Health Disparities and Diabetes What can we do about it

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Health Disparities and DiabetesWhat can we do
about it?

• Patricia Thompson-Reid, MAT, MPH
• Division of Diabetes Translation, CDC

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Definitions

• Public Health
• What we as a society do collectively to assure
  the conditions for people to be healthy
• Institute of Medicine 1988

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Definitions

• Health Disparity
• Systemic and potentially remediable differences
  in one or more aspects of health across socially,
  demographically or geographically defined
  populations or
• population subgroup.
• Differences in health status based on incidence,
  prevalence, mortality, burden of disease and
  other adverse conditions that exist among
  specific population groups (NIH, 2000)
• Society for Equity and Health (www.iseqh.org)

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Healthy People 2010

• The second goal of the Healthy People 2010 is The
  Elimination of Health Disparities among
  different segments of the population.
• This includes differences that occur by gender,
  race, ethnicity, education , income disability,
  geographic location or gender.
• Race and ethnicity persist with increasing health
  disparities among all the above categories.

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CDCs Mission

• Health Protection
• prevention, promotion of health, preparedness.
• Health Equity
• Absence of health disparity, health equality
  among groups with more or less social advantage,
  fairness in the opportunity to achieve optimal
  health.

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Prevalence of Diabetes by Race and Sex, 2005

• www.cdc.gov/diabetes/statistics/prev/national/fig2
  004.htm

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Racial and Ethnic Disparities in Diabetes

• African Americans are 1.4 to 2x more likely than
  whites to have diabetes .
• From 1980 through 2005, the age-adjusted
  prevalence of diagnosed diabetes doubled among
  black males and increased 69 among black
  females. 
• The rates of ESRD is 2.6x higher among African
  Americans than among white
•  Perneger TV, et al Diabetes Care
  199821896-901
• www. ahrq.gov/research/diabdisp.htm

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Racial and Ethnic Disparities in Diabetes

• American Indians and Alaska Natives
• Overall prevalence when adjusting for age is 2.2
  times that of White Americans.
• Alaska natives- 8.1
• American Indians in Southern US- 26.7
• Southern Arizona-27.6
• www.cdc.gov/diabetes

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Racial and Ethnic Disparities in Diabetes

• After adjusting for population age differences,
  the prevalence of Mexican Americans is 1.7
  greater than in non Hispanic whites.
• Residents of Puerto Rico are 1.8 times as
  likely to have diagnosed diabetes.
• www.cdc.gov/diabetes/data

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Prevalence of DiabetesAmong Women Age 45-64
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Why is this important ?

• Demographic trends over the next two decades will
  exaggerate current trends.
• Groups experiencing poorer health status are
  expected to grow at a greater rate over the next
  20 years.
• Impacts the health of the overall population in
  the US because of increased cost of delivering
  care.
• This will affect the way health care is delivered
  and financed.

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Table 1. Percent Distribution of U.S.
Population by Race/Ethnicity, 2000

• 2050 (National Vital statistics Report Vol 50,
  No16, 2002)

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Determinants of Health

• Health services
• Income and social status
• Social networks
• Physical environment
• Gender
• culture
• Employment and job security
• Working condition
• Early childhood care
• Education
• Food security
• Housing

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What do we knowabout Health Disparities?

• Strong associations between socioeconomic status
  and health.
• Self management and social conditions are as
  important as actions by health professionals in
  determining long term health
• The poor, the geographically vulnerable, the
  politically weak and other disadvantaged groups
  will be most affected.
• Pincus T, et. al. Annals of Intern Med,
  1998
• Marmot MG, Shipley, RG, Hamilton PJ ,J
  Epidemiol and Community Health, 1978
• WHO Commission on the Social Determinants of
  Health,

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What do we knowabout Health Disparities?

• Inequities in exposure to the social determinants
  of health cluster and accumulate over peoples
  lives(clean air, healthy food, decent housing).
• In order to make an impact on health disparities
  we have to examine the root causes.
• Pincus T, et. al. Annals of Intern Med,
  1998
• Marmot MG, Shipley, RG, Hamilton PJ ,J
  Epidemiol and Community Health, 1978

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What we know about disparities.

