Solving the Health Disparities Puzzle

toddSpring 2012Leave a Comment

By Jon Parham

Why is someone living in Benton County in northwest Arkansas expected to live 10 years longer than a resident of Phillips County in east Arkansas? Why is the infant mortality rate in Phillips County nearly twice that of Benton County?

There is no single cause to the differences in health and health care between different segments of the population just as there is no single answer to reducing those differences.

As the state’s only academic health sciences center, UAMS is engaged in addressing health disparities through research and clinical and academic programs. That work fits the call of health centers to be leaders in improving health and health care for the people they serve.

The state ranks at or near the bottom in many health categories and many east Arkansas counties share economic and demographic characteristics with the adjacent Mississippi River Delta, practically ground zero in the South for
health disparities.

“Health disparities is such a multi-dimensional issue because there are so many factors intertwined and interrelated that have impacted health and health care over time,” said Jim Raczynski, Ph.D., dean of the UAMS Fay W. Boozman College of Public Health.

It’s not just a matter of race, although there are persistent gaps between the health status of minorities and non-minorities in the United States. It’s not just a matter of economics, though like other social determinants of health, high poverty levels can usually be found in areas of greater health disparities.

“When you start looking at the social determinants of health disparities – access to care, poverty, education, work, living conditions – it moves you closer to the sources of a problem that has very expensive effects on health as well as the economy,” said Creshelle R. Nash, M.D., M.P.H., an assistant professor of health policy and management in the College of Public Health. “And health disparities affect us all since the costs of unreimbursed care for the uninsured or underserved is passed on to us in higher insurance premiums and health care costs.”

By the Numbers

A population of 2.9 million ranks the largely rural Arkansas among the 20 smallest states in the nation. Dismal rankings in numerous categories related to health status, incidence of disease and access to care place it among the least-healthy states.

The state ranks 45th of 50 in the incidence of stroke, 43rd in obesity, 45th in cardiovascular deaths, 45th in cancer deaths, 43rd in infant mortality, 42nd in the lack of health insurance and 45th for the number of children living in poverty. There are sizeable and growing shortages of health care professionals.

While the rankings show a disparity in health between the state and most of the nation, within Arkansas there are health disparities as well. In the fast-growing northwest region, home of Fortune 500 companies like Walmart and Tyson Foods, the life expectancy stretches to 80 years in Benton County. The infant mortality rate sits at about 6.5 per 1,000 live births.

Travel five-and-a-half hours away, to Phillips County in east Arkansas, a part of the impoverished Mississippi Delta region and with a higher minority population, life expectancy is shortened by a decade. The infant mortality rate jumps to 12.3 per 1,000 live births.

“While many people acknowledge that racial health disparities exist, there is less consensus on the question of why they occur, but it’s clear that your opportunity for health starts long before you need medical care,” said Kate Stewart, M.D., M.P.H., an associate professor of health policy and management in the College of Public Health.

All Arkansans should have the opportunity to make the choices that allow them to live a long, healthy life, regardless of their income, education or ethnic background, she said.

In Phillips County, as is the case in every county along the eastern border of Arkansas, one in three residents lives in poverty. In Benton County the rate is about one in eight.

These trends endure for generations, in a region where there is little inherited wealth and there are still instances in which someone is the first in their family to graduate from college. In many cases, those who achieve higher levels of education leave the region in search of job opportunities, Raczynski said.

The Arkansas Center for Health Disparities, which Raczysnki also directs, conducts research that continues to better identify the effects and causes of disparities while supporting efforts to reduce and eliminate them.

Partnerships and Education

Through the center’s work, Raczynski hopes to attract researchers who want to tackle projects for addressing health disparities. Funded projects to date have examined issues ranging from racial disparities in substance abuse to how health care access, affordability and quality of care relate to health disparities. In five years, the center will have funded about $7.5 million in research projects.

In addition to better understanding and documenting the scope of disparities, the center is one of several UAMS groups seeking to bring together community efforts that can help or rally research into finding new ways to address public health problems.

The UAMS Translational Research Institute includes a community engagement component for fostering collaborative partnerships in public health-based translational research. “One way to address disparities is to look outside health care at other sectors that may contribute to disparities,” said Stewart, who also is a part of the institute’s effort. “We may need to partner across sectors and involve organizations in housing or legal services, for example.”

A move toward a patient-centered medical home model for care also may help address disparities, Nash said. The medical home model emphasizes comprehensive, team-based care in which a personal physician is responsible for providing or arranging for the ongoing care of patients, including routine checkups, specialty care, therapy and patient education.

The goal of providing comprehensive, culturally competent care will remove many of the barriers that have reinforced disparities,” she said.

Cultural Competency

Culturally competent care – where health care professionals are aware of their own assumptions and biases and cognizant of and sensitive to the diverse cultures and health-influencing cultural factors of their patients – requires preparation. Students in medicine, nursing, pharmacy and the allied health professions all benefit from exposure to diverse cultures and situations they may encounter during their careers.

“We must have curricula formatted so that cultural competency is completely integrated into the fabric of each UAMS college curriculum,” said Billy Thomas, M.D., M.P.H., a neonatologist and leader of the UAMS Center for Diversity Affairs. Thomas was named in 2011 the university’s first vice chancellor for diversity.

At UAMS, cultural competency is addressed through formal lectures and instruction as well as in simulation labs where students interact with simulated patients from diverse backgrounds. Perhaps most importantly, Thomas said, students learn cultural competency through experiences.

Rotations in community clinics or family medicine clinics at the UAMS Area Health Education Centers put students into situations where they see patients from underserved populations.

We strive for positive interactions where students learn the impacts and reality of health disparities and how a culturally competent provider can help,” Thomas said.

Another element of cultural competency is recruiting students from underrepresented backgrounds to the health professions. Minority students are more likely to serve the underserved and to return to their communities for careers.

The Center for Diversity Affairs – which began in the 1970s in the College of Medicine and in 2011 was expanded into a resource for all of UAMS – has an array of thriving student programs. More than 500 students from kindergarten through college participate each summer in programs that promote science and health care education, provide laboratory research experiences and offer preparation courses for the ACT, the pharmacy college admissions exam and the medical college admissions exam.

Almost all of the minority students at UAMS participated in a UAMS summer program at some point, Thomas said. While the numbers of minority students at UAMS is not as high as Thomas and others would like, he believes the diversity programs are gaining momentum and expanding.

Nash echoed the optimism for the future. “We have an amazing opportunity in Arkansas to make a difference,” she said.

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