Nicole Johns of the Office of HIV Planning presented this updated version of the very popular "Where We Live Matters" to the Positive Committee on January 14, 2013.
1. WHERE WE LIVE MATTERS:
SOCIAL DETERMINANTS OF HIV RISK
Presented by
2. OUR PLACE DETERMINES OUR HEALTH
SOCIAL/
But all of POLITICAL /
these factors ECONOMIC
determine our DEMOGRAPHICS
ENVIRONMENT
place
INCOME
3. WHAT FACTORS IMPACT HEALTH?
• Genetics
• Access to medical care
• Health literacy
• Social networks
• Stress levels/coping mechanisms
• Income
• Social Stigma (racism, sexism, ageism, etc.)
• Education
• Safety/Violence
• Water, air, and soil quality
• Access to healthy foods
• Working conditions
• Transportation
8. WHO’S IN OUR SOCIAL NETWORK MATTERS
Individual risk is not determined by personal risk
behavior alone, but also the “pool” of disease in
their sexual/drug using networks
9. SOCIAL NETWORK DENSITY
Density – how many people in a network have had sexual
contact with each other
10. SORTING IN SOCIAL NETWORKS
Sorting – tendency of people with similar
characteristics (race, age, neighborhood) to
associate with one another and not others outside
the community
11. MIXING IN SOCIAL NETWORKS
Mixing – when someone has sexual contact with someone
outside their primary network
Concurrent partnerships – having more than one sexual
partner at a time
13. SEX RATIO IMBALANCE
Incarceration
Death by
Infant
accident and
mortality
homicide
More
women
than
men
14. PHILADELPHIA FACTORS - CONCURRENCY
Philly has the 4th highest incarceration rate in
the U.S. – 5.7 per 100 residents
Nearly 45% of African Americans have never
been married
Fewer than 10% of individuals living below the
poverty line are married
Philly has sex ratio of .82 for African Americans
(Nunn, Dickman, Cornwall, et. al 2011)
16. RACIAL/ETHNIC COMPOSITION
Philadelphia population: 1,526,006
White: 626,221 or 41.0 %,
46,893 Male & 66,239 Female below the poverty
level (2009)
Black: 661,839 or 43.4 %
79,976 Male & 111,335 Female below the
poverty level (2009)
Hispanic: 172,483 or 11.3%
31,600 Male & 37,799 Female below the poverty
level (2009)
Asian: 96,405 or 6.3%
Male 9,877 & 9,835 Female below the poverty
level (2009)
(US Census Data)
17. Northeast
Fairmont Airport
Park
Pennypack
Clark Park Park
Cobbs
Creek
Park
Phila Int.
Airport
18. BLACK POPULATION
19116
19116
19154
19154
19115
19115
19118
19118 19150
19150
19114
19114
19111
19111 19152
19152
19138
19138 19126
19126
19119
19119
19128
19128
19144
19144
m
n 19141
19141
19120
19120
19149
19149
19136
19136
19127
19127
19124 19135
19135
19124
19129
19129 19140
19140
19132
19132 19137
19137
19133
19133
19131
19131 19134
19134
19121
19121
19151
19151 19122
19122 19125
19125
19130
19130
19139
19139 19123
19123
19104 Legend
19104 19102
19102
19143
m
n
19103 19107
19103 19107
19106
19106 m
n La Salle, City Hall
19143 Airport
19146
19146
19147
19147 Runway
FCC
Parks
19142
19142 Rivers and Streams
19145
19145 tracts
19148
19148 BLACK POP %
0.07% - 4.44%
4.45% - 12.75%
12.76% - 32.4%
19112
19112
19153
19153 32.41% - 69.17%
69.18% - 94.44%
94.45% - 98.65%
Zip Code Boundaries
19113
19113
0 0.40.8 1.6 Miles
19. HISPANIC POPULATION
19116
19116
19154
19154
19115
19115
19118
19118 19150
19150
19114
19114
19111
19111 19152
19152
19138
19138 19126
19126
19119
19119
19128
19128
19144
19144
m
n 19141
19141
19120
19120
19149
19149
19136
19136
19127
19127
19124 19135
19135
19124
19129
19129 19140
19140
19132
19132 19137
19137
19133
19133
19131
19131 19134
19134
19121
19121
19151
19151 19122
19122 19125
19125
19130
19130
19139
19139 19123
19123
19104 Legend
19104 19102
19102
19143
m
n
19103 19107
19103 19107
19106
19106 m
n La Salle, City Hall
19143 Airport
19146
19146
19147
19147 Runway
FCC
Parks
19142
19142 Rivers and Streams
19145
19145 tracts
19148
19148 HISPANIC POP %
0.26% - 1.24%
1.25% - 1.88%
