SOPHE’s 23rd Annual

Virtual Advocacy Summit

#SOPHEAdvocacy2021
Ethnic Disparities in Overall Mortality Outcomes: Translating
Research to Action
By: Sri Banerjee MD, PhD, FACE, Jennifer S. Perkins, PhD, MPH, CHES, CSE, Vanessa Di-Felice, MD, MPH
October 13, 2021
Presentation Abstract
• Despite vast improvements in overall health for the general population, ethnic-racial
minorities still experience poorer health outcomes than their non-minority
counterparts. In this webinar, we will share original research findings from a nationally
representative dataset and provide concrete steps on how to transform original
research into actionable policy.
• We will explore how discrimination, residential segregation, and structural racism
continue to influence access and delivery of medical care through social determinants
of health from the context of Healthy People 2030.
• Also, we will share important findings pertaining to ethnic/racial mortality disparities.
For example, one of our important findings was that Non-Hispanic Black women
experience 2.5 times statistically significantly higher mortality than their White
counterparts.
Presentation Abstract (continued)
• We also found that similar disparities exist with obesity and pre-existing
cardiovascular disease leading to increased mortality in Non-Hispanic Black
individuals than White individuals.
• Through interactive audience engagement we will identify steps to address
disparities through policy implementation. Additionally, we will apply a concrete
adaptation of root cause analysis to identify sources of social disparities.
• We will also apply Health in all Policies framework in order to ensure that a
multisectoral approach is taken to address health disparities and empower
vulnerable populations.
• Approaches and perspectives are provided by a medical doctor and a
psychologist.
Objectives
• Analyze nationally representative datasets to explore DEI
principles
• Identify models to explain the process of DEI application
• Explain how social determinants of health can be used to
understand the effect of race on health outcomes 
• Apply Health in All Policies to convert academic research
to actionable policy 
Reflection Questions
Think of a time when you have
had a productive conversation
on diversity and public health
in a class discussion and
describe what contextual
factors (students, course topic,
faculty skills, etc.) made it
possible.
What are the greatest
challenges you have in
facilitating productive
conversations on diversity and
public health in your class
discussions?
 “When every person has the opportunity to
realize their health potential- the highest level
of health possible for that person - without
limits imposed by racial or structural
Health inequities. Health equity means achieving the
conditions in which all people have the
Equity opportunity to attain their highest possible
level of health.”

-Adopted from CDC Definition

Foundational Social
Determinants of Health
Framework • World Health Organization
• Commission on the Social
Determinants of Health
(CSDH) Framework
• Commission on Social
Determinants of Health.
(2010). A conceptual
framework for action on the
social determinants of
health. Geneva: World
Health Organization
Comparison of Definitions

Health Disparities Health Inequities

Differences in the incidence and prevalence of health Systematic and unjust distribution of social, economic, and
conditions and health status between groups based on: environmental conditions needed for health:
•Race/ethnicity • Unequal access to quality education, healthcare, housing,
•Socioeconomic status transportation, other resources (e.g., grocery stores, car
•Sexual orientation seats)
•Gender • Unequal employment opportunities and pay/income
•Disability status • Discrimination based upon social status/other factors
•Geographic location
•Combination of these
Comparison of Health Disparities Health Inequities Health Equity SDOH

Definitions Differences in the

incidence and
Systematic and unjust
distribution of social,
The opportunity for
everyone to attain his or her
Life-enhancing resources
whose distribution across
prevalence of health economic, and full health potential. populations effectively
conditions and health environmental conditions determines length and
status between groups needed for health. No one is disadvantaged quality of life.
based on: from achieving this potential • Food supply
• Race/ethnicity • Unequal access to because of his or her social • Housing
• Socioeconomic quality education, position or other socially • Economic relationships
status healthcare, housing, determined circumstance. • Social relationships
• Sexual orientation transportation, other • Transportation
• Gender resources (e.g., • Equal access to quality • Education
• Disability status grocery stores, car education, healthcare, • Health Care
• Geographic seats) housing, transportation,
location • Unequal employment other resources
• Combination of opportunities and • Equitable pay/income
these pay/income • Equal opportunity for
• Discrimination based employment
upon social • Absence of
status/other factors discrimination based
upon social
status/other factors
Health • Differences in the incidence and
prevalence of health conditions and
Disparities health status between groups, based on:
• Race/ethnicity

Categories- • Socioeconomic status

• Sexual orientation

ADDRESSING • Gender
• Disability status
• Geographic location
• Combination of these
 Black infant mortality
Non-Hispanic blacks/African Americans have 2.3 times the
infant mortality rate as non-Hispanic whites (CDC, 2020).

