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Health Disparities and Achieving Health Equity in North Carolina Giselle Corbie-Smith, MD, MSc NC Translational and Clinical Sciences Institute Program on Health Disparities Sheps Center for Health Services Research University of North Carolina at Chapel Hill. www.tracs.unc.edu/community.

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  1. Health Disparities and Achieving Health Equity in North CarolinaGiselle Corbie-Smith, MD, MScNC Translational and Clinical Sciences InstituteProgram on Health DisparitiesSheps Center for Health Services ResearchUniversity of North Carolina at Chapel Hill www.tracs.unc.edu/community nctracs@unc.edu

  2. Overview Definitions and frameworks Define Social Determinates of Health (SDH) and implications for research Interventions to achieve health equity Discuss NC TraCS funding sources and priorities

  3. Health Disparities http://www.cdc.gov/mmwr/pdf/other/su6001.pdf • “Health disparities are differences in health outcomes between groups that reflect social inequalities.” • Often interchanged with health inequities • Disparities can exist by: • race/ethnicity • gender • education • income • geographic location • sexual orientation • disability status

  4. Health Disparity Populations significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates in the population as compared to the health status of the general population disparity in the quality, outcomes, cost, or use of healthcare services or access to or satisfaction with such services as compared to the general population.”

  5. Factors that Lead to Health Disparities • Social Inequalities • Educational opportunities • Job opportunities • Housing opportunities • Law enforcement paterns • Economic Inequalities • Environmental Injustices • Unequal Access to Health Care Services • Unequal Provision of Health Care Services

  6. Heuristic Model of Racial Disparities in Health Outcomes (adapted from Williams 1997)

  7. Social Determinates of Health http://www.who.int/ social_determinants/en/ “Social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities…”

  8. A Key Social Determinant of Health http://www.scribd.com/doc/7778732/Dr-David-Williams-on-Health-Disparities Socioeconomic Status (SES) is a measure of income, education, employment opportunities, and social influence It is one of the most powerful predictors of health… more than genetics, carcinogen exposure or smoking. Mortality gap between high and low SES is GREATER than the gap between smokers and non-smokers in America

  9. Heart Disease and Stroke Disparities (Gender & Race) Number of deaths and age-adjusted death rates* for coronary heart disease and stroke, by sex and race/ethnicity — National Vital Statistics System, United States, 2006 http://www.cdc.gov/mmwr/pdf/other/su6001.pdf

  10. Infant Mortality Disparities (Race) http://www.cdc.gov/mmwr/pdf/other/su6001.pdf

  11. The Latino Paradox Since the early 1980’s Latino birth outcomes have been equal or better than the birth outcomes of white women Despite population having less income, insurance and education Benefit attributed to healthier food and lifestyles while pregnant Effect diminishes with acculturation Ceballos

  12. Excess Hospitalizations(Income Disparities)

  13. What is a Disparity in Healthcare? Populations with Equal Access to Health Care SOURCE: Gomes and McGuire, 2001, National Academy of Sciences

  14. Potential Origins for Disparities in Healthcare Kilbourne

  15. Van Ryn, Michelle, “Research on the Provider Contribution to Race/Ethnicity Disparities in Medical Care.” Medical Care 40(1) I-140-151.

  16. Unequal Access to Health Care Services • Availability: physical presence of health services for potential users: • proximity • operating hours & service scope • Accessibility: the means that people have to obtain medical services • Financing • Transportation • Waiting time (to appt; in office) • Language barriers

  17. Unequal Access to Health Care Services • Acceptability: the extent to which services meet users’ value orientations. • Patient satisfaction. • “Cultural competence” • “Services denied, delayed or provided under adverse circumstances have serious and sometimes life-threatening consequences of an LEP person and generally will constitute discrimination on the basis of national origin, in violation of title VI.”

  18. Health Services Research Framework for examining disparities in health care quality. Source: Swift, D. Guidance for the National Healthcare Disparities Report, NAS, Washington DC 2002, p. 12

  19. Percent of Population aged 18-64 Years with No Health Insurance by Income: US, 1994-5 Non-Hispanic White Non-Hispanic Black Hispanic CDC

