THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL
SCHOOL OF SOCIAL WORK
COURSE NUMBER:
COURSE TITLE:
SEMESTER AND YEAR:
SOWO 836
Examining Health Access and Health Disparities
Spring 2012
MEETING TIME/LOCATION:
Tuesday, 9-10:30am; Room 101
INSTRUCTOR:
Lisa de Saxe Zerden, MSW, PhD
Email: Lzerden@email.unc.edu
Phone: 919.962.6430
OFFICE HOURS:
425 (Students are always welcome to stop by but appointments
recommended so I will be in my office when you need me).
COURSE DESCRIPTION:
Examines disparities in health outcomes as a function of access to and quality of care for
persons disadvantaged by income, ethnicity, sexual orientation, and other factors.
Critically evaluates health and social policies related to exacerbation and resolution of
health inequities.
COURSE OBJECTIVES:
The student who successfully completes this course should be able to:
1. Identify the principles, foundation and provisions of the primary social welfare programs
that constitute the healthcare safety net in the United States.
2. Demonstrate the analytic, theoretical and value assessment skills that enable social
workers to evaluate policies and apply change strategies.
3. Apply concepts and principles of human rights, social justice, and social work ethics to
policy analysis, development and change strategies.
4. Describe major disparities in diagnosis, prognosis, and health outcomes in the United
States for persons of varying gender, race and ethnicity, sexual orientation, and level of
economic advantage.
5. Discuss the historical and political context of contemporary health disparities, including
their roots in discriminatory systems and policies.
6. Describe the interrelationships among a range of economic and social factors that result
in inadequate access to quality care.
7. Describe characteristics of healthcare systems and policies that inhibit the provision of
high-quality, culturally sensitive care.
8. Discuss ethical challenges for the social worker related to practicing in an environment
that is structured in a way that promotes unequal access to and quality of care.
9. Evaluate a range of policy and intervention solutions that have been proposed in order
to address and resolve health disparities.
10. Articulate strategies for the exercise of leadership and advocacy in successfully
addressing health disparities.
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TEACHING METHODS:
This course will stimulate new ideas and insights related to health disparities and policy.
During the course, students will agree and disagree with course content. Respectful
discussion and debate is strongly encouraged. Students should feel free to relate the
readings to broader policy, intervention, prevention, treatment, and systemic factors
previously discussed and from experience in the field.
Each session will include a combination of lecture, discussions, and classroom exercises. As
the semester progresses, there will be allotted time for group and individual consultation to
prepare for the final assignment. Depending on the week, guest speakers will be invited for
a portion of the class to discuss relevant content. Adult learning methods will be utilized.
Therefore, students are expected to complete all assigned readings before each class begins
so they can contribute to discussion in meaningful ways. Not every article will be discussed
in elaborate detail but should serve as a background for which the class topic is based. All
students are expected to attend classes, participate in class discussion and activities, and
make connections to class content in field and community contexts.
POLICY FOR ACCOMMODATIONS FOR STUDENTS WITH DISABILITIES:
Students with disabilities that affect their participation in the course and who wish to have
special accommodations should contact the University’s Disabilities Services
(http://disabilityservices.unc.edu) and provide documentation of their disability. Students
should discuss the specific accommodations they require directly with the instructor.
APA FORMATTING:
Students are expected to correctly cite all of your material following the 5 th ed. of the APA
manual. If you are not familiar with this style, please refer to the APA manual and/or the
School’s Writing Resources Page: (http://ssw.unc.edu/students/writing). This link provides
access to an array of resources including the newly updated “APA Quick Reference Guide.”
You may also schedule an appointment with the SSW Writing Support Team: Diane Wyant,
(dwyant@email.unc.edu) or Susan White, (sewhite@email.unc.edu).
POLICY ON ACADEMIC DISHONESTY:
Please refer to the APA Style Guide, The SSW Manual, and the SSW Writing Guide for
information on attribution of quotes, plagiarism and appropriate use of assistance in
preparing assignments. All written assignments should contain a signed pledge stating: "I
have not given or received unauthorized aid in preparing this written work". In keeping
with the UNC Honor Code, if reason exists to believe that academic dishonesty has
occurred, a referral will be made to the Office of the Student Attorney General for
investigation and further action as required.
