Eliminating Health Disparities

Advancing Health for All

Public health practitioners have long championed the health needs of underserved and impoverished communities. Despite these efforts, the disparities in health among U.S. social groups continue to widen. Today, African Americans die from HIV/AIDS at a rate seven times higher than non-Hispanic white Americans. One of every two American Indian babies born today will develop diabetes. Families living in poverty have shorter life expectancies and are at higher risk for cancer, diabetes, asthma, and cardiovascular disease. American men are four times more likely to die from firearms than women. And the infant mortality rate is almost double for mothers with fewer than 12 years of education compared with those with an education of 13 or more years.

Health disparities are the differences in health status that occur by gender, race or ethnicity, education or income, disability, geographic location, and sexual orientation. In 2000, the U.S. Department of Health and Human Services made eliminating health disparities a top priority and included it as one of two overarching goals in its report Healthy People 2010.

But the battle to eliminate health disparities is challenging and complex. Multiple factors that affect marginalized communities are often associated and difficult to study independently. Measuring ethnicity and race may also prove to be problematic. “As academics, can we separate experience from race?” says SPH associate professor Beth Virnig. “Moreover, can we separate culture from race?” Working within these ethnic or racial communities poses additional obstacles. Despite these challenges, SPH faculty members are passionate about their work and have made significant advances toward reducing health disparities and improving the lives of all Americans.

Health Disparities within Ethnic and Minority Groups

Health disparities can be found in all segments of the population. But ethnic and minority communities chronically experience higher rates of illness and death due to social factors such as barriers to health care, poverty, lower education, and environmental influences. This trend is alarming given that ethnic and minority groups are expected to grow and make up a significant portion of the total U.S. population. “We are becoming more diverse by the day,” says Kathleen Thiede Call, a member of the School’s Health Disparities Work Group. “We have to work with members of these communities to support improvements in their health and well-being.” 

As an epidemiologist, SPH associate professor Wendy Hellerstedt focuses her research on pregnancy and birth outcomes of adolescent girls in underserved communities.  Despite the overall decline of U.S. teen pregnancies, births among Native American girls are still higher than the national birth rate. For the Native Teen Voice Study, funded by the CDC and Association for Schools of Public Health, Hellerstedt examined the attitudes of adolescent Native Americans on pregnancy prevention and birth control. The work represents a community-based participatory research project, meaning the community helped design, implement, and analyze the study. “We know very little about the sexual behaviors and attitudes of Native American youth,” says Hellerstedt. “And there are especially very little data about Native American male youth and their thoughts on contraceptives and pregnancy.”

Preliminary data for the study reveal that Native American youth trust their elders, parents, schoools and Indian youth service agencies to provide accurate information on contraceptives, pregnancy prevention, and education relating to sexual behavior. The study also found that Native American youth are eager to have conversations with their parents and elders about this topic. “Young people have a wealth of ideas about how we can create effective public health interventions,” says Hellerstedt.

SPH professor Mary Story is working with colleagues at the Pine Ridge Indian Reservation in South Dakota on a childhood obesity prevention project called Bright Start, funded by the National Institutes of Health. “Diabetes has reached epidemic proportions within the American Indian population,” says Story. “It is our hope that our partnership with the Pine Ridge community will help stem the tide.” The program involves promoting physical activity and healthy eating at home and at school.

SPH staff member Mary Smyth echoes Story’s emphasis on the partnership nature of the project. “It is vital that we have community members involved in this research,” she says. The project is endorsed by the Pine Ridge tribal council. Despite the challenges presented by crushing poverty and high unemployment at Pine Ridge, both Story and Smyth are optimistic about the success of the Bright Start project, given the child-centered values of the Lakota tribe and their strong family systems.

Rhonda Jones-Webb, an associate professor in the School’s alcohol epidemiology program, first noticed the high prevalence of alcohol-related problems in the African-American community as a graduate student at the University of California-Berkley. “I wanted to understand the causes of alcohol-related problems and what type of policies could be implemented to reduce these problems,” says Jones-Webb.

Her research centers on a study that investigates how the alcohol environment contributes to high homicide rates in African-American communities. “For the most part, previous studies of the alcohol environment have focused on one or two racial and ethnic groups,” she explains. “Our study focuses on inner-city neighborhoods with high concentrations of multiple racial and ethnic groups.”

