Health disparities: Understanding and promoting healthy communities

ABSTRACT

This themed issue focuses on understanding and addressing several public health issues affecting communities today nationally and internationally. Health disparities, and global health in general, cover a large breadth of health concerns impossible to address in one issue. Here we provide a scope of some health disparities while focusing on health promotion and well-being of diverse populations, specifically within urban undeserved populations, rural communities in Peru, Roma minorities in Spain, and refugee communities. We focus on understanding contextual issue that affect health disparities as well as on examining the effectiveness of community-based interventions and community coalitions designed to address disparities.

KEYWORDS:

• Global health
• health disparities
• health equity

With interest in community health and global health increasing exponentially, more community researchers than ever before are studying health disparities and designing interventions to promote health equity. This themed issue of the Journal of Prevention and Intervention in the Community focuses on global health issues affecting communities today. These issues include the creation of coalitions to address urban determinants of health; the empowerment of African American adolescents to promote health and well-being; community perspectives on substance use among refugees resettled in the United States; and efforts to unpack the barriers to healthy lifestyles experienced by Latinos with disabilities. Three international efforts are included in this themed issue as well that focus on understanding the experiences of community health practicum students, implementing health service policies to improve the health of Roma community in Spain, and providing mental health services to victims of violence in the Amazon region of Peru.

Two terms warrant attention here, health disparities and health equity. Health disparity refers to a particular health difference that is closely linked with social or economic disadvantage. Health disparities negatively affect groups of people who have systematically experienced greater social or economic barriers to health based on their racial identity, ethnic group, religion, socioeconomic status, gender, mental health, disability, sexual orientation, geographic location, or other characteristics historically linked to discrimination or exclusion (Office of Minority Health & Health Equity, U.S. Department of Health and Human Services, 2010). Health equity, on the other hand, is a desirable goal/standard that entails special efforts to improve the health of individuals who have experienced social or economic disadvantage, exclusion or discrimination (Office of Minority Health & Health Equity, U.S. Department of Health and Human Services, 2010). Health disparities, and global health in general, cover a large breadth of public health concerns impossible to address in just one issue. In this themed issue, we provide a scope of some of these health disparities while focusing on health promotion and well-being of the population as a whole, specifically within urban underserved populations, rural communities in Peru, Roma communities, refugee communities, and youth with and without disabilities. We focus on understanding contextual issues that affect health disparities as well as on examining the effectiveness of community-based interventions and community coalitions designed to promote health equity.

Strong evidence indicates that health disparities are widening in the United States, and that our society’s poorer, less privileged groups–including ethnic and racially diverse individuals, urban underserved, and people with disabilities–continue to experience poor health outcomes (US Department of Health and Human Services, 2015). From a social determinants of health paradigm, it is argued that social and economic conditions, as well as systemic issues in the general society and in the healthcare system in particular, are at the root of health inequalities. Thus, the social determinants of health approach calls for attention to contextual issues and broad-based changes in social and economic policies and service systems (Phelan, Link, & Tehranifar, 2010).

Health disparities in the US mirror disparities observed on a global scale. Gaps in healthcare access and outcomes exist within countries and across countries and continents. The field of global health has come to encompass a transdisciplinary realm of research and practice directed toward improving health and well-being for all populations throughout the world (Mirza, 2012). This field emphasizes mutually beneficial partnerships among collaborators with a focus on pooling diverse experiences, skills, and knowledge to solve critical health problems and promote health equity and well-being. Global health interventions transcend disease-control measures and strive to address social, economic, cultural, and contextual barriers to health and well-being (Koplan & Baggett, 2008). The literature on both local-level and global-level interventions emphasizes system-level changes, mutually beneficial partnerships, and coalitions between institutions, communities, and academia. Several of the papers in this themed issue illustrate partnerships between diverse stakeholders, including academic researchers, practitioners, and local consumers, who have come together to understand or address disparities.

Efforts to promote local, national, and global health equity create opportunities for community psychologists and community-based researchers to design and implement interventions. Guided by social ecological frameworks and principles of community-based research, we can contribute to efforts to understand disparities and to develop, implement, and evaluate community-based innovations that give voice and participation to those most affected. To address health disparities, we as community researchers can engage in research that promotes system and policy level changes through broader community; we can embrace knowledge translation so that all of our research contributions have real, practical applications; and we can partner with local communities and individuals to conduct research that matters to them.

Based on the papers in this issue and guided by Phelan et al. (2010) discussion of health policy suggestions, we propose the following recommendations to those studying health disparities and promoting health equity:

1. Identify and address contextual issues that affect health disparities. Equipped with the Social Ecological Model along with the social determinants of health model, community researchers are well suited to identify and help address contextual issues that affect the health and well-being of communities. We must identify factors that place individuals at risk from the perspective of those most affected by the disparities. Often, individual-focused interventions—interventions aimed at changing behaviors—do not address the broader contextual factors that place people at risk for disparities and powerfully influence behaviors (Phelan et al., 2010). One may teach youth with disabilities about health behaviors related to nutrition and exercising, but if they do not have access to healthy and affordable produce in their communities, or opportunities to engage in physical activity, their health will be at risk. Several of the articles presented in this issue attempt to unpack these contextual factors that impact disparities. Mirza, Harrison, & Birman (this issue) studied the factors that impact substance use among Bhutanese and Iraqi refugees settled in the United States and Suarez-Balcazar, Agudelo, Mate, & Garcia (this issue) reported on the contextual factors that impact the lifestyles of Latino youth with disabilities.

