CHART 1
Methodological
g
Advances and Approaches
pp
in Gender and Health Research
Cara V
V. James
James, Ph
Ph.D.
D
Gender and Health Interest Group Meeting
AcademyHealth Annual Research Meeting
June 26, 2010
CHART 2
Acknowledgments
• Study Co-authors
Co authors
–
–
–
–
–
Alina Salganicoff
g Thomas
Megan
Usha Ranji
Marsha Lillie-Blanton
Roberta Wyn – Center for Health Policy
Research, UCLA
• Data Support
– Randal ZuWallack, Riki Conrey,
y and Kristian Omland of
ICF MACRO
• Advisory Committee
CHART 3
Distribution of U.S. Population by Race/Ethnicity, 2008
American
Indian/Alaska
Native
1%
Asian
4%
(2.3 million)
Native Hawaiian
& Other Pacific
Islander
<1%
(0.4 million)
(13.2 million)
Two or More
Races
2%
(4.5 million)
Hispanic
15%
(46.9 million)
non-Hispanic
Whit
White
66%
non-Hispanic
Black
12%
(199.5 million)
(37.2 million)
Total U.S. Population = 304.1 million
NOTES: Data do not include residents of Puerto Rico, American Samoa, Guam, the U.S. Virgin Islands, or the Northern Mariana Islands. Totals
may not add to 100% due to rounding. All racial groups and individuals reporting “two or more races” are non-Hispanic.
DATA: Table 3: Annual Estimates of the Population by Sex, Race and Hispanic Origin for the United States: April 1, 2000 to July 1, 2008 (NCEST2008-03). Population Division, U.S. Census Bureau.
CHART 4
Proportion of Women Who Self-Identify as a Racial and Ethnic
Minority,
y, by
y State
NH
VT
WA
MT
ND
MN
OR
WI
RI
MI
WY
PA
IA
NE
NV
IL
UT
CO
MO
DE
WV
KY
NC
TN
OK
AZ
NM
SC
AR
MS
TX
AL
GA
LA
AK
FL
HI
U S Total = 33% Minority Women
U.S.
CT
NJ
OH
IN
VA
KS
MA
NY
SD
ID
CA
ME
4 – 15% (16 states)
16 - 25% (13 states)
26 - 39% (14 states)
40 - 80% (7 states and DC)
Source: Kaiser Family Foundation analysis of March 2005, 2006, 2007 Current Population Surveys, U.S. Census Bureau.
MD
DC
CHART 5
Data and Methods
• Indicator Selection
– Relevant to women’s health; adequate sample size; policy
and pprogramming
g
g relevance;; reliable data source;; and
comparability across states
• Data
–
–
–
–
–
BRFSS (13 indicators)
Current Population Survey (6 indicators)
National Vital Statistics System (3 indicators)
Area Resource File (2 indicators)
Other Sources (9 indicators)
CHART 6
Indicators by Dimension
Health Status
1) Fair or Poor Health
2) Unhealthy Days
3) Limited Activity Days
4) Diabetes
5) Heart Disease
6) Obesity
7) Smoking
8) Cancer Mortality
9) New AIDS Cases
10) L
Low-Birthweight
Bi h i h
11) Serious Psychological
Distress
Access and
Utilization
1) No Health Coverage
2) No Personal Doctor
3) No Checkup (2 yrs)
4) No Dental Visit (2yrs)
5) No Dr Visit Due to Cost
6) No Mammogram (2 yrs)
7) No Pap Test (3 yrs)
8) Late or No Prenatal Care
Social Determinants
1) Poverty
2) Median Household
Income
3) Gender Wage Gap
4) No High School Diploma
5) Single Parent Household
6) Residential Segregation
g g
CHART 7
Health Care Payments and Workforce Indicators
•
•
•
•
•
•
•
•
Physician
Ph
i i Diversity
Di
i Ratio
R i
Primary Care Health Professional Shortage Area
Mental Health Professional Shortage Area
Medicaid-to-Medicare Fee Index
Medicaid Income Eligibility for Working Parents
Medicaid Income Eligibility for Pregnant Women
Family Planning Funding
Abortion Access
– Includes whether the state has a mandatory waiting period for an
abortion, allows Medicaid funding of abortions, and the percent of
women living in counties with no abortion provider
CHART 8
Report Measures
• Disparity Score
The ratio of the rate of the indicator experienced
p
by
y
women of color to the rate of the indicator
p
byy White women.
experienced
– Disparity score > 1 means minority women fared worse
than White women
– Disparity score = 1 means minority women fared the same
– Disparity score < 1 means minority women fared better
than White women
CHART 9
Other Report Measures
• Dimension Score
– Average
g of indicator disparity
p y scores. Each
indicator was multiplied by the ratio of White
y,
women in the state to White women nationally,
and then averaged.
