ELIMINATING HEALTH DISPARITIES A CALL TO …...Disparities Call to Action – 2006: Mecklenburg...

Recommendations for Addressing Health Disparities

in Mecklenburg County

Mecklenburg County Health Department Health Disparities Taskforce

May 2006

ELIMINATING HEALTH DISPARITIES:

A CALL TO ACTION

Mecklenburg County Health Disparities Elimination Taskforce Call to Action: A Framework For Change

Mecklenburg County Health Department Participant List

Domonique Brown Multicultural Health Coordinator Multicultural Health Winona Chestnut Director Fighting Back Rick Christenbury Public Service and Information Specialist Media Relation Cheryl Emanuel Community Healthy Administrator Health Administration Andrew Fair Health Communication Specialist Health Communications Adrienne Gent Program Coordinator Healthy Carolinians Shirley Hutchins Director Nursing/Clinical Services Michael Kennedy Director Administrative Core Services

Susan Long-Marin Manager Epidemiology Program Stephen Newman Prevention Wellness Administrator Health Administration Laura Ours Prevention Health Specialist Health Communications Donna E. Smith Epidemiology Specialist Epidemiology Program Dianne Thomas Director Fit City Martha Threatt Information & Public Service Specalist Fighting Back

Disparities Call to Action – 2006: Mecklenburg County Health Department 1

TABLE OF CONTENTS

TABLE OF CONTENTS ............................................................................................................................................1

EXECUTIVE SUMMARY .........................................................................................................................................2

CHARGE FROM THE COUNTY MANAGER .......................................................................................................2 DEVELOPING THE MCHD CALL TO ACTION PLAN........................................................................................3 KEY RECOMMENDATIONS.................................................................................................................................4

PURPOSE AND VISION............................................................................................................................................5

IMPORTANT MILESTONES IN HEALTH DISPARITIES ELIMINATION ....................................................6

DEFINITIONS.............................................................................................................................................................7

MECKLENBURG DEMOGRAPHICS.....................................................................................................................9

RACIAL AND ETHNIC HEALTH DISPARITIES...............................................................................................10

OVERVIEW OF HEALTH DISPARITIES............................................................................................................10 DETERMINANTS OF HEALTH...........................................................................................................................11 EXPLORING HEALTH DISPARITIES IN MECKLENBURG ............................................................................12

Health Disparities and Socioeconomic Status ...................................................................................................12 Health Outcome Differences ..............................................................................................................................13 Leading Causes of Death ...................................................................................................................................14 Health Risk Behaviors........................................................................................................................................14

KEY RECOMMENDATIONS.................................................................................................................................17

MCHD HEALTH DISPARITIES ELIMINATION PLAN ...................................................................................20


EXECUTIVE SUMMARY

The demographics of Mecklenburg County are changing and becoming increasingly more diverse. According to the US Census, the population of Mecklenburg has grown by 9% since 2000 to about 756,016 residents in 2004. Racial and ethnic minorities make up 43% of the county’s population (US Census Bureau, 2004). While this diversity remains one of our greatest assets, it also presents a range of health improvement challenges that must be addressed. The overall health status of Mecklenburg County residents has improved in the past decade; however, the health status of many county residents continues to lag behind that of the general population. Racial and ethnic minorities have higher rates of premature death. Infant mortality rates for minorities are more than double that of whites. Racial and ethnic minority populations in the county are also disproportionately impacted by HIV disease, diabetes and certain types of cancer. For Mecklenburg County residents to realize an optimal level of health, the county must work to address and eliminate these and other disparities in health.

CHARGE FROM THE COUNTY MANAGER On October 18, 2005, County Manager Harry L. Jones, Sr. declared “Eliminating Health and Mental Health Disparities” a priority for Mecklenburg County. He charged the Mecklenburg County Health Department (MCHD) with lead responsibility for developing the MCHD Call to Action to Eliminate Health Disparities. A Steering Committee consisting of members from various division of the Health Department was established to guide the department’s capacity to identify and address disparities in the county. Based upon input from the County Manager, the Steering Committee was asked to identify the following key issues in their strategic planning process:

1. Populations disproportionately impacted by health disparities and the magnitude of the problem in Mecklenburg County,

2. The urgency and need to address health disparities in the county, 3. Key recommendations to impact and improve the health status of populations impacted

by health disparities. The MCHD Call to Action to Eliminate Health Disparities builds upon the work of the NC Office of Minority Health and Health Disparities and the Department of Health and Human Services (NC DHHS) Steering Committee for Eliminating Health Disparities. The Call to Action provides a strategic framework to identify, monitor and address health disparities in Mecklenburg County.

HEALTH DISPARITIES OVERVIEW

Defining Racial and Ethnic Health Disparities The National Institute of Health defines health disparities as differences in the incidence, prevalence, mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States. Research suggests issues of social inequality are involved and must be addressed before differences in health outcomes among racial and ethnic groups can be eliminated. While health disparities are readily demonstrated


through data, the causes and means of prevention are not well understood. The magnitude of this problem led the U.S. Department of Health and Human Services (US DHHS) to make eliminating health disparities by 2010 a national goal and has inspired members of Congress to introduce legislation to help achieve this goal. North Carolina has also made eliminating health disparities a major focus for the state and has included it as an overarching goal for the NC 2010 Health Objectives. Determinants of Health Status The Steering Committee reviewed Healthy People 2010 and NC 2010 Health Objectives conceptual framework as a foundation for Strategic Planning and to understand the determinants of health status and health disparities. Healthy People 2010 suggests that population health is determined by a complex interaction of multiple factors including individual behavior, biological factors, physical and social factors, environmental factors, policies, interventions and access to health care services.

