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 2010
MEETING TIME/LOCATION:
Tuesday, 9-10:30am; Room 300
INSTRUCTOR:
Lisa de Saxe Zerden, MSW, PhD
Email: Lisa.zerden@gmail.com
Phone: (617) 935-6157
OFFICE HOURS:
By appointment
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 resolution of disparities.
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 highquality, 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. The adult learning method will be used. Therefore, students are
expected to complete all assigned readings before each class begins. 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 report on the
progress of their individual or group health disparities project.
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, the study
guide on the school’s website, or see Diane Wyant, the School’s editor (dwyant@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:
Mechanic, D., Rogut, L. B., & Colby, D. C. (2005). Policy challenges in modern health care.
Piscataway, NJ: Rutgers University Press.
Additional required readings for this course can be obtained via blackboard or the UNC
electronic library.
GRADING SYSTEM:
H = 94 and above
P = 80 to 93
L = 70 to 79
F = 69 and below
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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, information
about class content, etc., 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 to discuss and apply them.
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.
COURSE OVERVIEW:
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.): SES, employment and neighborhood
Class 4: Frameworks and theories to understand racism and health disparities
Class 5: Overview of Healthcare in the U.S.—How the system is financed and related policies
Class 6: Improving health and access to quality health care
Class 7: Impact of social injustice in healthcare: Examples and interventions
Class 8: How immigration, acculturation and national origin influence health
Class 9: Disparities related to gender and sexual orientation & Discussion on policy memos
Class 10: Substance abuse and mental health disparities
Class 11: Health Care Disparities in Developing Countries
Class 12: The role of social workers in addressing health disparities
Class 13: Interventions to Reduce Disparities in an Age of Scarce Resources
Class 14: Final presentations
Class 15: Final presentations (cont.) and class wrap-up
COURSE REQUIREMENTS OVERVIEW:
Requirement
% of Grade
Date/Due Date
Class Participation
Writing Reflections
Midterm Assignment: Horton Example
Policy Memo Final Assignment
Health Disparities Presentation
20%
20%
25%
20%
15%
Ongoing
Weeks 4 & 9
Week 7
Week 14
Weeks 14 & 15
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COURSE READINGS AND COURSE OUTLINE:
JAN 12, 2010
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:
http://www.healthypeople.gov/Document/html/uih/uih_bw/uih_2.htm#goals
Krieger, N. (2001). A glossary for social epidemiology. Journal of Epidemiology and
Community Health, 55, 693-700.
JAN 19, 2010
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
Readings:
Mechanic Ch. 5: Fundamental Sources of Health Inequalities (Link & Phelan)
Mechanic Ch. 8: Patterns & Causes of Disparities (Williams)
Video: Unnatural causes: Is inequality making us sick?: In sickness and in wealth (view in class)
JAN 26, 2009
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
Readings:
Barbeau, E.M., Krieger, N., Soobader, M. (2004). Working class matters: Socioeconomic
disadvantage, race/ethnicity, gender and smoking in NHIS 2000. American Journal of
Public Health, 94(2): 269-278.
Moore, L.V., Diez Roux, A. Associations of neighborhood characteristics with the location
and type of food stores .American Journal of Public Health, 96(2): 325-331.
Yen IH, Syme SL (1999). The social environment and health: discussion of the
epidemiologic literature. Annual Review of Public Health; 20: 287-308.
Video: Unnatural causes: Is inequality making us sick?: Place matters (view in class)
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Recommended not required:
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:
http://www.macses.ucsf.edu/News/Reaching%20for%20a%20Healthier%20Life.pdf
FEB 2, 2010
Week 4: Frameworks and theories to understand racism and health disparities

Writing reflection #1 due
1. Individual risk factors vs. social conditions
2. Lifecourse health development theory (LCHD)
3. Historical trauma and population health
Readings:
Mechanic Ch. 1: Morality, Polictics and Health Policy (Monroe)
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.
Recommended not required:
Halfon, N. & Russ, S., & Regaldo, M. (2005). The lifecourse health development
model: A guide to children’s health care policy and practice. Zero to Three, January.
FEB 9, 2010
WEEK 5: Overview of Healthcare in the U.S.—How the system is financed and related policies
1. Medicaid
2. Medicare
3. Private sector healthcare and reform
Readings:
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.
