REACH 2010: working together to achieve the goal of eliminating health disparities.
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Community Health Planning↗
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Racial disparity in the diagnosis of obesity among people with diabetes.
Studies have suggested that many of the estimated 30.5% of all adults, and 54.8% of adults with diabetes, who have a body mass index (BMI) of 30 or greater do not have a diagnosis of obesity. The records of 265 people with diabetes in the Racial and Ethnic Approaches to Community Health (REACH) 2010 Charleston community were audited for race, sex, BMI, and a documentation of obesity, to determine the likelihood of a diagnosis of obesity for people with BMI of 30 or greater, based on race and sex. Significant differences in diagnosis were observed by race, with three times as many records of obese White people with diabetes containing a diagnosis of obesity as of diabetic African Americans. Disparities in prevalence of obesity based on a BMI of 30 or greater were observed as well, with a higher proportion of African Americans meeting the criteria. Studies suggest that these disparities may contribute to the increased burden of disease experienced by African Americans with diabetes.
Adult↗
The Association between self-reported discrimination, physical health and blood pressure: findings from African Americans, Black immigrants, and Latino immigrants in New Hampshire.
The relationship between perceived racial discrimination and both blood pressure and perceived physical health has been documented among African Americans. However, this association has not been well-studied for Black or Latino immigrants. We used multiple regression analysis with a cross-sectional sample of 666 African Americans, Black immigrants, and Latino immigrants from the New Hampshire Racial and Ethnic Approaches to Community Health 2010 Initiative to assess the relationship between discrimination and measures of physical health and blood pressure. The study found evidence of a significant U-shaped relationship between discrimination and systolic blood pressure for all three cohorts. Evidence was also found supporting a negative linear relationship between discrimination and physical health. In addition, the association between discrimination and physical health was attenuated for Latinos compared with the other groups. Future research should evaluate how factors associated with acculturation or cumulative exposure to discriminatory stressors may affect the protective resources of immigrants.
Adolescent↗
Assessing resource environments to target prevention interventions in community chronic disease control.
The recent emphasis in public health and medicine on the environmental determinants of chronic illness has created the need for a more comprehensive way to assess barriers and facilitators of healthy living. This paper reports on the approach taken by a Centers for Disease Control and Prevention (CDC)-funded project whose goal is to reduce disparities in diabetes and cardiovascular disease in Los Angeles' African American communities. Findings from this community-based participatory research project suggest that while location is an important variable in evaluating nutritional and physical activity resources, quality and price considerations are at least as useful. We argue that every community or neighborhood is located within a resource environment for medical care, recreation, food, and other health-promoting or health-compromising goods and services that affect the lives and health of its residents.
Adolescent↗
Diabetes-specific emotional distress among African Americans and Hispanics with type 2 diabetes.
This study examines baseline levels and correlates of diabetes-related emotional distress among inner-city African Americans and Hispanics with type 2 diabetes. The Problem Areas in Diabetes (PAID) scale, which measures diabetes-related emotional distress, was administered to 180 African American and Hispanic adults participating in the REACH Detroit Partnership. We examined bivariate and multivariate associations between emotional distress and biological, psychosocial, and quality of health care variables for African Americans and Hispanics. Scores were significantly higher among Hispanics than African Americans. Demographic factors were stronger predictors of emotional distress for Hispanics than for African Americans. Daily hassles, physician support, and perceived seriousness and understanding of diabetes were significant for African Americans. Understanding the personal, family and community context of living with diabetes and conducting interventions that provide support and coping strategies for self-management have important implications for reducing health disparities among disadvantaged racial and ethnic groups.
Adult↗
Addressing disparities through coalition building: Alabama REACH 2010 lessons learned.
Community-based coalitions have become accepted vehicles for addressing complex health problems. Few articles have described the challenges and lessons learned from such a process. The purpose of this paper is two-fold: 1) to describe the processes involved in building and maintaining the REACH 2010 Alabama Breast and Cervical Cancer Control Coalition (ABCCCC) and 2) to highlight the lessons learned from this venture. Principles from community-based participatory research were used 1) to establish and maintain the ABCCCC, 2) to build coalition capacity, and 3) to develop breast and cervical cancer interventions. Over 95% of our coalition has been maintained over a 7-year period. The ABCCCC received a total of 17 breast and cervical cancer mini-grants. Adherence to ground rules such as exhibiting respect and trust and practicing open communication helped to solidify our partnership. Lessons learned from the ABCCCC can provide others with an in-depth exploration of the processes involved in coalition formation and maintenance.
Alabama↗
Preventing chronic disease.
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Chronic Disease↗
Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices.
