Health Disparities Issues Research Articles

Women’s Health During Health Care Transformation

Women’s Health During Health Care Transformation

HUD’s Livable Communities Conference: Building Capacity for Change Through Evidence Dissemination and Partnership-Based Training

A growing prioritization for addressing the health needs of low-resource individuals in public housing has resulted from increased recognition of disparities and the effects of housing and the built environment on residents' health. With scarce financial resources, creating capacity for local partnerships to plan and implement small-scale, evidence-based improvements may be more sustainable. The "Livable Communities Conference" held in Philadelphia in 2011 is one example of a capacity-building event. The goals of the event were to engage local housing authority staff, residents, and service providers in education and planning around health disparities issues in public housing by presenting evidence of effective practices, creating networking opportunities for developing strategic partnerships, and training to foster action planning for strategic local initiatives. The 2-day conference included one day of scientific and practice-based presentations and one day of professionally facilitated workshop activities including small and larger group discussions. The event successfully convened wide-ranging stakeholders and exposed participants to "bigger picture" views, and was successful in disseminating best practices information from research and practice perspectives. Wider recruiting for participation and improved integration of Day 1 and Day 2 activities and participants could have yielded even further impact. Based on the success and the perceived potential impact of this event, facilitating similar community capacity-building events that convene a wide range of stakeholders to discuss health in public housing and low-resource communities is recommended. Discussions around the personal dynamics of partnerships and resistance to change also proved useful.

Culturally tailored postsecondary nutrition and health education curricula for indigenous populations

BackgroundIn preparation for the initial offering of the University of Alaska Fairbanks (UAF), Interior–Aleutians Campus Rural Nutrition Services (RNS) program, a literature review was conducted to establish the need for the proposed program and to substantiate the methodology for delivering integrated, culturally tailored postsecondary education and extension to Alaska Natives and rural Alaskans. There was a striking absence of peer-reviewed journal articles describing culturally tailored postsecondary health curricula for indigenous populations.ObjectiveTo complete and discuss a current (November 2012) literature review for culturally tailored postsecondary health curricula designed and delivered for indigenous populations.Methods/DesignThe author conducted an expanded online search that employed multiple configurations of key terms using Google and Google Scholar, as well as pertinent sources. The author located archived reports in person and contacted authors by email.ResultsThe expanded search produced a modest amount of additional literature for review. A disappointing number of publications describing or evaluating culturally tailored postsecondary health curricula in mainstream institutions are available. Related resources on culturally tailored extension and resources for the development and delivery of culturally tailored nutrition and health curricula were identified.ConclusionsThe present results demonstrate a significant absence of literature on the topic, which may or may not indicate the absence of sufficient culturally tailored postsecondary health curricula for indigenous populations. There are indications that culturally tailored postsecondary health curricula for indigenous populations have the potential to effectively address certain issues of health literacy and health disparities.

Abstract B70: Colorectal cancer-related disparities according to rurality, socioeconomic status, and race.