Mechanic Ch. 2: Cross Pressures: Contemporary Politics of Health Reform (Skocpol & Keenan)
Mechanic Ch. 3: Employer-Based Health Insurance System: Mistake or Cornerstone (Glied)
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FEB 16, 2010
WEEK 6: Improving health and access to quality health care
1. Ideological and cultural issues to tackle
2. Brief history of health Insurance in the U.S.
3. Health reform
Readings:
Kaiser Family Foundation [KFF] (2009). National health insurance—a brief history of reform
efforts in the U.S. Available: http://www.kff.org/healthreform/upload/7871.pdf
Guendelman, S., Angulo, V., & Oman, D. (2005). Access to health care for children and
adolescents in working poor families: Recent findings from California. Medical Care,
43(1), 68-78.
KFF (2009). Massachusetts Health Care Reform: Three Years Later. Available:
http://www.kff.org/uninsured/upload/7777-02.pdf
FEB 23, 2010
WEEK 7: Impact of social injustice in healthcare: Examples and interventions
1. Impact of social injustice on the health of marginalized populations
2. Addressing racial inequality in healthcare through civil rights
3. Brainstorming health disparities topic for final (in class)
Readings:
Mechanic Ch. 9: Addressing Racial Inequality in Health Care (Rosenbaum and Teitelbaum)
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.
MAR 2, 2010
WEEK 8: How immigration, acculturation and national origin influence health
 Midterm assignment due
1. Effects of immigration and acculturation on health
2. The Latino Health Paradox
3. Case example: Latino injection drug users
Readings:
DeRose, K. P., Escarce, J. J., & Lurie, N. (2007). Immigrants & health care: Sources of
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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.
Video: Unnatural Causes: Becoming American (view in class)
Recommended not required:
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 16, 2010
WEEK 9: Disparities related to gender and sexual orientation & Discussion on policy memos
 Writing reflection #2 due
1. Women and health inequity
2. LGBT health disparities
3. Policy memo workshop
Readings:
Rieker, P. P., & Bird, C. E. (1999). Gender matters: an integrated model for understanding
men's and women's health. Social Science and Medicine, 48, 745-755.
Diamant, A.L, Wold, C., Spritzer, K., & Gelberg, L. (2000). Health behaviors, health status, and
access to and use of health care: A population-based study of lesbian, bisexual, and
heterosexual women. Archives of Family Medicine, 9, 1043-1041.
Recommended not required:
Mays, V., Yancey, A., Cochran, S., Weber, M., & Fielding, J. (2002). Heterogeneity of health
disparities among African American, Hispanic, and Asian American women:
Unrecognized influences of sexual orientation. American Journal of Public Health,
92(4), 632-639.
MAR 23, 2010
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 populations
Readings:
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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,
138: 2027-2032.
Amaro, H., Raj, A., Vega, R.R., Mangione, T.W., & Perez, L.N. (2001). Racial/ethnic disparities
in the HIV and substance abuse epidemics: communities responding to the need.
Public Health Reports, Sep-Oct; 116(5): 434-48.
MAR 30, 2010
WEEK 11: Health Care Disparities in Developing Countries
1. Global health inequality
2. Structural approaches to reducing health disparities
Readings:
World Health Organization (WHO). (2002). World Health Report 2002: Reducing Risks,
Promoting Healthy Life. Overview and Message from the Director-General. Available:
http://www.who.int/whr/2002/en/Overview_E.pdf
Gupta, G.R., Parkhurst, J.O., Ogden, J.A., Aggleton, P., & Mahal, A. (2008). Structural
approaches to HIV prevention. Lancet, 372: 764–775.
Bertozzi, S.M., Laga, M., Coutinho , A. (2008). Making HIV prevention programmes work.
Lancet, 372: 831–844.
APR 6, 2010
WEEK 12: The role of social workers in addressing health disparities
1. Role of social work profession
2. Policy practice and legislative action
3. Advocacy
Readings:
McDonough-Figueira, J. (1993). Policy Practice: The Neglected Side of Social Work
Intervention. Social Work, 38(2),179-188,
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'
Responsiveness to Health Disparities: The Case of Breast Cancer Screening. Health
and Social Work, 30(3), 221-232.
