|
|
Eliminating
Health Disparities
|
 |
Healthy
People 2010
|
Healthy People 2010, the nation’s
health objectives for the Year 2010, is focused on two overarching
goals: (1) Increase Quality and Years of Healthy Life and (2) Eliminate
Health Disparities. These goals illuminate the vision of a healthy
nation. These goals provide the leadership and motivation for a systematic
approach to health improvement. The effort to develop Healthy People
2010 engaged multiple groups, organizations, and citizens across the
country. These national goals constitute an enormous challenge to
the nation as a whole and to the states.
The concept to "eliminate health disparities"
was strongly supported when it was taken to the public for review
and comment. Many advocacy groups felt that accepting lower standards
for racial and ethnic groups as compared to the total population
was unjust. The health objectives established for the Year 2000
set targets specifically for racial and ethnic minority groups,
women, people with low incomes, people with disabilities, and specific
age groups. The 2000 targets were challenging and called for greater
improvements – however, these targets rarely aimed at achieving
equity by 2000.
The Healthy People 2010 document lays
out a framework to help the nation understand the disparities. Critical
policy development, program planning, resource allocation, and monitoring
can be implemented more effectively by offering standardized data
that correctly identifies high risk populations. The goal of "Eliminating
Disparities" can be better understood and embraced. All people
in the nation will be challenged with the same standards for health
and safety.
|
| |
|
Healthy
Carolinians 2010
|
When Governor James B. Hunt, Jr. issued his
1999 Executive Order No. 147 to establish the Governor’s Task
Force for Healthy Carolinians, he laid out six goals. One of these
goals was to "Remove health disparities among the disadvantaged."
(See Chapter, North Carolina 2010 Health Goals.) Governor Hunt’s
directions to the Task Force for Healthy Carolinians clearly aligned
the 2010 North Carolina health objectives with the national efforts.
Governor Hunt’s vision for a healthy North
Carolina builds on the work that began with the North Carolina health
objectives for the Year 2000 that called for "reducing health
disparities among the disadvantaged." Like the national health
objectives for the Year 2000, North Carolina set specific targets
for high-risk groups. These targets for high-risk populations were
set at a different level than the overall target for the state.
Healthy Carolinians task forces across North Carolina used the 2000
health objectives to develop initiatives for the high-risk populations.
The Governor’s Task Force for
Healthy Carolinians has taken its challenge very seriously and has
diligently worked to produce a framework that supports the work
of communities, public health, hospitals, health and human services
agencies, health care providers, elected officials, and all interested
public in eliminating health disparities in North Carolina. The
definition of health disparities used in the North Carolina 2010
Health Objectives adapted from Healthy People 2010, is: "Differences
in health status among distinct segments of the population including
differences that occur by gender, race or ethnicity, education or
income, disability, or living in various geographic localities."
(For more information see, User’s Guide)
|
| |
|
Strength
of a Diverse Population –
Assets of Multicultural Communities
|
Anthropologists believe
that all people have the same basic human needs, and that every culture
responds to these same human needs. The difference lies in how a particular
group meets these needs. Working with people from different cultures
to define and address basic human needs enriches our own experience,
it expands our vision, it contributes to new ideas and new solutions,
and it increases creativity and innovation. Much is learned from sharing
visions, customs, beliefs, and values. Combining perspectives and
solutions of various cultures that reside in our communities enables
us to develop and implement more comprehensive approaches with much
greater impact on social and economic problems. A diverse population
that works together has a shared humanity, a common vision, and a
credibility that will influence individuals, families, neighborhoods
and the broader community. The development of multicultural partnerships
to address health and safety issues are an asset for any community
or state.
North Carolina’s population
is becoming more diverse. With increasing minority populations,
an aging population, and in-migration from other states and countries,
North Carolina will be a very different state in 2010. These changes
bring new strengths and challenges to the state. These demographic
changes magnify the importance of addressing disparities in health
status. The diversity and multicultural characteristics of our evolving
population will offer new solutions to address old problems. If
the leadership over the next decade represents the new demographics,
as well as provides a link to North Carolina’s strong public
health history, the assets of multicultural society can be harnessed
and a common destiny created.
|
| |
|
Underlying
Determinants of Health
|
Health status is the product of complex interactions
of multiple factors. In 1986, the World Health Organization stated,
"Health is a state of complete physical, mental, and social well-being,
and not merely the absence of disease or injury." This definition
expands health outside the traditional, formal medical and health
care system and challenges public health and communities to respond
to health, disease, and disability in new ways. For both individuals
and populations, health depends not only on the health care system,
but also on other factors including individual behavior, genetic makeup,
exposure to health threats, and social and economic conditions.
