Health Disparities
Among Older People
Presentation for
Minnesota Gerontological Society
Webinar
October 19, 2009
LaRhae Knatterud, MAPA
Definition of Health Disparity
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“Differences in health status between a defined
portion of the population and the majority.
Disparities can exist because of socioeconomic
status, age, geographic area, gender, race or
ethnicity, language, customs and other cultural
factors, disability or special health need.” (MN Dept
of Health)
There is considerable dispute globally regarding
what is avoidable disparities and what is not, e.g.,
unequal access to clean air and water. U.S. tends
not to distinguish between these, and most
disparities are considered avoidable.
Factors in Health Disparities
Individual Factors
•Age
•Genetics
•Health behaviors
•Chronic illness
Community Factors
•Education
•Health care access
•Community norms
•Neighborhoods
System Factors
•Health care
•Local public health
•Social services
•Social, economic and health
systems
Approach to Measuring Disparity
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Most common method is to compare health
of one group defined as a reference group
with the health of other groups.
Examples of common measures of health
disparities for older people are:
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Life expectancy
Chronic disease prevalence and incidence rates
Utilization of health care services
Most Frequent Disparities Found
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For all ages, including the older population,
the most frequent disparities are in health
status and health care utilization for elders in
ethnic, immigrant and tribal communities.
While these non-white groups of elders are
still a small proportion of Minnesota’s 65+
population, they are growing.
Between 2000 and 2030, nonwhite elders will
grow from 2% to 7% of 65+ population.
Example of Health Disparity/Not
Cancer
 Breast cancer mortality rate in Minnesota is 50%
higher in black women than in white non-Hispanic
women even though the incidence rates are similar.
More black women have cancer diagnosed at a later,
less treatable stage.
Arthritis (Not considered a health disparity)
 Risk factors associated with increased risk are not
modifiable and include gender, age and genetic
predisposition.
Some Specific Disparities
in Minnesota’s Older
Population
Common Health Disparity Elements
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Disease rates
Obesity rates, physical activity rates and
tobacco use
Injury rates
Health insurance coverage rates
Health care utilization rates
Rates of mental health impairments
(Alzheimer’s)
Fall-related Injuries and Death
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By location – MN rural elders are more likely to be hospitalized
from falls than urban elderly (48.5% vs 44.44%)*
By gender – 70% of those treated for falls are older women,
30% are older men
By age group - patients aged 75 to 84 years old accounted for
the largest proportion of injurious fall-related ED visits among
the elderly (40.3 percent), followed by patients 85 years and
older (32.4 percent) and patients 65 to 74 years (27.3 percent).
By race - White elders are more likely to experience falls
Housebound status and living alone are risk factors
*Deaths from motor vehicle crashes are much higher in rural than urban Minnesota 25.8 vs 17.2 per 100,000
Health Care Access and Use
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By location –fewer rural elders say their health is
excellent than urban elders (22% vs 27%)
By gender – women use health care more than men
(true for all ages)
By age – access and use increase with age
By race – access and use is more limited for
nonwhite elders; in Medicaid, there are still access
and use issues tied to cultural competence
Health Literacy
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By gender – older men are more likely to have health literacy
issues than women
By race - up to 20 percent of Spanish-speaking Latinos do not
seek medical advice due to language barriers. Asians and
Hispanics often report difficulties understanding written
information from doctor's offices and instructions on
prescription bottles. Up to 40 percent of African-Americans
have problems reading
By education – two-thirds of elders 60+ have low to marginal
reading skills. Adults with poor literacy are likely to have three
times as many prescriptions filled as adults with higher literacy
Rates of Chronic Conditions
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By location – MN rural elders had higher mortality rates in all
top leading causes of death* than urban elders (926.2 vs 633.6
per 100,000)
By gender – men die at higher rates than women in all leading
causes of death
By race – death rates from top leading causes of death are
higher for African-American (40% higher for men and 20%
higher for women). While death rates for Hispanic, Asian and
Indian are lower than these, they experience higher mortality
from cancers due to later diagnosis and shorter survival
periods. Current and cumulative lifetime exposure to avoidable
and unavoidable risk factors and risk behaviors have major
impact on poor health outcomes
*Heart disease, cancer, stroke, injury and COPD
Alzheimer’s and Related Conditions
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Gender – women more likely than men because the live longer
than men (16% vs 11% of persons 71+)
Age – prevalence in older age groups is higher. 13% of
persons 65+ have Alzheimers, and 50% of those are 85+
Education – those with <12 yrs of education have 35% greater
risk of developing dementia than those with >15 yrs of
education
Race – African-Americans are reported to be more likely than
