Abstract: This report describes a comprehensive national study of the community health worker (CHW) workforce. The 27-month research project utilized a survey of verified CHW employers in all 50 States, more in-depth interviews of employers and CHWs in 4 States, conducted a comprehensive review of the literature, and made national and State workforce estimates using databases from the Census and the U.S. Department of Labor, Bureau of Labor Statistics.
During the past decade, private insurers, business enterprises, and the Federal government, responding to the high cost of providing adequate health care to employees and the population at large, implemented or proposed changes in health care delivery and financing. Some of the factors contributing to the cost challenges included population changes, provider shortages, accelerating technological progress, and the increasing complexity of the health care system. Population projections have been predicting a large increase in the U.S. elderly population (estimated to be 87 million in 2050) and, due to higher fertility among minorities, an increase in population diversity and the size of younger cohorts of individuals from low-income families. These changes in the size, structure and diversity of the population have been and will be requiring a broader range of health services for entire families and communities. Cultural understanding, community health education, and translation services have been and will be increasingly needed for delivering effective care to families and communities that are often isolated and underserved. Additionally, many providers are in short supply and have been caring for increasingly large and diverse patient populations in regulated environments that discourage patient/provider interaction and continuity of care. The diffusion of new science and technology while offering encouraging solutions has not yet reached a scale large enough to outpace providers' shortages and the escalating cost of care. However, telemedicine and new methods of disseminating scientific information have been empowering individuals with less extensive clinical training but strong personal and community skills to become valuable members of established medical teams for improving access, patient communication and compliance, outreach, prevention, and early diagnoses in underserved communities.
These converging demographic and economic forces set the stage for the emergence of the community health worker workforce and its utilization in cost containment and cost-effective strategies aimed at providing health care to the underserved.
Abstract: Racial and ethnic disparities in health care in the United States have been well documented, with research largely focusing on describing the problem rather than identifying the best practices or proven strategies to address it. Methods: In 2006, the Disparities Solutions Center convened a one-and-a-half-day Strategy Forum composed of twenty experts from the fields of racial/ethnic disparities in health care, quality improvement, implementation research, and organizational excellence, with the goal of deciding on innovative action items and adoption strategies to address disparities. The forum used the Results Based Facilitation model, and several key recommendations emerged. Findings: The forum's participants concluded that to identify and effectively address racial/ethnic disparities in health care, health care organizations should: (1) collect race and ethnicity data on patients or enrollees in a routine and standardized fashion; (2) implement tools to measure and monitor for disparities in care; (3) develop quality improvement strategies to address disparities; (4) secure the support of leadership; (5) use incentives to address disparities; and (6) create a messaging and communication strategy for these efforts. This article also discusses these recommendations in the context of both current efforts to address racial and ethnic disparities in health care and barriers to progress.
Abstract: Policy makers are increasingly attending to the problem of racial and ethnic health disparities, but much of this focus has been on evidence of inequality in health care systems. This attention is important and laudable, but eliminating inequality in the health care system would be insufficient to eliminate racial and ethnic disparities and improve the health of all Americans. Social and economic factors, such as disadvantaged socioeconomic status, racism, discrimination, and geographic inequality shape virtually all risks for poor health. Interventions that focus solely on improving access to health care, or on reducing individual behavioral and psychosocial risks, therefore have limited potential to reduce racial and ethnic health disparities. The elimination of health disparities requires comprehensive, intensive strategies that address inequality in many sectors, including housing, education, employment, and health systems. These interventions must be targeted at many levels, including individuals and families, workplaces, schools, and communities.
Abstract: Addressing health disparities has been a national challenge for decades. The National Institutes of Health-sponsored Centers for Population Health and Health Disparities are the first federal initiative to support trans-disciplinary multilevel research on the determinants of health disparities. Their novel research approach combines population, clinical, and basic science to elucidate the complex determinants of health disparities. The centers are partnering with community-based, public, and quasi-public organizations to disseminate scientific findings and guide clinical practice in communities. In turn, communities and public health agents are shaping the research. The relationships forged through these complex collaborations increase the likelihood that the centers' scientific findings will be relevant to communities and contribute to reductions in health disparities.