1.89% - 2.75%
19112
19112
19153
19153 2.76% - 4.22%
4.23% - 10.01%
10.02% - 88.49%
Zip Code Boundaries
19113
19113
0 0.40.8 1.6 Miles
20. WHITE POPULATION
19116
19116
19154
19154
19115
19115
19118
19118 19150
19150
19114
19114
19111
19111 19152
19152
19138
19138 19126
19126
19119
19119
19128
19128
19144
19144
m
n 19141
19141
19120
19120
19149
19149
19136
19136
19127
19127
19124 19135
19135
19124
19129
19129 19140
19140
19132
19132 19137
19137
19133
19133
19131
19131 19134
19134
19121
19121
19151
19151 19122
19122 19125
19125
19130
19130
19139
19139 19123
19123
19104 Legend
19104 19102
19102
19143
m
n
19103 19107
19103 19107
19106
19106 m
n La Salle, City Hall
19143 Airport
19146
19146
19147
19147 Runway
FCC
Parks
19142
19142 Rivers and Streams
19145
19145 tracts
19148
19148 WHITE / POP2000
0.28% - 2.41%
2.42% - 16.5%
16.51% - 45.3%
19112
19112
19153
19153 45.31% - 73.6%
73.61% - 90.16%
90.17% - 100%
Zip Code Boundaries
19113
19113
0 0.40.8 1.6 Miles
21. RACIAL/ETHNIC DISPARITIES
Compared with Whites, Black and Hispanics:
Generally
Earn less income and have less schooling
At the same educational level, have lower
incomes
At the same educational/income level, are
more likely to have grown up in disadvantaged
circumstances
At a given income level
Have less wealth (all earnings, properties,
investments)
Live in unstable neighborhoods
(RWJF 2011)
22. RACIAL SEGREGATION AND SOCIAL
FACTORS
Race may help determine place, but people of
different ethnic/racial groups experience similar
health outcomes in severely disadvantaged
neighborhoods
Segregation is the primary cause of racial
differences in socio-economic status (SES)
The worst urban context in which Whites live is
better than the average context for Black
communities.
23. EDUCATIONAL ATTAINMENT
Educational attainment affects health through:
Health knowledge
Employment and income
Sense of control
Social networks
People with more education are more likely to:
Live longer
Experience better health outcomes
Practice health-promoting behaviors
Have close friends on whom they can rely
Have greater family stability and supportive
marriages
24. LESS THAN HIGH SCHOOL, MALES > 25, 2010
19116
19116
19154
19154
19115
19115
19118
19118 19150
19150
19114
19114
19111
19111 19152
19152
19138
19138 19126
19126
19119
19119
19128
19128
19144
19144
m
n 19141
19141
19120
19120
19149
19149
19136
19136
19127
19127
19124 19135
19135
19124
19129
19129 19140
19140
19132
19132 19137
19137
19133
19133
19131
19131 19134
19134
19121
19121
19151
19151 19122
19122 19125
19125
19130
19130
19139
19139 19123
19123
19104 Legend
19104 19102
19102
19143
m
n
19103 19107
19103 19107
19106
19106 m
n La Salle, City Hall
19143 Airport
19146
19146
19147
19147 Runway
FCC
Parks
19142
19142 Zip Code Boundaries
19145
19145 Rivers and Streams
19148
19148 tracts
M12THGNL / POP2010
0%
0.01% - 5.85%
19112
19112
19153
19153 5.86% - 8.1%
8.11% - 10.73%
10.74% - 13.17%
13.18% - 56.79%
19113
19113
0 0.40.8 1.6 Miles
25. LESS THAN HIGH SCHOOL, FEMALES >25, 2010
19116
19116
19154
19154
19115
19115
19118
19118 19150
19150
19114
19114
19111
19111 19152
19152
19138
19138 19126
19126
19119
19119
19128
19128
19144
19144
m
n 19141
19141
19120
19120
19149
19149
19136
19136
19127
19127
19124 19135
19135
19124
19129
19129 19140
19140
19132
19132 19137
19137
19133
19133
19131
19131 19134
19134
19121
19121
19151
19151 19122
19122 19125
19125
19130
19130
19139 19123
19123
19139 Legend
19104
19104 19102
19102
19143
m
n
19103 19107
19103 19107
19106
19106 m
n La Salle, City Hall
19143 Airport
19146
19146
19147
19147 Runway
FCC
Parks
19142
19142 Zip Code Boundaries
19145
19145 Rivers and Streams
19148
19148 tracts
F12THGNL / POP2010
0%
0.01% - 6.54%
19112
19112
19153
19153 6.55% - 10.07%
10.08% - 13.21%
13.22% - 16.73%
16.74% - 37.5%
19113
19113
0 0.40.8 1.6 Miles
