Addressing Racial & Ethnic Health Inequities: The Role of Public Health Social Work

1. Addressing Racial & Ethnic Health Inequities: The Role of Public Health Social Work Tamara J. Cadet, PhD., LICSW, MPH Associate Professor Simmons University School of Social Work

2. Learning Objectives • Grasp the significance of racial and ethnic health disparities and inequities • Understand why social work and public health social work (PHSW) practitioners need to address health disparities and inequities • Define key terms and their meanings related to health disparities, health equity and social determinants of health • Utilize key resources and readings to enhance knowledge on this content • Understand possible strategies for PHSW to address racial and ethnic disparities/inequities • Apply knowledge of PHSW in actual racial and ethnic disparities/inequities

3. Introduction • The US population continues to diversify, racially and ethnically • Estimates by the U.S. Census indicate that by 2060, more than half of the US population will identify as a minority (Colby & Ortman, 2014)) • Achieving health equity, eliminating disparities, and improving the health of all U.S. population groups is one of the nation’s health goals as specified by Healthy People 2020, the U.S. Department of Health and Human Services “blueprint” for improving overall health: https://www.healthypeople.gov/

4. Why Focus on Racial and Ethnic Health Disparities and Inequities • Race and ethnicity intersect with other key factors such as socioeconomic status, geographic location, immigration status and nationality to produce health inequities • When studying health, many roads lead back to race and ethnicity • This does not mean other disparate groups based on sexual orientation, gender, homelessness, or disability status are less important but that focus on race/ethnicity is important focus

5. Terminology There is a difference between health disparities, health inequities and health equity: Health Equity means efforts to ensure that all people have full and equal access to opportunities that enable them to lead healthy lives. To achieve health equity, we must treat everyone equally and eliminate avoidable health inequities and health disparities (http://healthequity.sfsu.edu/)

6. What is a Health Disparity? • A higher burden of illness, injury, disability or mortality experienced by one population group relative to another. • Differences between population groups in health insurance coverage, access to and use of care, quality of care. • Not all health disparities are unjust – some are just a part of life! • We expect the young to be healthier than the old; some people are genetic carriers for diseases; some participate in jobs/hobbies that have high mortality associated with them

7. What Causes Racial/Ethnic Health Disparities? • A complex and interrelated set of individual, provider, health system, societal, and environmental factors contribute to disparities in health and health care (Kaiser Foundation, 2016) • Individual factors include a variety of health behaviors from maintaining a healthy weight to following medical advice. • Question for discussion: • What are some individual factors that can contribute to disparities?

8. Provider Factors • Provider bias and cultural/linguistic differences are another potential cause of racial/ethnic disparities; barriers, such as poor patient-provider communication and other factors can lead to lower quality of care, lower patient satisfaction, less engagement in care • Bias (or prejudice) against minorities • Greater clinical uncertainty when interacting with minority patients • Beliefs (or stereotypes) held by the provider about the behavior or health of minorities (Institute of Medicine, 2002)

9. Question: Provider Factors How might patient-provider communication impact care? Photo credit: Healthworkscollective.com and http://mindthegap.smarthealthmessaging.com/

10. Systemic Factors That Contribute to Health Disparities • How health care is organized, financed, and delivered, including lack of access to care, inability to make it to appointments, high deductibles/copays, affects health outcomes and can produce disparities and differences in health outcomes among groups of people. • Social and environmental factors, such as poverty, education, proximity to care, lack of childcare, work considerations, and neighborhood safety affect ability to utilize health care system • Question for discussion: what are some other systemic factors that affect people you work • with?

11. Relationship to Social Determinants of Health • Social determinants of health (SDOH) are systemic factors which affect health outcomes, defined as: “the circumstances in which people are born, grow up, live, work, and age. This also includes the systems in place to offer health care and services to a community. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics. (Social Determinants of Health Key Concepts External, World Health Organization). • SDOH affect racial and ethnic groups through the following: poverty, inadequate housing, structural racism/discrimination, poor socioeconomic opportunities, food insecurity, quality of education, exposure to crime & violence, social norms and attitudes (e.g. discriminatory attitudes)

12. Summary of Disparities and Examples • Health disparities can be seen as persistent differences in health conditions and illness rates that cut across many illness categories and demographic groups • Disparities exist in different contexts and are rooted in the discriminatory and inequitable distribution of healthcare resources (Smedley et al., 2003)

13. Example #1 • African American children are more likely to die from asthma compared to non-Hispanic White children (Centers for Disease Control, 2006) • Questions for discussion: • Why do we think this is? • What are possible individual factors? • What are possible provider factors? • What are possible systemic factors? • How can social work help?