The North Carolina 2010 health objectives uses
the following definition of Determinants of Health that has been
adapted from Healthy People 2010: "The array of critical influences
that determine the health of individuals including biology (individual’s
genetic makeup), family history (that may suggest a risk for disease),
behaviors, social environment (interactions with family, friends,
coworkers, and other), physical environment, policies and interventions,
and access to health care."
|
| |
|
Defining
and Understanding Health Disparities
|
Health status is a dynamic that often manifests
in the relationships between health and income, education, race and
ethnicity, cultural influences, environment, and access to quality
medical services. Disparities in health status do not fit nicely into
any one of these. Rather, many health problems cross multiple characteristics
and are a result of a complex interaction among the different factors.
The greatest challenge in understanding health disparities is having
access to data that discloses relevant information about race and
ethnicity, education and income, disability, and geographic locations.
While more data are needed, there are enough data showing a strong
relationship between poverty and poor health. The poor, regardless
of race or ethnicity, share a disproportionate burden of poor health.
The following discussion highlights how
health disparities occur among different demographic groups in North
Carolina. This discussion is adapted from Healthy People 2010.
Race
and Ethnicity
Current knowledge about biologic and genetic
characteristics of different populations does not explain the health
disparities experienced by several minority groups compared with
the White population. Many health practitioners believe that race
is not a major factor, but rather that the socio-economic
environment, limited access to health care, cultural barriers, limited
educational and employment opportunities, specific health behaviors,
and discrimination (real or perceived) contribute to the high rates
of illness and death among certain racial and ethnic groups.
Data depicting
race and ethnicity show dramatic health disparities.
In North Carolina, the mortality
rate for coronary heart disease for Minorities in 1998 was 19.2
percent higher than for Whites. This disparity has increased steadily
over the past 20 years, beginning in 1979 when the Minority rate
was slightly less than the White rate. The racial disparity in mortality
from coronary heart disease is greater among women than among men.
Minority women presently have a 28.4 percent higher mortality rate
than White women, up from a 9.8 percent difference in 1979. The
present disparity between Minority and White men is 13.2 percent,
a reversal of the disparity seen in 1979 when the heart disease
mortality for Minority men was slightly less than for White men.
A significant, even larger disparity exists
by race in stroke mortality. Minorities have a much higher death
rate. This disparity increased markedly from a 17.6 percent difference
in 1979 to 48.7 percent in 1981. It has remained in the 40 to 50
percent range throughout the two decades.
The 1998 death rates of AIDS, for the
White population of 3.2/100,000 compared to 19.9 per 100,000 of
African American/Blacks is a dramatic demonstration of health disparities.
Likewise, 1999 infant mortality data reveal that only 6.4 per 1,000
Hispanic/Latino infants and 6.7 per 1,000 White infants die before
their first birthday compared to 15.7 per 1,000 African American/Black
infants and 13.4 per 1,000 Native American infants dying.
Geographic
Location
While almost two-thirds of the population
in North Carolina live in urban areas, most of the counties are
designated rural. North Carolina’s current prosperity is not
widely shared. There are significant disparities between fast-growing
metropolitan areas and slow- or no-growth rural counties. Rural
counties generally have a higher rate of poverty, with the rural
population having less formal education. Rural counties, with lower
wages, often lose their young people to urban counties. This leaves
an aging population.
Access to health care in rural areas,
especially dental health care, is a significant problem. Four counties
have no dentists in practice, and 26 additional counties have no
dentists who accept Medicaid. Seventy-nine counties qualify as nationally
recognized dental professional shortage areas. A similar shortage
exists for dental hygienists. Cardiovascular disease and stroke
occur at a higher rate in the eastern part of North Carolina.
In virtually all disease mortality
rates, there is a geographic disparity in North Carolina. Take coronary
heart disease again as an example. The western region has a lower
rate than the piedmont region, which has a lower rate than the eastern
region. Contrasting eastern North Carolina with the rest of the
state, the coronary heart disease mortality rate is greater there
and the disparity is growing, from 11.0 percent higher in 1979 to
18.5 percent higher in 1998. Stroke mortality in the east is 14.5
percent greater than the rest of the state. The geographic disparity
in stroke mortality rates has held constant over twenty years.
