gradient in health. Many researchers who study racial and ethnic disparities face a problem with understanding causes of disparities. SES in the U.S. is racially- and ethnically-bound. That is, SES is highly associated with race, with minority groups over represented in lower SES groups. The prevalence of poverty was highest in Blacks and Hispanics/Latinos. This shows that there is a need to pull apart, or disentangle, the effects of SES on health from the effects of race and ethnicity on health. Similarly, disparities in attainment of a college degree persisted over time, with Asians consistently having the highest rates over time, followed by Whites, Blacks and Hispanics. College degree attainment rates were more than 50% higher for Whites than for Blacks or Hispanics.

Cardiovascular Disease (CVD), Hypertension and Stroke in males and females

- The prevalence of heart disease was higher in men - Men had a higher rate of uncontrolled blood pressure than women - Stroke prevalence rates were similar between men and women

SES and Chronic Diseases

- There is a consistent social gradient in health for a number of diseases and conditions. For coronary heart disease/hypertension/stroke, diabetes, kidney/liver disease, ulcers, and chronic lower respiratory disease those with higher education and higher income fare better than those with lower education and income. - The pattern was mixed or opposite for cancer, however. Apart from cervical cancer, individuals with lower income had a lower prevalence of cancer in all sites (any cancer) than those with the highest income. A similar pattern was seen for education as well, with individuals with higher education having a higher prevalence of the cancers, except for cervical cancer. The social gradient in cancer was not as clear, and the reasons for these patterns are unclear.

SES and Mental Health

- There is a tight link between mental health and SES. Data shows increasing reports of depression with increasing levels of poverty. For each emotion, a higher prevalence of experiencing the emotion for populations at higher poverty levels; these emotions appear to be a great burden for the poorest individuals, highlighting the need for public health efforts to address these issues.

Unique Challenges to Health in LGBTQI Persons: Homelessness

- Top 5 reasons for homelessness or risk for becoming homeless in LGB youth: -Ran away because of family rejection -Forced out by parents/guardians because of sexual orientation or gender identity - Physical, emotional, or sexual abuse at home - Aged out of the foster system - Financial or emotional neglect from family

In which LGBTQI population is suicide a major disparity?

- Transgender

Gender Minority:

- Transgender and Intersex individuals

Lesson 10 Summary

- Transgenders are at the greatest risk for suicide - Transgender youth are at high risk for homelessness -Lesbian/bisexual women have unique risks for breast and cervical cancer - Gay men have high rates of eating disorders - Lesbian women have high rates of obesity

Men develop cancer at a faster rate than women, but women may be living with cancer for a longer period of time than men. TRUE OR FALSE

- True

Wealth in Whites and Asians with only a high school education is predicted to be greater than wealth in Hispanics with a college degree, or Blacks with a graduate degree! TRUE OR FALSE

- True

Females outlive males. TRUE OR FALSE

- True. There are more males ages 0-34, but more females over the age of 35

Disparities:

- Usually have some ethical issues at its source. For example, uninsured or under-insured populations report lower rates of preventive screenings and wellness visits than well-insured populations.

Sex:

- We refer to biological sex as male or female.

Gender:

- We refer to identity as male or female, regardless of biological sex.

Mental Health Problems in men and women

- Women were more likely to report serious psychological distress - Men were less likely than women to report feelings of sadness, hopelessness or worthlessness. - Given social norms regarding males and females in the U.S., there may be a certain level of stigma associated with males reporting pain, sadness and distress. Thus, these rates may be sorely underestimated in men. - Women were more likely to report the use of antidepressants and anxiety medication than men; this may indicate better mental health treatment-seeking behavior in women. This may partially explain higher rates of suicide in men. - Men die from suicide at a substantially higher rate than women.

Septicemia is an example of:

- a health difference; this is something that is a higher burden in women due to biology (only women give birth).

Inequalities:

- are similar to health disparities. Unjust and avoidable differences in people's health across the population and between specific population groups

Internalized racism:

- evident in societal structures, processes and values. E.g. don't provide info to providers because they think they will be judged

Review Camara Jones' Cliff Model on social determinants of health.

- fall off cliff = developing disease - primary prevention: fence = encourage to eat healthy; personal responsibilities to act on knowledge they have; no evidence that disease exists- - Secondary prevention: safety net = free healthcare, early detection screenings - usually low-cost or free community programs (Provide education) - Tertiary: ambulance = quality can differ, have disease and are trying to prevent further problems ; intervention (diabetes = insulin) - goal is to not get people to the edge of the cliff, want them away from it - this means we need changes in structure through mandates and policy change

Social capital:

- includes social ties, social networks, and relationships

Material capital:

- includes tangible assets like property, cars, and investments

Personally-mediated racism:

- intentional and unintentional, person to person, acts of omission and commission

Omission:

- not providing a service when one is needing

Physicians not referring patients of color for diagnostic tests because of assumptions about the patient's medical adherence is an example of which type of racism?

- personally mediated

Work content:

- provides details on the type of work environment individuals are exposed to, including (1) exposure to hazardous chemicals or conditions, (2) job demands and control, (3) long work hours and strenuous shifts, (4) job security and payoffs, and (5) access to health insurance, sick leave, and vacation time. Figure 3 shows the prevalence of severe illnesses and injuries, by occupation, using data collected by the Bureau of Labor Statistics. Those with highest rates of severe illnesses and injuries are those in positions that require heavy manual labor.

Comission:

- providing a service, but the wrong kind of service

Inequities:

- refer to differences in the distribution or allocation of resources between groups.

Socioeconomic Status:

- refers to an individual's social and economic standing in society, and is based on access to income, education, assets, power, investments, etc. Related terms are social class or socioeconomic position.

Human capital:

- refers to education, skills and capabilities,

Institutionalized Racism:

- structural barriers, inaction in the face of need (government shutdown = no health care), structured opportunities

Cycle of Poverty

1. Exposures 2. Vulnerabilities 3. Further Social Stratification 4. Further Ill Health 5. Further Social Stratification

SES and Disability

3 pathways to aging that lead to disability. - Pathway 1: describes age-related changes that are not associated with the disease, and include lowered metabolism, muscle weakness, and cognitive declines, which all lead to frailty. - Pathway 2: describes the consequences of disability, which can then lead to chronic diseases. For example, someone with activity limitations would likely have reduced physical activity, which can increase body fatness along with a whole host of related chronic diseases like hypertension or diabetes. -Pathway 3: describes the effects of external forces, mainly social determinants of health, which lead to disability and may exacerbate disability's influences on aging and disease. A tight link between chronic disease, disability, and SES.

Lesson 10

Sexual Orientation and Gender Identity

Lesson 11

Socioeconomic Status and Health