Challenges and Successes in Reducing Health Disparities Workshop Summary (2008) / Chapter Skim
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Appendix D: Community Approaches to Addressing Health Disparities
Appendix D: Community Approaches to Addressing Health Disparities
Pages 161-192
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From page 161... ...
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)
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From page 162... ...
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.
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From page 163... ...
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.
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From page 164... ...
. The state of the evidence about these socioeconomic pathways to health disparities is crucial to the justification of community approaches.
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From page 165... ...
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)
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From page 166... ...
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.
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From page 167... ...
? Community Local Factors Improved Setting - Services available Community Status - Built environment - Social environment FIGURE D-1 Clinical and community approaches to health.
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From page 168... ...
168 CHALLENGES AND SUCCESSES IN REDUCING HEALTH DISPARITIES TABLE D-1 Characteristics of Clinical, Hybrid, and Community Interventions to Improve Health Level Clinical Hybrid Community Intervention locus Health care Centered clinically Neighborhoods, or settings and related or in the community, nongeographically organizations but combine defined communities efforts from both disciplines Theory for health Evidence base of Simultaneously Improve community improvement impact of clinical addressing clinical factors (social, interventions on and community economic, health factors will have environmental, more direct and political) and health lasting impact will also improve Advantages Address biological Address biological Address social determinants of and social determinants of health; determinants of health; proven impact on health; sustainable sustainable designs; health; enhance designs; enhance community clinical resources and enhance community resources and capacity and clinical capacity resources and capacity Disadvantages Limited evidence of Limited evidence Limited evidence of impact on reducing of impact on any health impact; disparities in health health outcomes; target-efficiency outcomes; employ interventions often problem (target narrow clinical local, may be broad, timeframe perspective; challenging to scale long, not specific for challenges for up; time-consuming, health)
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From page 169... ...
explain disparities. Do not look at social determinants of Overlook novel areas for health.
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From page 170... ...
. 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)
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From page 171... ...
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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From page 172... ...
Clinically Centered Hybrid Approaches These approaches invite community, public health, policy, and research experts into the clinical setting in order to make clinical care more responsive to vulnerable populations (i.e., low-income individuals, or persons of color) and to make clinical interventions more effective in improving their health.
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From page 173... ...
Health Management and Support Health management and support reforms are often built around new professional and paraprofessional roles that connect with community residents. Examples include clinical disease managers, community health workers who are usually employed by health systems, and more independent peer educators.
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From page 174... ...
. • Community health workers (CHWs)
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From page 175... ...
. Policy-Centered/-Driven Hybrid Approaches The two best examples of policy-driven hybrid approaches to community health disparities are the federal CDC Racial and Ethnic Approaches to Community Health (REACH)
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From page 176... ...
The theory of REACH's community participation and health outcomes is best depicted in their "logic model," which traces the connections between community awareness, coalition and community organization, community changes processes, health behavior changes, and health outcomes. In practice, REACH projects are expected to define the community coalitions and capacity, design, and intervention and tactics that have the basis to affect the targeted health outcome, produce community and community systems change, produce a significant amount of behavioral change, and ultimately reduce the observed disparity of interest.
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From page 177... ...
Research-Centered Hybrid Approaches in the Community Researchers are now quite comfortable using secondary data analyses to study health disparities. It would be interesting for them to partner with community development, environmental development, and urban planning leaders, to conduct community-targeted secondary analyses, merging clinical and community-level data to study impacts of development on heath.
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From page 178... ...
In many respects, cost-benefit or cost-effectiveness analysis of this form of clinical service is the easiest case; broader-based or hybrid approaches will require much more effort and sophistication to capture the full range of social costs and benefits. Indeed, many of the effects represent externalities in the economic sense and will not be typically priced or valued in traditional economic markets.
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From page 179... ...
• Creation of an information clearinghouse on disparities that net works individuals, programs, and opportunities, houses databases with information on local and regional health and health disparities and relevant community characteristics, and lists community-based disparities reduction programs and links to their evaluations • Finding new mechanisms to increase interaction among social s cientists, medical investigators, public health, and community development scholars in the pursuit of a community-level knowl edge base leading to effective interventions Taking Advantage of Large-Scale Translational Research Opportunities (Bench to Bedside to Barrio) Historically, translational research has focused on "bench to bedside" (Zerhouni, 2003)
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From page 180... ...
According to the CTSA literature, "CTSAs represent a new culture of translational healthcare research in which community engagement is key to success." The CTSA Community Engagement Steering Committee (one of eight subcommittees to coordinate institution topic-specific efforts with the national CTSA consortium) is charged with ensuring the successful implementation of a broad community-engagement plan among the CTSA sites by sharing knowledge, expertise, and resources and by effectively engaging communities in the translational research process via bidirectional dialogues.
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From page 181... ...
The California Campaign represents an initiative that embodies both the philosophical commitment to prevention of a public health perspective as well as the professional and organizational leadership of the American Public Health Association. The research opportunities provided in CTSAs, Disparities Centers, and other large-scale initiatives may be important factors in bringing at least academic public health into a stronger and more applied community role in reducing health disparities.
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From page 182... ...
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.
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From page 183... ...
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)
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From page 184... ...
2. Community Development Banks/Corporations: While improve ment 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.
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From page 185... ...
The major examples, the University of Pennsylvania and the University of Chicago, have largely focused on community eco nomic 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.
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From page 186... ...
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.
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From page 187... ...
There are currently a large number of alternative community disciplines, professionals, and organizations laying claim to the communitydevelopment 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.
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From page 188... ...
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.
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From page 189... ...
2005. Community health workers as interventionists in the prevention of heart disease and stroke.
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From page 190... ...
federally qualified community health centers. Health Services Research 42(6 Pt 1)
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From page 191... ...
2005. Lay health workers in primary care and community health.
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From page 192... ...
1998. A summary of the National Community Health Advisor Study.
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