  20. Health Disparities Data:North Carolina

  21. % with Health Insurance in NC by Race BRFSS, 2009

  22. Mental Health in NC by Race How satisfied are you with your life? BRFSS, 2009

  23. Alcohol Abuse in NC by Race BRFSS, 2009

  24. Teen Pregnancy Rate in NC by Race

  25. N. C. Adult/Adolescent HIV New Disease Cases in 2009

  26. Social/Environmental • Racial Segregation • Social Cohesion/Social Capital • Income Disparity • Exposures (Social, Environmental,…) • Health Status Disparities • Morbidity & Mortality • Health Status [Self-report/ measured] • Functional Status Classical Epidemiology • Individual • Cultural • Socioeconomic • Biological & Clinical • Behavioral • Living Conditions HealthOutcomes Varying Patient preferencesHealth behavior Political Economy Health Care Continuity & Concordance • Health Care Disparities: • Access to Care • Structure of Care • Process of Care • Patient Satisfaction • Provider • Knowledge • Attitudes • Practice Patterns • Communication • Cultural Competence Varyingeffectiveness or style Varying resources constraints • System/Policy • Organization & staffing • Insurance • Supply & Distribution of Clinicians & other Resources CHERP Health Disparities Primer http://www.hypnoclients.com/inprogress/cherp/primer3.php

  27. Social/Environmental • Racial Segregation • Social Cohesion/Social Capital • Income Disparity • Exposures (Social, Environmental,…) • Health Status Disparities • Morbidity & Mortality • Health Status [Self-report/ measured] • Functional Status Classical Epidemiology • Individual • Cultural • Socioeconomic • Biological & Clinical • Behavioral • Living Conditions HealthOutcomes Varying Patient preferencesHealth behavior Political Economy Health Care Continuity & Concordance • Health Care Disparities: • Access to Care • Structure of Care • Process of Care • Patient Satisfaction • Provider • Knowledge • Attitudes • Practice Patterns • Communication • Cultural Competence Varyingeffectiveness or style Varying resources constraints • System/Policy • Organization & staffing • Insurance • Supply & Distribution of Clinicians & other Resources CHERP Health Disparities Primer http://www.hypnoclients.com/inprogress/cherp/primer3.php

  28. Social/Environmental • Racial Segregation • Social Cohesion/Social Capital • Income Disparity • Exposures (Social, Environmental,…) • Health Status Disparities • Morbidity & Mortality • Health Status [Self-report/ measured] • Functional Status Classical Epidemiology • Individual • Cultural • Socioeconomic • Biological & Clinical • Behavioral • Living Conditions HealthOutcomes Varying Patient preferencesHealth behavior Political Economy Health Care Continuity & Concordance • Health Care Disparities: • Access to Care • Structure of Care • Process of Care • Patient Satisfaction • Provider • Knowledge • Attitudes • Practice Patterns • Communication • Cultural Competence Varyingeffectiveness or style Varying resources constraints • System/Policy • Organization & staffing • Insurance • Supply & Distribution of Clinicians & other Resources CHERP Health Disparities Primer http://www.hypnoclients.com/inprogress/cherp/primer3.php

  29. Social/Environmental • Racial Segregation • Social Cohesion/Social Capital • Income Disparity • Exposures (Social, Environmental,…) • Health Status Disparities • Morbidity & Mortality • Health Status [Self-report/ measured] • Functional Status Classical Epidemiology • Individual • Cultural • Socioeconomic • Biological & Clinical • Behavioral • Living Conditions HealthOutcomes Varying Patient preferencesHealth behavior Political Economy Health Care Continuity & Concordance • Health Care Disparities: • Access to Care • Structure of Care • Process of Care • Patient Satisfaction • Provider • Knowledge • Attitudes • Practice Patterns • Communication • Cultural Competence Varyingeffectiveness or style Varying resources constraints • System/Policy • Organization & staffing • Insurance • Supply & Distribution of Clinicians & other Resources CHERP Health Disparities Primer http://www.hypnoclients.com/inprogress/cherp/primer3.php

  30. Social/Environmental • Racial Segregation • Social Cohesion/Social Capital • Income Disparity • Exposures (Social, Environmental,…) • Health Status Disparities • Morbidity & Mortality • Health Status [Self-report/ measured] • Functional Status Classical Epidemiology • Individual • Cultural • Socioeconomic • Biological & Clinical • Behavioral • Living Conditions HealthOutcomes Varying Patient preferencesHealth behavior Political Economy Health Care Continuity & Concordance • Health Care Disparities: • Access to Care • Structure of Care • Process of Care • Patient Satisfaction • Provider • Knowledge • Attitudes • Practice Patterns • Communication • Cultural Competence Varyingeffectiveness or style Varying resources constraints • System/Policy • Organization & staffing • Insurance • Supply & Distribution of Clinicians & other Resources CHERP Health Disparities Primer http://www.hypnoclients.com/inprogress/cherp/primer3.php

