Objectives through CBPAR for com m unity and system change To - PDF document

6/5/2012 Addressing social determ inants Objectives through CBPAR for com m unity and system change � To describe a community-based participatory action research (CBPAR) model, and selected community and Aida L. Giachello, Ph.D . system level interventions aimed at y P Professor f addressing the social determinants of Department of Preventive Medicine health Feinberg School of Medicine Northwestern University, Chicago a-giachello@northwestern.edu 18 th National Health Equity Research Webcast, June 5, 2012 University of North Carolina Gillings School of Global Public Health www.minority.unc.edu/ institute/ 2012/ 1 2 2 Defining Health Defining Health Disparities � A state of complete physical, mental and social � When a disproportionate number of well-being and not merely the absence of individuals in a specific population have diseases [ WHO, 1948] either: � The fundamental conditions and resources for � The fundamental conditions and resources for � higher risk, higher rates of disease health: [ Ottawa Charter for Health Promotion, (morbidity), or are dying more WHO, 1986] � Peace � Income frequently from specific diseases than � Shelter � Sustainable resources the general population and these � Education � Social justice disparities are UNFAI R, UNJUST and � Food � Equity AVOI DABLE 3 4 Increased Attention to Health Disparities in the Last Decade Social Determinants of Health � Pres. Clinton Health � WHO Social Determinants � Recognizes that social conditions affect health & Disparities Legislation Commission can potentially be altered by social/ health � Healthy People 2010 & � CDC community Initiatives policies & programs 2020 � It is a departure from efforts to address a single � Private foundations � Institute of Medicine 2002 � Institute of Medicine 2002 disease and causes disease and causes � Lets Move Campaign to Report Unequal � Acknowledges that we need to take a address childhood obesity Treatment: Confronting multidisciplinary approach to achieve health � Pt. Protection & Racial and Ethnic equity Affordable Care Act Disparities in Healthcare � It calls for improvement: health/ m edical (ACA) � AHCQ Annual National care, education, housing, econom ic Health Disparities Report developm ent, labor, justice, transportation, since 2003 agriculture, etc. 5 6 1

6/5/2012 Percentage of All Persons Below Poverty in Source of Health Disparities: the U.S. by Race/Ethnicity, 1996-2007 1. Low Socio-Economic Status (SES) 35 � Low SES is one of the most powerful indicator & 30 predictor of poor health 25 � Americans without a high school degree have a All races death rate 2 to 3 times higher than those who 20 White % % have graduated from college have graduated from college 15 African American � Adults with low SES have levels of illnesses in Asian American their 30s and 40s similar to those seen among 10 Hispanic/ Latino the highest SES group after 65+ 5 � Minorities have lower levels of education, income, professional status and wealth than whites 0 Source: Williams, 2001; 2003: ibid 7 8 Source: 2010 Census of Population and Housing. http: / / www.census.gov Percentage of Persons with Less than 9th grade by Race/Ethnicity, 2008 Universe: 2008 population � It is impossible to talk about the health of 35 ages 25 + racial and ethnic minority populations without 30 talking about their socio-economic 25 circumstances All � S � Some minorities are characterized by 20 i iti h t i d b Hispanic % Hispanic -Native Born sociologists as belonging to the urban 15 Hispanic - Foreign Born underclass - - a socially isolated group Asian African American 10 experiencing high poverty, high dependence on White public assistance, and multiple social problems 5 with limited access to health and human 0 resources All Hispanic Hispanic - Hispanic - Asian African White Native Foreign American Born Born Source: Pew Hispanic Center, Race/ Ethnicity Statistical Portrait of Hispanics in the US, 2008 9 10 Source of Disparities: Source of Disparities: 3. Institutional Racism & Sexism & 2. Lack of Access to Health and Mental 4. Poor Quality of Medical Care Health Services � Racial & ethnic minorities (& women as a group) � Measured by: receive fewer procedures & poorer quality medical � Lack of regular source of care/ medical home care than whites across virtually every therapeutic and mental health services intervention � Lack of health insurance plan � Lack of health insurance plan � Inconveniences in obtaining care � Disparities exist in the Clinical Encounter as health � Transportation, waiting time in doctor/ clinic, professionals tend to have negative stereotypes of racial and ethnic minorities, the poor & women as a & cultural, linguistic/ health literacy barriers, group � Lower overall use of health services 11 12 Source: IOM, Unequal Treatment Report, 2002; AHCQ, NHDR, 2003) 2