Recent results from her NIH-funded study reveal that neighborhoods with higher concentrations of African Americans have a higher risk of homicide and greater access to malt liquor and malt liquor advertisements than other neighborhoods. Asian-American and Hispanic neighborhoods also had a greater availability of malt liquor than Caucasian neighborhoods. “Much of the marketing of malt liquor is specifically targeted to African-American and Hispanic youth and young adults. Malt liquor is marketed with an element of danger and with advertisements that glamorize violence. This is a cause for alarm,” adds Jones-Webb. “Alcohol advertising influences more positive drinking attitudes among underage youth. Additionally, alcohol consumption is involved in about one-half of all homicides.”

Under a contract from the Minnesota Department of Health, SPH associate professor Joän Patterson and her research associate Marline Spring are studying Hmong families who have children afflicted with severe neurological disorders. The aim is to determine what factors contribute to or undermine a “medical home,” which is primary care that is comprehensive, coordinated, family-centered, and culturally effective for children with special health needs. “The children in the study were afflicted with severe neurological disorders and their needs were extensive,” says Patterson. “The medical home concept works effectively if the primary care physician and the parents are able to have good communication and work collaboratively.”

Results from the study show that both physicians and Hmong parents operate from different sets of cultural beliefs and practices that affect the successful implementation of a medical home. “All of the Hmong parents had the highest regard for their children’s doctors,” says Patterson.  “However, because of their cultural background, the parents were less oriented toward having an equal partnership with their children’s physicians.” Similarly, American health care practices impede the development of the medical home concept because physicians are not allowed adequate time with patients to develop an equal relationship. Patterson adds that additional funding for the project will allow primary care physicians to visit their patients’ homes to deepen their understanding, as well as provide support for the Hmong mothers, who often are isolated because of the extensive care needs of children with severe disorders.

Disparities in Quality of Care

For almost a decade, SPH associate professor Kathleen Thiede Call has surveyed Minnesotans on their health insurance coverage and access to health care services. Call is the co-principal investigator, with SPH associate professor Lynn Blewett, of the State Health Access Data Assistance Center (SHADAC). SHADAC helps states monitor rates of health insurance coverage, understand factors associated with uninsurance, and evaluate state policy initiatives.  Much of Call’s research focuses on racial and ethnic disparities in health care coverage and access to care.  “Minnesota is consistently rated as one of the healthiest states in the country with the lowest rates of uninsurance, but that only holds true when looking at statewide averages,” says Call. “There are big gaps in health care access and outcomes when looking at subpopulations based on income, age, race, ethnicity, and country of birth.”

In a 2003 study, funded by the Minnesota Department of Human Services, Call and her collaborators found that immigrants covered by state health insurance programs reported the highest barriers to care. These barriers included difficulty getting translators, mistrust of health care providers, and discrimination from providers based on income, type of insurance, race, and ethnicity.

In addition, Call also studied health care access among Latino communities in the rural Midwest. She found that although community clinics provided free or low-cost care and that schools, government agencies, and religious organizations connected Latinos to the health care system, Latino families still received inadequate care due to their uninsured status, limited income, and linguistic and cultural barriers.

Beth Virnig uses Medicare data to investigate racial disparities in the quality of care enrollees receive and their barriers in accessing health care services. Her research revealed that African Americans are less likely to receive hospice care and treatment for symptoms despite having comparable health care plans to other ethnic and minority groups.  She also found that geographic location—specifically in impoverished regions with a large minority population—influenced health outcomes even after controlling for race and ethnicity. “We need to figure out what causes these disparities and what barriers in the system are producing them,” says Virnig.

SPH assistant professor Donna McAlpine is a medical sociologist. Her work uses community-based participatory research methods to understand barriers to health care access among individuals from diverse racial and ethnic backgrounds. McAlpine recently completed a study that examined the need for substance abuse treatment services in Minnesota. The study, funded by the U.S. Department of Health and Human Services, surveyed adults in the state and included individuals from many racial and ethnic groups.

Health Disparities Goals in the SPH

The SPH multicultural services office was established to help increase diversity in the student body and in turn produce a more diverse public health workforce. Director of Recruitment and Multicultural Services Rickey Hall says that many public health students of color have an interest in working in their own communities after graduating. “We hope that a public health degree will allow students to learn the skills to address the health needs of their own communities,” says Hall.

SPH Dean John Finnegan began his work on health disparities in the 1970s. While helping to create effective public health communication campaigns, he found a gap in the access and understanding of this information, especially among individuals living in poverty and those with lower levels of education. “We found that the information we wanted to communicate was not relevant to their survival,” says Finnegan. “To be poor is to live in a very different world.” Finnegan stresses the importance of health disparities research to the School and broader community. “Pursuing research in this area is everybody’s business because it affects the health of the whole community,” he says. “Public health outcomes will be dependent upon how we address health disparities.”