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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000428737.56051.96
AJN Reports

From Disparity to Equity

Jacobson, Joy

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Racial and ethnic health disparities persist, but nursing is providing several solutions.

Poverty, discrimination, too few primary care providers, a lack of diversity among clinicians, “food deserts”: the causes of inequities in health and health care have been debated and studied for decades. But eliminating them, as was the goal of Healthy People 2010, a Department of Health and Human Services initiative that sets health promotion and disease prevention goals and objectives with 10-year targets, has proved elusive. In some areas, stark racial and ethnic disparities in health and health care persist.

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* Although death rates among infants born to non-Hispanic black mothers declined from 2007 to 2008, black infants were more than twice as likely to die as white infants (12.67 and 5.5 deaths per 1,000 lives births, respectively).

* A survey of U.S. Hispanics found that 25% of Puerto Ricans had three or more cardiovascular disease risk factors such as hypercholesterolemia, obesity, hypertension, or smoking.

* The incidence of breast cancer diagnosed at an advanced stage steadily increased in black women from 2000 to 2007, while steadily decreasing in white women.

* From 2000 to 2009, the rate of AIDS diagnosis in boys and men ages 13 to 24 rose by 116% in blacks, by 35% in Hispanics, and by 50% in whites.

* A 2012 study found that, compared with white children, twice the number of Hispanic children were in poor health and twice the number of black children had visited an ED for asthma in the prior year.

Now, Healthy People 2020 has broadened its targets ( Its goal is “health equity,” which it says will require “efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.” But how will we get there?

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Many recent initiatives have taken aim at various aspects of the problem (see Efforts to Reduce Disparities). Antonia Villarruel, cochairwoman of the Diversity Steering Committee of the Future of Nursing: Campaign for Action, an initiative of the Robert Wood Johnson Foundation and AARP, believes that nursing has an obligation to focus on correcting a particularly glaring inequity of its own: the lack of diversity in its workforce. “We can't say we are champions of the underserved when we can't address racial, ethnic, and gender disparities in our own profession,” she said. For example, the 2008 National Sample Survey of Registered Nurses found that non-Hispanic whites are 66% of the U.S. population but 83% of the nursing workforce.

The Campaign for Action was started in 2011 to help nurses nationwide in implementing the recommendations of a 2010 Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health. The steering committee is working with the campaign's state coalitions on promoting a more diverse workforce and ensuring that patients get good care “regardless of race, religion, creed, ethnicity, gender, sexual orientation, or any aspect of identity.” Committee members review requests for funding and technical assistance and provide links to state and local chapters of national organizations such as the National Association of Hispanic Nurses.

There was no major recommendation in the IOM report addressing nursing diversity and health disparities, Villarruel said, “because it's implicit.” Addressing disparities and diversity, she said, is integral to achieving all of the recommendations. For example, one of the major recommendations was allowing NPs to practice to the full extent of their training and licensure. In addressing the many legislative and academic issues at play, said Villarruel, nurses must also involve the people most affected: minority populations at risk for poor care access.

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Nursing education is another central aspect of the Future of Nursing recommendations, and at Florida International University (FIU) in Miami, it's a way of targeting health disparities. Lorraine Nowakowski, a nurse who's a clinical specialist at the Herbert Wertheim College of Medicine at FIU, said Miami has many neighborhoods with high rates of health disparities. Nowakowski, the only nurse at the medical school, recently described FIU's interprofessional student teams, called NeighborhoodHELP (Health Education Learning Program), funded by the Green Family Foundation. The goal is not only to train the students to work well on a team representing many disciplines, but also to employ a new model—interdisciplinary and tied to the community it serves—to improve the health of Miami's most vulnerable residents.

