Reminder

— 1st assignment due today

— Form a group
Heterogeneity among
Health Populations

Dr. Crystal Jiang

 Learning Objectives

— Increase knowledge of health disparities and the

context in which they exist
— Develop an understanding of health literacy and its
determinants
— Explore ways to audience segmentations in health
promotion
+

WHO (2009). Global health risks: mortality and burden of disease attributable to selected major risks
Health Disparity
— Its definitions vary
— Representative definitions include:

— Differences in the incidence, prevalence, mortality and burden of

diseases and other adverse health conditions that exist among
specific populations (NIH, 2011)
— Differences in health outcomes that are closely linked with social,
economic and environmental disadvantage (OMH, 2011)
— Health inequalities that are considered unnecessary, avoidable and
unfair/unjust (WHO, 2008)
— Key: differences in health status between one population
group in comparison to a more advantaged group
Distinctions to Make:
— Disparities in Health Care:
— Differences in the quality of health care

— Health Inequity:
— Equity in health implies that ideally everyone should have a fair
opportunity to attain their full health potential
— Health inequity reflects barriers to opportunity, usually as a
result of systemic, avoidable and unjust social and economic
policies and practices
Face of Health Disparities
— Although often interpreted with racial or ethnic disparities,
many dimensions of disparity exist
— If a health outcome is seen in a greater or lesser extent
between populations, there is disparity:
— Race or ethnicity
— Sex & sexual identity
— Age
— Socioeconomic status
— Geographic location
— Education & literacy
 Face of Health Disparities: Ethnicity
— American Indians and Alaska Natives

— Mortality rate from chronic liver diseases:

3 times higher than national level
— Infant mortality rate: twice
— STDs: 6 times higher
— Injury rate: 3 times higher
Face of Health Disparities: Sex
— POLL: Take a guess
Face of Health Disparities: Sex
Face of Health Disparities: Sex Orientation

LGBT groups have:

— • Higher rates of Substance Abuse
— • Higher rates of HIV and other STD
— • Low rates of mammography and Pap smear screening
— • Higher rates of unhealthy weight control/perception
— • Higher rates of smoking
— • Higher rates of depression / anxiety
— • Higher rates of violence victimization

Sources: American Association of Medicine

Face of Health Disparities: Sex Orientation

Why do such disparities appear?

 Face of Health Disparities: Age
— We have seen many examples of age-related disparities
— The elders are more vulnerable to chronic diseases and communicable
diseases
— Cognitive function usually declines with age
— Health disparities among racial, economic, geographic and linguistic
elders
— The elders in ethnic minorities: health insurance coverage and medical
access
Face of Health Disparities: SES &Location
Urbanization leads to changes in lifestyle and environments
Face of Health Disparities: Education
Education
— Better-educated people are healthier
— Health disparities across education groups increase
(Goldman & Lakdawalla, 2001)
— As the price of healthcare drops
— As the uses of technology increase in healthcare (same as the
effect of digital divide)

Why?
Relevant Reflection
— Claim A:
High medical care prices promote an unfair distribution of resources
by impeding access to care for the poor so policies seek to lower the
overall price of health care
— European or Canadian-style National Health Systems

— Claim B:
Universal health insurance or other blanket price subsidies for health
care can exacerbate health inequality so a better approach to limiting
disparities would emphasize subsidies that are targeted towards the
poor.
— US-style Medicaid Systems

Goldman & Lakdawalla (2001)

Face of Health Disparities: Health
Literacy
Health literacy:
— A constellation of skills, including the ability to perform
basic reading and numerical tasks required to function in the
health care environment (AMA)
— The ability to find, understand and use the health
information to take care of ourselves and to improve health
and wellbeing (CPHA)

Obtain Understand Use

 Obtain Understand Use

• Listening to • Understanding • Selecting over-

news about a doctors’ the-counter
health topic instructions medications
What is the difference between
LITERACY & HEALTH LITERACY?
— Mastering health literacy tasks requires the use of more
than one literacy skills simultaneously.

— Requires critical thinking skills

— Involves specialized vocabulary

— Everyone has difficulty understanding health information

at some time
— Unfamiliar or technical language
— Patient anxiety
— Amount of information
Face of Health Disparities: Health Literacy
— While individuals have shouldered more for self-
management, their health literacy unfortunately has not
increased as quickly.
— only 12% of adults have the health literacy skills required to
manage and prevent disease (NAAL)

— Health literacy skills are a stronger predictor of an

individual’s health status than age, income, employment
status, education level or racial/ethnic group
HEALTH CONSEQUENCES OF LOW HEALTH LITERACY
People with limited literacy skills face
greater challenges

— Older adults
— People with low income
— Minority populations
— People with limited education
Gaze path of a reader who does not have limited
literacy skills skimming a page

Source: Colter, A., &

Summers, K. (2014).
Gaze path of a user who has limited literacy skills
reading (and re-reading) every word.