Abstract Background: The goal of the current study was to assess colorectal cancer (CRC)-related disparities according to geographic residency status, area-level socioeconomic status, and race (African American vs. white). Although numerous scientific endeavors have taken place to address the issue of cancer-related health disparities, especially racial disparities, less have focused on socioeconomic status and fewer still, disparities according to geographic residency (i.e., rural, suburban, urban). The health promoting effect that was once associated with rural living has diminished and, in fact, reversed for many health outcomes including cancer. However, of the studies of cancer outcomes that have been conducted according to geographic residency status, the findings have been mixed. Methods: This study utilized cross-sectional and longitudinal data from the Georgia Comprehensive Cancer Registry on all incident cases of colorectal cancer diagnosed in the state for the years 2000-2009. In addition to individual-level predictors, census tract (CT)-level designation of socioeconomic status (upper-middle, lower-middle, and low) and geographic residency status was obtained by matching with Census 2000 data. The outcomes of interest were the odds of late stage disease at diagnosis, the odds of receiving treatment, and all-cause 5-year survival following diagnosis. Results: African Americans [OR, 1.21; 95% confidence interval (CI), 1.14-1.29] and, to a lesser degree, residents of lower-middle SES CTs (OR, 1.07; 95% CI, 1.00-1.14) experienced an increased odds of being diagnosed with a late stage tumor. For colon cancer, African Americans (OR, 0.74; 95% CI, 0.64-0.87) and those of lower-middle (OR, 0.77; 95% CI, 0.64-0.91) and low SES CTs (OR, 0.76; 95% CI, 0.62-0.92) had a decreased odds of receiving surgery while suburban residency (OR, 1.17; 95% CI, 0.99-1.39) was positively associated with receiving surgery. Rural residency (OR, 0.82; 95% CI, 0.71-0.96) and living in low SES CTs (OR, 0.85; 95% CI, 0.73-0.98) were associated with decreased odds of receiving chemotherapy. For rectal cancer, low SES residents (OR, 0.68; 95% CI, 0.52-0.87) were at a decreased odds of receiving surgery while suburban residency (OR, 1.15; 95% CI, 0.99-1.33) was positively associated with receiving radiotherapy. For colon and rectal cancer, African Americans {[colon: hazard ratio (HR), 1.13; 95% CI, 1.07-1.22] [rectum HR, 1.12; 95% CI, 0.99-1.26]} and those living in lower-middle [(colon: HR, 1.10; 95% CI, 1.03-1.19) (rectum HR, 1.25; 95% CI, 1.11-1.40)] and low SES CTs [(colon: HR, 1.24; 95% CI, 1.14-1.35) (rectum HR, 1.29; 95% CI, 1.11-1.50)] experienced an increased risk of death following diagnosis. Rural residency [(colon: HR, 1.10; 95% CI, 1.02-1.18) (rectum HR, 1.20; 95% CI, 1.07-1.36)] was associated with an unadjusted increased risk of death, but this effect was completely explained after adjustment for SES. Summary: In this study, we found significant disparities in colorectal cancer outcomes according to geographic residency, census tract-level SES, and race. These findings highlight progress that has been made, but also indicate the importance of continuing to pursue policies and interventions to eliminate health disparities according to geographic residency status, SES, and race. Citation Format: Robert B. Hines, Asal Mohamadi, Talar W. Markossian. Colorectal cancer-related disparities according to rurality, socioeconomic status, and race. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr B70.

Veteran-Specific Suicide Prevention

Suicide rates have been increasing in some subgroups of Veteran populations, such as those who have experienced combat. Several initiatives are addressing this critical need and the Department of Veterans Affairs (VA) has been recognized for its leadership. This integrative review adopts the Research Impact Framework (RIM) to address suicide-specific prevention activities targeting Veterans. The RIM is a standardized approach for developing issue narratives using four broad areas: societal-related impacts, research-related impacts, policy-related impacts, and service-related impacts. The questions addressed in this review are: (1) What are the major initiatives in Veteran-specific suicide prevention in four areas of impact-society, research, policy, and services? (2) Are there gaps related in each impact area? and (3) What are the implications of this narrative for other strategies to address suicide prevention targeting Veterans? Systematic application of the RIM identifies exemplars, milestones, gaps, and health disparity issues.

Legacy for Children TM : a pair of randomized controlled trials of a public health model to improve developmental outcomes among children in poverty

BackgroundOne in five Americans under age 18 lives in a family below the Federal poverty threshold. These more than 15 million children are at increased risk of a wide variety of adverse long-term health and developmental outcomes. The early years of life are critical to short- and long-term health and well-being. The Legacy for ChildrenTM model was developed in response to this need and marries the perspectives of epidemiology and public health to developmental psychology theory in order to better address the needs of children at environmental risk for poor developmental outcomes.Methods/designThe Legacy for ChildrenTM group-based parenting intervention model was evaluated as a pair of randomized controlled trials among low-income families in Miami and Los Angeles. The study was designed to allow for site-stratified analysis in order to evaluate each model implementation separately. Evaluation domains include comprehensive assessments of family, maternal, and child characteristics, process outcomes, and prospective programmatic cost. Data collection began prenatally or at birth and continues into school-age.DiscussionThe societal costs of poor developmental outcomes are substantial. A concerted effort from multiple sectors and disciplines, including public health, is necessary to address these societal concerns. Legacy uses a public health model to engage parents and promote overall child well-being in families in poverty through rigorous evaluation methodologies and evidence-based intervention strategies. This study collects rich and modular information on maternal and child outcomes, process, and cost that will enable a detailed understanding of how Legacy works, how it can be refined and improved, and how it can be translated and disseminated. Taken together, these results will inform public policy and help to address issues of health disparities among at-risk populations.Trial registrationNCT00164697

Patients With Lupus: An Overview of Culturally Competent Practice

This article examines the need for culturally competent social work practice with systemic lupus erythematosus (SLE) patients. Because women are disproportionately impacted by this chronic autoimmune disease, and the majority of women are women of color, it is essential to address the related issues of health disparities among and between people of color, language and cultural barriers, and socioeconomic factors that impact those living with lupus. This article reviews the essential components of culturally competent social work practice, and provides implications for culturally competent program development, education and training, and direct service delivery.