16. Example #2 • During 2010–2012, American Indian and Alaska Natives adults were about twice as likely to be diagnosed with type 2 diabetes as non-Hispanic whites (Centers for Disease Control, 2016) • Questions for discussion: • Why do we think this is? • What are possible individual factors? • What are possible provider factors? • What are possible systemic factors?

18. Health Equity • Reminder:  • health disparities, are differences in health status between people related to social or demographic factors such as race, gender, income or geographic region • Inequities are created when barriers prevent individuals and communities from accessing these conditions and reaching their full potential

19. What is Health Equity? • Health equity is when everyone has the opportunity to be as healthy as possible; reducing health disparities are one way we can measure our progress toward achieving health equity • Another way to think about is - reducing health disparities brings us closer to reaching health equity (https://www.apha.org/topics-and-issues/health-equity)

20. Definition: Health Equity • Health inequities= disparities that are socially determined; systematic inequality between more and less advantaged social groups, is avoidable and preventable, thus unfair • A health disparity is inequitable if it is systematically associated with social disadvantage (Bravement, 2006)

23. Statement by American Public Health Association • “By health equity, we mean everyone has the opportunity to attain their highest level of health. • Inequities are created when barriers prevent individuals and communities from accessing these conditions and reaching their full potential. • Inequities differ from health disparities, which are differences in health status between people related to social or demographic factors such as race, gender, income or geographic region. Health disparities are one way we can measure our progress toward achieving health equity. • How do we achieve health equity? We value all people equally. We optimize the conditions in which people are born, grow, live, work, learn and age. We work with other sectors to address the factors that influence health, including employment, housing, education, health care, public safety and food access.1  We name racism as a force in determining how these social determinants are distributed.”

24. Summary Health equity is the principle underlying a commitment to reduce—and eliminate—disparities in health and in its determinants, including social determinants (Braveman, 2006) Photo credit: Wisconsin Center for Health Equity

25. Exercise: Fill in the Blank on Inequities • Exercise: Name all the inequities that shape health outcomes: • A system of structuring opportunity and assigning value based on [fill in the blank], which • Unfairly disadvantages some individuals and communities • Unfairly advantages other individuals and communities • Saps the strength of the whole society through the waste of human resources

26. Inequities are Complex

27. Exercise: Map Inequities Across America, babies born just a few miles apart have dramatic differences in life expectancy https://www.rwjf.org/en/library/articles-and-news/2015/09/city-maps.html

28. Return to the Question: “Why Focus on Race and Ethnicity?” • Racial/ethnic inequities are widespread, longstanding, and profound: • Blacks and Hispanics are more likely to experience poverty, low educational levels, poor neighborhood conditions. For example, African Americans are far more likely than whites to experience the following hardships, even after adjusting for income, education, employment status, transfer payments, home ownership, gender, marital status, children, disability, health insurance and residential mobility: Inability to meet essential expenses, unable to pay full rent on mortgage, unable to pay full utility bill, more likely to have utilities shut off, more likely to experience eviction

29. Geography and Race Shape All Aspects of Health Care • Social determinants of health visible everywhere: • Pharmacies in predominately black neighborhoods are less likely to have adequate medication supplies (Morrison et al., 2000) • Hospitals in black neighborhoods are more likely to close (Buchmueller et al., 2006) • MDs are less likely to participate in Medicaid in racially segregated areas (Greene et al., 2006)

30. How Inequities “Happen” • The case of breast cander: • Differences in life opportunities, exposures, and stresses result in differences in underlying health status (e.g. black women more likely to get breast cancer at younger age than white women) • Differences in access to health care, including preventive and curative services (e.g. black women more likely to be diagnosed at later stage of breast cancer than white women) • Differences in the quality of care received within the health care system (e.g. higher mortality rate from breast cancer among black women compared to white women)