TEXTBOOKS AND OTHER READINGS:
There is no required text for this course. All readings will be accessible through the UNC
library system (http://www.lib.unc.edu/index.html?searchtab=ejournals) or posted on
Sakai. If a reading has not uploaded or the link is broken please notify the instructor as
soon as possible.
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GRADING SYSTEM:
H = 94 and above
P = 80 to 93
L = 70 to 79
F = 69 and below
ATTENDANCE AND PARTICIPATION:
Student attendance at all class sessions is expected. If you will not be able to attend a class,
notify the instructor as soon as possible. It is your responsibility to obtain handouts and
information about class content from your classmates if you are unable to attend a class. In
order to fully participate in and benefit from each session, students must complete required
readings and come to class prepared and on time. Student who miss 2 or more classes
without seeking permission from the instructor, or who are continually late, will receive an
“L” grade.
LATE ASSIGNMENTS:
Late assignments are strongly discouraged. To obtain permission to submit an assignment
after the deadline, the student must seek approval from the instructor before the due date.
If permission for late submission is not granted before breaking a deadline, the grade will
automatically be reduced 10% each day, including weekends. In case of an emergency, a
late paper may be accepted without penalty at the discretion of the instructor. Avoid having
last minute computer failures prevent you from turning papers in on time. Plan ahead!
CELL PHONE POLICY:
Cell phones are a disruption to the learning process. Please turn off cell phones during class.
Requirement
COURSE REQUIREMENTS OVERVIEW:
% of Grade
Class Participation
Reading Questions
Reading Summary Memo
Reflection
Midterm: Health Disparity Outline
Final Health Disparity Presentation
10 points
10 points
10 points
10 points
30 points
30 points
Date/Due Date
Ongoing
2 days before session
2 days before session
Week 6 or Week 11
Week 8
Weeks 14 & 15
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COURSE OVERVIEW:
1/10/12
1/17/12
1/24/12
1/31/12
2/7/12
2/14/12
2/21/12
2/28/12
3/6/12
3/13/12
3/20/12
3/27/12
4/3/12
4/10/12
4/17/12
Class 1: Introduction and course overview; why study health disparities?
Class 2: Patterns and causes of health disparities—past and present
Class 3: Pattern and causes of health disparities (cont.)
Class 4: Frameworks and theories to understand racism and health disparities
Class 5: Overview of Healthcare in the U.S.—How system is financed and policies
Class 6: Health care in the U.S. (cont.); health care reform, access to health
Class 7: Health care disparities in developing countries ** Guest Speaker**
Class 8: Examples and interventions of community approaches to improve health
SPRING BREAK
Class 9: How immigration, acculturation and national origin influence health
Class 10: Substance abuse and mental health disparities ** Guest Speaker**
Class 11: The role of social workers in advocacy and addressing health disparities
Class 12: Interventions to Reduce Disparities in an Age of Scarce Resources
Class 13: Final presentations
Class 14: Final presentations and class wrap up
COURSE READINGS AND COURSE OUTLINE:
JAN 10, 2012
Week 1: Introduction and course overview; why study health disparities?
1. Introductions and course overview
2. Introduction to health disparities in diagnosis, prognosis, and health outcomes
Readings:
Healthy People 2010. A Systematic Approach to Health Improvement. Available on
Sakai. (*Focus on pages 11-26).
Epstein, H. (2003, October 12). Ghetto Miasma; Enough to make you sick? The New York
Times. Available: http://www.nytimes.com/2003/10/12/magazine/ghettomiasma-enough-to-make-you-sick.html?pagewanted=all&src=pm
Braithwaite, K. (2008). Health is a human right, right? American Journal of Public Health,
98, 5-7.
Recommended:
Krieger, N. (2001). A glossary for social epidemiology. Journal of Epidemiology and
Community Health, 55, 693-700.
JAN 17, 2012
Week 2: Patterns and causes of health disparities—past and present
1. Background and history of disparities in healthcare
2. Patterns and causes of health disparities
3. Inequalities in healthcare access and utilization of services
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Readings:
Link, B.G & Phelan, J.C. (2006). Fundamental Sources of Health Inequalities. In Mechanic,
D., Rogurt, L.B., Colby, D.C. & Knickman, J.R. (Eds.), Policy Changes in Modern
Health Care (71-84). New Brunswick: Rutgers University Press.