CONTEXT: An overarching national health goal of Healthy People 2010 is to eliminate disparities in leading health care indicators including immunizations. Disparities in US childhood immunization rates persist, with inner-city, black, and Hispanic children having lower rates. Although practice or clinic-based interventions, such as patient reminder/recall systems, have been found to improve immunization rates in specific settings, there is little evidence that those site-based interventions can reduce disparities in immunization rates at the community level. OBJECTIVE: To assess the effect of a community-wide reminder, recall, and outreach (RRO) system for childhood immunizations on known disparities in immunization rates between inner-city versus suburban populations and among white, black, and Hispanic children within an entire county. SETTING: Monroe County, New York (birth cohort: 10 000, total population: 750 000), which includes the city of Rochester. Three geographic regions within the county were compared: the inner city of Rochester, which contains the greatest concentration of poverty (among 2-year-old children, 64% have Medicaid); the rest of the city of Rochester (38% have Medicaid); and the suburbs of the county (8% have Medicaid). INTERVENTIONS: An RRO system was implemented in 8 city practices in 1995 (covering 64% of inner-city children) and was expanded to 10 city practices by 1999 (covering 74% of inner-city children, 61% of rest-of-city children, and 9% of suburban children). The RRO intervention involved lay community-based outreach workers who were assigned to city practices to track immunization rates of all 0- to 2-year-olds, and to provide a staged intervention with increasing intensity depending on the degree to which children were behind in immunizations (tracking for all children, mail, or telephone reminders for most children, assistance with transportation or scheduling for some children, and home visits for 5% of children who were most behind in immunizations and who faced complex barriers). STUDY PARTICIPANTS: Three separate cohorts of 0- to 2-year-old children were assessed-those residing in the county in 1993, 1996, and 1999. STUDY DESIGN: Immunization rates were measured for each geographic region in Monroe County at 3 time periods: before the implementation of a systematic RRO system (1993), during early phases of implementation of the RRO system (1996), and after implementation of the RRO system in 10 city practices (1999). Immunization rates were compared for children living in the 3 geographic regions, and for white, black, and Hispanic children. Immunization rates were measured by the same methodology in each of the 3 time periods. A denominator of children was obtained by merging patient lists from the practice files of most pediatric and family medicine practices in the county (covering 85% to 89% of county children). A random sample of children (>500 from the suburbs and >1200 from the city for each sampling period) was then selected for medical chart review at practices to determine demographic characteristics (including race and ethnicity) and immunization rates. City children were oversampled to allow detection of effects by geographic region and race. Rates for the 3 geographic regions and for the entire county were determined using Stata to adjust for the clustered sampling. MAIN OUTCOME MEASURES: Immunization rates at 12 and 24 months for recommended vaccines (4 diphtheria-tetanus-pertussis:3 polio:1 measles-mumps-rubella: > or =1 Haemophilus influenzae type b on or after 12 months of age). RESULTS: DISPARITIES BY GEOGRAPHIC REGION: Baseline immunization rates (1993) for 24-month-olds were as follows: inner city (55%), rest of city (64%), and suburbs (73%), with an 18% difference in rates between the inner city and suburbs. By 1996, immunization rates rose faster in the inner city (+21% points) than in the suburbs (+14% points) so that the difference in rates between the inner city and suburbs had narrowed to 11%. In 1999, rates were similar across geographic regions: inner city (84%), rest of city (81%), and suburbs (88%), with a 4% difference between the inner city and suburbs. DISPARITIES BY RACE AND ETHNICITY: Immunization rates were available in 1996 and 1999 by race and ethnicity. Twenty-four-month immunization rates in 1996 showed disparities: white (89%), black (76%), and Hispanic (74%), with a 13% difference between rates for white and black children and a 15% difference between white and Hispanic children. In 1999, rates were similar across the groups: white (88%), black (81%), and Hispanic (87%), with a 7% difference between rates for white and black children, and a 1% difference between white and Hispanic children. CONCLUSIONS: A community-wide intervention of patient RRO raised childhood immunization rates in the inner city of Rochester and was associated with marked reductions in disparities in immunization rates between inner-city and suburban children and among racial and ethnic minority populations. By targeting a relatively manageable number of primary care practices that serve city children and using an effective strategy to increase immunization rates in each practice, it is possible to eliminate disparities in immunizations for vulnerable children.
Black or African American↗
Does federal funding for breastfeeding research target our national health objectives?