31. We Seemingly Have Tried: The Persistence of Racial/Ethnic Disparities  • Despite broad efforts, we have largely FAILED! • In spite of: • A War on Poverty • A Civil Rights Revolution • Medicare and Medicaid • The Hill-Burton Act • Major advances in medical research & technology • We have made little progress in reducing the elevated death rates of Blacks in particular and other minorities • (Williams, Priest, & Anderson, 2016)

32. Why Social Workers Should Care • Our commitments to service, social justice, cultural competence, and diversity • Thinking about/doing something about situations that are discriminatory, that constrain people’s ability to exercise self-determination, or that limit individuals’ capacity to participate fully in society is what health disparities are about Photo credit: Wayne State University School of Social Work

33. We Are and Have Been Health Social Workers! Long history of involvement in health concerns, dating back to the turn of the 20th century (Ruth & Marshall, 2017) Half of all social workers work within health, and the remaining social workers are employed addressing social determinants of health such as housing, child welfare, education, etc. (Ruth & Marshall, 2017) NASW, 2016  has specified standards for social work in health settings: these include the importance of prevention, the need to address health disparities, and recognition of the importance and complexity of this field of practice and the profession’s “leadership role in the psychosocial aspects of health care” (https://www.socialworkers.org/LinkClick.aspx?fileticket=fFnsRHX-4HE%3D&portalid=0)

34. Public Health Social Work Model • Finally, as discussed earlier, the social determinants of health, which impact health disparities, are based in our social environment • Addressing health disparities and inequities in a comprehensive manner which takes into account all levels can make a difference • PHSW can and should take the lead

35. The Social Work Health Impact Model (Ruth, Wachman & Schultz, 2014)

36. PHSW Strategies to Address Ethnic and Racial Health Disparities/Inequities • Promoting techniques for self-managing health conditions (McPheeters et al.,2012) • Connecting patients to the healthcare system through navigation and warm handoffs (Chin et al., 2012; Quiñones et al., 2011) • Ensuring that patients that require interpreters get them (University of Wisconsin, 2010)

37. PHSW Strategies to Address Ethnic and Racial Health Disparities/Inequities • Developing programs and educational resources to generate awareness about health conditions • Conducting outreach and early identification through programs dedicated to prevention • Capacity building with community groups to create safer neighborhoods to decrease stress, increase healthy behaviors and promote likelihood of engaging in health care • Collaborate with professionals from other disciplines to ensure that patients are receiving comprehensive, not fragmented care –de-siloizing efforts such as “huddles,” “warm hand-offs,” and interprofessional education on racial injustice

38. Successful Model: Boston’s Community Asthma Initiative (CAI)   Addresses health disparities in neighborhoods and schools most affected by asthma Impact: School absences greatly reduced; 68% decrease in asthma-related emergency-department visits; and an 84% decrease in hospitalizations. View this short video: https://www.youtube.com/watch?v=cxLRWqQwIBs

39. Successful Model: Boston’s Community Asthma Initiative (CAI)   • Works with each family to understand their child’s asthma and the medications used to treat it • Helps family identify and reduce asthma triggers in the home and other places where the child spends time • Works with partners and coalitions to address asthma health disparities through changes in policies at the local and state level • Other programs • http://bphc.org/whatwedo/healthy-homes-environment/asthma/Pages/Boston-Asthma-Home-Visit-Collaborative.aspx

40. Activity: Disparities in Context  • What does it mean to recognize and address health disparities in the context of public health social work practice? Read the Equity Stories (https://www.apha.org/~/media/files/pdf/topics/equity/equity_stories.ashx) from the American Public Health Association and choose one as your focus. In small groups or on your own, answer the following: • How would you summarize the health disparity in this story? What specific factors contributed to this issue? • What was done to improve outcomes for the population affected? In particular, how did public health social work leaders partner with the population affected? • What lessons could you take away to use in your own context or with your population of interest?