Williams, D.R. (2006). Patterns & Causes of Disparities. In Mechanic, D., Rogurt, L.B.,
Colby, D.C. & Knickman, J.R. (Eds.), Policy Changes in Modern Health Care (115134). New Brunswick: Rutgers University Press.
Moniz, C. (2010). Social work and the social determinants of health perspective: A good
fit. Health & Social Work, 35(4): 310-313.
Recommended:
Drexler, M. (March 3, 2005). Spreading the health: Government's role in addressing health
disparities. Harvard School of Public Health Symposium Series 2005: Health
Disparities & the Body Politic. Available:
http://134.174.190.199/disparities/book/HealthDisparities.pdf (Focus on p.11-24)
JAN 24, 2012
Week 3: Pattern and causes of health disparities (cont.): SES, employment and neighborhood
1. Patterns and causes of health disparities (cont.)
2. SES, neighborhood, employment and other factors related to health inequality
3. Video: Is inequality making us sick? Place Matters (view in class)
Readings:
Williams, D.R., & Jackson, B.P., (2005). Social sources of racial disparities in health.
Health Affairs, 24(2): 325-334, doi: 10.1377/hlthaff.24.2.325.
Moore, L.V., Diez Roux, A. (2006). Associations of neighborhood characteristics with the
location and type of food stores .American Journal of Public Health, 96(2):
325-331.
Kwate, N.O. (2008). Fried chicken and fresh apples: Racial segregation as a fundamental
cause of fast food density in black neighborhoods. Health & Place,14;32-44.
Recommended:
The John D. and Catherine T. MacArthur Foundation Research Network on
Socio-economic Status and Health (2008). Reaching for a healthier life: Facts on
Socio-economic status and health in the U.S. Available on Sakai.
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JAN 31, 2012
Week 4: Frameworks and theories to understand racism and health disparities
1. Individual risk factors vs. social conditions
2. Lifecourse health development theory (LCHD)
3. Historical trauma and population health
Readings:
Krieger, N. (2001). Theories for social epidemiology in the 21st century: An eco-social
perspective. International Journal of Epidemiology, 30,(4) 668-677.
Jones, C.P. (2000). Levels of Racism: A Theoretic Framework and a Gardener’s Tale.
American Journal of Public Health, 90(8), 1212-1215.
Halfon, N. (2009). Life Course Health Development: A New Approach for Addressing
Upstream Determinants of Health and Spending. Policy Brief (Available on
Sakai).
FEB 7, 2012
WEEK 5: Overview of Healthcare in the U.S.—How the system is financed and related policies
1.
2.
3.
4.
Federal health agencies
Federal financing of health care in the US
Private sector health care and reform
Role of social workers in health care settings
Readings:
Barusch, A.S. (2012). Health: Chapter 6. In A.S., Foundations of social welfare policy:
Social justice in human perspective (164-203). Belmont, CA: Brooks/Cole,
Cengage Learning.
Horton, S. (2006). The double burden on safety net providers: Placing health disparities
in the context of the privatization of health care in the US. Social Science &
Medicine, 63(10), 2702-2714.
Kaiser Family Foundation (2005). Medicare and Medicaid at 40: Key Medicare and
Medicaid Statistics, Available at: http://www.kff.org/medicaid/40years.cfm
Recommended:
Holahan, J., & Garrett, B. (2009). Rising Unemployment, Medicaid and the Uninsured:
January 2009. Available at: http://www.kff.org/uninsured/upload/7850.pdf
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FEB 14, 2012
WEEK 6: Overview of Healthcare in the U.S (cont.); Improving access to quality health care
 Reflection due today or week 11
1. Ideological and cultural issues to tackle
2. Brief history of health Insurance in the U.S.
3. Health reform and role of social work
Readings:
Golden, R.L. (2011). Coordination, integration, and collaboration: A clear path for social
work in health care reform. Health & Social Work, 36(3): 227-228.
Zabora, J.R. (2011). How can social work affect health care reform? Health & Social
Work, 36(3): 231-232.
