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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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slide1

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

overview
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

health disparities
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
health disparity populations
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.”

slide5

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
social determinates of health
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…”

a key social determinant of health
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

heart disease and stroke disparities gender race
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

infant mortality disparities race
Infant Mortality Disparities (Race)

http://www.cdc.gov/mmwr/pdf/other/su6001.pdf

the latino paradox
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

slide13

What is a Disparity in Healthcare?

Populations with Equal Access to Health Care

SOURCE: Gomes and McGuire, 2001, National Academy of Sciences

slide15

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

unequal access to health care services
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
unequal access to health care services1
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.”
slide18

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

percent of population aged 18 64 years with no health insurance by income us 1994 5
Percent of Population aged 18-64 Years with No Health Insurance by Income: US, 1994-5

Non-Hispanic White

Non-Hispanic Black

Hispanic

CDC

mental health in nc by race
Mental Health in NC by Race

How satisfied are you with your life?

BRFSS, 2009

slide29

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

slide30

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

slide31

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

slide32

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

slide33

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

slide34

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

slide35

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

more information
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

science of eliminating health disparities nih recommendations
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

eliminating health disparities
Eliminating Health Disparities

Kilbourne

Disparities are complex social problems requiring multifaceted responses

Require detecting, understanding and reducing the disparity

health disparities health reform
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

example of research address sd
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

nc tracs funding
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

community academic partnership grantee
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
other disparities tracs grantees
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)

references websites
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/