6/5/2012 Public Response for Health Disparities: In Summary : Blaming the Victim � There is a consistent and powerful association � Eat healthy, � Find a job, if between social factors, poor health exercise more, you don’t have � Inequality in health and medical care persists etc. one one � Disparities come at a personal and societal p p price � Buy health � Change � Differential access may lead to disparities in insurance neighborhood quality � Don’t be poor 13 13 14 14 Source: AHCQ, 2003 � This information is not new. In 1844, Friedrich � In the late 19 Century Emile Durkheim Engels wrote about the conditions of the demonstrated the relationship between social working class in England in 1844 integration and suicide � Throughout the 20 th Century there have been � In 1898 W.E.B. Dubois wrote about the racial & ethnic disparities in health in the Philadelphia thoughtful work examining socio-cultural Negro-the first documentation of the health factors in health and illness status of racial & ethnic minorities groups in the � This gradually lead to the acknowledgement US. of culture in health care and the need for cultural competency in services delivery 15 16 COMMUNI TY AND SYSTEM Community Based Participatory Action CHANGE Research (CBPAR): Key Elements � Partnership building � Elements of policy and systems change � Calls for meaningful involvement of 1) Changes in community norms ordinary people and key stakeholders 2) Organizational practices and policies � Embraces community empowerment as a 3) Administrative Regulatory policies & practices philosophy, process and outcomes � Capacity building through training • Within government agencies � Research: Assessment of Needs and 4) Legislation (laws) Assets • Passed at the local, state, federal levels � Action � Moving from DATA to SOCIAL ACTION 17 18 18 3

6/5/2012 Phase I: Community Participatory Action Differences Between Research & Coalition Building Model ( Giachello et al 2003) Mainstream & CBPAR 1 2 3 4 6 Capacity- Assessment, Action RES. Finalize Community Coalition Mainstream Data Dissemi- Process Building ACTION PLAN Entry Collection & Formation (logic Model) nation � (Training ) Flexible Analysis � Rigid � Considerable amount of Values � No or little community Examples: Goals & Community Community Community community participation participation Orientation Objectives Activities Organizing & Community Forums/Town Dialogue � Coalition-building � There is shared Mapping PI is in control Meetings Strategies St t i � governance. Community governance Community Close decision-making Problem Topic have a sense of � No accountability to Focus Committee Definition area 101 & Strengths & ownership S trengthening Groups community Formations 201 Limitations � � The real action starts The project ends when Resources data is collected & when data is collected Community Telephone Needed Establishing Applied analyzed and analyzed Involvement Com. Action survey Research coalition � Partnership with � Sharing of funds, jobs, Evaluation community not equal TA or training Photo Voice � It tend to stress � Stress community assets community deficits 19 20 Examples of Projects Addressing Social Partnerships-Building & Sustainability Determinants: to Address Social Determ inants 1. Environmental Health, Blue Island, Illinois MULTI -SECTORAL PARTNERSHI PS Blue Island Community residents experience respiratory problems NEIGHBORHOOD EMPLOYERS BLOCK CLUBS (asthma), cancer, etc. as a result of a petrochemical industry in the APPOINTED PARK DISTRICT & ELECTED area OFFICIALS Objective: Needed data to document GROCERY STORES SCHOOLS problems & bring concerns to policy-makers PROFESSIONAL ORGANIZATIONS CHAMBER OF e.g. ADA COMMERCE Methods: Applied the CBPAR model. Community collected over 1,500 FAITH COMMUNITY CBOs face-to-face door-to-door household surveys ( Giachello et al, 2002) RESTAURANTS MEDIA CDOH WIC FOOD INSPECTION 21 21 22 Environmental Health… Sometimes, vindication comes in the mail. Survey Results: � Serious health problems were associated with air pollution caused by the Clark Oil Refinery Plant Clark Oil Refinery Plant � Community mobilized, confronted Illinois & Federal Environmental Protection Agencies � Engaged in a class action suit & industry was closed 24 23 4