How does your grantmaking currently address health disparities?

1. How does your grantmaking currently address health disparities?

2. Health Disparities and Achieving Health Equity in North CarolinaGiselle Corbie-Smith, MD, MScUniversity of North Carolina at Chapel HillNC Translational and Clinical Sciences InstituteProgram on Health DisparitiesSheps Center for Health Services Research www.tracs.unc.edu/community nctracs@unc.edu

3. Overview Definitions and frameworks Define social determinates of health (SDH) Interventions to achieve health equity Resources for learning more

4. Health Disparities http://www.cdc.gov/mmwr/pdf/other/su6001.pdf • “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

5. Factors that Lead to Health Disparities • Social Inequalities • Educational opportunities • Job opportunities • Housing opportunities • Law enforcement patterns • 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 (adapted from Williams 1997)

7. Social Determinates of Health http://www.who.int/ social_determinants/en/ “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…”

8. A Key Social Determinant of Health http://www.scribd.com/doc/7778732/Dr-David-Williams-on-Health-Disparities 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

10. United States: Gaps in Children’s General Health Status

11. United States: Gaps in Adult Health Status

12. 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 http://www.cdc.gov/mmwr/pdf/other/su6001.pdf

13. Infant Mortality Disparities (Race) http://www.cdc.gov/mmwr/pdf/other/su6001.pdf

14. 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

19. What is a Disparity in Healthcare? Populations with Equal Access to Health Care SOURCE: Gomes and McGuire, 2001, National Academy of Sciences

20. Potential Origins for Disparities in Healthcare Kilbourne

21. Van Ryn, Michelle, “Research on the Provider Contribution to Race/Ethnicity Disparities in Medical Care.” Medical Care 40(1) I-140-151.

22. 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

23. Unequal Access to Health Care Services • Acceptability: the extent to which services meet users’ value orientations • Patient satisfaction • “Cultural competence” • Providers • Organization

24. Health Disparities Data:North Carolina

27. NC: % of Adults who could NOT see a doctor in previous 12 months due to cost

30. Social/Environmental • Racial Segregation • Social Cohesion/Social Capital • Income Disparity • Exposures (Social, Environmental,…) • Health StatusDisparities • Morbidity & Mortality • Health Status [Self-report/ measured] • Functional Status Classical Epidemiology • Individual • Cultural • Socioeconomic • Biological & Clinical • Behavioral • Living Conditions HealthOutcomes Varying Patient preferencesHealth behavior Political Economy Health Care Continuity & Concordance • Health CareDisparities: • Access to Care • Structure of Care • Process of Care • Patient Satisfaction • Provider • Knowledge • Attitudes • Practice Patterns • Communication • Cultural Competence Varyingeffectiveness or style Varying resources constraints • System/Policy • Organization & staffing • Insurance • Supply & Distribution of Clinicians & other Resources CHERP Health Disparities Primer http://www.hypnoclients.com/inprogress/cherp/primer3.php

31. Social/Environmental • Racial Segregation • Social Cohesion/Social Capital • Income Disparity • Exposures (Social, Environmental,…) • Health StatusDisparities • Morbidity & Mortality • Health Status [Self-report/ measured] • Functional Status Classical Epidemiology • Individual • Cultural • Socioeconomic • Biological & Clinical • Behavioral • Living Conditions HealthOutcomes Varying Patient preferencesHealth behavior Political Economy Health Care Continuity & Concordance • Health CareDisparities: • Access to Care • Structure of Care • Process of Care • Patient Satisfaction • Provider • Knowledge • Attitudes • Practice Patterns • Communication • Cultural Competence Varyingeffectiveness or style Varying resources constraints • System/Policy • Organization & staffing • Insurance • Supply & Distribution of Clinicians & other Resources CHERP Health Disparities Primer http://www.hypnoclients.com/inprogress/cherp/primer3.php

32. Social/Environmental • Racial Segregation • Social Cohesion/Social Capital • Income Disparity • Exposures (Social, Environmental,…) • Health StatusDisparities • Morbidity & Mortality • Health Status [Self-report/ measured] • Functional Status Classical Epidemiology • Individual • Cultural • Socioeconomic • Biological & Clinical • Behavioral • Living Conditions HealthOutcomes Varying Patient preferencesHealth behavior Political Economy Health Care Continuity & Concordance • Health CareDisparities: • Access to Care • Structure of Care • Process of Care • Patient Satisfaction • Provider • Knowledge • Attitudes • Practice Patterns • Communication • Cultural Competence Varyingeffectiveness or style Varying resources constraints • System/Policy • Organization & staffing • Insurance • Supply & Distribution of Clinicians & other Resources CHERP Health Disparities Primer http://www.hypnoclients.com/inprogress/cherp/primer3.php

33. Social/Environmental • Racial Segregation • Social Cohesion/Social Capital • Income Disparity • Exposures (Social, Environmental,…) • Health StatusDisparities • Morbidity & Mortality • Health Status [Self-report/ measured] • Functional Status Classical Epidemiology • Individual • Cultural • Socioeconomic • Biological & Clinical • Behavioral • Living Conditions HealthOutcomes Varying Patient preferencesHealth behavior Political Economy Health Care Continuity & Concordance • Health CareDisparities: • Access to Care • Structure of Care • Process of Care • Patient Satisfaction • Provider • Knowledge • Attitudes • Practice Patterns • Communication • Cultural Competence Varyingeffectiveness or style Varying resources constraints • System/Policy • Organization & staffing • Insurance • Supply & Distribution of Clinicians & other Resources CHERP Health Disparities Primer http://www.hypnoclients.com/inprogress/cherp/primer3.php

