1. 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

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
“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
The is a modification of the the Williams theoretical model of the multiple causes of disparities in outcomes related to race and health. Several models exist, and this is a reasonable one. In these analyses we can address some but not all of these factors, including social status, access to care and professional behavior.
Heuristic Model of Racial Disparities in Health Outcomes
(adapted from Williams 1997)

7. Social Determinates of Health
“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…”
So, what are social determinates of health… <read definition>
social_determinants/en/

8. A Key Social Determinant of Health
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
In addition, Americans who have not graduated from high school have a death rate two to three times higher than those who have graduated from college.
And, Low SES adults have levels of illness in their 30s and 40s that are not seen in the highest SES group until after the ages of

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
Heart Disease Rate
Stroke Rate
Female
103.1 ( )
42.6 (
Male
176.5 ( )
43.9 ( )
American Indian/
Alaskan Native
97.4 ( )
29.4 ( )
Asian/Pacific Islander
77.1 ( )
37.0 ( )
Black
161.6 ( )
61.6 ( )
Hispanic
106.4 ( )
34.2 ( )
White
134.2 ( )
41.7 ( )
Per 100,000

10. Infant Mortality Disparities (Race)
Maternal Race/Ethnicity
Infant Mortality Rate (2000)
Infant Mortality Rate (2006)
American Indian/
Alaskan Native
8.30
8.28
Asian/Pacific Islander
4.87
4.55
Black, Non-Hispanic
13.59
13.35
White, Non-Hispanic
5.70
5.58
Hispanic
5.59
5.41
Total
6.89
6.68
With white, non-Hispanic as the reference population, these are statically significant.
Number of deaths among infants aged <1 year per 1,000 live births.

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
A disparity is an inequality. In the United States, we believe that health care should not differ by race, ethnicity, socioeconomic status, or geographic location. When these differences do exist, they are referred to as disparities. We see this when racial and ethnic minorities receive lower quality healthcare than whites. It is important to understand that differences in race and ethnicity (among other things) will always exist; it is wrong, however, when these differences lead to unequal care.

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

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. Components of Health Care Quality
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
Type of Health Service
Components of Health Care Quality
Safety
Effectiveness
Patient Centeredness
Timeliness
Preventive
Acute
Chronic
Terminal

22. Percent of Population aged 18-64 Years with No Health Insurance by Income: US, 1994-5
I guess this is no surprise, but is no less telling, that regardless of race, poor people are more likely to not have insurance. When you look across groups, what is also interesting is that for men, and most groups of women regardless of income, Hispanics are least likely to have insurance, followed by African Americans, and Whites. [next slide]
Non-Hispanic White
Non-Hispanic Black
Hispanic
CDC

23. Health Disparities Data: North Carolina
Now lets look at data from the NC Office of Minority Health, Health Disparities Report Card

24. % with Health Insurance in NC by Race
% Covered Column1
White 84.2 ( )
African American
Asian 81.9 ( )
Native American 70.5 ( )
Latino 36.6 ( )
Aside, 16.4% of Spanish speaking Latinos have coverage, and 78.3 of English speaking Latinos have coverage.
BRFSS, 2009

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

26. Alcohol Abuse in NC by Race
This is BRFSS data, so this data is among adults.
All of them are statistically significant when compared to white.
BRFSS, 2009

27. Teen Pregnancy Rate in NC by Race
For every 1, year old teen girls in North Carolina, the rates – by race/ethnicity – are:
From a report released by the Adolescent Pregnancy Prevention Council of North Carolina on 1/18/2011

28. N. C. Adult/Adolescent HIV New Disease Cases in 2009
2009 HIV/STD
Surveillance Report
From the Division of Public Health

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
Health Outcomes
Political Economy Health Care
Varying Patient preferences Health behavior
Continuity & Concordance
Health Care Disparities:
Access to Care
Structure of Care
Process of Care
Patient Satisfaction
Provider
Knowledge
Attitudes
Practice Patterns
Communication
Cultural Competence
Varying effectiveness or style
Varying resources constraints
System/Policy
Organization & staffing
Insurance
Supply & Distribution of Clinicians & other Resources
CHERP Health Disparities Primer