Ofosu, A. (2011). Implications of health care reform. Health & Social Work, 36(3): 229230.
Kaiser Family Foundation (2009). National health insurance—a brief history of reform
efforts in the U.S. Available: http://www.kff.org/healthreform/upload/7871.pdf
Kaiser Family Foundation (2009). Massachusetts Health Care Reform: Three Years Later.
Available: http://www.kff.org/uninsured/upload/7777-02.pdf
Recommended:
Mackey, J. (August 11, 2009). Op-Ed: The Whole Foods Alternative to Obamacare. Wall
Street Journal:
http://online.wsj.com/article/SB10001424052970204251404574342170072865070.html
FEB 21, 2012
WEEK 7: Health Care Disparities in Developing Countries
1. Global health inequality
2. Structural approaches to reducing health disparities
3. Guest Lecturer: Kumi Smith, MPH
Gill, B. ,& Oakie, S. (2007). China and HIV -- A Window of Opportunity. New England
Journal of Medicine, 356(18): 1801-1805.
Rennie, S., & Behets, F. (2006). Desperately Seeking Targets: The Ethics of Routine HIV
Testing in Low-Income Countries. WHO Bulletin, 84(1): 52-57.
Garrett, L. (2007). The Challenge of Global Health. Foreign Affairs, 2007. 86(1):14-38.
Foreign Affairs Roundtable Discussion. Available at:
http://www.foreignaffairs.com/discussions/roundtables/how-to-promote-global-health
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FEB 28, 2012
WEEK 8: Examples and interventions of community based approaches to improve health
 Midterm outline due
1. Impact of social injustice on the health of marginalized populations
2. Addressing racial inequality in healthcare through civil rights
3. Group work on health disparities presentation
Readings:
Gehlert, S., Coleman, R. (2010). Using community-based participatory research to
ameliorate cancer disparities. Health & Social Work, 35(4): 302-309.
Gamble, V. N. (1997). Under the shadow of Tuskegee: African Americans and health
care. American Journal of Public Health, 87, 1773-8.
Isaac, E., Rowland, M., & Blackwell, L. (2007). Fighting health disparities: The
Educational role of the African American church. Cross Currents, 57(2), 261-265.
Wiechelt, S.A., Gryczynski, J., Jeannette, L., (2009). Designing HIV prevention
interventions for urban American Indians: Evolutions of the ‘Don’t Forget Us’
program. Health & Social Work, 34(4): 301-304.
MAR 6, 2012 : NO CLASS, ENJOY YOUR SPRING BREAK
MAR 13, 2012
WEEK 9: How immigration, acculturation and national origin influence health
1.
2.
3.
4.
Effects of immigration and acculturation on health
The Latino Health Paradox
Case example: Latino injection drug users
Video: Unnatural Causes-- Becoming American (view in class)
Readings:
DeRose, K. P., Escarce, J. J., & Lurie, N. (2007). Immigrants & health care: Sources of
vulnerability. Health Affairs, 26(5), 1258-1268.
Zambrana, R.E., Carter-Pokras, O. (2010) Role of acculturation research in advancing
science and practice in reducing health care disparities among Latinos.
American Journal of Public Health, 100(1), 18-23.
Galarneau, C. (2011). Still Missing: Undocumented immigrants in health care reform.
Journal of Health Care for the Poor and Underserved, 22: 422–428.
Recommended:
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Vega, W.A., & Amaro, H. Latino outlook: Good health, uncertain Prognosis. (2002). In
T.A. LaVeist (Ed.), Race, Ethnicity, and Health—A public health reader (47-75).
San Francisco: Jossey-Bass.
Sherrill, W., Crew, L., Mayo, R., Mayo, W., Rogers, B., & Haynes, D. (2005). Educational
and health services innovation to improve care for rural Hispanic communities in
the US. Education for Health: Change in Learning & Practice, 18(3), 356-367.
MAR 20, 2012
WEEK 10: Substance abuse and mental health disparities
1. Substance abuse and mental health disparities among racial/ethnic groups
2. Treatment and interventions tailored towards minority and vulnerable populations
3. Guest Speakers TBD.
Readings:
Mechanic, D. (2007). Mental health services then and now. Health Affairs, 26(6): 15481550.
