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Appendix D
Community Approaches to Addressing Health Disparities
Carol Horowitz, M.D., M.P.H.1 Edward F. Lawlor, Ph.D.2
INTRODUCTION
A major national enterprise has grown up since the Institute of Medicine (IOM) report devoted to documenting health disparities; understanding their clinical, service, and social determinants; and mounting specific projects that address particular combinations of health status and racial and ethnic populations. This work has given extraordinary visibility to the existence of significant and stubborn disparities and mobilized an impressive number of university centers, provider groups, and community partners. Significant federal and private foundation funding has mapped onto this agenda. A great deal of innovation and adaptation has been spawned in this field, most notably the establishment and federal support for a broad body of community-based participatory research. Important state policy initiatives, such as the recently enacted Massachusetts Health Reform, have specific governance and accountability for disparities reductions.
Despite the number and variety of health disparities initiatives, there is growing restlessness that this enterprise is not yielding effective and scalable approaches and, most importantly, evidence of significant outcomes (Lurie and Fremont, 2006). For example, the Centers for Disease Control and Prevention’s (CDC’s) recent interim report on Healthy People 2010 worried that among the 195 disparities objectives there has only been
1
Assistant Professor, Departments of Health Policy and Medicine, Mount Sinai School of Medicine.
2
Dean and the William E. Gordon Professor, George Warren Brown School of Social Work, Washington University in St. Louis.
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measurable improvements in 24 categories, declines in 14, and no change in 157 (CDC, 2007).
A number of concerns underlie this restlessness:
Many initiatives do not embody the kind of community voice, support, and participation that is necessary for sustainable long-term results.
Many initiatives are divorced from other significant community-development strategies that have the potential to influence the known determinants of health disparities (e.g., housing, safety, education, and civic engagement).
Many initiatives are not built on a platform of governance, management, and adequate stable financing that assures a continuity of response from prevention, to early detection, to treatment, and to evaluation.
In simple terms, these initiatives have developed along two different paths. One broad approach to disparity reduction involves essential clinical services and interventions, generally developed by health status or diagnostic categories and supported by categorically clinical funding streams. Thus, a huge number of specific health disparities programs have emerged to address asthma, diabetes, breast and cervical cancers, cardiovascular disease, and other conditions. These programs have the advantage of being targeted to known disparities, can be tailored to provider and community resources, and have the potential to pursue evidence-based strategies. Often these programs are mounted by academic medical centers, health systems, or other provider organizations.
At the other end of the spectrum, an alternative set of community programs and policies proceed instead to address the socioeconomic “fundamentals” of community development and health. These initiatives, generally not on the radar of disparities researchers, are designed to enhance the strengths and assets that already exist in communities; to increase human, physical, and social capital; and to navigate complex processes of economic change (such as gentrification) in communities. These programs fall under the rubric of community building, community economic development, comprehensive community collaborations, and others in the so-called community-development field. Examples include the Local Initiative Support Corporation (LISC) and Community Builders.
For our purposes, however, many of these community-development approaches have significant health aspirations (sometimes explicit and sometimes implicit), often command huge investments and resources, as well as involve the same institutions—churches, schools, hospitals—and community leaders as community-based disparities programs. There is
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much to be learned about the overall impacts of these approaches, as well as their specific health consequences.
The thesis of this review for the IOM is that the “action” in community approaches to addressing health disparities lies in better understanding, design, and implementation of “hybrid” approaches to community development and health disparities. We define hybrid approaches as those derived from a combination of clinical, community, and other heterogeneous sources such as public health and policy. The best of these approaches have the virtue of empowering and mobilizing community resources and residents, but at the same time implementing systematic, sustainable, and clinically sound approaches to health behavior, screening, prevention and promotion, and treatment. Admittedly, the knowledge base for this assertion is thin; in fact, we believe one of the key frontiers in this field lies in creating an evidence-based approach, yielding results for community development that build off of the knowledge base about both community and health disparities that is more purposeful about evaluation and accomplishes better sharing and translation of information across disciplines and stakeholders.
