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
www.tracs.unc.edu/community
nctracs@unc.edu
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
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
http://www.cdc.gov/mmwr/pdf/oth
er/su6001.pdf
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.”
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
Biology, Culture and
Geography
Racism
Political, Economic
and Legal Structures
Access to Care
Social
Status
Change in
Biological
Processes
Health
Outcomes
Resources and
Practices
Heuristic Model of Racial Disparities in Health Outcomes
(adapted from Williams 1997)
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…”
http://www.who.int/
social_determinants/en/
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 http://www.scribd.com/doc/7778732
/Dr-David-Williams-on-HealthDisparities
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 (102.7-103.6)
42.6 (42.3-42.9
Male
176.5 (175.7-177.2)
43.9 (43.5-44.3)
American Indian/
Alaskan Native
97.4 (92.8-102.0)
29.4 (26.9-32.0)
Asian/Pacific Islander
77.1 (75.4-78.9)
37.0 (35.8-38.2)
Black
161.6 (160.1-163.1)
61.6 (60.7-62.6)
Hispanic
106.4 (104.9-107.8)
34.2 (33.4-35.0)
White
134.2 (133.8-134.6)
41.7 (41.5-42.0)
http://www.cdc.gov/mmwr/pdf/oth
er/su6001.pdf
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
http://www.cdc.gov/mmwr/pdf/oth
er/su6001.pdf
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
Excess Hospitalizations
(Income Disparities)
What is a Disparity in Healthcare?
Populations with Equal Access to Health Care
SOURCE: Gomes and McGuire, 2001, National Academy of Sciences
Potential Origins for Disparities in
Healthcare
Kilbourne
Van Ryn, Michelle, “Research on the Provider Contribution to Race/Ethnicity Disparities
in Medical Care.” Medical Care 40(1) I-140-151.
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
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.”
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
Preventive
Acute
Chronic
Terminal
Components of Health Care Quality
Safety
Effectiveness
Patient
Centeredness
Timeliness
Percent of Population aged 18-64 Years with No
Health Insurance by Income: US, 1994-5
60
50
40
30
20
10
0
Men
Women
Non-Hispanic White
Poor
CDC
Men
Women
Non-Hispanic Black
Middle Income
Men
Women
Hispanic
High Income
Health Disparities Data:
North Carolina
% with Health Insurance
in NC by Race
BRFSS,
2009
Mental Health in NC by Race
How satisfied are you with your life?
70
60
50
40
Very Satisfied
Satisfied
30
Dissatisfied
20
Very Dissatisfied
10
0
White
African
American
Asian
Native
American
Hispanic
BRFSS,
2009
Alcohol Abuse in NC by Race
Binge Drinking in NC by Race
25
20
15
10
5
0
White
African
American
Asian
Native
American
Hispanic
% Reporting
3+ times in a
month of
having >5
drinks at a
time
BRFSS,
2009
Teen Pregnancy Rate in NC by Race
Teen Pregnancy Rate
140
120
100
80
Teen
Pregnancy
Rate
60
40
20
0
White
African American
Latina
N. C. Adult/Adolescent HIV New
Disease Cases in 2009
Rate HIV incidence per 100,000
80
70
60
50
Rate HIV
incidence
per
100,000
40
30
20
10
0
White
Black
AmInd
Asian
Hispanic
Social/Environmental
• Racial Segregation
• Social Cohesion/Social Capital
• Income Disparity
• Exposures (Social, Environmental,…)
Health Status Disparities
Classical
Epidemiology
• Morbidity & Mortality
• Health Status
[Self-report/ measured]
• Functional Status
Individual
Political
Economy
Health Care
• Cultural
• Socioeconomic
• Biological & Clinical
• Behavioral
• Living Conditions
Continuity &
Concordance
Varying Patient
preferences
Health behavior
Provider
• Knowledge
• Attitudes
• Practice Patterns
• Communication
• Cultural Competence
System/Policy
• Organization & staffing
• Insurance
• Supply & Distribution of Clinicians
& other Resources
Varying
effectiveness
or style
Health
Outcomes
Health Care Disparities:
• Access to Care
• Structure of Care
• Process of Care
• Patient Satisfaction
Varying
resources
constraints
CHERP Health Disparities Primer
http://www.hypnoclients.com/inprogress/cherp/primer3.php
Social/Environmental
• Racial Segregation
• Social Cohesion/Social Capital
• Income Disparity
• Exposures (Social, Environmental,…)
Health Status Disparities
Classical
Epidemiology
• Morbidity & Mortality
• Health Status
[Self-report/ measured]
• Functional Status
Individual
Political
Economy
Health Care
• Cultural
• Socioeconomic
• Biological & Clinical
• Behavioral
• Living Conditions
Continuity &
Concordance
Varying Patient
preferences
Health behavior
Provider
• Knowledge
• Attitudes
• Practice Patterns
• Communication
• Cultural Competence
System/Policy
• Organization & staffing
• Insurance
• Supply & Distribution of Clinicians
& other Resources
Varying
effectiveness
or style
Health
Outcomes
Health Care Disparities:
• Access to Care
• Structure of Care
• Process of Care
• Patient Satisfaction
Varying
resources
constraints
CHERP Health Disparities Primer
http://www.hypnoclients.com/inprogress/cherp/primer3.php
Social/Environmental
• Racial Segregation
• Social Cohesion/Social Capital
• Income Disparity
• Exposures (Social, Environmental,…)
Health Status Disparities
Classical
Epidemiology
• Morbidity & Mortality
• Health Status
[Self-report/ measured]