Existing Racial Black maternal mortality

Pregnancy Related Mortality Ratios (PRMR) for black women
Health with at least a college degree was 5 times as high as white
women with similar education (CDC, 2020).
Disparities
(Statistics) Prostate cancer mortality among Black men
Deaths from prostate cancer have dropped significantly in
recent decades among all men. However, Black/African-
American men are twice as likely as White men to die of
prostate cancer and continue to have the highest prostate
cancer mortality among all US population groups.
Search Strategy
Intersectionality
Intersectionality
Coined in 1989 by Kimberlé Williams
Crenshaw in a paper in 1989.
Intersectionality identifies multiple
factors of advantage and
disadvantage.
Analytical framework for
understanding how aspects of a
person's social and political identities
combine to create different modes of
discrimination and privilege.
Intersecting and overlapping social
identities may be both empowering
and oppressing
Healthy People Healthy people addresses public health
priorities by setting national objectives and
2030 tracking them over the decade.
Strategies for
Actionable DEI
Research
 Use Use a suitable DEI-related health model

Find Find dataset to conduct additional research

Actionable
Health
Research Identify an analytic technique that
Identify addresses DEI principles

Apply HP 2030 and HiAP to transform

Apply research into actionable policy
World Conference on Social Determinants of Health-Rio de Janeiro, Brazil, 19-21 October
2011

RIO POLITICAL DECLARATION ON SOCIAL DETERMINANTS OF HEALTH

To adopt better governance for health and development

To promote participation in policy-making and implementation
To further reorient the health sector towards reducing health
inequities
To strengthen global governance and collaboration
To monitor progress and increase accountability
Social Determinants of Health
Objectives
Reduce Reduce Increase
• Reduce the proportion of • Reduce the proportion of • Increase employment in
children with a parent or people living in poverty working-age people
guardian who has served (baseline) (baseline)
time in jail (No change)

Increase Reduce Increase

• Increase the proportion of • Reduce the proportion of • Increase the proportion of
children living with at least 1 families that spend more high school graduates in
parent who works full time than 30 percent of income college the October after
(baseline) on housing (baseline) graduating (baseline)

Increase
• Increase the proportion of
federal data sources that
include country of birth
(research)
Important datasets readily available for
DEI research
National Health and Nutritional Examination Survey

Behavioral Risk Factor Surveillance System

National Survey on Drug Use and Health

National Health Interview Survey

Social or Chronic
Factors

Principles of
Disease Condition
Systematic Effect
Modification
(PRISEM)
Framework
Health Outcome
 Principles of
Disease Condition
Systematic Effect
Modification
(PRISEM)
Framework
Health Outcome
 Principles of
Cardiovascular Systematic Effect
Disease Modification
(PRISEM)
Framework
Health Outcome
 Principles of
Cardiovascular Systematic Effect
Disease Modification
(PRISEM)
Framework
Areas of DEI research

Infectious Cardiovascula
Cancer
Disease r Disease

Environmental ….and many

Obesity
Health others
 Infectious Disease
Disparities
Ethnic Disparities in Chronic Hepatitis B Mortality Outcomes: African
Americans and Caucasians

Mortality among individuals living with chronic hepatitis B infection

continues to exceed that of uninfected individuals in a nationally
representative sample.  More specifically, individuals of African American
descent who have chronic Hepatitis B have higher 10-year mortality than
Caucasians with chronic Hepatitis B in comparison to their uninfected
counterparts.  African Americans are well known to have lower insurance
coverage rates and poorer access to care.

Presented at the 2021 International Hepatitis B Virus Conference in

Toronto, Canada
Ethnic Disparities in Chronic Hepatitis B Mortality Outcomes: African Americans and
Caucasians
Mortality among individuals living with chronic hepatitis B infection continues to exceed that of
uninfected individuals in a nationally representative sample.  More specifically, individuals of
African American descent who have chronic Hepatitis B have higher 10-year mortality than
Caucasians with chronic Hepatitis B in comparison to their uninfected counterparts.  African
Americans are well known to have lower insurance coverage rates and poorer access to care.