DISPARITIES IN A COMMUNITY CONTEXT
Although many concepts and constructs of community abound, this paper treats communities as largely geographical or spatial units, though only as the best proxy for capturing a set of social relations and social institutions.3 This means that we are largely concerned with so-called place-based approaches to health disparities and aligned with the literature on neighborhood or area effects on health (Diez Roux, 2001; Sampson, 2003).
A large literature focused on the role of socioeconomic and community factors in health outcomes has grown up in social science, public health, and the field of community organization and development. The backdrop to this literature on community effects is an even larger literature on the socioeconomic determinants of racial and ethnic health disparities. The pathways by which socioeconomic position and resources affect health status are well understood in concept, but more difficult to attribute empirically. Education, for example, provides opportunities for certain occupational pathways, which in turn produce different income streams, occupational exposure to health hazards, wherewithal to engage in positive health behaviors, and access to communities and social networks that are believed to reinforce health behaviors. Perceptions of racial discrimination, for example, have been linked across a large body of studies to
3
For a complete discussion and review of different concepts of community see Robert Chaskin (1997).
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health behavior, physical health, and mental health, although the precise mechanisms for how discrimination translates into physical or behavioral outcomes via stress or other pathways is less well established empirically (Williams et al., 2003).
The state of the evidence about these socioeconomic pathways to health disparities is crucial to the justification of community approaches. If policy and programs can in fact systematically affect social variables such as education, employment, or housing, and these improvements translate into health outcomes, then we have the beginnings of a model for influencing significant health disparities at the community level. However, the empirical understanding of how these socioeconomic mechanisms work at the community level is still quite limited. Nonetheless, many observers believe that research and policy experimentation specifically devoted to influencing these indirect socioeconomic pathways to health disparities should proceed apace. Alegría et al. (2003), for example, have argued that interventions in schooling, housing, and income support (earned income tax credits) are empirically defensible and justified in the field of mental health disparities. Adler and Newman’s conclusion about the role of social capital in generating health outcomes is similar: “The literature on social capital has not yet explained why neighborhoods with similar demographics differ on social cohesion and trust, or established whether social capital is stable. But the associational evidence between social trust and health outcomes is striking and suggests that these are complementary frontiers worthy of exploration for addressing health issues along with raising income or educational attainment” (Adler and Newman, 2002, p. 67).
The literature on community effects on health disparities demonstrates that many community factors contribute to differential health outcomes by race and ethnicity, over and above individual characteristics (Bigby, 2007). A recent annotated bibliography of this literature by itself runs 93 pages long.4 The sources of these community influences are numerous and complex, including risks created by the built environment such as lead in housing, access to the “ingredients” of healthy living such as affordable healthy foods, lack of community resources such as parks and green spaces that promote activity, ambient levels of stressors such as violence that may have physical and psychological sequlae, and disadvantages in access and in quality of health services and public health supports.
Despite the extent of this literature, again there is relatively little rigorous empirical evidence that demonstrates the mechanisms by which community characteristics or the ways in which community interventions produce observable differences in health outcomes. In part, this stems from
4
For a review of this literature see Rebecca Flournoy and Irene Yen, The Influence of Community Factors on Health (PolicyLink, 2004).
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the daunting statistical and data requirements for sorting out the multiple influences on health—the selection of individuals (with given health characteristics) into neighborhoods in the first place, the necessity for broad and multiple levels of data, and the substantial need for statistical variation across communities and groups, especially in nonexperimental data (Duncan and Raudenbush, 2001; Kawachi and Berkman, 2003).