• Functional Status
Individual
Political
Economy
Health Care
• Cultural
• Socioeconomic
• Biological & Clinical
• Behavioral
• Living Conditions
Continuity &
Concordance
Varying Patient
preferences
Health behavior
Provider
• Knowledge
• Attitudes
• Practice Patterns
• Communication
• Cultural Competence
System/Policy
• Organization & staffing
• Insurance
• Supply & Distribution of Clinicians
& other Resources
Varying
effectiveness
or style
Health
Outcomes
Health Care Disparities:
• Access to Care
• Structure of Care
• Process of Care
• Patient Satisfaction
Varying
resources
constraints
CHERP Health Disparities Primer
http://www.hypnoclients.com/inprogress/cherp/primer3.php
Social/Environmental
• Racial Segregation
• Social Cohesion/Social Capital
• Income Disparity
• Exposures (Social, Environmental,…)
Health Status Disparities
Classical
Epidemiology
• Morbidity & Mortality
• Health Status
[Self-report/ measured]
• Functional Status
Individual
Political
Economy
Health Care
• Cultural
• Socioeconomic
• Biological & Clinical
• Behavioral
• Living Conditions
Continuity &
Concordance
Varying Patient
preferences
Health behavior
Provider
• Knowledge
• Attitudes
• Practice Patterns
• Communication
• Cultural Competence
System/Policy
• Organization & staffing
• Insurance
• Supply & Distribution of Clinicians
& other Resources
Varying
effectiveness
or style
Health
Outcomes
Health Care Disparities:
• Access to Care
• Structure of Care
• Process of Care
• Patient Satisfaction
Varying
resources
constraints
CHERP Health Disparities Primer
http://www.hypnoclients.com/inprogress/cherp/primer3.php
Social/Environmental
• Racial Segregation
• Social Cohesion/Social Capital
• Income Disparity
• Exposures (Social, Environmental,…)
Health Status Disparities
Classical
Epidemiology
• Morbidity & Mortality
• Health Status
[Self-report/ measured]
• Functional Status
Individual
Political
Economy
Health Care
• Cultural
• Socioeconomic
• Biological & Clinical
• Behavioral
• Living Conditions
Continuity &
Concordance
Varying Patient
preferences
Health behavior
Provider
• Knowledge
• Attitudes
• Practice Patterns
• Communication
• Cultural Competence
System/Policy
• Organization & staffing
• Insurance
• Supply & Distribution of Clinicians
& other Resources
Varying
effectiveness
or style
Health
Outcomes
Health Care Disparities:
• Access to Care
• Structure of Care
• Process of Care
• Patient Satisfaction
Varying
resources
constraints
CHERP Health Disparities Primer
http://www.hypnoclients.com/inprogress/cherp/primer3.php
Social/Environmental
• Racial Segregation
• Social Cohesion/Social Capital
• Income Disparity
• Exposures (Social, Environmental,…)
Health Status Disparities
Classical
Epidemiology
• Morbidity & Mortality
• Health Status
[Self-report/ measured]
• Functional Status
Individual
Political
Economy
Health Care
• Cultural
• Socioeconomic
• Biological & Clinical
• Behavioral
• Living Conditions
Continuity &
Concordance
Varying Patient
preferences
Health behavior
Provider
• Knowledge
• Attitudes
• Practice Patterns
• Communication
• Cultural Competence
System/Policy
• Organization & staffing
• Insurance
• Supply & Distribution of Clinicians
& other Resources
Varying
effectiveness
or style
Health
Outcomes
Health Care Disparities:
• Access to Care
• Structure of Care
• Process of Care
• Patient Satisfaction
Varying
resources
constraints
CHERP Health Disparities Primer
http://www.hypnoclients.com/inprogress/cherp/primer3.php
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
Political
Economy
Health Care
• Cultural
• Socioeconomic
• Biological & Clinical
• Behavioral
• Living Conditions
Continuity &
Concordance
Varying Patient
preferences
Health behavior
Provider
• Knowledge
• Attitudes
• Practice Patterns
• Communication
• Cultural Competence
System/Policy
• Organization & staffing
• Insurance
• Supply & Distribution of Clinicians
& other Resources
Varying
effectiveness
or style
Health
Outcomes
Health Care Disparities:
• Access to Care
• Structure of Care
• Process of Care
• Patient Satisfaction
Varying
resources
constraints
CHERP Health Disparities Primer
http://www.hypnoclients.com/inprogress/cherp/primer3.php
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
http://www.cdc.gov/mmwr/pdf/other/su6001.pdf
Interventions to address
Health Disparities
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
Eliminating Health Disparities
• Disparities are complex social problems
requiring multifaceted responses
• Require detecting, understanding and
reducing the disparity
Kilbourne
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
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
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
Strives to address nutrition
related disparities affecting
African Americans
Little by Little
Increase fruit and vegetable
consumption among low
income women
Strives to address nutrition
related disparities affecting
low income women
Funding
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
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
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)
Questions?
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):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/