Research also suggests that the development of comprehensive strategies to eliminate health disparities will require close collaboration and linkages with community assets, workforce diversity, economic development, and a more responsive, accessible and efficient health care delivery system. DEVELOPING THE MCHD CALL TO ACTION PLAN Essential Elements of the Plan The MCHD Health Disparities Steering Committee developed an internal perspective on health disparities elimination by adapting key recommendations from the NC DHHS Call to Action plan. Representatives from various MCHD programs worked collaboratively to formulate division- and program-specific objectives and strategies for each recommendation considered to address health disparities in the county. Participating MCHD divisions developed an action plan as part of the overall MCHD Eliminating Health Disparities Call to Action.

ESSENTIAL ELEMENTS OF THE MCHD CALL TO ACTION PLAN ► Objectives: measurable steps needed to achieve relevant key recommendations. ► Strategies: specific action steps for each relevant objective. ► Evaluation Measures: an evaluation approach to measure progress towards meeting the recommendation/objectives; ► Available Resources: identification of resources currently available to meet the recommendation.


KEY RECOMMENDATIONS FROM STEERING COMMITTEE

This report presents the following key recommendations to policy makers, health care providers, civic groups, educational institutions, businesses and community leaders who seek to address and eliminate health disparities in Mecklenburg County.

1. Increase awareness of health and service disparities, especially

disparities related to race/ethnicity, disability, and socioeconomic status. 2. Promote, develop, and enhance the community’s capacity to engage in

healthy living and the elimination of disparities in health status. 3. Monitor progress toward the elimination of health disparities. 4. Promote customer-friendly services that meet the needs of underserved

populations (i.e., the poor and minority groups). 5. Identify and advocate for public policies that aid in closing the health

status gap.


PURPOSE AND VISION

PURPOSE

The purposes of this Call to Action to Eliminate Health Disparities are:

1. To provide a framework for understanding the magnitude of racial and ethnic disparities in Mecklenburg County,

2. To briefly discuss some of the social determinants linked to health disparities,

3. To provide recommendations to reduce health disparities and improve population health in Mecklenburg to the County Manager and Board of County Commissioners.

4. To describe the role of the Mecklenburg County Health Department in addressing these issues.

THE HEALTH PARITY VISION

“Everyone in Mecklenburg County will enjoy good health regardless of their race/ethnicity, disability or socioeconomic status.”

Eliminating health disparities transcends the public health and health care industry. It is an individual, community, state and national issue. The vision requires reorientation of our individual and collective thinking, policies, programs and resource allocations toward the goal of healthy living for everyone in Mecklenburg County. Adoption of this vision indicates a desire to make Mecklenburg County a community in which health status is not distributed by race/ethnicity, gender, disability, economic resources, or geographic location.

The Mecklenburg County Health Department is taking a leadership role in promoting and collaborating with external partners such as policy-makers, community and faith-based organizations, civic groups, educational institutions, health care providers, and businesses. This alliance will work to make the vision of health parity a reality for everyone in Mecklenburg County.


IMPORTANT MILESTONES IN HEALTH DISPARITIES ELIMINATION

Mecklenburg County has embraced the national and state public policy agenda to eliminate health disparities by the year 2010. Key national and state policies have played a pivotal role in elevating the issue of eliminating health disparities in our county. In 1998, health disparities elimination became a national priority. Then President Bill Clinton and then Surgeon General Dr. David Satcher articulated the goal of eliminating disparities in six key health categories by 2010. This important public policy challenged states to increase efforts to address the persistent disparities in health between racial/ethnic minorities and whites. The national initiative focused on cardiovascular disease, cancer screening and management, infant mortality, diabetes, HIV/AIDS, and immunizations. These six health areas were selected because they reflect areas of disparity that are known to affect multiple racial and ethnic groups at all life stages. Resources were allocated through Racial and Ethnic Approaches to Community Health (REACH) 2010 to invest in disparate communities and seek solutions to the nation’s growing disparities. The year 2001 marked an important milestone in North Carolina’s efforts to address the health challenges facing racial/ethnic minority populations. Secretary Carmen Hooker Odom as Secretary of the North Carolina Department of Health and Human Services (DHHS) gave heightened focus to health disparities elimination by including it as one of her four top priorities. Her office challenged all Divisions/Offices in the DHHS to participate in efforts to identify service gaps and come up with creative solutions to increase access to programs and services for racial/ethnic minorities and underserved populations. The 2015 vision of the Mecklenburg County Board of County Commissioner (BOCC) is to have the lowest per capita incidence of substance abuse in the nation and have lower than the national average per capita cases of cancer, HIV/AIDS and other sexually transmitted diseases, heart disease, teenage pregnancy and infant mortality, among many other health indicators. It is policy of the BOCC to acknowledge the existence of health disparities in Mecklenburg County and provide leadership in addressing this threat to public health. This is done by engaging community stakeholders in comprehensive assessment and planned implementation of best practice, culturally sensitive, measurable, and innovative practices, consistent with local, state, and federal law.


DEFINITIONS

Many different definitions for disparities exist in scientific literature. In fact, many terms mentioned in this report can be defined in multiple ways depending upon methods utilized during research. The following definitions are provided to guide the readers’ understanding of this report.

TERM DEFINITION

Access to Health Care

The timely use of personal health services to achieve the best health outcomes (Institute of Medicine, 1993). As stated by the Health Policy Institute of Ohio: “Factors impeding access to health care include a lack of financial resources, a cultural preference that discourages health-seeking behavior, low health literacy levels, language barriers, lack of diversity in the health care workforce, and a mistrust of the health care system due to a prior negative experience. Additional impediments to access include systemic barriers such as the lack of available and proximate providers, the lack of transportation, the lack of or poor health insurance coverage, the lack of access to a regular source of care, and legal or bureaucratic barriers to receiving public aid.” (Goldberg, J., Hayes, W., and Huntley, J, 2004)

Disparities in Health Differences in the incidence, prevalence, mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States (National Institute of Health, 2001).