The most intriguing recent empirical evidence of community-level effects per se comes from the Move to Opportunity (MTO) demonstration, in which 4,600 families in public housing in five cities were randomly assigned to different treatment groups of housing options and community environments. Adults in the experiment showed significant improvements in mental health and reductions in obesity with moves to new and higher-income communities; teenage girls showed improvements in mental health and reductions in risky behavior. Interestingly, teenage boys exhibited increases in risky behaviors relative to the control group (Kling and Liebman, 2004). Residents in individual MTO sites have shown substantial declines in specific health outcomes that need medical attention, such as injuries and asthma attacks. Other studies involving movers to new communities from distressed public housing, the so-called HOPE VI studies, however, have not yet shown improvements in health status, despite extraordinarily high rates of chronic and mental health conditions at baseline in this population. (Harris and Kaye, 2004; Manjarrez et al., 2007).
The critical role of community-level factors in addressing health disparities has led some commentators to argue that communities should become the “unit of analysis” for interventions, and community development should become the broad framework for implementing approaches (Robinson, 2005). Failure to make communities the unit of analysis means that a number of opportunities to design innovative and effective approaches are lost. First, most disparities of interest have important “nonhealth” community predispositions—environment, levels of community violence, and so on. Second, many disparities represent mixtures of social and health factors that cannot be easily disentangled into a simple clinical intervention. High rates of obesity and diabetes in communities reflect such a complex bundle of medical, health behavior, mental health, community resources, and access to health care. Third, many interventions require the active participation of community residents in order to be effective; this participation cannot be imposed. Fourth, many disadvantaged communities simultaneously exhibit health disparities because of the coexistence of poverty, racial concentration and segregation, and lack of access to health and other key supports. In the city of Chicago, for example, a relatively small number of disadvantaged neighborhoods on the south and west sides exhibit the highest rates of asthma, cancer, heart disease, sexually transmitted infections, diabetes, deaths from injuries and violence, and other critical health
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outcomes. Even in the face of this overlapping epidemiology, “siloed” approaches to health disparities miss the opportunity to marshal large-scale community participation and resources to design approaches that sweep at least across interrelated health-related conditions—for example, substance use, violence, high-risk sexual behavior—in a community.
A MULTILEVEL FRAMEWORK
As shown in Figure D-1, there have historically been two paths toward addressing the health needs of individuals in communities. In the clinical setting, interventions improve health care processes and outcomes, but there is limited evidence of their impact on health disparities. In the community setting, interventions improve community status, but there is limited evidence of their impact on health. Policy and public health interventions can influence health through clinical or community settings, and may address health directly.
Over the past decade, in recognition of the inadequate improvements in minority health, clinical, policy, public health, and community leaders have begun to consider what we will call a hybrid approach to health improvement, namely integrating features of clinical, community, and other (i.e., public health) approaches to address both biological and social determinants of health. These hybrid approaches can be focused in communities or in clinical settings, but the expertise of both is brought to bear on the problem, the solution, the evaluation, and plans for dissemination and sustainability. We compare their features in Table D-1. Following the table, we provide an overview of clinical and community approaches to disparities. We then discuss the issues and opportunities for advancing hybrid approaches. Finally, we conclude with a set of ideas about how hybrid approaches might be organized and implemented at scale.
CLINICALLY DRIVEN APPROACHES
Without question, the effective therapies developed and tested using basic science, clinical, and health services research have significantly contributed to improving the life expectancy of Americans of all racial and ethnic backgrounds. Yet, these diagnostic and therapeutic breakthroughs and unprecedented health care spending have not resulted in elimination of health care or health disparities for the majority of health conditions, even among populations with equal access to care. Several shortcomings of the current approach may help explain this disconnect. Table D-2 shows the building blocks of clinically oriented research to improve health. After each are descriptions of potential missteps that may occur if clinical interven-
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FIGURE D-1 Clinical and community approaches to health.