Source: Colter, A., &

Summers, K. (2014).
Gaze path of a user with limited literacy skills reading
only the text that looks easy to read.

Source: Colter, A., &

Summers, K. (2014).
Practice Quiz
The Newest Vital Sign
 0 Circle the date of a medical appointment
Below Basic
on a hospital appointment slip. (101)

Give two reasons a person should be

Basic
tested for a specific disease, based on
information in a clearly written pamphlet.
(202)

Intermediate Determine what time a person can take a

prescription medication, based on
information on the drug label that relates
the timing of medication to eating. (253)

Proficient Calculate an employee’s share of health

insurance costs for a year, using a table.
(382)
500
Source: National Center for Education Statistics, Institute for Education Sciences
「中文健康識能評估 表」簡式量表 (developed by Taiwanese scholars）

Lee et al. (2012)

Health literacy depends on both
individual and systemic factors
— Communication skills of lay people and professionals

— Patients' health knowledge and health beliefs

— Culture

— Demands of the healthcare and public health systems

— Demands of the context and particular situation

Health literacy depends on both
individual and systemic factors
— Communication skills of lay people and professionals

— Include literacy skills (e.g., reading, writing, numeracy), oral

communication skills, and comprehension

— Health professionals may converse easily with colleagues in their

specialized field but find it difficult to communicate with
patients or the lay public.
Health literacy depends on both
individual and systemic factors
— Patients' health knowledge and health beliefs

— People with limited or inaccurate knowledge about the body

and the causes of disease may not:
— Understand the relationship between lifestyle factors (such as
diet and exercise) and health outcomes
— Recognize when they need to seek care

— Health information can overwhelm people with advanced

literacy skills
Health literacy depends on both
individual and systemic factors
— Culture

— Culture affects:
— How people communicate and understand health information
— How people think and feel about their health
— When and from whom people seek care
— How people respond to recommendations for lifestyle change
and treatment
Health literacy depends on both
individual and systemic factors
— Demands of the healthcare and public health systems

— Individuals need to read, understand, and complete many kinds

of forms in order to receive treatment and payment
reimbursement.

— Individuals need to know about the various types of health

professionals and services as well as how to access care.
Health literacy depends on both
individual and systemic factors
— Demands of the context and particular situation

— Health contexts are unusual compared to other contexts

because of an underlying stress or fear factor.

— Healthcare contexts may involve unique conditions such as

physical or mental impairment due to illness.

— Health situations are often new, unfamiliar, and intimidating.

 What can be done?
— Increase health literacy skills
— Health education

Source: http://www.uhn.ca/docs/HealthInfo/Shared%20Documents/Health_Literacy_for_Patients_and_their_Families.pdf
What can be done?
— Make health systems more sensitive and responsive to issues of
literacy
— readability and numerical concepts embedded in instructions
— use of relevant examples
— avoid using jargon
— older adults have shown to learn better from visual presentations
— pictorial and other visual
— touch screens

— Health Literacy Online

Face of Health Disparities
Health Disparities in Child Health

Lee et al. (2015)

Health Disparities in Child Health

Lee et al. (2015)

Health Disparities in Child Health

Lee et al. (2015)

What Do Health Disparities Mean for
Health Communication?

There is a Strong Need for Audience Segmentation

 Audience Segmentation
— Originated from marketing and audience research – a
necessary condition for public communication success

— The process of dividing people into more similar

subgroups based upon defined criterion

— Segments: smaller groups of the target market that

require unique and/or similar strategies.
Theory & Method in Segmentation
— What criteria are properly used to segment an
audience or market?
— A variety of techniques and strategies
— Little direction for preferred strategy
— Can’t apply every strategy in one intervention

— What’s needed: Identify subgroups that have

common similar determinants of behavior in
question
Slater, M.D. (1996). Theory and Method in Health Audience Segmentation. J
of Health Comm, vol. 1: 267-283.
 Bases to segment by:
• Self-efficacy
• Age • Perceived benefits/costs
• Income
• Stage of behavior change
• Sex
• Social norms
• Race
• Family size • Perceived threats

Objective Objective Inferred Inferred

general Behavioral general behavioral

• Access to health care • Personality

• Past behaviors • Lifestyle
• Distance to resources • Risk preferences
• Behavior of social networks • Values
• Media consumption
Computational Approach To Segmentation
Segmenting dietary behaviors
Segmentation Methods

— It is easy to segment audience by demographics

(education, race, income, gender, geography), but the
segmentations may not be that informative

— Inferred variables are more informative but harder to

measure

— Can start with demographic sub-groups and then further

subdivide by behavioral
Next Time （Oct.6）

— Group sign-up due

— Edgar & Volkman 2012