Disparities in Health Care

Differences between two or more population groups in health care access, coverage, and quality of care, including differences in preventive, diagnostic, and treatment services (Families USA’s Minority Health Initiatives, 2005).

Health A complete state of physical, mental, social and spiritual well being (World Health Organization, 1946).

Health Inequities Systematic and important differences in health between different groups of people that are both preventable and unfair (Whitehead, 1990).

Health Literacy The degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions. (Institute of Medicine, 2005)

Social Determinants Social and economic factors hypothesized to affect health outcomes, including: demographic and population factors; environmental factors; and social, economic educational, health care, cultural, or other systems (Alameda County Health Department, 2002)

Socioeconomic Status

The socio-economic status is characterized by the economic, social and physical environments in which individuals live and work, as well as demographic and genetic factors (Ross, 1995).


Racial and Ethnic Populations

The following racial and ethnic classifications reflect standards for the minimum classification of data on race and ethnicity used by the Bureau of the Census in the 2000 decennial census. (Office of Management and Budget, 1997)

-- American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

-- Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

-- Black or African American. A person having origins in any of the black racial groups of Africa.

-- Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.

-- Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

-- White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.


*Non-Hispanic Other Races include persons with an unknown race category and persons who choose more than racial/ethnic category. Source: US Census Bureau, American Community Survey

57%

28%9%

4%2%

0.2%

White, Non Hispanic

Black, Non Hispanic

Hispanic

Asian/ Pacific Islander

Other

Am. Ind/Alaska Native

MECKLENBURG COUNTY POPULATION, 2004Total Population=756,016

*

*

*

* Non-Hispanic Other Races include persons with missing/unknown racial categories and persons who choose more than one racial/ethnic category.

MECKLENBURG DEMOGRAPHICS

MECKLENBURG COUNTY: AN AREA OF RAPID GROWTH 2004 Population Estimates According to US Census estimates, 756,016 persons reside in Mecklenburg making it the most populous county in North Carolina. Between the 1990 and 2000 Census, Mecklenburg’s population increased by 36 percent and exceeded the rate of growth experienced by both the state (21.4%) and nation (13.4%) In 2004, the racial/ethnic make-up of the county was about 28% black or African American (non- Hispanic), 57% white (non-Hispanic) and 9% Hispanic, with the remaining 6% consisting primarily of Asians or Pacific Islanders, Other races, and American Indians.

Changing Demographics Shape Future Efforts to Improve Health in Mecklenburg The racial and ethnic composition of Mecklenburg County has changed dramatically in the past decade. In fact, some racial and ethnic minority populations are growing at a much more rapid pace than the majority white population. In the past decade, Hispanics and Asians have grown more rapidly than any other racial and ethnic groups, and African Americans have increased by 44%. As racial and ethnic minorities often experience poorer health outcomes compared to their white counterparts, these demographic changes will shape future efforts to improve health and health care in Mecklenburg County.

Table 1. MECKLENBURG COUNTY DEMOGRAPHICS Changes in the Racial/Ethnic Profile Using 1990 and 2000 Census Data

Racial/Ethnic Population 1990 Census 2000 Census Percent Change

(increase)

White* 360,554 425,144 18% Black or African-American* 133,866 192,403 44% Asians or Pacific Islander* 8,235 22,000 167% American Indian/Alaska Native* 1,869 2,130 14% Hispanics/Latinos 6,693 44,871 570%

TOTAL** 511,433 695,454 36% * Non-Hispanic ** Total includes Whites, Blacks/African-Americans, Asians/Pacific Islanders, American Indians/Alaska Natives Hispanics/Latinos and Other/Unknown races.The majority of growth seen in the Asian/Pacific Islander population occurred among Asians. Asians alone grew by 161% between the 1990 and 2000 Census.


"The future health of the nation will be determined to a large extent by how

effectively we work with communities to reduce and eliminate health disparities

between non-minority and minority populations experiencing

disproportionate burdens of disease, disability, and premature death."

~ Guiding Principle for Improving

Minority Health~ Centers for Disease Control and

Prevention: Office of Minority Health

RACIAL AND ETHNIC HEALTH DISPARITIES

OVERVIEW: HEALTH DISPARITIES Advancements in medical technology and health care in the past century have paved the way for significant improvements in the overall health of Americans. Life expectancy for persons at every age group has increased while US infant mortality and chronic disease death rates have notably declined (National Center for Health Statistics, 2004). Despite these promising gains, the health status of many Americans continues to lag behind that of the general population. People of lower socioeconomic status (SES) and racial and ethnic minorities experience poorer health outcomes, more challenges in accessing quality care, and higher mortality rates than individuals of higher SES or persons classified as white (US DHHS, 2001)(CDC, 2006). These differences in burden of disease are often called disparities. The National Institute of Health defines health disparities as differences in the incidence, prevalence, mortality and burden of disease and other adverse health conditions that exist among specific population groups in the United States. While disparities in health are most frequently noted in terms of race/ethnicity, income, and gender, health disparities may also exist in other dimensions. Differences in health status have been documented across various geographical locations, age groups and disability status. The commitment to understanding and eliminating racial and ethnic health disparities is a major priority for the nation. Healthy People 2010, a comprehensive, nationwide health promotion and disease prevention agenda, includes health disparities elimination as one of its overarching goals. The Agency for Healthcare Research and Quality, a division of the Department of Health and Human Services, is mandated by Congress to produce an annual report on prevailing racial and ethnic disparities in health care delivery. The National Office of Minority Health was created with the primary mission to promote health and quality of life by preventing and controlling the disproportionate burden of disease, injury and disability among racial and ethnic minority populations. In addition to these examples, there are several more efforts and initiatives to eliminate racial and ethnic health disparities in the nation, the majority of which are spearheaded by the US Department of Health and Human Services. Although it is widely accepted that disparities in health exist, understanding the reasons why they exist is a much more complex matter. There is no singular determinant of health, in fact the health of an individual or population is influenced by multiple, interrelated factors.