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TABLE D-1 Characteristics of Clinical, Hybrid, and Community Interventions to Improve Health
Level
Clinical
Hybrid
Community
Intervention locus
Health care settings and related organizations
Centered clinically or in the community, but combine efforts from both disciplines
Neighborhoods, or nongeographically defined communities
Theory for health improvement
Evidence base of impact of clinical interventions on health
Simultaneously addressing clinical and community factors will have more direct and lasting impact
Improve community factors (social, economic, environmental, political) and health will also improve
Advantages
Address biological determinants of health; proven impact on health; enhance clinical resources and capacity
Address biological and social determinants of health; sustainable designs; enhance community and clinical resources and capacity
Address social determinants of health; sustainable designs; enhance community resources and capacity
Disadvantages
Limited evidence of impact on reducing disparities in health outcomes; employ narrow clinical perspective; challenges for sustainability and effectiveness (beyond efficacy)
Limited evidence of impact on health outcomes; interventions often local, may be challenging to scale up; time-consuming, intensive to initiate
Limited evidence of any health impact; target-efficiency problem (target broad, timeframe long, not specific for health)
Feasibility of implementation
Feasible in tightly controlled settings
Feasible with adequate development time and collaboration
Feasible with adequate infrastructure, resources and large-scale collaborations
Challenges of translation/ replication
Translation to routine practice may be difficult
Replication may be difficult due to strong local influences
Both may be difficult given size and scope
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TABLE D-2 Steps in Isolated Clinical Research Addressing Health Disparities and Their Pitfalls
Research Step
Pitfall If Lack Community Partnership
Potential Impact of Pitfall
Identify concerns
Look through narrow clinical lens.
Patient/community ideas and priorities not taken into account.
Do not look at social determinants of health.
Identified reasons for health disparities do not adequately explain disparities.
Overlook novel areas for assessment and intervention.
Design study
Design lacks combination of cultural and evaluative competence.
Target population may not be interested in participating, study may not be relevant.
Increased likelihood of negative study.
Identify sites, recruit patients
Inconvenient locations for patients.
Sites chosen do not include epicenters of illness (site convenient, not relevant).
Steps not taken to build trust.
Recruitment strategies not motivational.
Poor recruitment/response rates.
Fail to target the most appropriate population.
Assess processes
Labeled successes may not impact outcomes.
Omit qualitative evaluations.
Do not solicit evaluations by subjects.
Increased screening, contact with health care or surveillance, not clear if improved health.
Unable to identify or act on study shortcomings.
Assess outcomes
Find no outcome improvement due to earlier flaws.
Missed opportunity.
“Blame the victim”: lack of improvement is patient’s fault.
Disseminate impact
Disseminate scientifically but not to community.
Community does not have ability to act on results.
Results not used to inform/influence policy.
Reinforce “drive-by research” attitude held by community.
Lost opportunity to capitalize on benefits beyond the specific project.
Sustain intervention
Interventions not designed with sustainability in mind.
Benefit disappears along with funding.
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tions are conducted in isolation from the wider sociocultural context where patients spend the vast majority of their lives.
Two examples of the incomplete impact of clinical research merit further description: breast cancer treatment and diabetes prevention. Breast cancer is an area where disparities in processes, namely screening, often using community-centered education, appear to be narrowing, yet disparities in breast cancer deaths persist (Dietrich et al., 2006; Earp et al., 2002; Erwin et al., 1999; Smith-Bindman et al., 2006; Weir et al., 2003). Minority women with early-stage breast cancer are far less likely to receive necessary adjuvant treatments, even when equally referred to oncologists (Bickell et al., 2006). Perhaps the simpler process (mammography) is easier to address than is breast cancer treatment, which requires a multidisciplinary approach. Perhaps women of color also face disproportionate nonclinical barriers to treatment.
Diabetes is another area in which clinicians and clinical researchers are making strides and yet persons of color do not appear to reap sufficient benefits. Minority individuals are more likely to develop and die from diabetes, and disparities in death between whites and blacks/Latinos are widening (Mokdad et al., 2003). If prevention efforts are not developed and widely implemented, one in two black and Latino children born this decade will develop diabetes, as opposed to one in four whites (Narayan et al., 2003). Several clinically based programs, most notably the large, multisite Diabetes Prevention Program, found that weight loss among overweight adults with pre-diabetes can prevent or delay diabetes (Knowler et al., 2002). In this program, weight loss even eliminated racial and ethnic disparities in incident diabetes. Despite this unusually promising result, the program has been neither expanded, nor continued, even at the sites where its effectiveness was proven. Less expensive methods are needed to achieve the degree of weight loss and diabetes prevention seen in this costly, time-consuming efficacy trial (Eddy et al., 2005).