Barry, C.L. & Huskamp, H.A., (2011). Moving beyond Parity: Mental health and addiction
care under the Affordable Care Act. New England Journal of Medicine; 365: 973975.
Wells, K., Klap, R., Koike, A., & Sherbourne, C. (2001). Ethnic disparities in unmet need
for alcoholism, drug abuse, and mental health care. American Journal of
Psychiatry, 158: 2027-2032.
McGuire, T.G., & Miranda, J. (2008). New evidence regarding racial and ethnic
disparities in mental health: Policy Implications. Health Affairs, 27(2): 393-403.
doi: 10.1377/hlthaff.27.2.393
MAR 27, 2012
WEEK 11: The role of social workers in advocacy and addressing health disparities
 Reflection due today if you did not hand it in week 6
1. Role of social work profession in addressing health disparities and improving access
2. Policy practice and legislative action
3. Advocacy
Readings:
Poindexter, C.C. (1999). Promises in the Plague: The Ryan White CARE Act as a Case
Study for Legislative Action. Health and Social Work, 24, 35-41.
Altpeter, M., Mitchell, J.F. & Pennell, J. (2005). Advancing Social Workers'
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Responsiveness to Health Disparities: The Case of Breast Cancer Screening.
Health and Social Work, 30(3), 221-232.
Praxis Project (2005). Advocating for Better Policies. Available:
http://www.unnaturalcauses.org/assets/uploads/file/UC_PolicyAdvocacy.pdf
(*This will be a helpful tool to consider as you plan your final presentation).
Recommended:
Shaw-Ridley, M., & Ridley, C.R. (2010). The health disparities industry: Is it an ethical
conundrum? Health Promotion & Practice,11: 454-464.
Wallack, L. (2002). Public health, social change, and media advovacy. Social Marketing
Quarterly, 8(2): 25-31.
McDonough-Figueira, J. (1993). Policy Practice: The Neglected Side of Social Work
Intervention. Social Work, 38(2),179-188,
Gamble, V., & Stone, D. (2006). U.S. policy on health inequities: the interplay of politics
and research. Journal of Health Politics, Policy & Law, 31(1), 93-126.
APR 3, 2012
WEEK 12: Interventions to Reduce Disparities in an Age of Scarce Resources
1. Policy intervention efforts to address health disparities
2. Case examples: tobacco policy, obesity epidemic, and HIV/AIDS in the U.S.
Readings:
Warner, K.E. (2006). Tabacco Policy in the U.S.: Lessons for the Obesity Epidemic. In
Mechanic, D., Rogurt, L.B., Colby, D.C. & Knickman, J.R. (Eds.), Policy Changes in
Modern Health Care (99-114). New Brunswick: Rutgers University Press.
MacMaster, S.A., Vail, K.A., & Neff, J.A. (2002). The Xchange point: A drop-in center for
African American active injection drug users. Health & Social Work, 27(3):227231.
Marlatt, A.G., & Witkiewitz, K. (2010). Update on harm-reduction policy and
intervention research. Available at:
http://dionysus.psych.wisc.edu/lit/Articles/Marlatt2010a.pdf
APR 10, 2012
WEEK 13: Final presentations
APR 17, 2012
WEEK 14: Final presentations and class wrap up
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SOW0 836, HEALTH ACCESS & DISPARITIES CLASS ASSIGNMENTS:
CLASS PARTICIPATION: (10 POINTS)
All students are expected to complete the readings and to actively participate in class
discussions. If you do not feel comfortable speaking in class, you may also email me a three
one-page reflection papers by week 13.
READING QUESTIONS: (10 POINTS)
Due: 2 days before class session that reading was assigned
Each student will pick one article from class and be responsible for critically analyzing the text
to develop 2-3 discussion questions based on the reading. These questions will be used to
supplement lecture and stimulate class discussion. Questions are due to the instructor 2 days
before the class session. Students are expected to contribute to the class discussion based on
their critical analysis of the article they reviewed.