DETERMINANTS OF HEALTH STATUS

Adapted from Healthy People 2010

DETERMINANTS OF HEALTH Healthy People 2010 suggest that the most important key to eliminating health disparities is to understand the determinants of health and how they relate to one another. Health is defined as a state of complete physical, mental and social well-being and not merely an absence of disease or infirmity. Whether people are healthy or not is determined by their circumstances and environment. Factors such as where we live, the state of our environment, our individual

biology and behavior, and our social environments, as well as policies and interventions, and access to quality health care have a considerable impact on health. Other factors that determine health include: income and social status; education; physical environment; social support networks, health services and gender. Current research suggests that social, physical and economic factors may influence a person’s health status more so than access and use of health care services (Wilkinson R, Marmot M.,2003) (World Health Organization, 2006). Individuals are unlikely to be able to control many of these factors which directly impact their health. As an example, individuals can change personal behavior practices to impact their health (i.e., increasing physical activity, eating more fruits and vegetables or enrolling in smoke cessation program). However, environmental factors (i.e., water and air quality; roads; healthy workplaces) are much harder to change. The World Health Organization states that “the context of people’s lives determine their health, and so blaming individuals for having poor health or crediting them for good health is inappropriate.”


Map 2

Map 1

EXPLORING HEALTH DISPARITES IN MECKLENBURG Health Disparities and Socioeconomic Status While health disparities are readily demonstrated through data, the causes and means for prevention are not well understood. Research suggests issues of social inequality are involved and must be addressed before differences in health outcomes among racial and ethnic groups can

be eliminated. Among topics being studied are differences in access to health care, the effects of racism and segregation, and SES. The Centers for Disease Control and Prevention notes SES is “central to eliminating health disparities because it is closely tied to health and longevity. At all income levels, people with higher SES have better health than those at the level below them.” SES status includes income, education, occupation, and neighborhood and community characteristics. Researchers have found that African American and Hispanic families, more frequently than white families, live in areas of concentrated poverty resulting in racial as well as economic segregation. Low-income neighborhoods may offer inadequate healthcare

services, lower

quality educational opportunities, fewer job opportunities, and higher crime rates when compared to more mixed-income or high-income communities, all factors which may contribute to continued poverty and the development of poor health outcomes. A review of 2000 US Census data suggests such a pattern of racial and economic segregation in Mecklenburg County. African Americans representing 28% and Hispanics making up over 6% of the population are the two largest racial/ethnic minority groups in the County. While African Americans and Hispanics live throughout the community, mapping census tract data shows these two groups heavily concentrated in a crescent-shaped area stretching from southwest to east around the northern end of the city of Charlotte. African Americans more commonly reside on the west side (See Map 1) and


Map 3

TABLE 2. HEALTH OUTCOMES 2001 Rates* (cases/100,000 population)

Six Zipcodes Mecklenburg County

Diabetes Mortality 27.0 19.6 Hospitalization 21.7 13.6 Heart Disease Mortality 172.3 145.4 Hospitalization 114.5 101.3 Stroke Mortality 62.7 49.2 Hospitalization 33.0 26.6 Asthma Mortality 1.7 1.2 Hospitalization 7.5 5.4 * 2001 Cases per 2000 US Census Population

Hispanics are more frequently found to the east. Mapping median household income for the county shows a concentration of lowest incomes in a similar crescent pattern. (See Map 2). Other indicators associated with low economic status such as receipt of Medicaid or food stamps also map in this same pattern.

Mapping health data shows this crescent shaped area of black/Hispanic and low-income resident concentration also experiences many poor health outcomes including high rates of sexually transmitted diseases and deaths from diabetes and HIV disease. (See Map 3.) Six zipcodes (28217, 28208, 28216, 28206, 28205 28212) representing over 186,000 people (or almost ¼ of the county population) make up a large portion of the crescent area referred to above. An examination of demographic data from the 2000 US Census for these six zipcodes shows, when compared to Mecklenburg County as a whole, a higher proportion of African American and Hispanic residents, a lower median household income, a lower percentage of college

graduates, a lower percent of private transportation, and a higher proportion of families with limited English proficiency. When looking at health outcomes for this same area, hospitalization and mortality rates for heart disease, stroke, diabetes, and asthma are higher than those for the county. (See Table 2.) Combining census information with

health outcome data can provide a picture of SES related to health disparity in a community and suggest populations most in need of assistance. Further research is required to understand which SES factors or combinations of factors have the greatest impact on health and what type of interventions can result in improved health outcomes. Health Outcome Differences When comparing Mecklenburg to North Carolina and the United States, most health indicators for the total county appear favorable. Rates for many causes of death have been decreasing during the past decade in both white and other race populations. The overall mortality rate has been falling for both groups since 1994. However, this decrease in rates has not always been accompanied by an elimination of differences between white and other race rates.