COMPREHENSIVE COMMUNITY-DEVELOPMENT APPROACHES
Community-development and community-building approaches emphasize the development of community capacity and community connections as the means to producing better outcomes such as economic opportunity, safety, housing conditions, and health status (Chaskin et al., 2001). Community-building approaches tend to emphasize local leadership development, promotion of collaborations, strengthening the capacity of community-based organizations, strengthening of social capital, and generation of new resources for housing and economic development.
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A classic example of a comprehensive community-development approach based on a community-building philosophy would be initiatives supported by the LISC:
LISC helps resident-led, community-based development organizations transform distressed communities and neighborhoods into healthy ones—good places to live, do business, work and raise families. By providing capital, technical expertise, training and information, LISC supports the development of local leadership and the creation of affordable housing, commercial, industrial and community facilities, businesses and jobs. (LISC, 2006)
These community-building programs individually and collectively represent substantial commitments of public and private resources, as well as community leadership and effort. LISC alone claims to have mobilized over $7.8 billion for projects in 300 urban and rural communities (LISC, 2006). Development banks, such as ShoreBank, or commercial banks with large community-development portfolios, represent significant sources of capital and expertise. Bank of America, for example, expects to invest $750 billion in community economic development over the next 10 years. Major foundations, such as Ford, McArthur, and Kellogg, have also built their strategy and funding priorities around these comprehensive community-development initiatives, in most cases leveraging an additional set of federal and state development resources. These sums dwarf the scale of most disparities interventions, yet there seems to be little effort devoted to capture and leverage these resources to strategically improve environment and community capacity in ways that produce measurable health outcomes.
On the whole, these comprehensive community-building initiatives and the national health disparities agendas have proceeded on largely separate tracks. While the connections of community-building initiatives and the efforts of public health and disparities programs operating in communities may seem self-evident, a recent review by Kieffer and Reischman (2004) concludes that the “reality is that many public health interventions are not coupled with community building strategies; and many groups undertaking community building do not include measures of improved public health as an outcome of their activities” (p. 2).
The implications of this disconnect are significant. Health disparities initiatives by themselves cannot command the level of resources and community attention necessary to impact the myriad of physical, social, and economic factors that underlie community health outcomes. Since community leadership and institutions are critical to the success of any health intervention, it may be necessary for community health interventions to
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Solving Organization, Finance, and Policy for Hybrid Approaches
Efforts to mount a systematic approach to racial and ethnic disparities at the community level are hampered by governance, funding, and management challenges of the health delivery system utilized by racial and ethnic minorities.
Governance
Especially since the demise of health planning in the 1980s, most areas of the country have no accountable party and no organized mechanism for governing health resources across the spectrum of public health, hospital systems, community health centers, and the myriad of private health providers and resources that are necessary for building effective health disparities collaborations. Governance of health is fragmented into different levels of administration (e.g., city, county, state), “fiefdoms” of health provision (e.g., public health versus hospitals), as well as different geographic jurisdictions. St. Louis, for example, is an agglomeration of 97 municipalities and a complex web of city, county, and state (both Illinois and Missouri) jurisdictions.8 It is hard to overestimate the significance of these kinds of political, administrative, and even statistical fragmentations for mounting strategic approaches to disparities. This lack of overarching governance means that the most basic elements of a strategic approach—collecting data, creating a continuity of screening, prevention, and care—are dauntingly difficult administratively.