Presented at the 2021 International Hepatitis B Virus Conference in Toronto, Canada

Infectious Disease Disparities

Racial Differences in the Association Between Endocrine Disruptors and Obesity
In this diverse cohort, our research shows that high BPA levels lead to obesity. In addition,
Hispanic Americans experience increased obesity from BPA than other races. Improved
biomonitoring of BPA levels, increased surveillance efforts, and addressing issues with health
equity are needed to improve health outcomes.
Presented at the American College of Epidemiology in September 2021

Obesity Disparities
Long-term Cardiovascular Mortality Disparities by Race in US Adults
Over the age of 20, there is higher CVD-mortality in Non-Hispanic Black men (HR, 1.15; 95% CI, 0.91–2.05,
p > .05) and women (HR, 2.50; 95% CI, 1.56–3.99) than in their White counterparts even after controlling
for medical (obesity, CVD, diabetes) and demographic (education, age, food insecurity level, and poverty
level) variables.
In conclusion, Black Americans experience higher probability of death from cardiovascular disease in 10-
year follow-up than other races. Due to the chronicity of CVD, disparities are compounded over a long
period of time. The observed ethnic disparities in treatment and control, with the relative deficits
observed in Black Americans, are potentially due to ethnic differences in healthcare-seeking behaviors
and access to care. Policy considerations should address how to improve equitable screening and
prevention, as it pertains to race.
Accepted to present at the American Heart Association in November 2021 in Boston, MA

Cardiovascular Disease Disparities

Gender Disparities
Cardiovascular
Disease
Disparities
Gender Disparities
Long-term Cardiovascular Mortality Disparities by Race in US
Adults

Over the age of 20, there is higher CVD-mortality in Non-

Hispanic Black men (HR, 1.15; 95% CI, 0.91–2.05, p > .05) and
women (HR, 2.50; 95% CI, 1.56–3.99) than in their White
counterparts even after controlling for medical (obesity, CVD,
diabetes) and demographic (education, age, food insecurity
level, and poverty level) variables.

In conclusion, Black Americans experience higher probability of

death from cardiovascular disease in 10-year follow-up than
other races. Due to the chronicity of CVD, disparities are
compounded over a long period of time. The observed ethnic
disparities in treatment and control, with the relative deficits
observed in Black Americans, are potentially due to ethnic
differences in healthcare-seeking behaviors and access to care.
Policy considerations should address how to improve equitable
screening and prevention, as it pertains to race.

Accepted to present at the American Heart Association in

November 2021 in Boston, MA
Racial Disparities in the effect of Low Cognitive Function On All-Cause Mortality
Our research shows that low cognitive function leads to higher mortality. In addition, Hispanic
Americans experience poorer outcomes from low cognitive function than other races. Improved
identification of dementia, increased surveillance efforts, and addressing issues with health
equity are needed to improve survival.
Accepted to be presented at the World Congress of Neurology
11:30 AM-1:00 PM-October 6, 2021

Neurological Disease Disparities

Racial Disparities In The Influence Of Endocrine-Disrupting Chemicals On Hypertension-
Related Mortality In The US Adult Population
In conclusion, there was increased mortality outcomes among BPA (Bisphenol A)-exposed, Non-
Hispanic Black individuals experiencing hypertension than those individuals without
hypertension. Due to the chronicity of exposure among environmental hazards, social
disparities are compounded over a long period of time. Environmental exposures like BPA
should be monitored especially among vulnerable populations and thereby improve
hypertension-related health outcomes.
Accepted to be presented at the Hypertension conference for American Heart Association
in October 2021

Environmental Health Disparities

Depression and cancer-related mortality among Hispanic/Latino Americans in NHANES 2005-
2010
There is a significant relationship between poor mental health and cancer mortality among Latino adults.
Latino adults have a much stronger relationship between poor mental health and cancer mortality than Non-
Hispanic White adults. Consequently, Latino adults need better access to mental health services and cancer
health. Public health professionals should be made aware of cancer-related racial gaps and advocate for
reducing health disparities.

Mental Health Disparities

Cancer Disparities
Gender Modifies the Effect of Rheumatoid Arthritis on All-Cause Mortality
Prevalence of RA in this population was 1.9% among males and 2.8% among females. The mean
follow-up was 11.1 years. For all-cause mortality, the overall unadjusted hazard ratio (HR) of
rheumatoid arthritis to no rheumatoid arthritis was 2.89 (95% confidence interval [CI], 2.48-3.37, p
< 0.001). Adjusted HR was elevated, 1.34 (CI 1.04-1.73, p < 0.05), among female participants with
RA but closer to 1.0 (1.02 CI 0.83-1.25, p > 0.05) among male participants with RA, after controlling
for medical and demographic risk factors.
Accepted to be presented at the American College of Rheumatology conference for American Heart
Association in November 10 2021

Rheumatology Disparities
Obesity modifies the effect of sexual minority status in leading to increased mortality
According to our research, sexual minority status is associated with increased overall mortality. However,
the presence of obesity increases the strength of the association. Individuals with obesity and positive for
sexual minority (lesbian, gay, or bisexual status) status where found to have 2 times higher mortality than if
they were positive for obesity status and heterosexual status. The importance of intersectionality is
established through this principle where obesity stigma combines with sexual minority status.