When the medical school was launched several years ago, it conducted community-based participatory research and determined the four neighborhoods with the worst health outcomes and greatest disparities. An “outreach team” consisting of FIU staff and a police officer visits these neighborhoods, interviewing residents for possible inclusion in NeighborhoodHELP. Each participating household is assigned a team consisting of a medical student, one to three nursing undergraduate or graduate students, and a social worker. (Law students are also available, as needed.) The students make referrals for low-cost primary or specialty care at a neighborhood clinic; a mobile clinic has also begun making rounds, and a telemedicine system for in-home monitoring is in the works. Outcomes data are being collected and will be reported on after this year, the fourth year of data collection.

“The team establishes a relationship over time,” Nowakowski said. “In health care the patient comes to our world. But we go to the patient's world.” Working with patients in their community, she said, “is the most important piece of it.”

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Maria De Los Santos, a clinical assistant professor at FIU's College of Nursing and Health Sciences, has worked on NeighborhoodHELP for four years. She sees the interprofessional teams, which tend to reflect the racial and ethnic mix of the neighborhoods served, as an opportunity for students to see firsthand “the connection between social determinants and well-being,” she said. Faculty and students also provide primary care at the UHI CommunityCare Clinic, which serves a large Muslim community and other underserved ethnic groups in Miami.

The clinic is free, but the patient is responsible for some modest laboratory costs, she said. “For prescription medications, we have to look at the $4 formulary at local pharmacies and be more conscientious of costs. The students have to ask: Can I achieve the same outcome in another way without affecting quality?”

De Los Santos proposes what some might view as a drastic solution to the seemingly intractable dilemma of health disparities: that all nurses perform some work as volunteers. “When you go into a service profession you're held to a higher standard,” she said. “The only way to reach everyone without placing a huge tax burden on society is a combination of volunteerism, philanthropy, and public support.”

It's this sort of “higher standard” that the FIU program appears to be setting. Across the country, De Los Santos said, “we've become so focused on academics that we've lost sight of some of the more moral obligations in our curriculum. In our program we want students to develop some empathy and to give back.”—Joy Jacobson

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Efforts to Reduce Disparities

The United States far outspends other nations on health care—$7,500 per capita in 2008; by comparison, the next-highest spender, Norway, averaged $5,000 per person, according to the Commonwealth Fund—but that expenditure hasn't been equitable. In recent years, many public and private initiatives have aimed at reducing racial and ethnic disparities in health and health care. Here is a sampling.

Health Disparities and the Affordable Care Act. The new federal health law will target health disparities with a focus on preventing chronic illness, funding primary care centers for low-income communities, and banning insurance discrimination.

Finding Answers: Disparities Research for Change. A Robert Wood Johnson Foundation initiative features The Roadmap to Reduce Disparities, a step-by-step guide for health care organizations, and the Finding Answers Intervention Research (FAIR) Database, a searchable online catalog of 388 articles from 11 systematic reviews on racial and ethnic health disparities that may be searched by disease, population, setting, or intervention.

National Partnership for Action to End Health Disparities. In 2011, the Office of Minority Health at the U.S. Department of Health and Human Services published the National Stakeholder Strategy for Achieving Health Equity. The product of thousands of comments and contributions, the strategy can be used by communities and takes into account the social, behavioral, environmental, and biological factors that affect health.

Health in Mind: Improving Education Through Wellness. A joint effort of the Healthy Schools Campaign and the Trust for America's Health “focuses on policy recommendations for immediate, practical changes at the federal level” to address the achievement gap in education and health disparities among the nation's children.

The Clinton Health Matters Initiative. Announced in November 2012, this partnership of the William J. Clinton Foundation, General Electric, Tenet Healthcare Corporation, and Verizon will target the preventable chronic illnesses endemic in underserved communities. Remote monitoring of health is a central aspect of the initiative.

The NIH Health Disparities Strategic Plan and Budget. Under this plan, each institute in the National Institutes of Health must conduct disparities research and public outreach and encourage a diverse health care workforce.

© 2013 Lippincott Williams & Wilkins, Inc.


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