Geronimus Arline T, Pearson Jay A, Linnenbringer Erin, Eisenberg Alexa K, Stokes Carmen, Hughes Landon D, Schulz Amy J
School of Public Health, University of Michigan.
Institute for Social Research, University of Michigan.
Milbank Q. 2020 Dec;98(4):1171-1218. doi: 10.1111/1468-0009.12484. Epub 2020 Nov 2.
Policy Points Despite 30 years of attention to eliminating population health inequity, it remains entrenched, calling for new approaches. Targeted universalism, wellness-based local development, and Jedi Public Health approaches that are community informed, evidence based, and focused on improving everyday settings and diverse lived experiences are important policy directions. State and federal revenue transfers are necessary to mitigate the harms of austerity and assure greater equity in fiscal and population health in places like Detroit, Michigan.
US population health inequity remains entrenched, despite mandates to eliminate it. To promote a public health approach of consequence in this domain, stakeholders call for moving from risk-factor epidemiology toward consideration of dynamic local variations in the physiological impacts of structured lived experience.
Using a community-based, participatory research approach, we collected and analyzed a unique data set of 239 black, white, and Mexican adults from a stratified, multistage probability sample of three Detroit, Michigan, neighborhoods. We drew venous blood, collected saliva, took anthropometric measurements, and assayed specimens to measure allostatic load (AL), an indicator of stress-mediated biological dysregulation, linking participants' AL scores and survey responses. In a series of nested Poisson models, we regressed AL on socioeconomic, psychosocial, neighborhood, and behavioral stressors to test the hypothesis that race/ethnicity and poverty-to-income ratio (PIR) are conceptually fluctuating variables whose impacts on AL are sensitive to structured lived experience.
White and Mexican Detroit participants with PIR < 1 have higher AL than counterparts nationally; black participants in Detroit and nationwide had comparable AL. Within Detroit, disparities by PIR were higher in whites than blacks, with no significant difference by PIR in Mexicans. The size of estimated effects of having PIR < 1 for whites is 58 percentage points greater than that of Mexicans and twice that of blacks.
Structurally rooted unobserved heterogeneity bias threatens the validity of independent main effects interpretations of associations between race/ethnicity, socioeconomic characteristics, or place and health. One-size-fits-all analytic or policy models developed from the perspective of the dominant social group insufficiently address the experiences of diverse populations in specific settings and historical moments; nor do they recognize culturally mediated protective resources residents may have developed against material and psychosocial hardship.
政策要点 尽管在消除人群健康不平等方面已关注了30年，但这种不平等现象仍然根深蒂固，需要新的方法。有针对性的普遍主义、基于健康的地方发展以及基于社区信息、以证据为基础且专注于改善日常环境和多样化生活经历的绝地公共卫生方法是重要的政策方向。州和联邦收入转移对于减轻紧缩政策的危害以及确保密歇根州底特律等地在财政和人群健康方面实现更大公平是必要的。
尽管有消除美国人群健康不平等的任务要求，但这种不平等现象仍然根深蒂固。为了在这一领域推广一种有成效的公共卫生方法，利益相关者呼吁从风险因素流行病学转向考虑结构化生活经历对生理影响的动态局部差异。
我们采用基于社区的参与性研究方法，从密歇根州底特律市三个社区的分层多阶段概率样本中收集并分析了239名黑人、白人及墨西哥裔成年人的独特数据集。我们采集静脉血、收集唾液、进行人体测量并检测样本以测量应激负荷（AL），这是一种应激介导的生物失调指标，将参与者的AL分数与调查回复联系起来。在一系列嵌套泊松模型中，我们将AL对社会经济、心理社会、社区和行为应激源进行回归，以检验种族/族裔和贫困收入比（PIR）是概念上波动的变量，其对AL的影响对应于结构化生活经历敏感这一假设。
PIR<1的底特律白人及墨西哥裔参与者的AL高于全国同类人群；底特律和全国范围内的黑人参与者的AL相当。在底特律市内，白人中PIR导致的差异高于黑人，墨西哥裔中PIR差异不显著。白人PIR<1的估计效应大小比墨西哥裔高58个百分点，是黑人的两倍。
结构根源的未观察到的异质性偏差威胁着对种族/族裔、社会经济特征或地点与健康之间关联的独立主效应解释的有效性。从占主导地位的社会群体视角开发的一刀切的分析或政策模型不足以解决特定环境和历史时刻中不同人群的经历；它们也没有认识到居民可能针对物质和心理社会困难所形成的文化介导的保护资源。