41. Takeaway • You can provide services but you are also responsible, as a social worker, for helping to ensure the availability, accessibility, quality and acceptability to and for the services; that means putting racial and ethnic inequities “on the table” • In-class Exercise or Group Assignment: Let’s work through some examples by examining common health conditions associated with health disparities/health inequities: • Heart disease and stroke • Diabetes • Maternal and infant and child health

42. A Call to Action: How Social Workers Can Work Towards Health Equity • Maintain focus and commitment to social justice, particularly racial/ethnic justice • Use your advocacy skills to target health issues that disproportionately affect socially disadvantaged clients and groups • Learn about public health social work: Infuse public health approaches into practice and educate colleagues about health inequities • Emphasize addressing SDOH by helping clients: • Find safe housing • Secure employment • Enroll self or children in school or preschool • Link to health and social services • Know their rights

43. Final Thoughts “[At the heart of the concept of health disparities is…social justice]—that is, justice with respect to the treatment of more advantaged vs. less advantaged socioeconomic groups when it comes to health and health care” (Braveman, 2014) “True compassion is more than flinging a coin to a beggar; it understands that an edifice which produces beggars needs restructuring…” Dr. Martin Luther King Jr.

44. Selected Resources • American Public Health Association. (2015). Better health through equity – Case studies in reframing public health work. Retrieved from https://www.apha.org/~/media/files/pdf/topics/equity/equity_stories.ashx • Keefe, R. H. (2010). Health disparities: A primer for public health social workers. Social Work in Public Health, 25(3-4), 237-257. • Mitchell, F. M. (2015). Racial and ethnic health disparities in an era of health care reform. Health & Social Work, 40(3), e66-e74. • Social Work in Illness Prevention and Health Promotion. Retrieved from https://us.sagepub.com/sites/default/files/upm-binaries/44223_6.pdf • Unnatural causes. Retrieved from http://www.pbs.org/unnaturalcauses/explore_learn.htm • Walters, K. L., Spencer, M. S., Smukler, M., Allen, H. L., Andrews, C., Browne, T., Maramaldi, P., Wheeler, D., Zebrack, B. & Uehara, E. (2016). Health equity: Eradicating health inequalities for future generations (Grand Challenges for Social Work Initiative Working Paper No. 19). Cleveland: American Academy of Social Work and Social Welfare. Retrieved from http://aaswsw.org/wp-content/uploads/2016/01/WP19-with-cover2.pdf

45. Bibliography • American Public Health Association. (2018). Health Equity. Retrieved from https://www.apha.org/topics-and-issues/health-equity • Balfour, P. C., Ruiz, J. M., Talavera, G. A., Allison, M. A., & Rodriguez, C. J. (2016). Cardiovascular Disease in Hispanics/Latinos in the United States. Journal of Latina/o Psychology, 4(2), 98–113. • Boston’s Community Asthma Initiative, http://www.childrenshospital.org/Centers-and-Services/Programs/A-_-E/community-asthma-initiative-program • Braveman, P. (2006). Health disparities and health equity: concepts and measurement. Annu. Rev. Public Health, 27, 167-194. • Buchmueller, T. C., Jacobson, M., & Wold, C. (2006). How far to the hospital?: The effect of hospital closures on access to care. Journal of health economics, 25(4), 740-761. • Centers for Disease Control. (2006). The state of childhood asthma, United States, 1980-2005. Retrieved from http://www.cdc.gov/nchs/data/ad/ad381.pdf • Centers for Disease Control. (2014). African Americans Heart Disease and Stroke Fact Sheet. Retrieved from https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_aa.htm • Centers for Disease Control (2016). Selected CDC-Sponsored Interventions, United States, 2016. Retrieved from https://www.cdc.gov/minorityhealth/strategies2016/ • Chin, M. H., Clarke, A. R., Nocon, R. S., Casey, A. A., Goddu, A. P., Keesecker, N. M., & Cook, S. C. (2012). A Roadmap and Best Practices for Organizations to Reduce Racial and Ethnic Disparities in Health Care. Journal of General Internal Medicine, 27(8), 992–1000. http://doi.org/10.1007/s11606-012-2082-9

