1. Introduction to Public Health November 7, 2004 Community Assessment with Health Disparities Groups Judith Bradford, Ph.D. Community Health Research Initiative Survey and Evaluation Research Lab jbbradfo@vcu.edu

2. Defining the Population

3. 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

4. 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.

5. 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.

6. Policy Framework

7. Healthy People Movement 1979: The Surgeon General’s Report on Health Promotion and Disease Prevention 1980: Promoting Health/Preventing Disease HP2000: National Health Promotion and Disease Prevention Objectives

8. 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

9. 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.

10. 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.

11. Subgroups of Concern for Eliminating Disparities Differences that occur by…. gender race or ethnicity education or income disability living in rural localities sexual orientation

12. 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)

13. 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

14. 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

15. 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

16. Focus Areas - 1 Access to quality health services Arthritis, osteoporosis, and chronic back conditions Cancer Chronic kidney disease Diabetes Disability and secondary conditions Educational and community-based programs Environmental health Family planning Food safety Health communication

17. 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

18. Focus Areas - 3 Physical activity and fitness Public health infrastructure Respiratory diseases Sexually transmitted diseases Substance abuse Tobacco use Vision and hearing

19. Limitations of Current System for HP2010 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

20. For example, sampling for heath needs of LGBT communities What’s 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?

21. 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)

24. 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

25. 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

26. 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.

27. 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 individual’s 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.

28. 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.

29. 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?

30. Social-Ecological Model for Levels of Influence McElroy KR, Bibeau D, Steckler A, Glanz. An ecological perspective on health promotion programs. Health Education Quarterly 15:351-377, 1988.

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

32. Community-based participatory research CBPR… 1. recognizes community as a unit of identity 2. builds on strengths and resources within the community 3. Facilitates collaborative, equitable partnership in all phases of the research 4. Promotes co-learning and capacity building among all partners 5. Integrates and achieves a balance between research and action for the mutual benefit of all partners

33. CBPR… 6. emphasizes local relevance of public health problems and ecological perspectives that recognize and attend to the multiple determinants of health and disease. 7. involves systems development through a cyclical and iterative process. 8. disseminates findings and knowledge gained to all partners and involves all partners in the dissemination process. 9. involves a long-term process and commitment. Minkler M, Wallerstein N (Eds.). Community Based Participatory Research for Health. San Francisco: Jossey-Bass & Co., 2003.

34. 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.