Introduction to Public Health November 7, 2004

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Introduction to Public HealthNovember 7, 2004

• Community Assessment with Health Disparities
  Groups
• Judith Bradford, Ph.D.
• Community Health Research Initiative
• Survey and Evaluation Research Lab
• jbbradfo_at_vcu.edu

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Defining the Population
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Communities

• Of geography, such as a group of Census tracts,
  or a county or city
• Of individuals with shared characteristics, such
  as demographic and/or other personal
  characteristics
• Of affiliation, such as faith communities

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Critical Concepts

• Community health is profoundly affected by the
  collective behaviors, attitudes, and beliefs of
  everyone who lives in/belongs to the community.
• Partnerships are effective tools for improving
  health in communities.

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Core Issues and Challenges

• Definition of community members -- who is in the
  community?
• Trustworthy understanding of their
  characteristics and needs.
• Feasible methods of gathering needed information
  about them.
• Effective methods for involving community members
  in assessment and interpretation.

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Policy Framework
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Healthy People Movement

• 1979 The Surgeon Generals Report on Health
  Promotion and Disease Prevention
• 1980 Promoting Health/Preventing Disease
• HP2000 National Health Promotion and Disease
  Prevention Objectives

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Healthy People 2010

• Overarching purpose promoting health and
  preventing illness, disability, and premature
  death
• ... grounded in science, built through public
  consensus, and designed to measure progress

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Healthy People 2010

• Two overarching goals
• Increase quality and years of life
• Eliminate health disparities
• Format 467 objectives to improve health,
  organized into 28 focus areas.

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HP2010 Perspective

• increase life expectancy and quality of life
  over the next 10 years by helping individuals
  gain the knowledge, motivation, and opportunities
  they need to make informed decisions about their
  health
• encourages local and state health leaders to
  develop community-wide and statewide efforts that
  promote healthy behaviors, create healthy
  environments, and increase access to high-quality
  health care.

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Subgroups of Concern for Eliminating Disparities

• Differences that occur by.
• gender
• race or ethnicity
• education or income
• disability
• living in rural localities
• sexual orientation

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Major HP2010 Data Sources

• National Health Interview Survey (NHIS)
• National Health and Nutrition Examination Survey
  (NHANES)
• National Vital Statistics System - Mortality
  (NVSS-M)
• School Health Policies and Programs Study (SHPPS)
• National Survey of Family Growth
• National Vital Statistics System - Natality
  (NVSS-N)
• National Hospital Discharge Survey
• National Household Survey on Drug Abuse (NHDA)
• National Profile of Local Health Departments
  (NPLHD)
• Behavioral Risk Factor Surveillance System
  (BRFSS)
• HIV/AIDS Case Surveillance System
• Youth Risk Behavior Surveillance System (YRBSS)
• Medical Expenditure Panel Survey (MEPS)

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10 Leading Health Indicators

• Physical activity
• Overweight and obesity
• Tobacco use
• Substance abuse
• Responsible sexual behavior
• Mental health
• Injury and violence
• Environmental quality (social)
• Immunization
• Access to health care

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Public Health Infrastructure

• HP2010 Goal Ensure that ... health agencies have
  the infrastructure to provide essential public
  health services effectively
• Data and information systems
• Workforce
• Public health organizations
• Resources
• Prevention research

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Essential Public Health Services

• Monitor heath status
• Diagnose and investigate
• Inform, educate, and empower
• Mobilize community partnerships
• Develop policies and plans
• Enforce laws and regulations
• Link people to personal health services
• Assure a competent health care workforce
• Evaluate effectiveness, accessibility, and
  quality
• Research for new insights and solutions

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Focus Areas - 1

• Disability and secondary conditions
• Educational and community-based programs
• Environmental health
• Family planning
• Food safety
• Health communication

• Access to quality health services
• Arthritis, osteoporosis, and chronic back
  conditions
• Cancer
• Chronic kidney disease
• Diabetes

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Focus Areas - 2

• Heart disease and stroke
• HIV
• Immunization and infectious diseases
• Injury and violence prevention
• Maternal, infant, and child health

• Medical product safety
• Mental health and mental disorders
• Nutrition and overweight
• Occupational safety and health
• Oral health

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Focus Areas - 3

• Physical activity and fitness
• Public health infrastructure
• Respiratory diseases
• Sexually transmitted diseases

• Substance abuse
• Tobacco use
• Vision and hearing

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Limitations of Current System forHP2010
Community Assessment

• Disparities populations .
• are not always easy to find
• are sometimes difficult to define (and therefore
  to count)
• may be poorly understood by the system
• may have low political/social priority
• may even be considered less valuable or otherwise
  inconvenient

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For example, sampling for heath needs of LGBT
communities

• Whats the question?
• Who is in the community?
• On a scale of 1 - 10.
• How complete are available data?
• How difficult to obtain currently unavailable
  data?
• Which sampling strategies are most effective?