46. Bibliography • Council on Social Work Education. (2018). Results of the nationwide survey of 2017 social work graduates – The National social work workforce study. Retrieved from https://www.socialworkers.org/LinkClick.aspx?fileticket=C0r5P1zkMbQ%3d&portalid=0 • Greene, J., Blustein, J., & Weitzman, B. C. (2006). Race, Segregation, and Physicians’ Participation in Medicaid. The Milbank Quarterly, 84(2), 239–272. http://doi.org/10.1111/j.1468-0009.2006.00447.x • Henry J. Kaiser Foundation. (2016). Disparities in Health and Health Care: Five Key Questions and Answers. Retrieved from http://files.kff.org/attachment/Issue-Brief-Disparities-in-Health-and-Health-Care-Five-Key-Questions-and-Answers • McPheeters, M. L., Kripalani, S., Peterson, N. B., Idowu, R. T., Jerome, R. N., Potter, S. A., & Andrews, J. C. (2012). Quality Improvement Interventions to Address Health Disparities: Closing the Quality Gap: Revisiting the State of the Science. Vanderbilt University Evidence-based Practice Center • Morrison, R. S., Wallenstein, S., Natale, D. K., Senzel, R. S., & Huang, L. L. (2000). “We don't carry that”—failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics. New England Journal of Medicine, 342(14), 1023-1026. • National Association of Social Workers. (2016). NASW standards for social work practice in health care settings. Retrieved from http://www.socialworkers.org/practice/standards/HealthCareStandards_SW%20Practice_Final.pdf • National Healthcare Quality and Disparities Reports. Data Query: Table 6_4_1_5_1.2b. Retrieved from http://nhqrnet.ahrq.gov/inhqrdr/data/query • Quiñones, A. R., O’Neil, M., Saha, S., Freeman, M., Henry, S. R., & Kansagara, D. (2011). Interventions to improve minority health care and reduce racial and ethnic disparities. Washington, DC: Department of Veterans Affairs.

47. Bibliography • Smedley, B. D., Stith, A. Y., & Nelson, A. R. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: The National Academic Press. • US Census (2015). Retrieved from  https://census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf • University of Wisconsin Population Health Institute. (2010). Professionally trained medical interpreters. Retrieved from http://whatworksforhealth.wisc.edu/program.php?t1=22&t2=17&t3=28&id=637 • Williams, D. R., Priest, N., & Anderson, N. (2016). Understanding associations between race, socioeconomic status and health: Patterns and Prospects. Health Psychology, 35(4), 407–411.

48. Tamara Cadet, PhD, LICSW, MPH Tamara Cadet, PhD, LICSW, MPH is Associate Professor at the School of Social Work at Simmons University. She also holds a faculty appointment of the Harvard School of Dental Medicine in Oral Health Policy and Epidemiology. Dr. Cadet brings her more than 25 years of practice experience in many capacities and settings to her teaching and to her research. Dr. Cadet has worked in the fields of substance abuse, adoption, mental health, health care, schools, and oncology with children, adults, families, and older adults, as both a social worker and as a community organizer. Her ultimate objective is to advance efforts to develop health promotion interventions for underserved and underrepresented older adults in order to contribute to reducing oncology-related disparities. To this end, her research has primarily focused on improving access to cancer prevention, early detection, and treatment services for older minority adults. She is specifically interested in behavioral factors that influence health behaviors. Dr. Cadet is currently adapting and evaluating a mammography decision aid for use among older women with low health literacy levels. She collaborates with colleagues to investigate the psychosocial and cultural factors that influence older adults and their cancer-screening behaviors using national datasets, including the Health and Retirement Study (http://hrsonline.isr.umich.edu/). She has also served on the HRSA funded Behavioral Health Workforce and Education and Training Program team as the Co-Director of Education and currently as the Program Evaluator.

49. Acknowledgements • The Advancing Leadership in Public Health Social Work Education project at Boston University School of Social Work (BUSSW-ALPS), was made possible by a cooperative agreement from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number G05HP31425. We wish to acknowledge our project officer, Miryam Gerdine, MPH. Thanks also to Sara S. Bachman, BUSSW Center for Innovation in Social Work and Health, and the Group for Public Health Social Work Initiatives • The ALPS Team: • Betty J. Ruth, Principal Investigator bjruth@bu.edu • Madi Wachman, Co-Principal Investigator madi@bu.edu • Alexis Marbach Co-Principal Investigator alexis_marbach@abtassoc.com • Nandini Choudhury, Research Assistant nschoud@bu.edu • Jamie Wyatt Marshall, Principal Consultant jamiewyatt1@gmail.com