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
Health Outcomes
Political Economy Health Care
Varying Patient preferences Health behavior
Continuity & Concordance
Health Care Disparities:
Access to Care
Structure of Care
Process of Care
Patient Satisfaction
Provider
Knowledge
Attitudes
Practice Patterns
Communication
Cultural Competence
Varying effectiveness or style
Varying resources constraints
System/Policy
Organization & staffing
Insurance
Supply & Distribution of Clinicians & other Resources
CHERP Health Disparities Primer

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
Health Outcomes
Political Economy Health Care
Varying Patient preferences Health behavior
Continuity & Concordance
Health Care Disparities:
Access to Care
Structure of Care
Process of Care
Patient Satisfaction
Provider
Knowledge
Attitudes
Practice Patterns
Communication
Cultural Competence
Varying effectiveness or style
Varying resources constraints
System/Policy
Organization & staffing
Insurance
Supply & Distribution of Clinicians & other Resources
CHERP Health Disparities Primer

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
Health Outcomes
Political Economy Health Care
Varying Patient preferences Health behavior
Continuity & Concordance
Health Care Disparities:
Access to Care
Structure of Care
Process of Care
Patient Satisfaction
Provider
Knowledge
Attitudes
Practice Patterns
Communication
Cultural Competence
Varying effectiveness or style
Varying resources constraints
System/Policy
Organization & staffing
Insurance
Supply & Distribution of Clinicians & other Resources
CHERP Health Disparities Primer

33. 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
Health Outcomes
Political Economy Health Care
Varying Patient preferences Health behavior
Continuity & Concordance
Health Care Disparities:
Access to Care
Structure of Care
Process of Care
Patient Satisfaction
Provider
Knowledge
Attitudes
Practice Patterns
Communication
Cultural Competence
Varying effectiveness or style
Varying resources constraints
System/Policy
Organization & staffing
Insurance
Supply & Distribution of Clinicians & other Resources
CHERP Health Disparities Primer

34. 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
Health Outcomes
Political Economy Health Care
Varying Patient preferences Health behavior
Continuity & Concordance
Health Care Disparities:
Access to Care
Structure of Care
Process of Care
Patient Satisfaction
Provider
Knowledge
Attitudes
Practice Patterns
Communication
Cultural Competence
Varying effectiveness or style
Varying resources constraints
System/Policy
Organization & staffing
Insurance
Supply & Distribution of Clinicians & other Resources
CHERP Health Disparities Primer

35. 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
Health Outcomes
Political Economy Health Care
Varying Patient preferences Health behavior
Continuity & Concordance
Health Care Disparities:
Access to Care
Structure of Care
Process of Care
Patient Satisfaction
Provider
Knowledge
Attitudes
Practice Patterns
Communication
Cultural Competence
Varying effectiveness or style
Varying resources constraints
System/Policy
Organization & staffing
Insurance
Supply & Distribution of Clinicians & other Resources
CHERP Health Disparities Primer

36. 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

37. Interventions to address Health Disparities

38. 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

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

40. 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

41. 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
HOPE Works projects in Eastern North Carolina. They wanted to work on obesity issues, but realized that women were struggling with their finances. It was unreasonable to ask women to spend more money on healthy foods if they were already struggling to make ends meet. So they worked with the women’s sewing circles to create jobs for these women making conference bags. While they were at the sewing circles, they also talked about healthy food options.

42. EBIs Addressing Health Disparities
Name of Intervention
Targeted Outcome
Disparities Addressed
Body and Soul
Increase fruit and vegetable consumption among African American faith groups
Strives to address nutrition related disparities affecting African Americans
Eat for Life
Increase fruit and vegetable consumption among African Americans
Little by Little
Increase fruit and vegetable consumption among low income women
Strives to address nutrition related disparities affecting low income women
Here are two examples of Evidence Based Interventions addressing health disparities. Each have a targeted outcome of increasing consumption of fruits and vegetables, but the first two are customized for African American communities and the last is focused on low income women.

43. Funding

44. 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

45. 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

46. 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)

47. Questions?

48. 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):
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):
Websites