– States grouped according to score as:
• Better-than-average
• Average
• Worse-than-average
CHART 10
Disparities
p
were evident in every
y state,,
and on most indicators,
and
each p
population
p
group
g
p faced its own
particular set of challenges
CHART 11
Specific Indicators
• New AIDS case rate for women of color was more
than 11 times that of White women (26.4 per 100,000
,
)
vs. 2.3 pper 100,000)
– Average disparity in new AIDS case rate was more than 3.5
times larger
g than disparities
p
in any
y other indicator
• Uninsured rate for women of color was more than
t i th
twice
thatt off Whit
White women (28% vs. 13%)
• Rate
ate for
o noo high
g school
sc oo diploma
d p o a was more
o e than
t a three
t ee
times higher for women of color than for White
women (23% vs. 7%)
CHART 12
Challenges Faced by Racial and Ethnic Populations
• American Indian and Alaska Native women
women’ss outcomes
were among the worst on nearly all indicators
• Hispanic women consistently had problems with access to
and utilization of care
• Black women had among the worst rates for many
indicators of health and social determinants
• Asian American
American, Native Hawaiian and Other Pacific
Islander women had lower rates of preventive screenings
• White women had higher rates of smoking
smoking, cancer
mortality, psychological distress and no routine checkup
CHART 13
Small disparities are sometimes
the result of both White women
and women of color doing poorly
CHART 14
State-Level Disparity Scores and Prevalence of Cardiovascular
Disease for White Women
Higher Disparity Score, Lower Prevalence of
Cardiovascular Disease
Higher Disparity Score, Higher Prevalence of
Cardiovascular Disease
DC
1
2
ND
Disparity Score = 1.0
(No Disparity)
IL
MI
NH OH
CT
CAMT
CO SD
IN
NY NJ
KS
LA
DE
PA NC
VTHI
WIMA
OR
VA
RI
OK
MN NEIAWA AZ
MO FL AR MS KY
SC
MD
ME
NM ID AK
NV
TN TX
GA
AL
UT WY
4
WV
3
Lower Disparity Score, Lower Prevalence of
Cardiovascular Disease
Lower Disparity Score, Higher Prevalence of
Cardiovascular Disease
National Average for White
Women = 2.7%
CHART 15
Few states had consistent scores
across all three dimensions
CHART 16
Summary of Dimension Scores
• Only 4 states, Virginia, Maryland, Georgia and
Hawaii,, pperformed better-than-average
g on all 3
dimensions
• Six states, Montana, South Dakota, Arkansas,
Louisiana, Mississippi, and Indiana performed
worse-than-average on all three dimensions
CHART 17
Small disparities
p
in one dimension
do not necessarily correspond to
small disparities in other
dimensions
CHART 18
Small Disparities in One Dimension Do Not Always Correspond
with Small Disparities
p
in Other Dimensions
State
Health
Status
Access
Social
Determinants
Di t i t off C
District
Columbia
l bi
W
Worse
B tt
Better
W
Worse
Ohio
Worse
Better
Worse
Pennsylvania
Worse
Better
Worse
Texas
Better
Worse
Worse
Arizona
Better
Worse
Worse
Okl h
Oklahoma
W
Worse
W
Worse
B
Better
CHART 19
Phase II:
Understand the Causes of Disparities
and the Impact of State Policies
Disparities in Health and Access
CHART 20
Research Questions
• What is the relationship between disparities in
access and utilization and disparities in health
among?
• Do disparities in the social determinants of
health affect disparities in both access to and
the utilization of care,
care and health status?
• What is the impact of state policies on
disparities in health and access to care?
CHART 21
The Analysis Plan
• Use factor analysis to determine the relationship
between the indicators of each dimension.
• C
Construct a S
Structurall Equation
i Model
d l to ddetermine
i
the relationship between:
– Access and health
– Social determinants and access
• Use regression analyses that control for the social
determinants to see the affect of each policy variable
on access and utilization.
CHART 22
Policy Variables
Initial Policy Variables
• Physician Diversity Ratio
• Primary Care Health
P f i l Sh
Professional
Shortage
t
Area
A
• Mental Health Professional
Shortage Area
• Medicaid-to-Medicare Fee
Index
• Medicaid Income Eligibility
for Working Parents
• Medicaid
M di id Income
I
Eligibility
Eli ibili
for Pregnant Women
• Family Planning Funding
• Abortion Access
Additional Policy Variables
• Unemployment Benefits
– Avg. Weekly Benefit
– Annual Participation Rate
• Food Stamps
– Benefit
B fi A
Amount
– Participation Rate
• TANF
– Benefits/Median Income
– TANF Cases/Poor Children
CHART 23
Health Status Factor Solutions
Factor 1
(4.51)
Fair or Poor Health
0.92
Diabetes
0.77
Heart Disease
0.77
Obesity
0 68
0.68
Current Smoker
0.52
Factor 2
(1.53)
Factor 3
(1.41)
0.76
Unhealthy Days
0 78
0.78
Limited Activity Days
0.66
Cancer Mortalityy
0.85
New AIDS Cases
0.81
Low Birthweight
0.88
CHART 24
Access and Utilization Factor Solutions
Factor 1
(3.18)
N Health
No
H lth C
Coverage
0 77
0.77
No Dental Visit in Past Year
0.78
No Health Care Due to Cost
0 85
0.85
Late or No Prenatal Care
0.75
Factor 2
(2.13)
No Personal Provider
0.68
No Check-up in Past 2 Years
0.88
g
in Past 2 Years
No Mammogram
0.80
No Pap Test in Past 3 Years
0.73
CHART 25
Social Determinants Factor Solutions
Factor 1
(2.92)
Poverty
0 82
0.82
Median Household Income
0.77
Gender Wage Gap
0.61
No High School Diploma
0.74
Female Headed Households with
Children
0.78
Factor 2
(1.82)
Physician Diversity Ratio
0.82
Pi
Primary
C
Care
HPSA
0.74
Mental Health HPSA
0.62
CHART 26
The Best Laid Plans of Mice and (Wo)Men
Always Go Awry
CHART 27
Implications
• Disparities measurement
• Combining
C bi i measures to create iindices
di
• How
H ddo we llearn what
h t ddrives
i
what?
h t?
• Drivers of health vs
vs. drivers of disparities
• Data needs
CHART 28
Thank you!!