Community Health Factors and Health Disparities
Based on a community health approach, the THRIVE tool addresses the features of communities which affect health and safety. These community factors represent key opportunities to reduce disparities in health and improve community health and wellbeing. According to the National Institutes of Health, health disparities are the “differences in the incidence, prevalence, mortality and burden of diseases and other adverse health conditions that exist among specific populations.” When a health condition affects the general population, it affects low income and people of color at a higher rate and more severely.
Trajectory of Health Disparities
What Leads to Health Disparities?
Prevention Institute has identified key elements leading to inequitable health outcomes for low income people and people of color. As depicted in the diagram above, we have arranged these elements into a course or trajectory First, people are born into a society that treats them unequally on the basis of race, class, and gender. Therefore, the trajectory starts with root factors of oppression, such as discrimination, poverty and racism. These root factors shape the overall community environment, and affect where people live, what they do, the education they receive, and their overall quality of life. It is important to note that the “community environment” has implications beyond the quality of air and water or the level of pollution in a community. It also refers to whole range of environmental factors affecting quality of life in a community, including the kind of housing, jobs and schools, and products available in a community. People who live in environments with pollution, high rates of joblessness, inadequate access to healthy and affordable food, few opportunities for physical activity, or that are targeted by corporations pushing unhealthy products such as alcohol, cigarettes and fast food, tend to experience adverse health outcomes. The environment influences the community it surrounds and shapes behaviors. Behavioral factors, such as how and what people eat, their level of alcohol consumption, their engagement in physical activity, or their propensity for violence, are all affected by the environments around them. The combination of environmental and behavioral factors contributes to an increased number of people getting sick and injured who then require medical services. Inequities in access to and quality of medical services for people of color and low income people are well-documented and contribute to even greater disparities in health outcomes. For example, if there is no affordable healthy food and no places to exercise in a neighborhood, a community is unable to easily eat healthy or engage in physical activity, and most likely will experience higher rates of cardiovascular disease and diabetes. These conditions, created by underlying factors in the community environment, are exacerbated lack of access to quality medical care.
When attempting to eliminate health disparities, most people look at increasing communities’ access to and quality of medical care. However, even with adequate access to quality medical services, inequities in health will not be significantly reduced. Health care often comes after people are already sick, and some serious health conditions can be treated, but not cured. Medical services also treat or screen one person at a time, and don’t affect the community overall. Thus, when attempting to address disparities in health, it is important to concentrate on those environmental and behavioral factors which affect health outcomes. It is important to focus on how we can prevent people from getting sick in the first place.
“Two Steps Back”: A Prevention-Oriented Approach
One way to think about a prevention-oriented model for reducing health disparities is to think backwards from a given health problem or medical condition, such as diabetes, injury, or cancer. The first step back is from the injury or illness to what researchers McGinnis and Foege called “the actual causes of death.” For instance, if diabetes is the medical problem, it is eating and activity patterns (as well as genetics) that underlie it. If injury is the medical condition, car crashes, falls and violence are the actual causes. If lung cancer in the medical condition, it can often be traced back to smoking. While it is critical to focus on those behaviors that contribute to poor health outcomes, it is equally important to remember that one’s behavior is shaped by one’s environment. As The Institute of Medicine has stated, “It is unreasonable to expect that people will change their behavior so easily when so many forces in the social, cultural, and physical environment conspire against change.” This requires an additional step back from the ‘actual causes’ to the environmental factors that impact health throughout communities and broadly influence behavior. In the case of lung cancer and smoking, we can step back to factors such as availability of tobacco and cultural norms that reinforce smoking as desirable.
The second step back, addressing the environmental factors depicted in the trajectory, presents a key opportunity for prevention. Through extensive research, Prevention Institute determined 13 environmental factors that either directly influence health outcomes (e.g., air and water quality) or directly influence behaviors that in turn affect health outcomes (e.g., the availability of healthy food affects nutrition). They are organized into 3 interrelated clusters: equitable opportunity, people, and place, and are the same community factors included in THRIVE.
McGinnis, J.M., Foege W.H. Actual causes of death in the United States. Journal of the American Medical Association: 270:2207–2212, 1993.
Additional Prevention Institute Resources:
- Health Disparities and Community Health Glossary of Terms
- A Community Resilience Approach to Reducing Ethnic and Racial Disparities in Health (PDF) (December 2005 ) The American Journal of Public Health published this article by Rachel Davis, MSW, Danice Cook, BA and Larry Cohen, MSW of Prevention Institute in its December 2005 issue (Vol 95, No. 12). The article captures outcomes from piloting a modified version of the THRIVE tool; including its demonstrated utility in urban, rural, and suburban settings.
- Health For All: California's Strategic Approach to Eliminating Racial and Ethnic Health Disparities (PDF) - Executive Summary (PDF) (November 2003) The California Strategic Approach delineates how the resources of diverse governmental and private institutions can be marshaled to work with communities to make significant progress towards eliminating health disparities in California. It illuminates the critical pathways that affect health and the key points for intervention to ensure health for all.
- Strengthening Communities: A Prevention Framework for Eliminating Health Disparities (July 2003) This Prevention Institute paper sheds light on the environmental conditions that hold the most promise for reducing health disparities in low-income, communities of color.
- Eliminating Health Disparities: The Role of Primary Prevention (PDF) ( February 2002) A Prevention Institute paper describing how health disparities can be reduced through systems-based prevention strategies that address the underlying factors influencing health.
- The Imperative of Reducing Health Disparities through Prevention: Challenges, Implications, and Opportunities (PDF) (August 2006).This paper was prepared for the Institute for Alternative Futures by Prevention Institute.
- Good Health Counts: A 21 st Century Approach to Health and Community for California (May 2006) This Prevention Institute paper was prepared for The California Endowment [coming soon]
- Prevention Institute Community Health and Health Disparities Website at http://www.preventioninstitute.org/healthdis.html
McGinnis JM & Foege WH. Actual causes of death in the United States . Journal of the American Medical Association: 270:2207–2212, 1993.
B.D. Smedley & S.L. Syme (Eds.) Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington , D.C. : National Academy of Sciences Press. Pg. 4.