Sexual Minority Disparities

             

  Male All Cause-Mortality     Female All Cause-Mortality (n=8,173)    

(n=15,878)

Variable HR 95% CI P-value HR 95% CI P-value Gender Disparities in

Rheumatoid Arthritis

Cardiovascular Diseasea
1.02

1.44
0.83-1.25

1.23-1.69
0.86

<0.001
1.34

1.69
1.04-1.73

1.39-2.04
0.03

<0.001
Rheumatoid Arthritis
Obesity 1.30 1.10-1.55 0.004 0.99 0.81-1.22 0.93 Table 1. Multivariable Cox Hazard Model
(Reference: BMI < 30)
for Rheumatoid Arthritis and all-cause
Diabetes 1.56 1.28-1.90 <0.001 1.55 1.23-1.96 <0.001
mortality after controlling for
Chronic Kidney Diseaseb 1.56 1.35-1.79 <0.001 1.63 1.34-1.98 <0.001 demographic and medical risk factors
stratified by gender.
Education            

Some High School 1.69 1.41-2.04 <0.001 1.37 1.11-1.67 0.003

a
Cardiovascular disease was defined by
High School Grad 1.47 1.28-1.69 <0.001 1.14 0.92-1.42 0.22
self-reported positive response to
congestive heart failure, stroke, angina,
Some College Reference Reference Reference Reference Reference Reference
coronary heart disease, or heart attack.
Age 1.08 1.07-1.08 <0.001 1.08 1.08-1.09 <0.001

Ethnicity            
b
Chronic Kidney Disease was ascertained
through the classification of Glomerular
Non-Hispanic White Reference Reference Reference Reference Reference Reference
Filtration Rate determined by the
Non-Hispanic Black 1.26 1.01-1.59 <0.001 1.19 0.97-1.47 0.09
Cockcroft-Gault equation.
Hispanic 0.98 0.78-1.23 0.68 1.07 0.78-1.45 0.68

Other 0.75 0.44-1.28 0.29 1.24 0.80-1.90 0.33

 •Cerdeña, J. P., Plaisime, M. V., & Tsai, J. (2020). From race-based to race-
Racism and Health conscious medicine: how anti-racist uprisings call us to act. The
Lancet, 396(10257), 1125-1128.
 The Implicit Association Test is frequently used to
measure the strength of automatic associations as
an index of implicit attitudes or unconscious biases

Implicit Bias Researchers have found many healthcare

practitioners to have implicit bias

One study showed that physicians whose IAT tests

revealed them to harbor pro-white implicit biases
were more likely to prescribe pain medications to
white patients than to Black patients
 Figure 1. Measures of racial discrimination: implicit and explicit.

Krieger N, Waterman PD, Kosheleva A, Chen JT, Smith KW, et al. (2013) Racial Discrimination &amp; Cardiovascular Disease Risk: My Body My
Story Study of 1005 US-Born Black and White Community Health Center Participants (US). PLOS ONE 8(10): e77174.
https://doi.org/10.1371/journal.pone.0077174
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0077174
Implicit Association Test
Healthy People 2030-Trend Directions

Healthy People
2030
HP 2030 to Action

01 02 03 04
Identify needs Set your own Find inspiration Monitor national
and priority targets and practical progress—and
populations tools use our data as a
benchmark
Anti-racist model being used for 2020 USPSTF—A Public Health Example
Windows of PROBLEMS

Opportunity
Policy Implementation
POLICIES

POLITICS
Alignment of problems, policies
and politics allows health
to come through

Alignment of problems, policies and politics in creating “windows of opportunity”

Source: Leppo K et al. (2013) Health in All Policies: Seizing Opportunities, Implementing Policies.
Finland, Ministry of Social Affairs and Health, p. 16.
 TIME STARTING POINT

Seizing
Windows of
WINDOW

OPEN

WINDOW CLOSED

Opportunity DRAWBACKS
Policy Implementation (2)
WINDOW

OPEN

MISSED
OPPORTUNITY WINDOW CLOSED

LONG-TERM
HEALTH POLICY
GOAL
“Windows of opportunity” in policy formulation and implementation
Source: Leppo K et al. (2013) Health in All Policies: Seizing Opportunities, Implementing Policies.
Finland, Ministry of Social Affairs and Health, p. 19.
Health in
All
Policies
Recent history of HiAP and international milestones
Alma-Ata Declaration on Primary Health Care
(1978)
Ottawa Charter for Health Promotion (1986)
International Conference on Health Promotion,
Adelaide (1988)
Adelaide Statement on
Health in All Policies (2010)
Rio Political Declaration on Social Determinants of
Health (2011)
UN General Assembly Resolution on the Prevention
and Control of Non-Communicable Diseases (2011)
Second Adelaide Statement on Health in All Policies
(2017 and updated in 2019)
HiAP promoted by international organizations, in
particular the WHO, and also promoted through the
CDC.
 Many of the determinants of health and health
inequities in populations have social, environmental,
and economic origins that extend beyond the direct
influence of the health sector and health policies.