Abstract: Community-based participatory research (CBPR) has emerged in the past decades as an alternative research paradigm, which integrates education and social action to improve health and reduce health disparities. More than a set of research methods, CBPR is an orientation to research that focuses on relationships between academic and community partners, with principles of co learning, mutual benefit, and long-term commitment and incorporates community theories, participation, and practices into the research efforts. As CBPR matures, tensions have become recognized that challenge the mutuality of the research relationship, including issues of power, privilege, participation, community consent, racial and/or ethnic discrimination, and the role of research in social change. This article focuses on these challenges as a dynamic and ever-changing context of the researcher-community relationship, provides examples of these paradoxes from work in tribal communities, discusses the evidence that CBPR reduces disparities, and recommends transforming the culture of academia to strengthen collaborative research relationships.
Abstract: Better-educated people are healthier, although the sources of this relationship remain unclear. Starting with basic principles of consumer theory, we develop a model of how health disparities are determined that does not depend on the precise causal mechanism. Improvements in the productivity of health care disproportionately benefit the heaviest health care users. Since richer patients tend to use the most health care, this suggests that new technologies--by making more diseases treatable, reducing the price of health care, or improving health care productivity--could widen socioeconomic disparities in health. An exception to this rule, however, is a simplifying technology, which can contract health disparities, since richer patients are more likely to invest effort in adhering to complex treatment regimens. We present a few empirical case studies to help illustrate the theoretical results. First, we show that a complicated treatment regimen (antiretroviral therapy for HIV) benefited well-educated patients disproportionately. In contrast, simplifying drugs for hypertension coincided with a contraction in cardiovascular disparities not seen in other diseases. Finally, nationally representative data suggest that there are wider disparities by education among the chronically ill populations--precisely the population one would expect to be the heaviest health care users.
OBJECTIVE: Our goal was to quantify the magnitude of energy imbalance responsible for the increase in body weight among US children during the periods 1988–1994 and 1999–2002.
METHODS: We adopted a counterfactual approach to estimate weight gains in excess of normal growth and the implicit "energy gap"—the daily imbalance between energy intake and expenditure. On the basis of Centers for Disease Control and Prevention growth charts, we constructed weight, height, and BMI percentile distributions for cohorts 2 to 4 and 5 to 7 years of age in the 1988–1994 National Health and Nutrition Examination Survey (N = 5000). Under the counterfactual "normal-growth-only" scenario, we assumed that these percentile distributions remained the same as the cohort aged 10 years. Under this assumption, we projected the weight and height distributions for this cohort at 12 to 14 and 15 to 17 years of age on the basis of their baseline weight-for-age and stature-for-age percentiles. We compared these distributions with those for corresponding age groups in the 1999–2002 National Health and Nutrition Examination Survey (N = 3091) 10 years after the 1988–1994 National Health and Nutrition Examination Survey. We calculated differences between the counterfactual and observed weight distributions and translated this difference into the estimated average energy gap, adjusting for increased total energy expenditure attributable to weight gain. In addition, we estimated the average excess weight accumulated among overweight adolescents in the 1999–2002 National Health and Nutrition Examination Survey, validating our counterfactual assumptions by analyzing longitudinal data from the National Longitudinal Survey of Youth and Bogalusa Heart Study.
RESULTS: Compared with the counterfactual scenario, boys and girls who were aged 2 to 7 in the 1988–1994 National Health and Nutrition Examination Survey gained, on average, an excess of 0.43 kg/year over the 10-year period. Assuming that 3500 kcal leads to an average of 1-lb weight gain as fat, our results suggest that a reduction in the energy gap of 110–165 kcal/day could have prevented this increase. Among overweight adolescents aged 12 to 17 in 1999–2002, results indicate an average energy imbalance ranging from 678 to 1017 kcal/day because of an excess of 26.5 kg accumulated over 10 years.