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Using existing data sets

• How to determine the distribution of identified
  cases in a geographic area defined by Census
  tracts?
• (using same-sex HH data from 1990 2000
  difficulty 2)

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How to capture reliable data on the local health
priorities of sexual minority African American
women?

• No existing federal data system contains directly
  relevant data.
• Successful example Community forum and priority
  setting through partnership with community
  organizations.
• Difficulty 8

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How to determine the HIV risks and prevention
needs of Transgender persons in Virginia?

• No existing federal data system will do this.
• Web-based and mail-back surveys.
• Strategies set up field study with regional
  managers and gatekeepers from careful
  translation of concepts even more careful
  selection of survey administrators.
• Anticipated difficulty 10

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Conclusions

• Current public health data systems are inadequate
  for comprehensive community assessment.
• There is a disconnect between HP2010 goals and
  readiness of public health infrastructure to
  fully respond.
• Additional assessment methods must be carefully
  chosen to fit the community of interest and
  challenges it presents.
• Effective participation by community of interest
  is critical.

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The need for social-behavioral research

• the nature of human relationships the degree
  to which an individual is interconnected and
  embedded in a community is vital to an
  individuals health and well-being as well as to
  the health and vitality of entire populations.

Berkman LF, Glass T. Social integration, social
networks, social support and health, in Social
Epidemiology, Berkman LF and Kawachi I, Eds. New
York Oxford University Press, 2000.
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What are our major challenges in conducting LGBT
assessments?

1. Acknowledging, accepting disparities within LGBT
   communities.
2. Placing higher priority on least understood
   areas.
3. Recognizing the power and implications of
   cultural context for LGBT health.
4. Finding common cause and forming strong
   affiliations to work across dividing lines.

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So many questions

1. Who is the population we wish to study?
2. What factors influence their lives and lead to
   health disparities?
3. What are the questions we need to ask and answer?
4. What methods are best to use?
5. How do we put it all together?

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Social-Ecological Model for Levels of Influence

• McElroy KR, Bibeau D, Steckler A, Glanz . An
  ecological perspective on health promotion
  programs. Health Education Quarterly 15351-377,
  1988.

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• Public Policy local, state and federal
  government policies, regulations, and laws
• Community social networks, standards and
  practices among organizations
• Institutional/Organ-izational rules, policies,
  procedures, environment, and informal structures
  within an organization or system

• Interpersonal family, friends, peers that
  provide social identity, support and identity
• Individual awareness, knowledge, attitudes,
  beliefs, values, preferences

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Community-based participatory research

• CBPR
• recognizes community as a unit of identity
• builds on strengths and resources within the
  community
• Facilitates collaborative, equitable partnership
  in all phases of the research
• Promotes co-learning and capacity building among
  all partners
• Integrates and achieves a balance between
  research and action for the mutual benefit of all
  partners

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• CBPR
• emphasizes local relevance of public health
  problems and ecological perspectives that
  recognize and attend to the multiple determinants
  of health and disease.
• involves systems development through a cyclical
  and iterative process.
• disseminates findings and knowledge gained to all
  partners and involves all partners in the
  dissemination process.
• involves a long-term process and commitment.
• Minkler M, Wallerstein N (Eds.). Community Based
  Participatory Research for Health. San Francisco
  Jossey-Bass Co., 2003.

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Contributions to the field of social and
behavioral health from LGBT health disparities
studies

1. Communities cannot be usefully studied without
   their own participation, through partnership and
   with mutual accountability.
2. As we do this work together, we are learning, and
   with each step forward, there is a general
   increase in knowledge. We are using what we
   learn.
3. LGBT community research provides a model for use
   by others a foundation that can be built upon
   to address and to learn from diversity.