801 Improving Community Emergency Medical Services/Emergency Rooms Ability To Care for Mechanical Circulatory Device Patients

and self-report questionnaires were used to assess cognitive function (Repeatable Battery for the Assessment of Neuropsychological Status, Anosognosia Questionnaire-Dementia, Controlled Oral Word Association Test) and SC ability (Self Care in Heart Failure Index). Hierarchical regression analysis was used to assess the relationship between immediate memory, delayed memory, attention, language, visuospatial/construction, executive function, insight and SC ability. Results: Participants were young (mean 55 years), mostly minority (57%) and well educated (mean 14 years). Cognitive impairment was noted in 44% of participants in the visuospatial/constructional domain, 20% in global cognition, 11% in immediate memory, attention and delayed memory, 9% in language and 3% in executive function. Being Caucasian and having worse immediate memory predicted better confidence in SC after controlling for age, gender and educational level (R 22%, p .001). Conclusions: Minorities reported less confidence in their HF self-care, perhaps related to cultural sensitivity of tools or quality of interactions with health care providers. Interestingly, patients with poorer memory reported better self confidence in their HF self-care, which could be attributed to their inability to recall the challenges in managing their health. Implications for practice include the need to address health disparities issues in self-care behaviors of HF patients as well as the contribution of immediate memory on the practice of these behaviors.

STI management and control in North America IUSTI region

In the USA, approximately 19 million new cases of sexually transmitted infections (STIs) occur annually,1 primarily affecting adolescents and young adults.2 Direct and indirect costs to the USA for STIs...

Management of Resource Dependency: Key to Implementation of Health Care Programmes: Insights from India

A population's health is a critical input for its economic growth. Although improvements in medical technology and spread of education have resulted in improvement in health indices, disparities in their distribution are starkly prevalent. These inequalities, result of poor utilisation of available interventions, need to be addressed as they impede economic growth. This would necessitate a persistent focus on management of implementation of health care interventions, aided by a dominant operational framework. Implementation literature is handicapped by lack of such a dominant framework and aggregated theory which could have guided practioners towards effective implementation. This paper attempts to address this felt need. Using a multiple embedded case processual study with interlinked multiple units of analysis; it studies the implementation of four national health programmes in three states of India. Positioned in the rural health context, it identifies effective implementation to be a function of management of resource dependency of a programme and cumulatively of the health system. Management of resource dependency is driven by identification of “Key resources” critical for service delivery under a programme. Effective implementation is achieved by the attention of the top management in identifying these Key resources, directing the system processes to generate, distribute and position resources and finally governance of the service delivery actions. Thus implementation is a function of attention, direction and governance. This operational framework, based on observable actions in the field, has significant implications for both practioners and researchers alike. It gives a framework to facilitate better implementation of health care interventions and hence address issues of health disparities. For researchers it generates a tentative mid range theory to act as a base for future research.

From economic development to public health improvement: China faces equity challenges

In the past three decades China has been going through a period of rapid economic growth, which has had profound repercussions for the nation’s public health system. Prior to the current health reforms much of the population was left uninsured and facing high financial risk from inadequate healthcare, with especially deep divisions between the urban and rural populations, which continues to pose a huge challenge to health equity and social justice. This paper explores the relationship between economic development and public health and discusses a series of health disparity issues that are emerging in China. These include: (1) health risk and access to care issues among unregistered urban populations (i.e. migrants); (2) low recognition of mental health, and the stigma associated with people with mental illness or communicable disease; and (3) challenges to the traditional system of family care for the elderly, as younger generations migrate to the cities and the remaining rural population ages. Implications for government policy and action to address these issues and improve public health as well as equity are discussed.

Abstract A2: Region 4 NCI CRCHD BMaP: A team science approach towards a multistate network to reduce cancer health disparities