Education
and Income
Income and education
are both measures of socioeconomic status. Inequality in income
and education underlie many health disparities. Research indicates
that population groups that suffer the worst health status are also
those that have the highest poverty rates and least education. Income
data provides an assessment of the resources available to individuals
or families to acquire food, housing, clothing, and health care.
In North Carolina, the youngest and the oldest are generally the
poorest. One in five children live in poverty and one in seven lack
health insurance.
Pregnancy outcomes provide a good example
of how the level of education can be a measure of health disparities.
In North Carolina (1998), 92.4 percent of the pregnant women with
at least some college initiated prenatal care during the first trimester,
compared to 68.1 percent of the pregnant women with less than a
high school diploma. Looking at low birth weight among the same
group, women with some college had 7.3 percent low birth weight
babies, while women with less than a high school diploma had 11.0
percent low birth weight babies. The percentage of the women with
some college who smoked during pregnancy was 6.8 percent compared
to 27.2 percent of women without a high school diploma.
Education is improving in North Carolina.
Between 1990 and 1998, the percentage of persons who graduated from
high school increased from 70 percent to 81 percent. In 1999, there
were 6.0 students per computer; however, there were 24.9 students
per computer connected to the Internet. Governor Hunt’s focus
on education has demonstrated significant improvement in the NAEP
scores. There are still challenges. North Carolina graduates need
advanced skills required in the new economy if they are to avoid
low-wage, low-hope jobs.
By 2010, the first years of the Baby Boomer
generation will be retiring. The Center for Aging Research and Education
Services and the Division of Aging, NC DHHS, report that about half
of the one million North Carolina Boomers are in occupations that
do not offer pensions. These individuals will need to save money
to supplement Social Security funds in later years. Because members
of minority groups, and single heads of household of all races,
have substantially lower average incomes and tend to be in jobs
without retirement pensions, it may be hard for them to accumulate
savings or other assets to prepare for old age.
Disability
(mental and physical functionality)
According to
the North Carolina Behavioral Risk Factor Surveillance System (1998),
an estimated 24 percent of non-institutionalized adults experience
activity limitation and/or perceive themselves to be a person with
a disability. There many different disabilities. People with disabilities
tend to have lower rates of physical activity and higher rates of
obesity. They tend to report more anxiety, pain, sleeplessness,
and days of depression and few days of vitality when compared to
people without activity limitations. Health promotion activities
are important for people experiencing a disability regardless of
race or ethnic group, gender, or primary condition or diagnoses
(e.g., major depression, arthritis, cerebral palsy, diabetes, spinal
cord injury, or fetal alcohol syndrome).
|
| |
|
Why
It is Important to Eliminate Health Disparities
|
Failure to focus on health disparities and
the determinants of health places serious limitations on the effectiveness
of preventive health care and health promotion programs. Inadequate
education and income are serious obstacles to learning about healthy
lifestyles, accessing health care, and providing for the basic food,
clothing, and shelter. The health disparities between the "haves"
and the "have nots" are evidenced in longevity, birth outcomes,
and health behaviors (diet, physical activity, etc.). North Carolina
can avoid having two tiers of health outcomes by understanding health
disparities and addressing health disparities through effective policies
and targeted programs.
Eliminating health disparities will require
both individual and societal efforts. North Carolina’s commitment
to improve primary and secondary education has been a major step
toward reducing health disparities, which will be evidenced in decades
to come. However, graduating from high school will not be enough
for the future workforce. North Carolinians will need to be life-long
learners to be eligible for better-paying jobs, with health insurance
and retirement pensions
|
| |
|
Call For Action-
Eliminating Health Disparities
|
In spite of the advancement in education, challenges
are still present. North Carolina still has unacceptable disparities
between Whites and minorities in measurements of joblessness, health
status, per capita income and poverty rates. The prosperity that North
Carolina has enjoyed over the past 10 years is not equally shared
by all. To respond to health disparities, North Carolina, at the state
and local levels, must:
- Develop comprehensive surveillance instruments to enhance data
collection that will improve measures of as education, income,
and socioeconomic status to better understand the problem.
- Plan appropriate interventions to address health disparities.
- Initiate research that will help understand the causes of disparities.
- Develop needed policies and funding.
- Mobilize communities (public-private partnerships).
- Unite resources into a common focus.
|
| |
|
|