Funding
Health care interventions to address disparities are financed through a bewildering array of public and private resources. Some of these resources flow from categorical grants and contracts specifically targeted to fund a program or agency dedicated to a particular health outcome such as infant mortality. HRSA funding of specific Health Start programs, such as programs to improve the systems of care for pregnant women experiencing domestic or family violence, would be an example of a highly targeted discrete funding stream. Some of the financing flows to public and private providers such as payments (grants or fee for service) to Federally Qualified Health Centers or other community-based clinics. Some of the relevant resources flow through either traditional Medicaid or Medicaid waiver schemes. Some of the resources flow through county or city public hospital and clinic systems. Some services and costs are simply unfunded,
8
See, for example, Terry Jones, Fragmented by Design (Jones, 2000).
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meaning that cross-subsidies from charity care, disproportionate share, or philanthropic sources need to be found. An example of the consequences of this patchwork of financing can be seen in programs to reduce racial and ethnic disparities in breast cancer: projects have been successful in motivating women to be screened but have often struggled to find and pay for mammography services, as well as timely follow-up care. This follows directly from the fragmentation of financing and services. The providers and payment for community health promotion are often disconnected from the providers and payment for mammography and advanced cancer care.
Many disparities interventions are funded through research mechanisms whose short timeframes (usually 2–5 years) often preclude the development of substantive partnerships and do not allow for sustaining partnerships or successful interventions. This stuttering funding can only lead to transient improvements in health for small populations and mounting distrust of community members who view such endeavors as academic fodder.
In order to create the combination of resources, as well as continuity of service for community residents, much greater attention will need to be paid to the governance and financing of disparities approaches. At a minimum, this means that some form of regional data collection, coordination, and accountability for disparities interventions much be accomplished. It also means that payers and providers will need to be vested in the financing and outcomes of disparities initiatives. The Massachusetts health reform provides this kind of recognition of the integral role of financing and governance, but it too has been criticized for not backing up the rhetoric of a disparities priority with hard sources of funding.
Critical to commanding the resources and instruments to address the environmental, housing, educational, employment, and social service correlates of health disparities will be a recognition that larger-scale public policy is a key element of the disparities agenda. The best spokesperson for this perspective has been Margaret Alegría, who has argued that much of the action in hybrid approaches lies in understanding and policy reform of such programs as the Earned Income Tax Credit and Special Education (Alegría et al., 2003). Key policy areas that will affect the course of disparities approaches include public housing transformation, changes in the Community Reinvestment Act Provisions, welfare reform, immigration policy, Medicaid, and health care coverage. Typically, advocates and investigators do not see such large-scale social policy issues as part of the set of disparities levers and concerns, but the resources involved and implications for communities dominate many of the research-driven projects that have come to define the disparities field.
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MODELS AND IDEAS FOR HYBRID COMMUNITY APPROACHES
In order to bring these hybrid approaches to scale, new community infrastructure and resources will need to be developed. Current approaches are typically small in scale, do not leverage significant resources, and do not capitalize on information and technical expertise. Creating scalable community approaches will require solutions to the financing problems inherent in many disparities initiatives. Community approaches that can be evaluated and that demonstrate statistical impact on disparities will also need to account for much larger populations and bring much greater analytic sophistication than most current community examples. Five models or heuristics are presented to give examples of how new hybrid approaches might be configured in ways that address many of the shortcomings identified in this paper.
Regional Health Authorities: A number of regional authorities already exist at different levels of aggregation. The Westside Health Authority in Chicago, for example, has led a number of community-development and health disparities initiatives with full community participation and advocacy. The Regional Health Commission in St. Louis addresses a range of data, provider, and policy functions from the perspective of the region as a whole. Regional Health Authorities effectively configured for addressing disparities would need to capture a financing stream (most likely though a Medicaid assessment or all-payer program), and adopt a dedicated focus on disparities reductions for particular communities to be effective.
Community Development Banks/Corporations: While improvement of community health is one of the stated initiatives of many comprehensive community-development initiatives, in practice the goals and resources are more tightly defined by housing and economic-development measures. However, these institutions and investments represent large flows of capital and often intensive community involvement. Bank of America, for example, will invest $750 billion in the next 10 years in community development. Many of these investments occur in exactly the same communities with a high prevalence of health disparities conditions. To organize this combined health/community-development approach, new partnerships would need to be struck with institutions such as Shorebank, LISC, Bank of America, the Department of Housing and Urban Development (HUD); as well as other regional investors and developers. Many of these initiatives are organized around community-development corporations that provide an initial infrastructure and governance of these collaborations.