OBJECTIVE: To determine the number and dollar amount of federally funded research projects in the area of infant nutrition/breastfeeding/lactation from 1994 to 1996, and the impact of these funded projects on the achievement of our national goals for increasing the rates of breastfeeding initiation and duration. METHODS: Data were obtained from the Computer Retrieval of Information on Scientific Projects database, available through the National Institutes of Health. Abstracts of funded projects were identified, printed, and subjected to content analysis. Key information identified from the abstracts included: National Institutes of Health institute, center, or division funding the project; type of extramural funding; amount of federal dollars awarded; and a classification of the project's impact (direct, indirect, or none) on achievement of the Healthy People 2000 goals for breastfeeding. RESULTS: The final sample consisted of 362 abstracts in the broad category of infant nutrition/breastfeeding/lactation, which were awarded approximately 40.4 million dollars in federal research funds over the 3 years addressed in this study. Of this amount, only 13.7% (5.6 million dollars) was awarded to projects determined to have either a direct or indirect impact on achieving the Healthy People 2000 goals for increasing the incidence and duration of breastfeeding. A total of 27 (7.5%) funded projects in this category, reflecting $4.1 million, had no relationship to breastfeeding per se, as they involved the use of human milk composition and technologies to improve artificial milks and develop new pharmaceuticals and therapies. CONCLUSIONS: These findings suggest an incongruity between the national priorities for breastfeeding and the funding of scientific research in this content area, and provide important information for researchers and policymakers with respect to identification and redirection of funding priorities.
Breast Feeding↗
Helping families raise children with special health care needs at home.
One goal of Healthy People 2010 is to reduce the number of people with disabilities in congregate care facilities, consistent with permanency-planning principles, to 0 by 2010 for persons aged 21 years and under (objective 6-7). Congregate care, in this regard, is defined as any setting in which 4 or more persons with disabilities reside, regardless of whether the residence is located in the community, such as a school, group home, nursing facility, or institution. Although this particular public health objective may reflect an unfamiliar concept for some pediatricians, the American Academy of Pediatrics supports the goals and objectives of Healthy People 2010 as well as the medical home and the provision of community-based, culturally effective, coordinated, and comprehensive care for children with special health care needs and their families. To advise families caring for children with special health care needs effectively, the pediatrician should be familiar with the principles of permanency planning and well informed of local family-support services. The pediatrician should also work with the family to identify the range of long-term supports and services available for their child. These supports may include respite for biological families as well as various additional parenting models such as shared parenting, foster care, alternate parents, and adoption. Although family-based supports are preferable, families may consider other out-of-home placements including group homes, placement in a nursing facility, or other forms of institutional care when sufficient family-based services are not available. Once all the options are understood, issues regarding quality of care can be individualized and judged by the parent or guardian, in close collaboration with the pediatrician and other professionals with expertise in permanency planning and long-term supports and services. The purpose of this clinical report is to educate physicians on the philosophy of providing a permanent family environment (permanency planning) for all children, including those with special health care needs, and the importance of adequate and accessible community services to support and maintain the well-being of all family members.
Adolescent↗
The expanding role of the pediatrician in improving child health in the 21st century.
Children in the United States increasingly are at risk for health problems that are precipitated or exacerbated by social, community, and environmental factors. Currently, pediatricians are unable to sufficiently address these health conditions without expanding their roles beyond that of providing health care to individual patients. Thus, to improve child health, physicians must work within their communities to identify the needs of the population they serve and take appropriate action to influence the private and public policies that address these needs. Healthy People 2010 establishes a well-supported framework that confronts the social and community factors that affect children's health and serves as a resource for community-minded pediatricians. In addition to Healthy People 2010, other successful initiatives have been created by pediatricians, and they must be expanded if the pediatric community is to alleviate the social, community, and environmental factors that negatively affect child health.
Child↗
The essential role of research in community pediatrics.
Several recommendations in the American Academy of Pediatrics policy statement "The Pediatrician's Role in Community Pediatrics" underscore the essential role of research as an agent of change to promote the health and well-being of children. This article provides (1) a framework for thinking about research in community pediatrics, (2) special considerations important in conducting community-level research, (3) an example of community-level research that has significantly decreased mortality in children (prevention of sudden infant death syndrome), (4) an example of a current issue illustrating the importance of community pediatrics research (promotion of school readiness), and (5) a discussion of future directions for research. Many of the leading health problems facing the United States as outlined in Healthy People 2010 are problems that affect children or have their roots in childhood and are likely to be addressed by community-level research and interventions. It seems clear that pediatricians should be learning to participate in, advocate for, and conduct more community pediatrics research.
Child↗
[Primary health care organization in the context of social exclusion/inclusion processes].
This article reports on a primary health care and training center in São Paulo, Brazil, and the organization of its activities based on equity and positive discrimination. Operating in the city center of São Paulo, the policy aims to provide health services access to certain target groups (homeless, sex workers, and slum-dwellers). It also raises discussion on the various forms of social life found in downtown areas, mainly those of vulnerable groups lacking access to public goods and services. The experience demonstrates the feasibility of implementing health policies based on universal access.