34. Social/Environmental • Racial Segregation • Social Cohesion/Social Capital • Income Disparity • Exposures (Social, Environmental,…) • Health StatusDisparities • Morbidity & Mortality • Health Status [Self-report/ measured] • Functional Status Classical Epidemiology • Individual • Cultural • Socioeconomic • Biological & Clinical • Behavioral • Living Conditions HealthOutcomes Varying Patient preferencesHealth behavior Political Economy Health Care Continuity & Concordance • Health CareDisparities: • Access to Care • Structure of Care • Process of Care • Patient Satisfaction • Provider • Knowledge • Attitudes • Practice Patterns • Communication • Cultural Competence Varyingeffectiveness or style Varying resources constraints • System/Policy • Organization & staffing • Insurance • Supply & Distribution of Clinicians & other Resources CHERP Health Disparities Primer http://www.hypnoclients.com/inprogress/cherp/primer3.php

35. Social/Environmental • Racial Segregation • Social Cohesion/Social Capital • Income Disparity • Exposures (Social, Environmental,…) • Health StatusDisparities • Morbidity & Mortality • Health Status [Self-report/ measured] • Functional Status Classical Epidemiology • Individual • Cultural • Socioeconomic • Biological & Clinical • Behavioral • Living Conditions HealthOutcomes Varying Patient preferencesHealth behavior Political Economy Health Care Continuity & Concordance • Health CareDisparities: • Access to Care • Structure of Care • Process of Care • Patient Satisfaction • Provider • Knowledge • Attitudes • Practice Patterns • Communication • Cultural Competence Varyingeffectiveness or style Varying resources constraints • System/Policy • Organization & staffing • Insurance • Supply & Distribution of Clinicians & other Resources CHERP Health Disparities Primer http://www.hypnoclients.com/inprogress/cherp/primer3.php

36. Social/Environmental • Racial Segregation • Social Cohesion/Social Capital • Income Disparity • Exposures (Social, Environmental,…) • Health StatusDisparities • Morbidity & Mortality • Health Status [Self-report/ measured] • Functional Status Classical Epidemiology • Individual • Cultural • Socioeconomic • Biological & Clinical • Behavioral • Living Conditions HealthOutcomes Varying Patient preferencesHealth behavior Political Economy Health Care Continuity & Concordance • Health CareDisparities: • Access to Care • Structure of Care • Process of Care • Patient Satisfaction • Provider • Knowledge • Attitudes • Practice Patterns • Communication • Cultural Competence Varyingeffectiveness or style Varying resources constraints • System/Policy • Organization & staffing • Insurance • Supply & Distribution of Clinicians & other Resources CHERP Health Disparities Primer http://www.hypnoclients.com/inprogress/cherp/primer3.php

37. More Information… “CDC Health Disparities and Inequalities Report — United States, 2011” Report outlining over 20 types of disparities categorized by: Social Determinates of Health Health-Care Access Mortality Morbidity Behavioral Risk Factors http://www.cdc.gov/mmwr/pdf/other/su6001.pdf

38. Interventions to address Health Disparities

39. 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

40. Eliminating Health Disparities Kilbourne Complex social problems require multifaceted responses Require detecting, understanding and reducing the disparity

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

42. EBIs Addressing Health Disparities

43. What can Philanthropic organizations do? Collaborative efforts between those traditionally involved with health and those with a focus on children, housing, the environment or nutrition Work across sectors—and with their public agency counterparts—to develop an integrated agenda that capitalizes on new investments in community programs to produce health benefits

44. What can Philanthropic organizations do? Support initiatives in disadvantaged communities that create opportunities for healthy living and healthy choices Identify, support and champion innovative models of community building and design Build on existing evidence in program design Join with federal and state agencies and businesses as partners in supporting and rigorously evaluating place-based, multisector demonstrations

45. Questions?

46. References & Websites Monographs RWJ Commission for a Healthier America http://www.commissiononhealth.org/ 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):377-396. 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):2113-2121. Websites http://rtips.cancer.gov/rtips/programDetails.do?programId=257161&topicId=102266&cgId=  http://rtips.cancer.gov/rtips/programDetails.do?programId=224488&topicId=102266&cgId=  http://rtips.cancer.gov/rtips/programDetails.do?programId=280192&topicId=102266&cgId= http://www.cdc.gov/mmwr/pdf/other/su6001.pdf http://www.conehealthfoundation.com/body_foundation.cfm?id=3242 http://www.scribd.com/doc/7778732/Dr-David-Williams-on-Health-Disparities http://www.who.int/social_determinants/en/

47. What are the direct and indirect ways of how funders can impact health disparities? How can you address health disparities in your grantmaking in the future?

49. Health Disparities & Health Reform

50. Health Disparities & Reform Cont…