2. Conduct community-based participatory research (CBPR). CBPR has been recognized widely as an optimal research paradigm to address health disparities (Israel et al., 2010; Jason et al., 2005; Minkler & Wallerstein, 2010). A CBPR approach underscores the active participation of community residents and diverse stakeholders throughout the research process, from identifying the issues to designing and implementing solutions (Israel et al., 2010). Global and local organizations, such as the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC), posit that a CBPR approach to research represents a promising method for addressing health inequities at the local, national, and global levels. CBPR underscores strong partnerships with local communities and leaders, the creation of coalitions, and collaboration with diverse stakeholders who could influence change. CBPR also allows for the creation of interventions that are owned by the community and interventions that are likely to succeed at empowering individuals and communities. Lewis and her colleagues (this issue) designed an intervention based on a CBPR approach that empowered African American adolescents to engage in healthy behaviors that promote health and well-being.

3. Advocate for the need to reduce resource inequalities. People with disabilities, urban low-income communities, underserved rural communities, refugees in the US and globally, and other disenfranchised communities experience a profound lack of resources and lack of opportunities to access them. According to Phelan et al. (2010), “People and collectivities use their knowledge, money, power, prestige and social connections to gain a health advantage, and thereby reproduce the SES gradient in health. Reducing resource inequalities should reduce health inequalities” (Phelan, p. S37). In the USA, The Society for Community Research and Action (SCRA) has created a mechanism for members to write policy statements, engage in advocacy activities, and bring issues to the attention of the American Psychological Association and the general public. Political efforts have also taken a global stage. In Europe, several organizations are advocating for health equity for ethnic minorities. Escobar-Ballesta, Garcia-Ramirez, Miranda, & Petrova-Benedict (this issue) conducted a critical analysis of political efforts to bring health equity to Roma ethnic minority communities in Spain and proposed a framework of health governance guided by principles of inclusion.

4. Prioritize and invest in interventions that work at the community and system level. Phelan et al. (2010) argue that we need to support community- and system-level interventions that bring the greatest benefit to the largest number of disenfranchised individuals. The authors argue that interventions that work are often only available to communities with the resources to implement the intervention. These successful interventions are frequently either too expensive or too complex to implement in underserved areas, and thus are not necessarily available to those most in need. This fact automatically increases disparities, as those more in need of interventions are less likely to have access to them. Phelan and colleagues provide examples of this phenomenon such as the need to provide healthcare to all citizens regardless of insurance ownership, or immigration or refugee status. Lewis and her colleagues (this issue) provide an example of an evidence-based intervention to empower African American youth to improve their health and well-being.

5. Underscore the value of emphasizing community-level analysis, policies, and social action. Community-level identification of needs and development, implementation, and evaluation of health interventions and practices emphasize the role of collective action in improving health; the identification of contextual and social mediators of health and well-being; and the role of health on an individual’s community participation and well-being. Community-level analysis emphasizes the potential role of all community-level settings—schools, local social agencies, neighborhood associations, community faith organizations, and government offices—in creating healthy communities (Campbell & Murray, 2004). All potential organizations within a given community become responsible actors for the health of the community. Watson-Thompson, May, Jefferson, Young, Young, & Schultz (this issue) describe a 10-year coalition in addressing urban health determinants that focused on community level changes in housing and crime. Their article illustrates the power of coalitions at the neighborhood and community level in facilitating community change.

6. Identify the needs of populations currently in crisis from a global perspective. Globally, we are experiencing a refugee crisis that is having a significant negative impact on people’s health. Hundreds of thousands of individuals from across the globe are fleeing violence and poverty in search of safety. These groups are more likely than any other group to experience poor physical health and poor mental health outcomes. Highlighted in this issue is the substance use of Iraqi and Bhutanese refugees and the lack of healthcare experienced by Roma/Gypsies settled in Spain.

7. Focus on community strengths, community capacity, and community assets. A strength-based approach facilitates the growth and transformation of a community faced with disparities. Often, minority and disadvantaged communities are subject to diminishing practices and policies that deny them the right to be who they are and to build on their strengths. Forging strong partnerships with communities and diverse stakeholders facilitates community capacity building (Suarez-Balcazar, Mirza, & Witchger Hansen, 2015). Rivera-Holguin, Velazquez, and Custodio (this issue) tell the story of a community capacity effort to provide community mental health services to people affected by violence in a rural community of Peru. Also from Peru, León-Montoya, María-Jesús Albar, & Fátima León-Larios (this issue) describe the experiences of students partnering with low-income communities to address issues of public health in their own communities.

Taken together, the seven articles in this themed issue call attention to the scope and breadth of health disparities and the need to address these disparities at several levels of analysis. All individuals in society are negatively impacted when individuals are denied the opportunity to live healthy and productive lives. This fact aside, providing for the health and well-being of our communities is unarguably the right thing to do. It is a social justice issue. We have the responsibility to promote social justice both locally and globally by creating healthy communities in which individuals and families can thrive.