0.02.04.06.08.0

10.012.014.016.018.0

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Dea

ths/

1000

Liv

e B

irths

White Other Races

Figure 1: Mecklenburg Infant Mortality RatesBy Race Group, 1994 - 2004

0.02.04.06.08.0

10.012.014.016.018.0

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Dea

ths/

1000

Liv

e B

irths

White Other Races

Figure 1: Mecklenburg Infant Mortality RatesBy Race Group, 1994 - 2004

AGE-ADJUSTED 1999-2003

MORTALITY RATES FOR OTHER

RACES EXCEED WHITE RATES:

• 1.4 times for heart disease • 1.2 times for all cancer • 1.2 times for breast cancer • 1.4 times for colon cancer • 2.2 times for prostate cancer • 1.6 times for stroke.

OTHER RACES HAVE HIGHER

RATES OF DEATH FROM MOTOR

VEHICLE INJURY, HIV DISEASE, DIABETES, AND HOMICIDE:

• 1.2 times for motor vehicle injury • 12.3 times for HIV disease • 2.9 times for diabetes, and • 3.7 times for homicide.

WHITES DIE AT HIGHER RATES

FROM CHRONIC OBSTRUCTIVE

PULMONARY DISEASE, ALZHEIMER’S DISEASE,

PNEUMONIA & INFLUENZA, AND

SUICIDE:

• 1.5 times for chronic obstructive pulmonary disease

• 1.4 times for Alzheimer’s dz • 1.3 times for pneumonia &

influenza • 1.7 times for suicide.

Figure 2. Racial Disparities in Leading Causes of Death

The overall death rate is higher for people of other races than whites in every age group. In data from 1999-2003, the age-adjusted rate for All Causes of Death is 1.3 times greater for other races than whites. While both whites and minorities saw a decline in infant mortality from 1990 until 1995, this trend has not continued since then, and the gap between white and other races, while some years showing a decrease, remains wide. The 2004 Infant Mortality rate is 2.3 times greater for other races than whites. (Figure 1). Leading Causes of Death Coronary health disease, cancer, and stroke are leading causes of death for both whites and other races, including African Americans, Asians, and Native Americans. However, people of other races may die at higher rates and younger ages. Unlike other groups, Hispanics in Mecklenburg County die at the highest rates from motor vehicle injury and homicide. This difference may be explained because rates for heart disease, cancer, and stroke increase with age, and the Hispanic population in Mecklenburg County is younger than the population as a whole. See Figure 2 for more information on disparities in leading causes of death.

Health Risk Behaviors Unprotected sex is a health risk behavior. The high other race mortality rate seen with HIV disease stems from the disproportionate number of HIV disease cases experienced by the African American community. Of 344 cases of HIV disease reported in 2004, 228 (66%) were black. Health behaviors contributing to the prevention of heart disease, some forms of cancer, stroke, and diabetes include not using tobacco products, maintaining a healthy weight, eating a diet rich in fruits and vegetables, and engaging in regular physical activity. Data from the 2004


Mecklenburg Behavioral Risk Factor Surveillance Survey (BRFSS) show the percent of whites compared with the percent of other races reporting smoking and not eating five or more servings of fruits & vegetables per day [2003] similar. The percent of people of other races is greater than the percent of whites in those reporting overweight or obesity (1.1 times) and not getting any physical activity per month (2.4 times). Disparities by income level are noted when comparing BRFSS responses of individuals with household incomes less than $50,000/yr and the responses of individuals with household incomes $50,000 or above. Individuals with a household income of less than $50,000 were: • 2.1 times more likely to report smoking, • 1.2 times more likely to eat less than 5 or more servings of fruits & vegetables per day

[2003], and • 2.6 times more likely to report no physical activity. The percent of individuals reporting overweight or obesity was similar across the two income levels.

% %Other Races White

Current Smoker 17.7 18.2 1 26.2 12.7 2Overweight or Obese 64.2 56.8 1.1 59.5 56.7 1No Exercise in Past Mo. 35.5 14.7 2.4 30.9 11.7 2.6No 5+ Fruits & VegPer Day [2003]

75.5 1.1

% Household

Income <$50,000

79.4 76.8 1 81.2

Disparity Ratio

Disparity Ratio

Figure 3. Health Risk Factors from the 2004 Behavioral Risk Factor Surveillance System

% Household

Income $50,000+

DATA SOURCES/INFORMATION Data are from the Behavioral Risk Factor Surveillance System, NC DHHS/State Center for Health Statistics and prepared by the Mecklenburg County Health Department Epidemiology Program.


REFERENCES

Alameda County Public Health Department. A Framework for Change: Reducing Health Disparities in Alameda County. 2002 Health Disparities Report.

Centers for Disease Control: Office of Minority Health. Eliminating Racial and Ethnic Health Disparities. http://www.cdc.gov/omh/AboutUs/disparities.htm. Accessed: March 17, 2006.

Families USA. Medicaid and Minority Health: Why Cutting Medicaid Will Exacerbate Health Disparities. http://www.familiesusa.org Accessed: March 17, 2006.

Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio. November 2004.

Institute of Medicine. Confronting the Nation’s Health Disparities. Spring Newsletter, 2005. http://www.iom.edu/CMS/27501.aspx Accessed: August 9, 2006.

Institute of Medicine. Unequal Treatment: Confronting racial and ethnic disparities in health care. National Academy Press, 2002.

National Center for Health Statistics. Health, United States, 2004 with Chartbook on Trends on the Health of Americans. Hyattsville, Maryland: 2004.

National Institutes of Health, addressing Health Disparities: The NIH Program of Action. What are health disparities? Available at: http://healthdisparities.nih.gov.