Brazil↗
Painting a truer picture of US socioeconomic and racial/ethnic health inequalities: the Public Health Disparities Geocoding Project.
OBJECTIVES: We describe a method to facilitate routine monitoring of socioeconomic health disparities in the United States. METHODS: We analyzed geocoded public health surveillance data including events from birth to death (c. 1990) linked to 1990 census tract (CT) poverty data for Massachusetts and Rhode Island. RESULTS: For virtually all outcomes, risk increased with CT poverty, and when we adjusted for CT poverty racial/ethnic disparities were substantially reduced. For half the outcomes, more than 50% of cases would not have occurred if population rates equaled those of persons in the least impoverished CTs. In the early 1990s, persons in the least impoverished CT were the only group meeting Healthy People 2000 objectives a decade ahead. CONCLUSIONS: Geocoding and use of the CT poverty measure permit routine monitoring of US socioeconomic inequalities in health, using a common and accessible metric.
Censuses↗
Preventive dental care and unmet dental needs among low-income children.
OBJECTIVES: We examined the ways in which levels of preventive dental care and unmet dental needs varied among subgroups of low-income children. METHODS: Data were drawn from the 2002 National Survey of America's Families. We conducted bivariate and multivariate analyses, including logistic regression analyses, to assess relationships between socioeconomic, demographic, and health factors and receipt of preventive dental care and unmet dental needs. RESULTS: More than half of low-income children without health insurance had no preventive dental care visits. Levels of unmet dental needs among low-income children who had private health insurance coverage but no dental benefits were similar to those among uninsured children. Children of parents whose mental health was rated as poor were twice as likely to have unmet dental needs as other children. CONCLUSIONS: Additional progress toward improving the dental health of low-income children depends on identifying and responding to factors limiting both the demand for and the supply of dental services. In particular, it appears that expanding access to dental benefits is key to improving the oral health of this population.
Adolescent↗
Changing the child labor laws for agriculture: impact on injury.
OBJECTIVE: The child labor laws are intended to protect young workers from the most dangerous jobs. However, children who work on their parents' farms are exempt from these laws. We evaluated the potential for preventing the occurrence of farm injuries among children by changing the US Federal Child Labor Laws, Hazardous Occupations Orders for Agriculture. METHODS: A retrospective case series of 1193 farm injuries among children from the United States and Canada was assembled. The Hazardous Occupations Orders were systematically applied to each case. Injury preventability was estimated. RESULTS: A total of 286 (24%) cases of injury involved immediate family members engaged in farm work. Among these children, 33% of those aged younger than 16 years and 36% of those aged 16 or 17 years were performing work prohibited under the Hazardous Occupations Orders. CONCLUSIONS: Removing the family farm exemption from the Hazardous Occupations Orders and raising the age restriction for performing hazardous agricultural work from 16 to 18 years would be efficacious in preventing the most serious injuries experienced by young family farm workers. Potential reductions in injury would meet Healthy People 2010 goals for reducing traumatic injury in the agricultural sector.
Accidents, Occupational↗
Relationship between children's dental needs and dental care utilization: United States, 1988-1994.
OBJECTIVES: This study describes the relationship between dental needs and dental care utilization among children. METHODS: Data from the third National Health and Nutrition Examination Survey (1988-1994) were used to analyze dental care needs and dental care utilization. RESULTS: Younger children with perceived needs (needs perceived by the child or responsible adult) were more likely to be episodic users of dental care than children without perceived needs. Younger children with normative needs (defined by the presence of untreated caries diagnosed by a dentist) were less likely to be regular users. Older children with perceived or normative needs were more likely to be episodic users and less likely to have had a previous-year visit than children with no needs. CONCLUSIONS: Despite their presence, dental needs do not drive dental care use among children, and children's dental care utilization is inadequate.
Adolescent↗
Healthy People 2010 and Asian Americans/Pacific Islanders: defining a baseline of information.
OBJECTIVES: Healthy People 2010: Understanding and Improving Health lists 6 areas of disparity in minority health services: infant mortality, cancer, cardiovascular disease, HIV/AIDS, diabetes, and immunizations. This study compiles existing Asian American and Pacific Islander (AAPI) health data to establish a baseline. METHODS: For federally-sponsored research (1986-2000), the Computer Retrieval of Information on Specific Projects (CRISP) database was analyzed. AAPI initiatives were divided by subpopulation and disparity area. MEDLINE articles (1966-2000) were similarly scrutinized. RESULTS: Few federal health-related grants (0.2%) and MEDLINE articles (0.01%) mention AAPIs. For the 6 disparity areas, significant AAPI data gaps remain. CONCLUSIONS: To reach the Healthy People 2010 goals and have useful data, researchers and grant makers must focus on obtaining baseline data for disaggregated AAPI subgroups.
Asia↗