• OMH Strategic Framework for Improving Racial and
  Ethnic Minority Health and for Reducing
  Disparities
• Need to Look at Root Causes
• Long term problem that needs to be addressed
• Contributing factors
• Strategies and practices
• Outcomes and impacts
• Long Term Goals and Objectives
• www.omhre.gov/npa

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Challenges

• Many strategies and practices address multiple
  contributing factors.
• System wide issues, wide variety of conceptual
  and organizational structural processes that
  influence ability to address problems.
• There is not always scientific evidence to
  demonstrate effectiveness of strategies or
  practices.
• Can we proceed without the science?

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Insurance and Access

• Medical insurance minimally contributes to
  eradicating socioeconomic differences in health.
• Health disparities have widened over the past 3-5
  decades in spite of the existence of Medicaid, or
  the NHS in England.
• Ross, CE, Mirowsky J . Millbank Q, 2000
• Keppel KG, Pearcy JN, Wagner DK. Healthy People
  2000 Stat Notes, 2002

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Reducing Disparities in Diabetes

• Utilize strategies and practices that address
  environmental and community level factors
• Promotion of a healthy physical environment that
  promotes the publics health.
• Foster a positive social environment by nurturing
  community values and norms conducive to health.
• Strengthening community assets for general well
  being. (social capital, participation, inclusion)
• Assure assess to health care to high risk
  populations through financing and other
  initiatives.

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Reducing Disparities in Diabetes

• Systems Level Strategies
• Increase resources for infrastructure
• Promote coordination and partnerships across
  categorical programs.
• Improve and disseminate science for successful
  practices.
• Improve communications systems and
  infrastructure.
• Leadership and commitment-strategic plans to
  address disparities.
• Increase minority participation in all the above

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National Approaches to Reducing Disparities

• REACH-Racial and Ethnic Approaches to Community
  Health
• CDC-YMCA Partnerships
• Pioneer Healthier Communities Initiative
• Steps to a Healthier US

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Current Division Of Diabetes Translations
Approaches to Reducing Disparities

• 1)The Appalachian Diabetes Control and
  Translation Project
• 2)The US/Mexico Border Diabetes Prevention and
  Control Project
• 3)The Native Diabetes Wellness Program
• 4)The National Initiative on Diabetes and Womens
  Health
• 5)Project Direct
• 6) The National Hispanic Latino Diabetes
  Initiative for Action

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Why Communities?

• Place has an important impact on health
• Communities set behavioral norms for their
  populations.
• Have the potential to influence the health
  behavior of individuals.
• Provide opportunities for building supportive
  environments.
• Provide opportunities for collaboration.

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Reducing Disparities in Diabetes

• Things we can do that are challenging
• Learn the community system
• Those who are served and those who are not being
  served.
• Determine how to provide services to those at
  greatest risk (i.e., elderly, disabled, migrant,
  homeless)
• Involve community members in this assessment
• Develop assessment systems that will help to
  better assess and monitor populations at risk.

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Working in Communities

• Mutual trust-two way learning
• Reciprocity- something for everyone
• Understanding challenges, and perspectives of
  disparate populations, (culture, values, history)
• Community engagement- structured dialog, joint
  problem solving, collaborative action.
• Advocacy

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Challenges and Opportunities

• We have limited knowledge of causal factors.
• We do not always have effective interventions.
• We do not have sufficient resources or for
  reducing disparities.
• Many are not aware of the disparities or how to
  approach the problem
• Public Health professionals should be trained in
  equity/social justice issues before working in
  communities.

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Assessment Asking the right questions and doing
the research

• Develop partnerships with communities
• Use a cross disciplinary research approach
• Policy-makers and practitioners must move beyond
  assumptions that once we have the science it is
  directly translatable.
• Involve community members in the development of
  the research question.

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Assessment (cont)

• Frame questions around extrinsic public health
  issues related to chronic diseases.
• Share results and information with policymakers
  and community members.

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Assurance

• Assure a workforce that is aware and understands
  equity and social justice issues and how to apply
  public health practice to reduce inequalities in
  populations.
• Access is important but only accounts for 15-20
  of variation in morbidity and mortality in
  populations
• Increase the availability of resources for a
  systems wide focus on inequalities.
• Improve communications to disparate populations
• Facilitate coordination and collaboration through
  partnerships.

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Policy Development

• Develop and support policies that impact the
  social determinants of health.
• Support the development of policies that impact
  health.
• Provide data to support the development of
  policies that will improve the social and
  physical environment for high risk populations.

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The Future Community

• Put communities back into their social contexts
  and develop indicators that can measure the
  impact of the social environment on health.
• Bring back the idealism in public health and
  focus again on values of equity and social
  justice.
• Ask the Hard Questions!!