Office of Management and Budget. Standards for the Classification of Federal Data on Race and Ethnicity. July 1997. http://www.whitehouse.gov/omb/fedreg/directive_15.html. Accessed: August 9, 2006

Roos NP, Black C, Frohlich N, Decoster C, et. al. A Population-Based Health Information System Med Care 1995; 33 (12 Suppl): DS13-DS20. 16.

United States Census Bureau. 2004 American Community Survey: Mecklenburg County, North Carolina Population and Housing Narrative Profile. http://factfinder.census.gov Accessed: March 22, 2006.

US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. Washington, DC.

Wilkinson R, Marmot M, editors. Social Determinants of Health: The Solid Facts. 2nd Edition. Geneva, World Health Organization: 2003.

World Health Organization. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June 1946, and entered into force on 7 April 1948.

World Health Organization. The Determinants of Health. http://www.who.int/hia/evidence/doh/en/index.html Accessed March 28, 2006


KEY RECOMMENDATIONS

The Health Parity Vision “Everyone in Mecklenburg County will enjoy good health regardless of their race/ethnicity, disability or socioeconomic status.”

Evidence of racial and ethnic disparities in health is consistent across a range of illnesses and healthcare services. Racial and ethnic minorities are disproportionately represented in the lower socioeconomic ranks, in lower quality schools, in poorer-paying jobs and are more likely to be enrolled in lower-end health plans placing them at increased risk for poor health outcomes and death. Obtaining an optimal level of health for Mecklenburg County residents will require a commitment to improving the health of all residents and changes to the social and economic conditions that actually cause inequities in health status.

A comprehensive approach is needed to address disparities in health and must include:

• A responsive and effective public health and medical system, • Increased education and awareness of health disparities in the general public, among key

stakeholders and healthcare providers. • Identification and creation of sound public policies that support evidence-based strategies

and interventions effectively addressing racial and ethnic health disparities, and • Strengthened capacity and enhanced infrastructure for the Health Department and the

community at-large for reducing health disparities. Achieving the Health Parity Vision In order to address and eliminate health disparities in Mecklenburg County and achieve the Health Parity Vision, The Mecklenburg Health Disparities Taskforce recommends that the County Manager adopt the following key recommendations.

I. Increase awareness of health and service disparities, especially disparities related to race/ethnicity, disability, and socioeconomic status.

Action Steps to Achieve Recommendation I • Convene community health forums to increase awareness of health disparities and

develop community ownership of the problem. • Increase awareness of health disparities among current and future county employees

through trainings, modules, etc. • Provide annual reports to the general public, key stakeholders and healthcare

providers on the existence and magnitude of health disparities in Mecklenburg County.

• Provide information on health education, nutrition, preventive health care (i.e., health screenings, wellness programs), smoking cessation, and other topics to employees of contractual vendors.


• Organize meeting/forum of Mecklenburg County government and private and publicly funded healthcare systems to increase awareness of health disparities in the healthcare setting and develop strategies and priority deliverables to address these problems.

II. Promote, develop, and enhance the community’s capacity to engage in healthy living and the elimination of disparities in health status.

Action Steps to Achieve Recommendation II • Build new and strengthen existing relationships with communities. • Support residents and community organizations in reaching their full potential to

identify and solve their health disparities issues. • Stimulate community-based health improvement partnerships. • Train local community leaders in public health issues. • Help develop Board and staff capacity for community based organizations. • Initiate community-based health disparities planning efforts. • Promote and increase awareness of culturally competent health education

opportunities for communities at risk for health disparities in Mecklenburg County.

III. Monitor progress toward the elimination of health disparities.

Action Steps to Achieve Recommendation III • Collect and report data on health and health care access/utilization by patients’ race,

ethnicity, socioeconomic status and, where possible, primary language. • Develop new reporting systems and measurements to monitor progress towards health

disparities elimination in Mecklenburg County. o Convene necessary agencies to discuss their policies and programs for

health disparities elimination. • Conduct community assessments of health needs and priorities. • Strengthen the community’s capacity to conduct community assessments by

increasing linkages with universities and local and state government.

IV. Promote customer-friendly services that meet the needs of underserved populations (i.e., the poor and minority groups).

Action Steps to Achieve Recommendation IV • Support the use of community health workers • Integrate cross-cultural education into the training of current and future county

employees. • Actively recruit underrepresented racial and ethnic minorities to increase diversity,

particularly at the management level. • Increase the number of bilingual staff. • Support the use of interpretative services where community need exists. • Implement educational programs to increase knowledge of how to best access care

and effectively navigate healthcare systems.


V. Identify and advocate for public policies that aid in closing the health status gap.

Action Steps to Achieve Recommendation V • Support existing policies and programs that promote health. • Support policies, programs and legislation that improve neighborhood living

conditions. Especially those programs that: improve access to nutritious foods, improve neighborhood safety, and improve access to safe, affordable housing.

• Support advocacy, coalition and asset building to create public will for prevention. • Support policies that strengthen the stability of patient-provider relationships in

publicly funded health plans.


MECKLENBURG COUNTY HEALTH DEPARTMENT STRATEGIC PLAN

ELIMINATING HEALTH DISPARITIES CALL TO ACTION

The following document describes the role of the Mecklenburg County Health Department in identifying and monitoring health

disparities and provides a strategic framework for addressing these issues in Mecklenburg County

Key Recommendations Objectives Strategies Evaluation Available Resources

1.1 Continue to incorporate health disparities information into State of Public Health report, Balanced Scorecard, Health Index, Report Card etc. to educate patients and community organizations

Strategy 1.1.1 Produce and present a public friendly version of the SOTCH (State Of The County Health) report and other tools tailored for various audiences

A portfolio will be created that will serve to document evaluation measures. This can include local articles on disparity, pictures of activities, meeting notices, revised patient materials, or any product that is a result of the reducing health disparities plan. The portfolio will be reviewed by senior advocacy group (Strategy 4.4.1) annually.The reading level of documents for the public will be evaluated for ease of understanding and documented in the evaluation portfolio.