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University–Community Partnerships: A number of successful university–community partnerships have been built in recent years, some with the formal support of HUD and other federal agencies. The major examples, the University of Pennsylvania and the University of Chicago, have largely focused on community economic development and urban schools. While there certainly are examples of academic medical centers and schools of public health that have significant community partnerships, they have not been organized and disciplined by a systematic approach to addressing disparities in particular communities. The emergence of CPBR, the emphasis on CTSAs, the community interest of academic public health, and the community training needs of many medical school make this an opportune time to consider scaling up and organizing university–community partnerships specifically for addressing disparities. To the extent that these partnerships can leverage the health care delivery system at major academic centers, there is also the potential to create more seamless structures of financing and health care service in these neighborhoods. These urban community models have the potential for not only addressing urban disparities but also utilizing university networks in rural health.
CBPR Practice Networks: As this appendix describes, one of the exciting developments in addressing disparities has been the number of projects and community relationships stimulated by CBPR. Despite the apparent early successes of this movement, it is operating at small scales and with little opportunity for cross-fertilization, data development, and comparative analysis. A structure that organizes and supports this movement across community sites has the potential to create a multiplier from these projects. A potential model for collaboration, data collection, and technical assistance are the national practice networks that are emerging in other areas of health services research. The extension of this idea to communities would involve the creation of comprehensive practice network structures and data and information systems at the community level. Even better, a consortium of community-based practice networks would allow better systematic and comparative evaluation of community-based disparities initiatives.
Provider Networks or Systems to Address Disparities: Many of the current priority conditions have a heavy reliance on improvements in access and quality of health services in low-income and minority neighborhoods. As a practical matter, sufficient funding and sufficient “market penetration” to create a statistical impact will require multiple health care plans, systems, and providers operating in consort. Versions of these arrangements have been created in
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cities to address ambulatory care provision, indigent care, and special service needs such as trauma care. These networks of systems typically require dedicated payment streams and some governance from the local health departments, state public health, or other public agent. Payment streams have included Medicaid provider assessment schemes, use of Disproportionate Share dollars, or allocations of city, county, or state revenues. A model for organizing these networks to address place-based disparities would be the creation of special health disparities districts, analogous to medical districts, that would provide incentives for health plans to create new community-based programs as well as access and quality improvement in relevant services.
SUMMARY AND RECOMMENDATIONS
The central problem for building community approaches to reducing health disparities is to knit together community, provider, funding, and academic resources at such a scale that there is the potential to have statistical effects on population health outcomes. Many of the initiatives to date have demonstrated good will, effective community collaborations, and reasoned approaches to addressing disparities, but they tend to be fragmented, small in scale, and inadequately or transiently funded. Considering realistically the magnitude of behavioral change and service provision that is necessary to have a statistical impact on disparities, at the community level much less nationally, it will require a level of commitment and organization that far outstrips current models of intervention. In effect, the disparities initiatives need to be upsized from a cottage industry to substantial organization and scale.
Hybrid approaches to improving health outcomes and reducing disparities have the advantage of being clinically centered in the community, but they leverage the community participation, resources, and environmental agenda that are associated with broader community-development strategies. In principle these hybrid approaches have greater potential for sustainability and scale. They have the disadvantage of being diffuse, community process oriented, and difficult to target narrowly on specific disparities interventions. Many varieties of these hybrid approaches exist, such as the REACH 2010 and CBPR projects, but little empirical evidence about outcomes and little analysis of strategies are available for making these approaches successful, scalable, and sustainable.