Abstract Background/Objectives: NCI CRCHD Region 4 BMaP (Arizona, Colorado, Oklahoma, New Mexico and Texas) was initiated in 2009. The overall goal is achieving measureable reductions in racial cancer health disparities through developing regional networks where resources can be pooled to facilitate team science approaches to cancer health disparity reduction. Methods: We established a regional hub infrastructure with specific cores: administration, training, bioinformatics, biospecimen/biobanking, clinical trials, community translation, emerging technologies, and ethical-legal-policy issues. Three methods, a group meeting and two survey tools were employed to identify regional resources. The NCI-developed Readiness Assessment Tool (RAT) collected data on cores; the “Face-to-Face” gathering provided for a SWOT analysis in cancer health disparities among Region 4 stakeholders. The online Comprehensive Needs Assessment (CNA) survey identified institutional-level characteristics necessary to develop a regional implementation plan. Results: 100% complete response for RAT and CNA surveys. Few reported significant needs although many reported significant institutional deficiencies in bioinformatics, biospecimen/biobanking, clinical trials, and emerging technologies. Primary diseases of interest include breast and colorectal cancers. In Region 4, few CRCHD funded investigators collected biospecimens in their research programs; and all members reported strong training programs. The Face-to-Face meeting strengthened existing partnerships and increased collaboration while providing attendees a regional overview of strengths, weaknesses, opportunities, and threats. Implications/Next Steps: Regional networks of health disparities researchers are already leverging resources to reduce cancer health disparities among minorities in the region. The GMaP/BmaP network provided contacts to leverage CHEs in the region. The program is investigating methods to create a region-wide virtual biorepository, with descriptions of biospecimens collected in research program by Region 4 PIs. Such a virtual biorepository database would be linked with other regioanl BMaP databases that are developed. In addition, Region 4 implementation plan includes creating bioethics training tools for biomedical research on US minority populations. Training materials to be developed would address missing bioethical topics on health disparities issues with an emphasis on Native Americans and Hispanic Populations, and within the topics of biospecimen collection and clinical trial participation. This aims at creating career opportunities in bioethics for students and junior investigators at minority serving institutions. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A2.

Federal Health-Care Reform: Opportunities for Obesity Prevention

Federal Health-Care Reform: Opportunities for Obesity Prevention

Sleep Is a Health Disparity Issue in Hispanics

Sleep Is a Health Disparity Issue in Hispanics

Getting started in CBPR: lessons in building community partnerships for new researchers.

There is a growing interest in community-based participatory research (CBPR) methods to address issues of health disparities. Although the success of CBPR is dependent upon the formation of community-researcher partnerships, new researchers as well as seasoned investigators who are transitioning to CBPR often lack the skills needed to develop and maintain these partnerships. The purpose of the article is to discuss the competencies needed by new researchers to form successful CBPR partnerships. The author presents a series of strategic steps that are useful in establishing academic-community partnerships and in initiating, maintaining and sustaining CBPR projects. These steps include suggestions regarding community engagement, selection of community advisory board members, outreach, the community's role in problem identification, selection of research methodologies, considerations related to the community setting, need for flexibility and patience, 'insider vs. outsider' conflicts, commitment and training issues, timing concerns for tenure-track faculty and the process of community empowerment. Community-based participatory research is both rewarding and time consuming, for both the researcher and members of the community. Given its promise to address health disparities, it is imperative that researchers acquire the skills needed to develop and cultivate durable community-researcher partnerships.

Investigating Health Disparities and Disproportionality in Child Maltreatment Reporting

We examined health disparities and disproportionality in child protective services (CPS) reporting at a regional academic health center. We computed disproportionate representation and disparity indices from archived CPS reports for pediatric patients (N = 1,020) from 2002 to 2006. Findings indicated that medical personnel reported African American and Hispanic pediatric patients to CPS (1) at higher rates than their representation in the general pediatric patient population and (2) at a rate approximately four times that of White pediatric patients. However, White pediatric patients were reported to CPS at lower rates than their general pediatric patient representation. Additional examination of socioeconomic factors demonstrated that pediatric patients from poor neighborhoods were reported to CPS (1) at higher rates than their numbers in the patient population and (2) five times more often than pediatric patients from prosperous neighborhoods. We found significant racial/ethnic and socioeconomic disproportionality and disparities in medical personnel's CPS reporting practices. These findings augment the limited literature investigating disparities and disproportionality in medical personnel's CPS reporting practices. The inclusion of pediatric and general departments allows for increased generalizability of study results. However, more rigorous empirical examination is needed to identify the causal factors responsible for noted differences. Consequently, healthcare systems' collection and examination of patients' racial/ethnic data are imperative to effectively address the multifaceted, social welfare issues of health disparities and disproportionality.