Therefore, public policies and decisions made in all

Importance of sectors and at different levels of governance can have
HiAP a significant impact on population health and health
equity.

Health considerations need to be taken into account

in policy-making: opportunities for co-benefits.
 The HiAP Framework for Country Action provides countries
with a practical means of enhancing a coherent approach to
HiAP. The framework sets out six key components to
facilitate action on health and health equity:

HiAP 1. Establish the need and priorities for action across sectors
Framework of 2. Frame planned actions
Country-Level 3. Identify supportive structures and processes
Action 4. Facilitate assessment and engagement
5. Ensure monitoring, evaluation and reporting
6. Build capacity

Multisectoral
players seeking
synergies
 Complex policy issues are often
multifactorial

Action by a number of government agencies

Challenges of or institutions - working together is required
Multi-Sectoral
Action Communication – issues in finding a
common language

Siloed thinking, conflicting interests, power

imbalances
Policy Champions/Policy Entrepreneurs
Health considerations need to be taken into account in policy-making:
opportunities for co-benefits.

Policy champion: a person or team willing and

able to lead and manage the policy process.

Kingdon attributes policy entrepreneurs some vital resources:

• Claim to a hearing – possesses expertise
• Negotiating skills – political ‘know-how’
• Sheer persistence.
 Actionable Research requires creating a plan with
the “end in sight” since the final goal is policy

The SDOH is a suitable framework for completing

equity research
Conclusion
Secondary datasets can be analyzed using effect
modification to establish racial inequities regarding
various body systems

Health in All Policies is a robust approach to convert

research to policy with the application of policy
windows of opportunity
 References
Banerjee, S. & Huth, J. (2021). Racial Disparities In The Influence Of Endocrine-Disrupting Chemicals On Hypertension-Related Mortality In The US Adult Population.
Hypertension. Link to Paper.

Banerjee, S., & Firtell, J. (2017). Pedagogical models for enhancing the cross-cultural online public health learning environment.  Health Education Journal, 76(5), 622-631.
Link to Paper

Banerjee, S. and Firtell, J. (2018). Addressing Critical Multiculturalism in Online Education using a Poly-Framework Approach. In K. Milheim (Ed.), Cultivating diverse online
classrooms through effective instructional design (pp. 321-335). Harrisburg: IGI Global. doi: 10.4018/978-1-5225-3120-3.ch013

Banerjee, S. & Panas, R. (2016, July 15). Application of Pedagogical Models for Enhancing Cross-Cultural Online Learning Environment. Invited talk given at National Faculty
Meeting Walden University; Arlington, VA. Link to Presentation

Beyer, K. M., Laud, P. W., Zhou, Y., & Nattinger, A. B. (2019). Housing discrimination and racial cancer disparities among the 100 largest US metropolitan areas.  Cancer, 125(21),
3818-3827.

Carnethon, M. R., Pu, J., Howard, G., Albert, M. A., Anderson, C. A., Bertoni, A. G., ... & Yancy, C. W. (2017). Cardiovascular health in African Americans: a scientific statement
from the American Heart Association. Circulation, 136(21), e393-e423.

Forscher, P. S., & Devine, P. G. (2017). Controlling implicit bias: Insights from a public health perspective. PsyArxiv

Sakellariou, D., Anstey, S., Polack, S., Rotarou, E. S., Warren, N., Gaze, S., & Courtenay, M. (2020). Pathways of disability-based discrimination in cancer care.  Critical Public
Health, 30(5), 533-543.

Goff, D., Bertoni, A. G., Kramer, H., Bonds, D., Blumenthal, R. S., Tsai, M. Y., & Psaty, B. M. (2006). Dyslipidemia Prevalence, Treatment, and Control in the Multi-Ethnic Study of
Atherosclerosis (MESA). Gender, Ethnicity, and Coronary Artery Calcium, 113(5), 647-56.
Saul, H., Liu, L., & Meunier, F. (2018). Call for action to end discrimination against cancer survivors. Journal of Cancer Policy, 17, 1-3.
 Acknowledgements
We would like to thank John Monaco for assistance with editing. We would also like to thank all
of those along the way that made this work possible.
Thank
you!