CONCLUSIONS: Quantifying the energy imbalance responsible for recent changes in weight distribution among children can provide salient targets for population intervention. Consistent behavioral changes averaging 110 to 165 kcal/day may be sufficient to counterbalance the energy gap. Changes in excess dietary intake (e.g., eliminating one sugar-sweetened beverage at 150 kcal per can) may be easier to attain than increases in physical activity levels (e.g., a 30-kg boy replacing sitting for 1.9 hours with 1.9 hours walking for an extra 150 kcal). Youth at higher levels of weight gain will likely need changes in multiple behaviors and environments to close the energy gap.
Abstract: This publication offers insight into the nature and extent of disparities in the Greater Cleveland area and describes economic and ethical reasons for expeditiously eliminating the injustice of health disparities. The publication outlines the causes of disparities, both nationally and in our region - personal and behavioral variables, lack of cultural competence, a disproportionately low number of minority health care professionals, financial barriers, lack of a "medical home," provider bias and inadequate access to quality health care. Insight into the effective use of health information technologies, which can help regional health care providers and health insurance companies identify factors that contribute to disparities in Northeast Ohio, is also provided.
Prescriptions for Change includes examples of ongoing regional efforts to eliminate disparities that can be expanded and replicated and provides recommendations for accelerating efforts to eliminate health disparities in Northeast Ohio. The recommendations are provided in sections, targeted to health care providers, researchers, insurance providers, local elected officials, grant makers and funders, secondary schools, colleges and universities, community organizations and regional business leaders.
Abstract: In the 2000 census, 36.4 million persons, approximately 12.9% of the U.S. population, identified themselves as Black or African American; 35.4 million of these persons identified themselves as non-Hispanic. For many health conditions, non-Hispanic blacks bear a disproportionate burden of disease, injury, death, and disability. Although the top three causes and seven of the 10 leading causes of death are the same for non-Hispanic blacks and non-Hispanic whites (the largest racial/ethnic population in the United States), the risk factors and incidence, morbidity, and mortality rates for these diseases and injuries often are greater among blacks than whites. In addition, three of the 10 leading causes of death for non-Hispanic blacks are not among the leading causes of death for non-Hispanic whites: homicide (sixth), human immunodeficiency virus (HIV) disease (seventh), and septicemia (ninth). This week's MMWR is the third in a series focusing on racial/ethnic health disparities. Eliminating these disparities will require culturally appropriate public health initiatives, community support, and equitable access to quality health care.
Abstract: Health disparities among racial and ethnic minorities are associated with poor health outcomes. African Americans bear a disproportionate amount of the burden of health disparities. The elimination of health disparities among the nation's racial and ethnic groups requires immediate action that the health care community cannot accomplish in isolation. Eliminating health disparities calls for new and non-traditional partnerships across diverse sectors of the community that include research initiatives using culturally competent and participatory action methodologies. While there is much evidence documenting health disparities in racial and ethnic groups, there is little evidence of successful interventions that address health disparities in African Americans. Furthermore, there is little direction for successful strategies for recruiting African Americans for participation in health disparities research. This article addresses important factors to consider when conducting research with low income African Americans based on the authors' research experience in health promotion and cancer detection and prevention. Strategies for successful conduct of research with low income African American populations are offered.
Abstract: Improving the health system can reduce the effects of health disparities, but it can do little to eliminate them. An upsurge in new research is documenting the impact of physical, social, and economic environmental factors: air quality, housing conditions, racism, relationship to community institutions, and neighborhood economic conditions, all of which affect health status over time. A combined focus on community and the policies that affect communities' environments presents opportunities for altering and ameliorating the underlying forces at the heart of the determinants of health. This Perspective presents examples of successful community involvement and policy change.
Abstract: The elimination of health disparities for African Americans requires culturally relevant, empirical knowledge, which in turn requires including African Americans in research studies. However, power-difference barriers and conceptual barriers continue to inhibit the recruitment of African Americans. The purpose of this article is to define and discuss certain barriers to the recruitment of African Americans into research studies and to present culturally and contextually sensitive strategies to overcoming these barriers. Power-difference barriers reflect unequal authority and often generate mistrust. Conceptual barriers reflect researchers' need for better understanding about African Americans. Effective strategies include collaboration with the community through a community advisory board and conducting community-based participatory action research. Also, integrating alternative conceptual frameworks with mainstream frameworks may reduce researchers' ideological assumptions about African Americans. To promote optimal recruitment of African Americans, researchers must be aware of power-difference barriers and conceptual barriers and move toward active collaboration with African American communities.