Commentary: Team Approach to Patient Navigation

I appreciate the opportunity to continue the dialog about patient navigators and the viewpoint of Mukkamala et al.1 I recognize that the original function of patient navigators was to help people suffering from health disparities navigate our highly complex medical delivery system. I also recognize that Michigan suffers from an extremely high unemployment rate and that the circumstances and poverty of the patient population add to health disparity issues. I will not dwell on which state has more cultural or economic barriers but will instead focus on the use of scarce resources to best serve these populations. Mukkamala et al1 comment that the navigator knows the patient from the time an abnormal screening occurs or a lump is found. Unlike family or friends, the navigator is a stranger at that moment and must establish a relationship of trust. Thus, part of the navigator's time must be spent on call for the mammography center. I assume that their navigator is only for breast patients and is not available for people with abnormalities on screening colonoscopies or people found in their primary care office with elevated prostate-specific antigen, painless jaundice, masses on chest x-rays, and so on. My point is that it is not possible to introduce another allied health professional at the moment of diagnosis or suspicion of cancer for all patients in all locations. In addition, there is a trusted health professional who has an existing relationship in most of those situations: the physician. That person is the health professional who is known and trusted by the patient, has the medical expertise to give appropriate advice and emotional support, and is present at the time of the suspicious event or diagnosis. Perhaps in radiology suites, the radiologist is a stranger and should not be put in the position of counseling a patient but should instead allow the physician who ordered the test to inform the patient of the abnormal result and develop the plan for therapy. In my office, we encourage relatives or friends to attend visits, take notes (we often write down the important points ourselves), or tape visits. We encourage and schedule follow-ups as testing is completed to ensure that the patients have the information they need and the time to ask questions. We have found that satisfaction is high, and there are no delays in the treatment process. Clearly, the information given to a patient must be accurate. What training and certification are necessary to ensure that the navigator will deliver the appropriate and accurate information to the patient? To my knowledge, there are no training programs for navigators, although many of them are nurses. However, some nurses have specialized in oncology, and some have not. We face a nursing shortage: Is navigation the best use of these highly trained personnel? If you pay a nurse at $20 per hour plus benefits to be a navigator, and the nurse sees 150 patients per year, his or her salary adds the expense of $360 per patient to provide this unreimbursed service. We often do not have a profit margin that can withstand another $360-per-patient expense. Compliance with regimens can be ensured by incorporating the navigation function into the job of other personnel. In my office, the person who checks the patient out after the visit schedules the follow-up appointments and all the tests, obtains prior authorizations, and gives the patient a card with a direct line to call with questions. That person—who is not a nurse—does not answer medical questions but develops a first-name relationship with the patient. This person is an important part of the health care team, along with the nurses, social workers, and physicians. Not having a specific person labeled as navigator does not negate the value of the team approach to care. In summary, I feel a well-functioning practice that incorporates the functions of patient navigator into the job of every person who interacts with the patient; has an efficient system of scheduling tests and obtaining and sharing results with the patient; and is sensitive to the cultural, psychologic, and economic barriers to care does not need to incur the expense of hiring patient navigators.

Community engagement in research: frameworks for education and peer review.

Community engagement in research may enhance a community's ability to address its own health needs and health disparities issues while ensuring that researchers understand community priorities. However, there are researchers with limited understanding of and experience with effective methods of engaging communities. Furthermore, limited guidance is available for peer-review panels on evaluating proposals for research that engages communities. The National Institutes of Health Director's Council of Public Representatives developed a community engagement framework that includes values, strategies to operationalize each value, and potential outcomes of their use, as well as a peer-review framework for evaluating research that engages communities. Use of these frameworks for educating researchers to create and sustain authentic community-academic partnerships will increase accountability and equality between the partners.

Oral health disparities and the workforce: a framework to guide innovation

Oral health disparities currently exist in the United States, and workforce innovations have been proposed as one strategy to address these disparities. A framework is needed to logically assess the possible role of workforce as a contributor to and to analyze workforce strategies addressing the issue of oral health disparities. Using an existing framework, A Strategic Framework for Improving Racial/Ethnic Minority Health and Eliminating Racial/Ethnic Health Disparities, workforce was sequentially applied across individual, environmental/community, and system levels to identify long-term problems, contributing factors, strategies/innovation, measurable outcomes/impacts, and long-term goals. Examples of current workforce innovations were applied to the framework. Contributing factors to oral health disparities included lack of racial/ethnic diversity of the workforce, lack of appropriate training, provider distribution, and a nonuser-centered system. The framework was applied to selected workforce innovation models delineating the potential impact on contributing factors across the individual, environmental/community, and system levels. The framework helps to define expected outcomes from workforce models that would contribute to the goal of reducing oral health disparities and examine impacts across multiple levels. However, the contributing factors to oral health disparities cannot be addressed by workforce innovation alone. The Strategic Framework is a logical approach to guide workforce innovation, solutions, and identification of other aspects of the oral healthcare delivery system that need innovation in order to reduce oral health disparities.

Promoting Psychological Research and Training on Health Disparities Issues at Ethnic Minority Serving Institutions Grants (ProDIGs)

Promoting Psychological Research and Training on Health Disparities Issues at Ethnic Minority Serving Institutions Grants (ProDIGs)