Recommended not required:
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.
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APR 13, 2010
WEEK 13: Interventions to Reduce Disparities in an Age of Scarce Resources
1. System and policy intervention efforts to address health disparities
2. Case examples: tobacco policy, obesity epidemic, and HIV/AIDS in the U.S.
Readings:
Mechanic Ch. 7: Tabacco Policy in the U.S.: Lessons for the Obesity Epidemic (Warner)
Rosenberg T, J. Alperen, J.K., & Chiasson, M.A. (2003). Why do WIC participants fail to pick
up their checks? An urban study in the wake of welfare reform. American Journal of
Public Health, 93: 477-481.
Recommended not required:
Fullilove, R.E., Green, L., & Fullilove, M.T. (2000). The Family to Family program: A structural
intervention with implications for the prevention of HIV/AIDS and other community
epidemics. AIDS, 14, S63-S67.
APR 20, 2010
WEEK 14: Final presentations

Final assignment due
APR 27, 2010
WEEK 15: Final presentations and class wrap-up
SOW0 836, HEALTH ACCESS & DISPARITIES CLASS ASSIGNMENTS:
WRITING REFLECTIONS:
Students will complete 2 writing reflection assignments due at the beginning of classes 4 and
9. Students can explore any topic of interest that relates to course content from any of the
class sessions Reflections can stem from class discussion, course readings, or from a journal
or news publication. Each reflection should be 2 pages and needs to demonstrate the
student’s ability to think critically and to analyze scholarly health policy information.
Students may want to consider the following kinds of questions when writing their
reflections:
What are the main health issues and related policies under discussion?
Who is affected most? How and why?
What are the article’s main conclusions?
What additional questions does this work raise? What are the ethical considerations
to be aware of?
What are the implications for social work and other healthcare professionals?
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MIDTERM ASSIGNMENT:
Using the Horton (2006) article discussed in Week 4 as an example, write a 4-5 page paper in
which you analyze the structures, policies, and organizational climate of your current
practice setting in terms of how they exacerbate or reduce disparities in access to or quality
of care. What are the institutional factors that contribute to this health disparity? Focus on
the following dimensions/questions:
1. Fiscal considerations (e.g. funding streams, mandates, billing requirements and
practices. Do uninsured/under-insured clients receive treatment?)
2. Procedural considerations (e.g. authorization, documentation, or productivity
requirements. How do administrative rules hinder/help professional autonomy?)
3. Other resources related to addressing disparities (e.g. culturally competent care,
language appropriate services, materials, etc.)
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.
FINAL ASSIGNMENT: POLICY MEMO & PRESENTATION
In this assignment, students will have the opportunity to explore a health disparity of their
choosing and present the topic to the class as though they are the expert(s). In small groups
or alone, students will pick a health disparity and specific population affected in order to
create a policy memo or fact sheet on the topic. This memo will be distributed to the class
during final presentations—it will be your responsibility to provide copies for all students.
The policy memo or fact sheet and presentation will be graded separately.
PART 1: The policy memo or fact sheet should address a specific health disparity. It needs to
be informative and concisely explain to the reader why this topic matters. Based on FigueiraMcDonough’s proposed four methods of social policy practice to be used by social workers
in their work toward social justice (and other sources from the course), students must
discuss how certain methods can be used to mitigate and/or possibly resolve their specific
health disparity topic. The policy memo or fact sheet should:
Describe the specific health disparity you have identified and the target population
affected
What are the specific policies related to this topic, or lack thereof?
What are the suggested actions necessary to improve this disparity? Why are these
public policy methods valid in helping to resolve the identified problem and improve
policy on the issue?
How can these changes be achieved on a micro, mezzo, and macro level?
PART 2: During the last two weeks of class students will be given 10 minutes* to present their
health disparity topic and related policies to the class as though they are the expert. The
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time allotted to each presentation will depend on the size and number of groups.
Presentations must address:
Who is the intended audience the memo/fact sheet was created for?
What are the policy practice recommendation(s) suggested.
Why are these chosen methods effective strategies to promote positive change?
Discuss obstacles and momentum that can hinder or facilitate change related to the
topic.
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