Abstract:As the nation's largest purchaser and regulator of health care, Medicare is positioned to be a leader in reducing racial and ethnic health disparities. Its leverage was demonstrated in 1966-the year of Medicare's inception-when hospitals desegregated as a condition for receiving Medicare reimbursement. Since then, Medicare has contributed to dramatic improvement in the health of the elderly and disabled minority population, although disparities between minority and white beneficiaries remain. A National Academy of Social Insurance study panel is exploring how Medicare could use its leverage to reduce disparities, for both its beneficiaries and the rest of the nation.
Abstract: Racial health inequality is related to socioeconomic status (SES), but debate ensues on the nature of the relationship. Using the US National Health and Nutrition Examination Survey I and the subsequent follow-up interviews, this research examines health disparities between white and black adults and whether the SES/health gradient differs across the two groups in the USA. Two competing mechanisms for the conditional or interactive relationship between race and SES on health are examined during a 20-year period for black and white Americans. Results show that black adults began the study with more serious illnesses and poorer self-rated health than white adults and that the disparity continued over the 20 years. Significant interactions were found between race and education as well as race and employment status on health outcomes. The interaction effect of race and education showed that the racial disparity in self-rated health was largest at the higher levels of SES, providing some evidence for the "diminishing returns" hypothesis; as education levels increased, black adults did not have the same improvement in self-rated health as white adults. Overall, the findings provide evidence for the continuing significance of both race and SES in determining health status over time.
Abstract: There has been an appeal to reduce health inequities by increasing community involvement and social capital. Poder es Salud/Power for Health is a community- based participatory prevention research project that seeks to address health disparities in the African American and Latino communities by enhancing community-level social capital. We provide specific examples of how this intervention uses community health workers and popular education to reduce language and cultural barriers and enhance community social capital. Although the communities share fundamental challenges related to health disparities, the ways in which the Latino and African American communities identify health concerns, create solutions, and think about social capital vary. Members of the project are working together to identify opportunities for cross-cultural collaboration.
Abstract: Health is unevenly distributed across socioeconomic status. Persons of lower income, education, or occupational status experience worse health and die earlier than do their better-off counterparts. This article discusses these disparities in the context of urban medical practice. The article begins with a discussion of the complex relationship among socioeconomic status, race, and health in the United States. It highlights the effects of institutional, individual, and internalized racism on the health of African Americans, including the insidious consequences of residential segregation and concentrated poverty. Next, the article reviews health disparities based on socioeconomic status across the life cycle, beginning in fetal health and ending with disparities among the elderly. Potential explanations for these socioeconomic-based disparities are addressed, including reverse causality (e.g., being poor causes lower socioeconomic status) and confounding by genetic factors. The article underscores social causation as the primary explanation for health disparities and highlights the cumulative effects of social disadvantage across stages of the life cycle and across environments (e.g., fetal, family, educational, occupational, and neighborhood). The article concludes with a discussion of the implications of health disparities for the practice of urban medicine, including the role that concentration of disadvantage plays among patients and practice sites and the need for quality improvement to mitigate these disparities.
Abstract: Disparities in U.S. health care result from a complex mixture of systemic quality and access problems intertwined with historic injury. The many dimensions of health disparities include race, ethnicity, socioeconomic status, and geography. It is critically important for policymakers to define the problem correctly so that our solutions address their intended goal-health security for all regardless of socioeconomic characteristics. Further, U.S. efforts to eliminate disparities must also be part of a broader effort to transform health care and thus must focus, first and foremost, on improving the quality of care delivered to the individual patient.