Epidemiology staff, Health Communication staff

1.2 Continue to participate and expand use of the annual Minority Health Conference put on by CACHE (Carolinas Association for Community Health Equity)

Strategy 1.2.1 Work with planning group to include/recruit more community members and decrease barriers to achieving this objective.

The number of community attendees will be tracked and documented in the portfolio.

Existing coalitions, MCHD+E6 staff, Health communication staff

1.3 Expand media relations and communications of Health Disparities issues

Strategy 1.3.1 The health communications team will intentionally work on raising the issue of health disparities in local media

Copies of local health disparities news stories will be placed in the portfolio.

Health Communication Team

1.4 All health department areas will display or discuss health disparities with patients, staff and audiences

Strategy 1.4.1 Produce posters that tell the HD story in explicit and implicit manner and conduct community evaluations of products before displaying

Number of displayed posters and pictures of the posters will be documented in the portfolio. Patients will be queried about the impact of the posters.

Health Communication Staff, MCHD Staff

1.5 Utilize public forums to explain and expand understanding of health disparities

Strategy 1.5.1 Attend public meetings and train consultants to attend community group meetings

Number of meeting attended, # of speakers trained, # of presentations given and # and make-up of the audience will be documented in the portfolio.

CACHE, MCHD staff

Strategy 1.5.2 Make list of available resources for Health Department employees to refer out to.

Include resource list in the portfolio Health Communication Team

1. Increase awareness of health disparities, especially disparities related to race/ethnicity, disability, and socioeconomic status

Mecklenburg County Health Department: Health Disparities Action Plan


2. Promote, develop and enhance the community’s capacity to engage in healthy living and the elimination of health disparities in health status.

2.1 Improve the health of adults and children through community based screenings, early identification, referral and follow-up.

Strategy 2.1.1 Collaborate/partner with private providers, advocacy groups and other health/human service agencies to increase access to preventive care, including those with special healthcare needs.

Minutes or other formal documentation of collaborating partners will be recorded in the portfolio. Number of patients will be tracked.

CACHE, MC+E13HD staff

2.2 Coordinate and maximize county resources for opportunities of prevention, health promotion and education and other public health services.

Strategy 2.2.1 Initiate community-based planning, strengthen multi-agency, multi-disciplinary process to provide services for families (i.e. physical activity and nutritional campaigns)

Performance GIS Data Base Tracking outputs

Internal County Agencies/Departments and Health Department

Strategy 2.2.2 Convene community health disparities forums (REACH 2010) to strengthen relationships with target populations to problem-solve health issues

Copies of health forum agendas will be included in the portfolio

CACHE, MCHD, Universities

Strategy 2.2.3 Educate and train local leaders in disparity health issues

Follow-up letters will go out to trained leaders with copies placed inb the portfolio.

MCHD E16Staff

2.3 Expand evidence-based curricula and approaches to address teen reproductive health and to reduce adolescent STIs and pregnancies.

Strategy 2.3.1 Initiate and increase dialogue with CMS and other youth coordinating agencies to implement evidence=based curricula surrounding teen reproductive health and STI education.

Documentation of meetings will be placed in portfolio

Charlotte Mecklenburg Schools, HD Staff

2.4 Improve neighborhoods living conditions (shelter)(safety) (food)

Strategy 2.4.1 Disseminate information regarding the connection between affordable housing and health.

Copies of disseminated information will be placed in the portfolio.

Charlotte Housing Partnership, Neighborhood Development, HD Staff

Strategy 2.4.2 Coordinate, support and participate in community policing/ violence prevention initiatives

Collected information to be included in portfolio

Health Department, Charlotte-Mecklenburg Police Department and appropriate County Departments

Strategy 2.4.3 Improve access to nutritious foods

Number of community farmers markets will be tracked and placed in portfolio

Health Department and other appropriate County Agencies/Departments



2.5 Identify barriers to effective healthcare delivery to minorities and implement culturally relevant strategies to address barriers.

Strategy 2.5.1Identify relative initiatives for collaboration and align resources. Create provider forum to identify major solutions from serving uninsured and underserved populations.

Agenda from forum will be included in Portfolio

Health Department, Private and Publicly funded Healthcare Facilities

2.6 Benchmark and establish programs for early identification ( middle and high school) and education of students who may have the potential and interest in the health care field.

Strategy 2.6.1 Initiate activities to link health care organizations with minority students interested in health care and science related careers.

Number and frequency of activities will be tracked

Health Department, Charlotte-Mecklenburg School System, Youth Programs

3. Monitor Progress towards the Elimination of Health Disparities.

3.1 MCHD will continue to conduct ongoing data collection, analysis, and monitoring of health-related data to identify segments of the population at-risk for or experiencing health disparities in Mecklenburg County

Strategy 3.1.1 Compile and analyze health-related data to identify the burden of disease experienced by various segments of the population and track trends over time.

Health disparity gap will be monitored to evaluate when and where progress is being made Reports will go into the portfolio.

Epidemiology Program

Strategy 3.1.2 Provide geocoding of health-related data to determine patterns of health and disease among Mecklenburg County residents.


Strategy 3.1.3 Distribute documentation (Health index/report card) to HDWG to highlight and measure progress of health disparity work.