  31. Social/Environmental • Racial Segregation • Social Cohesion/Social Capital • Income Disparity • Exposures (Social, Environmental,…) • Health Status Disparities • Morbidity & Mortality • Health Status [Self-report/ measured] • Functional Status Classical Epidemiology • Individual • Cultural • Socioeconomic • Biological & Clinical • Behavioral • Living Conditions HealthOutcomes Varying Patient preferencesHealth behavior Political Economy Health Care Continuity & Concordance • Health Care Disparities: • Access to Care • Structure of Care • Process of Care • Patient Satisfaction • Provider • Knowledge • Attitudes • Practice Patterns • Communication • Cultural Competence Varyingeffectiveness or style Varying resources constraints • System/Policy • Organization & staffing • Insurance • Supply & Distribution of Clinicians & other Resources CHERP Health Disparities Primer http://www.hypnoclients.com/inprogress/cherp/primer3.php

  32. Social/Environmental • Racial Segregation • Social Cohesion/Social Capital • Income Disparity • Exposures (Social, Environmental,…) • Health Status Disparities • Morbidity & Mortality • Health Status [Self-report/ measured] • Functional Status Classical Epidemiology • Individual • Cultural • Socioeconomic • Biological & Clinical • Behavioral • Living Conditions HealthOutcomes Varying Patient preferencesHealth behavior Political Economy Health Care Continuity & Concordance • Health Care Disparities: • Access to Care • Structure of Care • Process of Care • Patient Satisfaction • Provider • Knowledge • Attitudes • Practice Patterns • Communication • Cultural Competence Varyingeffectiveness or style Varying resources constraints • System/Policy • Organization & staffing • Insurance • Supply & Distribution of Clinicians & other Resources CHERP Health Disparities Primer http://www.hypnoclients.com/inprogress/cherp/primer3.php

  33. More Information… “CDC Health Disparities and Inequalities Report — United States, 2011” A new report outlining over 20 types of disparities categorized by: Social Determinates of Health Health-Care Access Mortality Morbidity Behavioral Risk Factors http://www.cdc.gov/mmwr/pdf/other/su6001.pdf

  34. Interventions to address Health Disparities

  35. Science of Eliminating Health Disparities: NIH Recommendations Partnerships and collaborations are critical Need to build health disparity research capacity and expand training opportunities for new researchers Electronic and print media need to be partners for disseminating information about health disparities and related research findings

  36. Eliminating Health Disparities Kilbourne Disparities are complex social problems requiring multifaceted responses Require detecting, understanding and reducing the disparity

  37. Health Disparities & Health Reform Insurance benefits explanations must be culturally & linguistically appropriate Workforce development both to serve more minorities and to reduce educational cost barriers for minority healthcare professionals Government departments and grants to address disparities (gender, race, age, disability status, etc…) Prevention efforts including childhood obesity, primary care, dental care, family planning, and chronic disease programs Data collection to understand causes of health disparities Quality improvement and comparative effectiveness research

  38. Example of Research Address SD HOPE Works Interested in addressing obesity BUT, women struggling with finances could not buy healthier foods Created a business that makes conference bags AND disseminated health information in sew circles that make conference bags

  39. EBIs Addressing Health Disparities

  40. Funding

  41. NC TraCS Funding Awards 2,000, 10,000 & 50,000 grants Focus on one of the seven health priority areas identified by TraCS through a series of meeting with community groups obesity, chronic disease, mental health & substance abuse, injury & violence, health care delivery & access, cancer, and childhood & youth issues

  42. Community Academic Partnership Grantee • Social Support for Pregnant and Parenting Teens Using Internet and Cell Technology • Uses text messaging and online social networking for pregnant and parenting teens to reduce the risk of child maltreatment • A UNC-UNCG-YWCA-Community Partnership to decrease disparities in Women's and Children's Health in the Triad

  43. Other disparities TraCS grantees Addressing Racial Disparities in HPV Vaccine Acceptability Assessing Racial Disparities in Hospitalization Rates in North Carolina Kidney Disease Patients Eliminating Disparities in Delivery of Women's Preventive Health Care Project SEED (Screening and Education to Eliminate Disparities)

  44. Questions?

  45. References & Websites Journal Articles Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2007. Ceballos M, Palloni A. Maternal and infant health of Mexican immigrants in the USA: the effects of acculturation, duration, and selective return migration. Ethn Health. Aug 2010;15(4):377-396. Kilbourne AM, Switzer G, Hyman K, Crowley-Matoka M, Fine MJ. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health. Dec 2006;96(12):2113-2121. Websites http://rtips.cancer.gov/rtips/programDetails.do?programId=257161&topicId=102266&cgId=  http://rtips.cancer.gov/rtips/programDetails.do?programId=224488&topicId=102266&cgId=  http://rtips.cancer.gov/rtips/programDetails.do?programId=280192&topicId=102266&cgId= http://www.cdc.gov/mmwr/pdf/other/su6001.pdf http://www.conehealthfoundation.com/body_foundation.cfm?id=3242 http://www.scribd.com/doc/7778732/Dr-David-Williams-on-Health-Disparities http://www.who.int/social_determinants/en/

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