Abstract: Health disparities have dominated recent discourse among public health and medical researchers. Ever since the United States began to compile health statistics, differences in health status have been noted between majority and non-majority populations. Myriad approaches have been undertaken in an attempt to reduce or eliminate racial and ethnic disparities in health. However, the disparities continue to persist. We are at a point in our history where innovative strategies must be explored that will be more effective in addressing racial and ethnic disparities in health. In large part, health disparities exist as a result of inequitable distribution of goods, resources, services and power in America. We have learned that improvements in health cannot come about solely through primary and secondary interventions but rather through an examination of the availability of resources that would allow individuals to improve their health. The goal of this paper is to provide an overview of the contextual factors that affect health disparities, to integrate theory to address disparities and to provide recommendations to encourage systematic changes to eliminate health disparities. It is hoped that this paper will bring about a national discussion relating to addressing the real issues we face in reducing and ultimately eliminating health disparities.
Abstract: The community action model is a 5-step, community-driven model designed to build communities' capacity to address health disparities through mobilization. Fundamental to the model is a critical analysis identifying the underlying social, economic, and environmental forces that create health and social inequities in a community. The goal is to provide communities with the framework necessary to acquire the skills and resources to plan, implement, and evaluate health-related actions and policies. The model was developed in the context of tobacco-related health disparities. Concrete policy outcomes demonstrate the model's potential application to a wide variety of grassroots policy development efforts.
Abstract: Focus group methodology uses focused interviews to obtain information from individuals and interactions among individuals in a small group setting. In this article we share the insights we have gained from using focus group methodology in work with an under-served population of black menopausal women. This methodology holds promise for advancing our understanding of, and ultimately eliminating, health disparities. Included is a discussion of planning and facilitating the focus group, recruiting group members, collecting and analyzing the data and reporting the results. Throughout, we explain how we applied these principles and we conclude by sharing lessons learned from our study on menopause and midlife experiences in Black women.
BACKGROUND: Significant health disparities directly affect the African-American population. Most previous studies of disparities in access to and utilization of healthcare have focused on black-white differences rather than focusing on "within-group" analysis of African Americans.
OBJECTIVE: To tease out the differential effects of modifiable risk factors (such as health insurance, usual source of care, and poverty) from personal characteristics (age, gender, rural residence) on healthcare utilization within the African-American population.
METHODS: Secondary data analysis of 3462 records from African-American respondents to the 1999 Medical Expenditure Panel Survey (MEPS) Household File, a nationally representative survey of the civilian, noninstitutionalized U.S. population in 1999.
RESULTS: We found significant variation in the number of office visits, outpatient clinic visits, hospital discharges, days hospitalized, and fills of prescribed medication among 3462 African-American respondents who represent a U.S. population of 36,538,639 persons. Personal nonmodifiable characteristics such as age and gender were significantly related to healthcare utilization. Poverty and rural residence were also significantly correlated, but the strongest modifiable predictors of healthcare utilization for African-American persons in 1999 were whether or not individuals had health insurance and/or a usual source of care. Emergency department visits were the only form of care that showed remarkably little variation based on these modifiable risk factors.
CONCLUSIONS: The three modifiable factors of poverty, uninsurance, and having a primary care medical home have a dramatic effect on patterns of care for African-American patients and could be independently targeted for intervention.
Abstract: Research on the social determinants of health has increasingly sought to understand the relative importance of different features of socioeconomic status. Much of the ensuing debate has wavered between education and income, with recent research leaning increasingly toward income. This research has not, however, consistently explored interactions between different features of socioeconomic status and, in trying to understand the independent effects of different components of socioeconomic status, may have missed important features of socioeconomic position. With an eye toward examining how features of socioeconomic status combine and coalesce, this paper examines variation in the income-health association by level of education. Theories derived both from medical sociology and health economics suggest synergistic interactions between income and education, but they are unclear as to the direction and magnitude of these interactions. Results from two large and nationally representative data sets (the 1996-1997 Community Tracking Study and the 1972-2000 General Social Survey) indicate that the positive relationship between income and health varies substantially in both its strength and shape by level of education. Education improves health, and its effects are larger at lower levels of income. Moreover, education reduces the strength and curvature of the income- health relationship. Consequently, those with more education have better health for all levels of income, and fewer income-based disparities exist among the well educated than among the less well educated. The linear "gradient" relationship between income and health is, thus, more characteristic of groups with higher levels of education. Additional analyses indicate that these interactions existed in the United States in each of the last three decades. The results are discussed in light of theory regarding the perpetuation of health disparities, as well as current debates regarding the apparent incompatibility of distributive versus aggregative goals in health policy.
