NOTE: You might need to cut and paste some of these weblinks into a browser.; sometimes they will not go to the direct page in the text. Health disparities; we hear this word frequently but what does it truly mean? First, some definitions; there is a difference between health disparities and health care disparities. A health disparity refers to a higher burden of disease morbidity, disability or mortality by one population vs another. A health care disparity refers to differences between populations in terms of insurance coverage, access to, and use services, and quality of health care. FYI, as a Q&A primer to this lecture, the following helpful website: https://www.kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/ Disparities have existed since mankind, and no doubt will continue into our future to a certain degree. Despite multiple initiatives to promote equality, there have also been attempts to lessen it by other parties, often by those who perhaps mean well, but who are perhaps uneducated on the fact. I sat on state committee a few years back and I confirmed through my observations that holding a certain title or possessing a special degree does not ensure one is informed on the subject matter. We need advocates who know the facts and who have a passion to create laws and programs for those who are affected by disparities. This chapter focuses on populations who have barriers in accessing health care or who have certain health-related conditions that are unaddressed. Often referred to as underserved, medically disadvantaged, or underprivileged, these populations are at greater risk for mental, physical and social health. The causes are many, some of which we discussed earlier when we talked about determinants of health. We also note disparities when accessing care due to race, age, sex and diagnosis ie. HIV/AIDS, mental illness. Exhibit 11.1 shows the predisposing, enabling and need characteristics of the vulnerable. As you can see, persons have little control over many of these attributes other than perhaps geographic location. Thus, these attributes can be easily associated with discrimination in the provision of services. Your book provides two Exhibits that comprehensively describes racial ethnic disparities for the four most common racial/ethnic minorities: Black American, Asian American, American Indians and Alaska Natives as well as some federal programs designed to eliminate these disparities. Some of these programs have been around for years and perhaps you are familiar with , such as Head Start and Healthy Start. The Indian Health Service is a program created specifically for American Indians and Alaska Natives. Women and children have been identified for years to suffer from disparities, especially single mothers. Although women live longer than men, they often have worse overall health than men. For example, women have a higher mortality rate from heart attack. Part of this is due to the fact that cardiac disease often manifests itself differently in women and it is ignored until a woman experiences a fatal MI. Another contributing factor is women often have higher levels of cholesterol, leading to cardiovascular disease. In terms of mental illness, women have higher incidences of anxiety and major depression than men, and are more likely to have suicidal tendencies, however, men are more successful at carrying out the act. A child’s health usually reflects mother’s health practices. Thus, child mortality rates are often used to determine the health of the family/community. Although infant mortality rates have improved over the last 10 years, the US is still the highest among OCED countries. (Kaiser Family Foundation, 2017) The mother is often the most influential family member to educate about wellness and preventive care, thus many government programs are aimed at maternal/child care. https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health Besides what a child learns at the dinner table (literally!) there is also the influence of others throughout their formative years; neighbors, friends, school, church and a particularly strong influence, social media. Otherwise, it really does take a village to raise a child. Your book mentions the new morbidities of childhood: obesity, drug and alcohol abuse, violence, learning disorders and emotional disorders. A student from another class recently wrote a paper on obesity. She honed in on its development in childhood and the influence of eating behaviors of family member/friends as well as inactivity as a result of social media/technology. The outcomes of obesity are many, I am sure you know most of them, namely type 2 diabetes, elevated cholesterol and the psychosocial effects such as bullying and suicide. I have several friends who are teachers in the public school system who report that their once dream job has changed dramatically over the years as their classrooms now comprise of children who routinely act out, have difficulty staying focused or following direction. Rather than one contributing cause, we are seeing the effects of multiple variables including the violence that sells in the form of movie films, video games and action toys. This also includes parents with drug problems/mental illness and grandparents who try to provide a home to come home to https://www.pbs.org/newshour/nation/more-grandparents-raising-their-grandchildren . As you can imagine, addressing these issues takes energy and time for both child and parent. A thorough assessment is vital to identify problems ASAP so a multi-disciplinary approach can be initiated. Often this starts in the school system with students being referred to outside resources. This is where government programs can help children who are vulnerable as a result of the previously identified attributes. Case management is a necessity; without some type of coordination, families cannot connect the dots and become more frustrated. Even so, as previously discussed last week, all is not a perfect world in the delivery of health services. Although they may be available, they still might not be accessible in every sense of the word. Rural vs metropolitan residence has a significant impact on health, but we are seeing this improve due to multiple factors. One of the key reasons for poor access to health care in rural communities is because this is where we often find lower income persons who are uninsured/underinsured. Another reason is physician shortage; most physicians are drawn to large cites because of the pay scale. As a result, we see more incidence of chronic disease being presented at late stages. Tobacco, alcohol and drug use are usually more prevalent in rural areas as well. In addition to hospital systems acquiring failing community hospitals or building small new hospitals, one thing that has been a game changer is telemedicine. https://mhealthintelligence.com/news/is-cms-giving-telehealth-its-due-in-its-new-rural-health-strategy Certain sub-populations are at higher risk for health risks. We have already identified race, women, children and those who live in rural areas. Also to be considered are the homeless; veterans, drug/alcohol abusers, and those who are abusive/homicide/suicide prone (who often all fall under the umbrella of mental health) and HIV/AIDS. Thus, those who have any of the above and/or have chronic illness and/or are disabled and who are underinsured or uninsured have a brick wall in front of them. We have initiatives in place to address these concerns yet we still fall short in changing this picture. Healthy People has been around for close to 30 years. Just a bit of history here; I was working in Cancer Control through the PA State Dept. of Health as a Principle Investigator (PI) for a large grant when Healthy People was initiated. . This was exciting news being in public health! As you are probably aware, Healthy People sets 10 year priority goals with multiple objectives and initiatives to meet the goals. Formative evaluation is set at the 5 year mark to measure progress and realign any goals. Go to the website and look at some of the initial goals and think about the progress we have made. https://www.cdc.gov/mmwr/preview/mmwrhtml/00001462.htm Another key strategy to address strategies in addition to Healthy People was the implementation of the ACA. The ACA has several provisions to address disparities besides the overall goal of expanding coverage, many being preventive and wellness initiatives. The Racial and Ethnic Health Disparities Action Plan builds on the foundation of the ACA, Healthy People and President Obama’s HIV/AIDS strategy https://obamawhitehouse.archives.gov/administration/eop/onap/nhas . For more information on the five main goals of this action plan as outlined in your book go to https://minorityhealth.hhs.gov/Default.aspx and skim through the report then go to the right of the webpage and look at the progress report to see what has been accomplished thus far. For this week’s discussion question, I would like you to select one of the populations or sub-groups identified earlier and make comment on programs or initiatives in your community to address the disparity. Ie. the homeless. I want you to get out of your comfort zone; please do not report in an area you work in every day ie. chronic disease. I do not want you to cut and paste from this Action report or reports from the IOM, CDC or AHRQ although you may research them to see how these issues are being addressed at a federal level. It is important that health service administrators not only know about the issues associated with disparities, but also be informed of what is available, what works, and what continues to remain an unmet need for certain populations. Besides trying to keep people healthy, we are also concerned with remaining sustainable in the future. I look forward to your investigation and sharing your findings with the class.
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