whites to have the disease, but further analysis shows that the
differences are largely explained by factors other than race
Source: http://alz.org/national/documents/report_alzfactsfigures2009.pdf
National and State
Resources
on Health Disparities of
Older People
National Report Card on Healthy Aging
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Provides state-by-state report card on 15
indicators of healthy aging
Examples include (and MN rankings are):
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health status (lower third in disability)
health behaviors (top in regular physical activity,
but lower third in obesity)
Preventive care and screening (best ranked state)
Injuries (lower third)
Minnesota Department of Health
Health Promotion and Chronic Disease Division
 http://www.health.state.mn.us/divs/hpcd
Eliminating Health Disparities Initiative (EHDI)
 http://www.health.state.mn.us/ommh
Behavioral Risk Factor Surveillance system (BRFSS)
 http://www.health.state.mn.us/divs/idepc/diseases/flu/brf
ssmn.html
Statewide Health Improvement Program (SHIP)
 http://www.health.state.mn.us/healthreform/ship
Data from Minnesota BRFSS
How is your general health? (2008)
Age
%
N
Excellent
Very
Good
Good
Fair
Poor
18 – 24
%
N
29.2
37
36.6
50
26.7
33
7.5
8
NA
25 – 34
%
N
26.5
89
44.6
179
22.1
89
5.3
24
1.4
4
35 – 44
%
N
22.9
155
45.3
301
25.6
162
4.5
34
1.7
14
45 – 54
%
N
21.2
201
41.4
374
26.1
239
7.8
78
3.6
29
55 – 64
%
N
16.8
157
38.9
357
28.2
254
11.4
109
4.8
49
65+
%
N
13.5
166
32.5
405
33.1
421
15
177
6
81
University of Minnesota
Health Disparities Working Group
 http://www.sph.umn.edu/faculty/research/hdwg
/training.html
 http://www.sph.umn.edu/faculty/research/hdwg
/home.html
Center on Aging/MN Chair in LTC and Aging
 http://www.hpm.umn.edu/coa
Minnesota Board on Aging and
Area Agencies on Aging
Chronic Disease Self- Management
 Partnership with MDH and local public health agencies
 Group education of older people at two-hour sessions
for six weeks to improve health literacy and provide
support as individuals learn better methods for selfmanagement
 Collecting data on improvement in health and change
in behaviors
 Working with older people in ethnic, immigrant and
tribal communities
Minnesota Board on Aging and
Area Agencies on Aging
“A Matter of Balance”
 Project to reduce fear of falling and increase
behaviors to reduce falling among older people
 Partnership between aging and local health networks
(and AoA/MBA and MDH)
 Trainers in all areas of state, including tribal
organizations, to train organizations serving older
persons in education and assessment of risk
Minnesota Dept of Human Services
Disparities and Barriers to Utilization Among Minnesota Health Care
Program Enrollees, describes findings based on a statewide
survey of 4,626 enrollees.
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About 7% of those surveyed were 65+ enrollees, many of whom
are members of ethnic, immigrant and tribal communities.
They reported their main problems with language, culture and
religion in the receipt of services, as well as worries that they
would not be able to afford services or services would not be
covered.
Strategies to address these issues include making programs and
related paperwork simpler and less complex to reduce
misunderstandings.
http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-5852-ENG
Minnesota Dept of Human Services
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Profiles of elders from ethnic, immigrant and
tribal communities enrolled in Minnesota
Senior Health Options indicate that less than
50% of elder enrollees speak English, and
that they speak 24 non-English languages.
There are many ways that cultural
differences require accommodations in how
care is delivered, what services are provided
or not provided, and how delicate or taboo
subjects are discussed.
Minnesota Dept of Human Services
Strategies that are successful in increasing access to
quality care
 Many experts are concluding that the model of
health care home is a very effective strategy for
providing quality health care to elders in ethnic,
immigrant and tribal communities.
 It allows key care providers to spend more time with
elder and focus on their special needs and their
unique cultural/religious situation.
 Primary prevention is effective strategy for whole
populations.
Hennepin County SHAPE
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SHAPE is a series of surveys collecting information on the
health of Hennepin County residents and factors that affect it.
More than 10,000 households in the county participated in the
SHAPE 2006 survey, providing information on 8,000 adults and
4,000 children.
SHAPE is a project of the Hennepin County Human Services
and Public Health Department, with University of Minnesota.
Interactive Adult Data Book is online and provide cross tabs on
results by 10 small geographic areas in the county and for
selected racial and ethnic groups.
Data is available for 1998, 2002 and 2006 surveys.
http://www.co.hennepin.mn.us and search for SHAPE.
Conclusions
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The most important determinant of health is
environmental conditions, followed by lifestyle.
Medical care ranks third as a determinant of health.
The chief underlying cause of health disparities is
increasingly understood to be social and economic
inequality; i.e., social bias, racism, limited education,
poverty, and related environmental conditions that
either directly produce ill health or promote
unhealthy behaviors that lead to poor health.
In order to reduce the occurrence of health
disparities, instead of just treating already high rates
of disease, preventive action must also occur at the
systems level.