Community Approaches to Addressing Health Disparities Carol Horowitz, M. D., M. P. H



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Community Approaches to Addressing Health Disparities
Carol Horowitz, M.D., M.P.H.

Assistant Professor, Departments of Health Policy and, Medicine

Mount Sinai School of Medicine
and
Edward F. Lawlor, Ph.D.

Dean and The William E. Gordon Professor

George Warren Brown School of Social Work

Washington University in St. Louis


Community Approaches to Addressing Health Disparities

Carol Horowitz and Edward F. Lawlor


INTRODUCTION
A major national enterprise has grown up since the 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, 2006). For example, the CDC’s recent interim report on Healthy People 2010 worried that among the 195 disparities objectives there has only been measurable improvements in 24 categories, declines in 14, and no change in 157 (CDC, 2007).
A number of concerns underlie this restlessness:


  • That many initiatives do not embody the kind of community voice, support, and participation that is necessary for sustainable long-term results.

  • That 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, civic engagement).

  • That 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, 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 cancer, 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; increase human, physical, and social capital; and 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 Initiatives Support Corporation (LISC), Community Builders, etc.
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 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 Institute of Medicine 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.1 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 on 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 health behavior, physical health, and mental health, though the precise mechanisms for how discrimination translates into physical or behavioral outcomes via stress or other pathway is less well established empirically (Williams, 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 these influencing these indirect socioeconomic pathways to health disparities should proceed apace. Alegria (2003), for example, has argued that interventions in schooling, housing, and income support (EITC) 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 & Newman, 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, in press). A recent annotated bibliography of this literature by itself runs 93 pages long.2 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 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 non-experimental data (Duncan and Raudenbush, 2001, Karachi 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 4600 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. (Liebman, Latz, and Kling, 2004). Residents in individual MTO sites have shown substantial declines in specific health outcomes such as injuries and asthma attacks needing medical attention. In other studies, such as 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 chromic and mental health conditions at baseline in this population. (Manjarrez, Popkin, and Guernsey, 2007, Harris and Kaye, 2004).
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 “non-health” community predispositions – environment, levels of community violence, etc. 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, 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 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 – e.g., substance use, violence, high risk sexual behavior -- in a community.
A MULTILEVEL FRAMEWORK
As shown in Figure 1 below, there have historically been two paths toward addressing health needs of individuals in communities. In the clinical setting, interventions improve healthcare 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 last 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 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 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.




Table 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 non-geographically 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 sustain-ability 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.


CLINICALLY DRIVEN APPROACHES
Without question, the effective therapies developed and tested using basic science, clinical and health services research and have significantly contributed to the improving life expectancy of Americans of all racial and ethnic backgrounds. Yet, these diagnostic and therapeutic breakthroughs and unprecedented healthcare spending, have not resulted in elimination of healthcare 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. Below are building blocks of clinically-oriented research to improve health. After each, are descriptions of potential missteps that may occur if clinical interventions are conducted in isolation from the wider sociocultural context where patients spend the vast majority of their lives.


Table 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 healthcare 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.

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 (Wier et.al., 2003, Smith-Bindman et.al., 2006, Earp et.al., 2002, Erwin et.al. 1999, Deitrich et. al. 2006,). 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 non-clinical 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 develop and die from diabetes, and disparities in death between Whites and Blacks/Latinos are widening (Mokdad et.al. 2001,). 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, weigh loss even eliminated racial and ethnic disparities in incident diabetes. Despite this unusually promising result, the program has been 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, Brown, Venkatesh, and Vidal, 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.
A classic example of a comprehensive community development approach based on a community building philosophy would be initiatives supported by the Local Initiatives Support Corporation (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.
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 ten 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 agenda 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” (2004, 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 become aligned with these larger community development efforts to be able to capture the necessary time and attention.
There are a number of good reasons why community health approaches to disparities reduction have not been built upon this platform of comprehensive community building. First, these approaches tend to emphasize community process over interventions and implementation. In this world, collaborations, connections, relationship building, partnerships, and process often take precedence over specific interventions and implementation. Second, these approaches vest enormous control with community residents and stakeholders to define their own assets and approaches, whatever the views of experts may be. Particular health disparities may or may not rise to the top of the community hierarchy of priorities and needs for attention and resources. Third, by the very nature of comprehensive community approaches, these initiatives may have low target efficiency for a particular health condition. Efforts to improve employment, education, safety, and other community factors may have marginal or indirect effects on a particular health condition of interest. Finally, these comprehensive collaborations are often slow and halting in their progress and observable outcomes.
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