Our analysis of current hybrid community approaches has identified a number of issues that need to be addressed to advance these clinical and community models. The goal of these hybrid models should be that they are simultaneously clinically excellent as well as community-responsive ini-
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tiatives. Significant adaptation will need to occur in the clinical enterprise in order to have mutuality and successful collaboration in the community. Innovation in the forms and utilization of data will be necessary. New commitments to community-level evaluation, including some version of social return on investment, will be necessary to learn from and advocate for these community-level initiatives. A new cadre of appropriately trained community-based researchers, with expertise in the community disciplines and experience with the cultural, social, and political realities of working in communities will need to be trained. CTSA opportunities will need to be seized, so that that the community side of this roadmap is highly responsive to community values and interests, not merely an appendage to the traditional clinical research enterprise. The resources of public health—both governmental and academic—will need to be reassessed and more effectively deployed to advance this agenda of hybrid approaches. Finally, solutions to the organizational and financing gaps in disparities programs will need to be fashioned.
There are currently a large number of alternative community disciplines, professionals, and organizations laying claim to the community-development and disparities agenda. Community health, community building, community organization and planning, urban planning, public health, environmental health, social work, and others all see themselves as primary professional leaders in this movement. From the perspective of communities, academic centers, health providers, social service organizations, public health agencies, faith-based organizations, and a host of advocacy organizations are all seeking to partner and mount their own versions of disparities programming. Meanwhile, some of the largest players in community development, the banks and developers, are often outside of the discussion, financing, and implementation of disparities programs.
Community collaborations (e.g., CBPRs) show great promise in the struggle to eliminate disparities. They can identify root causes of disparities, build on local assets, devise novel, clinically, and environmentally sensible designs with sustainability in mind, inspire robust research participation, and disseminate results so they inform policy and inspire further introspection and change. They are also community-organizing and -development initiatives in their own right. However, models for partnership in the literature describe years of planning—building relationships and crafting fair rules of engagement before research and interventions begin in earnest. While these processes must not be overlooked and local adaptation may be necessary for many interventions, the CBPR community must challenge itself to move from community-based planning (CBP) to “CBPR” with more efficiency and to find models that are proven to improve health and that can be exported to other communities or within the community, to address other health-related issues.
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The solution is not to choose one or another of these community players as primary. Rather, new mechanisms which bring together some of these stakeholders in partnership with community residents and with focus on substantial disparities programming will be necessary. Examples we have considered include regional health authorities, community-development corporations, university–community partnerships, CBPR practice networks, and new forms of health plan districts or networks.
Our analysis has produced a beginning agenda for the IOM Roundtable to pursue in building better linkages between community development and clinical services—hybrid approaches—in the name of reducing disparities.
Convene community-development organizations and funders, along with health disparities academic and practice leadership to design hybrid approaches.
Promote the creation of an evidence-based clearinghouse for information and technical assistance in community development for reduction in health disparities (such a clearinghouse could be mounted under the auspices of public, association, university or foundation organizations).
Convene the major health systems to address staffing, programming, disease management, and community partnerships approaches to disparities.
Influence the major existing clinical/research mechanisms—CBPR, CTSAs, REACH 2010—to leverage the full spectrum of community resources beyond the traditional scope of the clinical and research requirements of these mechanisms.
Commission a set of briefing papers that describe replicable models of community finance (e.g., disproportionate share hospital payment approaches), governance (e.g., health authorities), and communications innovations for effective and sustainable disparities reduction in communities.
Reexamine the framework and recommendations of the IOM report The Future of Public Health with the goal of reinvigorating a public health agenda in community and health disparities.
Convince a leading public health, health services, or community-development journal to publish a special issue on methods for evaluating community interventions and initiatives to reduce disparities—geographical and Health Impact Analysis, cost benefit and social return on investment analysis, multilevel and social network methods—as well as qualitative approaches.
Engage a leading foundation in supporting the training and professional development of a new cadre of community-savvy academic leaders in the field of health disparities.
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Identify and encourage a set of universities with the academic mission, resources, and community context to seriously and systematically build hybrid approaches that bring the same sophistication to community engagement and partnership that they brought to other dimensions of translational science.
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