26. POVERTY AND CHRONIC STRESS
Poverty/near poverty is
often stressful because so
much time/energy devoted
to daily tasks and securing
necessities
Stress can lead to harmful
coping mechanisms like
smoking, drug use and
risky sex
27. THE GAP WIDENS
Between 2005 and 2009 the average net worth
of households decreased considerably:
• Fell by 16%
Whites • From $134,992 to $113,149
• Fell by 53%
Blacks • From $12,124 to $5,677
• Fell by 66%
Hispanics • From $18,359 to $6,325
(Woolf & Braverman, 2011)
30. LINKS BETWEEN VIOLENCE AND HEALTH
Violence can affect health-related behaviors
Violence-related stress may lead to poorer health
Violence can influence health through its impact
on social and economic conditions
Health
Violence
(RWJ, 2011)
31. ASSAULTS – DOMESTIC, 2011
19116
19116
19154
19154
19115
19115
19118
19118 19150
19150
19114
19114
19111
19111 19152
19152
19138
19138 19126
19126
19119
19119
19128
19128
19144
19144
m
n 19141
19141
19120
19120
19149
19149
19136
19136
19127
19127
19124 19135
19135
19124
19129
19129 19140
19140
19132
19132 19137
19137
19133
19133
19131
19131 19134
19134
19121
19121
19151
19151 19122
19122 19125
19125
19130
19130
19139
19139 19123
19123
19104
19104 19102
19102
19143
m
n
19103 19107
19103 19107
19106
19106
19143
19146
19146
19147
19147 Legend
Assault-Domestic
19142
19142
19145
19145 19148
19148
m
n La Salle, City Hall
Airport
Runway
19112
19112
19153
19153 FCC
Parks
Rivers and Streams
19113
19113
Zip Code Boundaries
0 0.40.8 1.6 Miles
32. ASSAULTS, 2011
19116
19116
19154
19154
19115
19115
19118
19118 19150
19150
19114
19114
19111
19111 19152
19152
19138
19138 19126
19126
19119
19119
19128
19128
19144
19144
m
n 19141
19141
19120
19120
19149
19149
19136
19136
19127
19127
19124 19135
19135
19124
19129
19129 19140
19140
19132
19132 19137
19137
19133
19133
19131
19131 19134
19134
19121
19121
19151
19151 19122
19122 19125
19125
19130
19130
19139
19139 19123
19123
19104
19104 19102
19102
19143
m
n
19103 19107
19103 19107
19106
19106
19143
19146
19146
19147
19147 Legend
Assaults
19142
19142
19145
19145 19148
19148
m
n La Salle, City Hall
Airport
Runway
19112
19112
19153
19153 FCC
Parks
Rivers and Streams
19113
19113
Zip Code Boundaries
0 0.40.8 1.6 Miles
33. HOMICIDES, 2011
19116
19116
19154
19154
19115
19115
19118
19118 19150
19150
19114
19114
19111
19111 19152
19152
19138
19138 19126
19126
19119
19119
19128
19128
19144
19144
m
n 19141
19141
19120
19120
19149
19149
19136
19136
19127
19127
19124 19135
19135
19124
19129
19129 19140
19140
19132
19132 19137
19137
19133
19133
19131
19131 19134
19134
19121
19121
19151
19151 19122
19122 19125
19125
19130
19130
19139
19139 19123
19123
19104
19104 19102
19102
19143
m
n
19103 19107
19103 19107
19106
19106
19143
19146
19146
19147
19147
19142
19142 Legend
Homicide 2011
19145
19145 19148
19148
m
n La Salle, City Hall
Airport
Runway
19112
19112
19153
19153 FCC
Parks
Rivers and Streams
Zip Code Boundaries
19113
19113
0 0.40.8 1.6 Miles
34. Unemployment
High
Incarceration STI
rates
Low income
36. STIS AND HIV
CDC identified higher HIV prevalence among
heterosexual individuals who had previously
received an STI diagnosis (4.0%) vs. those who
did not (1.7%)
Transmission and acquisition of HIV may be
increased up to 10 times by the presence of other
sexually transmitted infections
38. HIV IN PHILADELPHIA
25,563 people are living with HIV/AIDS in the
Philadelphia 9 county region, almost 75% of
those live in Philly
Estimated another 5,000 HIV+ people are not
aware of HIV+ status
Philly’s HIV incidence rates are 4 times national
average
It is estimated that 2% of African Americans in
Philly are HIV+
39. 2009 ESTIMATE OF HIV
INCIDENCE - PHILADELPHIA
Local estimate of 941 new HIV infections in 2009
in adults and adolescents (95% CI, 659 – 1,222)
Case rate of 76.8 new HIV infections per 100,000
population