READING SUMMARY MEMO: (10 POINTS)
Due: 2 days before class session that reading was assigned
In addition to preparing discussion questions, each student is responsible for submitting a one
page memo outlining the main points of the article. Do not get lost in details or statistics;
Instead, ask yourself “what are the main points” to take away from this reading? Why does this
reading matter? Please include the title and authors on your memo and submit this to your
instructor 2 days before the class session so it can be uploaded to Sakai for your classmates.
REFLECTION PAPER (10 POINTS)
Due: Week 6, February 14, 2012 or Week 11, March 27, 2012
Students will complete 1 writing reflection assignments due either at the beginning of week 6
or 11. Students can explore any topic of interest that relates to course content from any of the
class sessions. Reflection papers should be 2-3 pages (not including reference page) and needs
to demonstrate student’s ability to think critically about health policy information in a variety of
contexts. Students may want to consider the following kinds of issues:







What are the main health issues and related policies under discussion?
Do you agree or disagree with a perspective or theory as discussed in class? Explain.
Are you aware of health disparities in your own community, professional setting?
What additional questions or issues did a reading or film from class bring up for you?
What are the cultural and/or ethical considerations for the policy under discussion?
What are the implications for social work practice given class content?
Discuss biases/flaws or a model to be emulated to reduce health disparities that you
are aware of from previous work experiences.
Let these points serve as ideas to get your reflection started; not every point needs to
be addressed. Reflections do not require extensive outside literature or research. Think of this
as a critical reflection that synthesizes material in your own thoughts. Do not summarize an
article for me, analyze it and explain how it is informed by your understanding of these issues.
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MIDTERM HEALTH DISPARITY OUTLINE: (30 POINTS)
Due: Week 8, February 28, 2012
The written component of this assignment will include a 7-10 page outline (not including
references) that addresses:
 Topic and prevalence of issue: who is affected and what comparison data can you offer
to highlight this health disparity?
 Learning objectives for the presentation at the end of the semester
 What are some theories or explanations as to why this disparity exists?
 Describe how an existing or proposed policy addresses or exacerbates the problem;
what are the underlying assumptions of the policy?
 What if any, has been the role of social work? Why this topic is relevant to social work
and social justice.
The midterm assignment will serve as a starting point to get your final health disparity
presentation organized. Outlines should provide the context for your topic, you should provide
a through and critical literature review with a synthesis of data highlighting the issues. The
assignment should explore possible pathways by which race, ethnicity, class, gender or any
other variable discussed in class, have resulted in disparate health outcomes among the
population of the given disease. All references need to be included in APA format and do not
count toward the 7-10 page limit. This could be handed in as a DETAILED outline, or essay
format, whichever the group prefers. Your instructor is available for group consultation before
the due date.
Note: the final assignment will focus more closely on specific actions (e.g. advocacy
activities, research, legislative change, organizational modification, etc.) that can be taken
to improve the quality of care provided to underserved or poorly served populations. Your
midterm assignment is the groundwork which will lead to more action/change oriented
steps.
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FINAL HEALTH DISPARITY GROUPS: (30 POINTS)
Each group is responsible for designing an informative 20-25 minute presentation that
describes a health disparity, the population affected, and the impact of local, state and/or
federal policy on mitigating or exacerbating health equity.
This presentation should offer a thorough and thoughtful analysis of the policy(ies) impacting
health disparities and access to health. Your presentation should include the following
components:
a. What are the main health issues and related policies under discussion? (i.e., Ryan
White Care Act on HIV/AIDS on the treatment of HIV in communities of color;
Federal ban on funding for syringe exchange programming and HPC prevalence;
Rates of obesity and food stamp utilization; asthma and housing policy.
b. Describe the prevalence and underlying causes of the problem (i.e.,
institutionalized racism, lack of insurance, environmental and/or structural
barriers). In other words, who is affected most? How and why does this happen?
c. Describe how an existing or proposed policy addresses or exacerbates the
problem. What are the underlying assumptions of the policy?
d. Review empirical research (peer-reviewed journal articles) about the
effectiveness of the policy. What does the research say about the strengths and
limitations of the policy in addressing the problem?
e. Include specific recommendations to improve the health disparity under
discussion and the level of change (micro, mezzo, macro); organizational
change. The Praxis reading from week 11 can help you think through a
specific advocacy plan.
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