Abstract: In this article, the authors draw on the disciplines of sociology and environmental and social epidemiology to further understanding of mechanisms through which social factors contribute to disparate environmental exposures and health inequalities. They propose a conceptual framework for environmental health promotion that considers dynamic social processes through which social and environmental inequalities--and associated health disparities--are produced, reproduced, and potentially transformed. Using empirical evidence from the published literature, as well as their own practical experiences in conducting community-based participatory research in Detroit and Harlem, the authors examine health promotion interventions at various levels (community-wide, regional, and national) that aim to improve population health by addressing various aspects of social processes and/or physical environments. Finally, they recommend moving beyond environmental remediation strategies toward environmental health promotion efforts that are sustainable and explicitly designed to reduce social, environmental, and health inequalities.
OBJECTIVES: We examined a community-based participatory diabetes intervention to identify facilitators of and barriers to sustained community efforts to address social factors that contribute to health.
METHODS: We conducted a case study description and analysis of the Healthy Eating and Exercising to Reduce Diabetes project in the theoretical context of a conceptual model of social determinants of health.
RESULTS: We identified several barriers to and facilitators of analysis of social determinants of a community-identified disease priority (in this case, diabetes). Barriers included prevailing conceptual models, which emphasize health behavioral and biomedical paradigms that exclude social determinants of health. Facilitating factors included (1) opportunities to link individual health concerns to social contexts and (2) availability of support from diverse partners with a range of complementary resources.
CONCLUSIONS: Partnerships that offer community members tangible resources with which to manage existing health concerns and that integrate an analysis of social determinants of health can facilitate sustained engagement of community members and health professionals in multilevel efforts to address health disparities.
Abstract: The Strategic Plan for National Institutes of Health (NIH) Obesity Research is intended to serve as a guide for coordinating obesity research activities across the NIH and for enhancing the development of new efforts based on identification of areas of greatest scientific opportunity and challenge. Developed by the NIH Obesity Research Task Force with critical input from external scientists and the public, the Strategic Plan reflects a dynamic planning process and presents a multidimensional research agenda, with an interrelated set of goals and strategies for achieving the goals. The major scientific themes around which the Strategic Plan is framed include the following: preventing and treating obesity through lifestyle modification; preventing and treating obesity through pharmacologic, surgical, or other medical approaches; breaking the link between obesity and its associated health conditions; and cross-cutting topics, including health disparities, technology, fostering of interdisciplinary research teams, investigator training, translational research, and education/outreach efforts. Through the efforts described in the Strategic Plan for NIH Obesity Research, the NIH will strive to facilitate and accelerate progress in obesity research to improve public health.
Abstract: A state minority health policy report card may provide an important tool for evaluating and promoting state policies to reduce health disparities. This study develops criteria that can form the basis of such a state report card and assesses the performance of all fifty states on these measures. The results indicate wide variation among states, with geographic region being a significant predictor of performance on all four measures. Future research should be conducted on other predictors of state variation in minority health policy and connections between state policy and health outcomes for minorities.
Abstract: Racial disparities in mortality over time reflect divergent pathways to the current large racial disparities in health. The residential concentration of African Americans is high and distinctive, and the related inequities in neighborhood environments, socioeconomic circumstances, and medical care are important factors in initiating and maintaining racial disparities in health. Efforts are needed to identify and maximize health-enhancing resources that may reduce some of the negative effects of psychosocial factors on health. Health and health disparities are embedded in larger historical, geographic, sociocultural, economic, and political contexts. Changes in a broad range of public policies are likely to be central to effectively addressing racial disparities.