4 times the national rate
90% increase in incidence among youth, 13-24
between 2006 to 2009
Driven by increases in young, black, MSM
40. Mistrust
of Health
Care
System
Social
Inequality
Historic and Modern
Inequality
Increased
Risk of HIV
and STD
Drug
and
Alcoho
l
Abuse Unprotecte
d Sex
Unsafe/
Unstable Concurrent
Incarceration
Neighborhoods
Partnerships
(Advocates for Youth, 2008)
41. NEIGHBORHOOD CHARACTERISTICS AND
HIV
Philadelphia neighborhoods with high rates of
HIV (GENERALLY) have these characteristics:
Low socio-economic status
High concentration of Black/African American
residents
High death rates due to
homicide, AIDS, septicemia or other illness
High birth risk
High neighborhood instability
High crime rates of multiple types
42. INCOME AND HIV
Poverty is associated with an increase in risk
behaviors
CDC found HIV prevalence associated with
socioeconomic status:
Prevalence higher among those :
With less than high school education* (2.8%)
Incomes at or below poverty* (2.3%)
Unemployed *(2.6%)
Homeless (3.1%)
*statistically significant differences
45. ADDITIONAL RESOURCES
Office of HIV Planning – Epidemiological profile
and Geographic Risk Analysis
http://www.hivphilly.org/documents.html
CDC:
http://www.cdc.gov/socialdeterminants/
World Health Organization:
http://www.who.int/social_determinants/en/
Robert Wood Johnson Foundation
Vulnerable Populations Portfolio
www.rwjf.org/vulnerablepopulations
Notes de l'éditeur
Concurrent relationships provide for different needs. Main partners offer emotional support and companionship while non-main partners may offer financial, housing or other supports.Among low income African Americans, concurrency is perceived as the norm.Lack of trust in partners, main and non-main also influenced concurrencyTrust also impacts condom use. Condoms more likely to be used with non-main partners.Lack of trust in community, affect marital decisions and concurrent partnerships. Lack of trust is related to lack of social capital in the community. High crime rates, low marriage rates and high poverty rates are associated with low levels of neighborhood social capital, low socioeconinomic status and poor health outcomes.Substance use
661, 839 42.7%
11.15% or 172,483 Asians are 96,405 6.23% Nat amer a little less than 7,000
40.47 or 626,211
Total male 719,813 >25=446,524
Female 806,193 > 25 621,028
Poverty is not a social driver, per se. It is the context in which people are poor that can lead to relational patterns resulting in forms of sexual networking that can spread HIV Earlier onset of sexual activity occasional transactional sex
574,413 total households for whom income was determined.16.8% <$10,0008.4 10 to 14,99913.8 15 to 24,99916.2 50 to 74,999Median household income $34,40027.9% social security10.7% SSI22.1 some public assistance including food stamps39.7 public health insuranceEmployed –no health ins. 17%Unemployed –no health ins 46.1%21.3% of all families below poverty level31.3 Poverty children under 18, 27% with children under 5
There were 68,550 or 11.4 total female headed households with their own children present.Total households 599,736
1151
7636
391
Black population total 661, 839 = a little over 13,000
Social drivers are understood not as unilateral variables that can be studied adequately in terms of causal, one-to-one relationships between any of them and HIV infection outcomes….they are interactive phenomena reflective of social and cultural processes, institutional practices, and sets of arrangements that facilitate HIV transmission or its prevention.Social drivers are complex, fluid, non-linear,and contextual, and they interact dynamically with biological, psychological, behavioral and other social factors
The CDC reported august of 2011 in the mmwr that there is an association between poverty and risk behaviors.