Epidemiology Program, Health Communications Staff

3.2 MCHD will include measures of racial and ethnic disparities in performance measurement.

Strategy 3.2.1 MCHD will provide a yearly overview of the county’s health highlighting racial and ethnic disparities as a part of the Balanced Scorecard management tool.

Number of disparities performance measures will be part of the portfolio

Epidemiology Program, Health Communications Staff



3.3 MCHD will conduct community health assessments which will include key questions geared towards collecting information on the current status of health disparities within the county.

Strategy 3.3.1 Encourage self-identification of race and ethnicity to foster accuracy of racial and ethnic coding.

Examples of survey questions will be included in portfolio


Strategy 3.3.2 MCHD will survey key stakeholders and community leaders on the existence and importance of addressing health disparities in Mecklenburg County.

Examples of survey questions will be included in portfolio

Epidemiology Program, Health Communications Staff, CACHE

4. Promote customer-friendly services that meet the needs of underserved populations (i.e., the poor and minority groups).

4.1 Promote a culturally sensitive clinic environment.

Strategy 4.1.1 Assure all lobbies and clinic waiting areas have information on availability of interpreter services posted.

Signage displayed in all areas. Photos of the signage will be placed in the portfolio

CHS Materials Management

Strategy 4.1.2 Work with architect for NW renovation to design a user friendly, accessible facility.

Facility is handicap accessible, main entrance is easily identifiable.

Strategy 4.1.3 Coordinate a diverse group to review/create customer educational materials and programs, i.e., age, language, reading level, ethnic groups, etc.

Group reviews materials for reading level and cultural sensitivity, annually. Diverse educational materials available and samples will be placed in the portfolio.

Strategy 4.1.4 Integrate culturally significant issues into visit intake process

Initial and return visit forms revised.

Strategy 4.1.5 Revise customer satisfaction survey to be more culturally sensitive

# of questions on survey that are culturally competent, compiled survey data

CHS translation services, community individuals and MC+E41HD staff

Strategy 4.1.6 Position greeters throughout the clinic to welcome and direct guests

4.2 Continue to work toward a more culturally sensitive workforce

Strategy 4.2.1 Provide annual diversity educational opportunities to staff.

Number of staff attending program/completing modules will be documented in the portfolio

Strategy 4.2.2 Increase internal communication to create awareness of diversity/cultural competency educational opportunities.



4.3 Continue to work toward recruiting and retaining, consistent with the Health Department's non-discrimination policy, a management team and staff that reflects the population of the service area

Strategy 4.3.1 Hire a volunteer coordinator to continue to recruit interpreters as client base expands

The ratio of minority clients to the # of interpreters will be monitored.

Area Health Education Center (AHEC) CACHE

Strategy 4.3.2 Collaborate with CHS to utilize volunteer base (Health Department would define roles/responsibilities)Strategy 4.3.3 Consult county Human Resources to assess process for hiring/establishing a diverse workforce and make plans to incorporate that process into recruitment efforts

4.4 Identify and promote MCHD services for audiences where health disparities exist.

Strategy 4.4.1 Establish a senior advocacy group.

Minutes of meetings will be included in the portfolio

Viable programs

Strategy 4.4.2 Work with MCHD Webmaster to develop link to educational materials & resources translated in Spanish

Number of web hits, # of clients who report they obtained info from website will be monitored and recorded in the portfolio.

Current MCHD website

Strategy 4.4.3 Develop mechanism for referring and ensuring patients who have service needs outside the health department are directed properly

5. Identify and advocate for public policies that aid in closing the health status gap.

5.1 Ensure that all County supported human service agencies utilize Health Disparity in program planning

Strategy 5.1.1 Distribute epidemiologic data on health disparities to County government leaders, community stakeholders prior to development of Balanced Scorecard metrics.

Changes in department measures; Corporate and Community Health Index

Balanced Scorecard (BS)

5.2 Provide effective health education targeting health literacy and risk-reducing behaviors to all public school students in grades PK – 12.

Strategy 5.2.1 Revise curriculum to require health class in each year of study in Charlotte-Mecklenburg Schools.

Changes in school curricula CMS Health Council

Strategy 5.2.2 Implement end-of-grade testing in health course of study.

Changes in school curricula MCHD Health Promotion



5.3 All sanctioned sources of food County-owned and operated facilities will offer selections that meet nutritional guidelines

Strategy 5.3.1 Vending machines in office buildings must offer healthy alternatives in order to maintain contract.

Contracts with vending machine operators will be on file. Vending machines will be monitored for compliance with this requirement.

Contractual, policy making authority of County and School administration

Strategy 5.3.2 Vending machines in schools will not be allowed to offer soda, nor non-nutritious snacks.

School health nurses will be asked to monitor the vending machines at their schools.

School Health Nurses, Chalotte Mecklenburg School Systems

5.4 Use of tobacco products on County-owned property will be prohibited

Strategy 5.4.1 County policy will restrict use of tobacco on all county property.

Policy, signage, enforcement Policy making authority of County

5.5 Inhibit spread of HIV and Hepatitis

Strategy 5.5.1 County Commissioners acting as Board of Health will continue to support recommedations from the 2004 HIV/AIDS Taskforce Report

Documentations of written recommendations will go in the portfolio

HIV DiseaseTask Force report

5.6 Health Department will support residency, internship and other learning opportunities for students pursuing health careers.

Strategy 5.6.1 Health Department will partner with school and community based groups working to foster interest in health careers, particularly in underrepresented communities.

Documentations of partnerships will be included in portfolio

Health Department Staff, Universities, Area Health Education Center (AHEC), Health Occupation Students of America (HOSA) chapters


ELIMINATING HEALTH DISPARITIES A CALL TO …...Disparities Call to Action – 2006: Mecklenburg...

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