health disparity research: opportunities and challenges

*Health Disparity Research:

Opportunities and Challenges

David SmithUnited Way of Greater Houston Dr. Katharine Ball-Ricks University of Texas Health Science Center at Houston School of Public Health

*Health Disparities*“…populations where there is a significant disparity in the

overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates in the population as compared to the health status of the general population”

* National Institutes of Health, 2013

*Populations generally affected*African Americans*Hispanics/Latinos*American Indians, Native Hawaiians & other Pacific Islanders*Asian Americans*Socioeconomically disadvantaged *Rural populations

*Health Disparities OR Inequalities

*Generally a result of:*Poverty*Environmental threats*Inadequate access to health care*Individual and behavioral factors*Educational inequalities (lack of education)

*Community Based Participatory Research and may include research on:* Cancer* Cardiovascular Disease* Chronic Kidney Disease* Diabetes* HIV and AIDS* Maternal and Child Health* Mental Health and Substance Abuse* Environmental (air quality, mold)* Obesity and Exercise

*Health Disparities Research

* Cross-CPCRN Study Administered in four 2-1-1 Systems

*Pooled Analysis Results

Purnell, Kreuter, Eddens, Ribsl, Hannon, Fernandez, Jobe, Gemmel, Morris & Fagin. Cancer control needs of 2-1-1 callers in Missouri, North Carolina, Texas and Washington. Under review at Journal of Health Care for the Poor and Underserved.

Standardized estimates of cancer control needs in 2-1-1 callers (4 states pooled) vs. U.SCancer Control Need 2-1-1 Respondents (n) 2-1-1*,

%BRFSS US %

p

No health insurance All (n=1408) 37.2 15.2 <.0001

Current cigarette smoker All (n=1408) 33.2 18.4 <.0001

Has smoke-free policy All (n=1408) 69.4 76.4 <.0001

Ever had a colonoscopy Men & women, 50+ (n=337

50.2 61.4 <.0001

Received HPV vaccination (self)‡ Women, 18-26 (n=229) 19.4 18.4 <.0001

Received HPV vaccination (daughter)

Have daughters 9-17, (n=271)

35.9 na <.0001

Up-to-date on mammographya Women, 40+ (n=529) 56.5 76.3 <.0001

Up-to-date on Pap testb Women, 18+ (n=1128) 75.7 78.0 <.0001

Note: na = not available*- Standardized by age and gender strata for the United States population.‡ - Unstandardized because of only one age stratum for women.a Within last 2 years ; b Within last 3 years

*2-1-1 Health and Human Services Research Consortium

* Pairing 2-1-1 systems and researchers• Combining, refining, and analyzing data• Providing evaluation and funding assistance• Laying ground rules for collaboration• Setting a research agenda

*Houston Pilot Results in 2010

Cancer risk factors & prevention needs: 2-1-1 Houston callers (n=375) vs Texas and US

Risk factor or preventive measure

Respondents (n) 2-1-1 TX* U.S.*No health insurance All (n=342) 42% 26% 15%

Had mammogram in the last 2 yrs

Women, 40+ (n=138)

45% 73% 76%Had Pap smear in

the last 3 yrsWomen, 18+

(n=321)79% 82% 83%

Ever had a colonoscopy

Men & women, 50+ (n=76)

32% 56% 62%Had FOBT within

past 2 yearsMen & women,

50+ (n=75)20% 19% 21%

Received HPV vaccination (self)

Women, 18-26 (n=46)

4% na naReceived HPV

vaccination (daughter)

Have daughters, 9-17 (n=99)

29% na 35%

Current cigarette smoker

All (n=329) 22% 19% 18% *2008 BRFSS; na=not available

* Increasing Cancer Screening and HPV Vaccination among Underserved Texans: A

Collaboration with Texas 2-1-1

Goals and AimsTo increase the use of cancer control strategies among disadvantaged adults who call 2-1-1, we will:1. Develop and pilot test an intervention2. Provide risk assessment and referral services3. Determine the effectiveness and cost effectiveness of

the 211 Telephone Cancer Control Navigator Program

*Preliminary Findings*Participating Call Centers:*Houston (CPRIT funded)*Weslaco (CPRIT funded)*El Paso (CNP funded;

now CPRIT funded)

* Preliminary Results of the Needs Assessment: Cancer Risk Factors & Prevention Needs

Risk factor or preventive measure

Respondents (n)

2-1-1 Houston

2-1-1 Weslaco

2-1-1 El Paso

TX** U.S.**

No health insurance All (n=3824) 44% 70% 71% 26%

15%

Had mammogram in the last 1-2 years

Women, 40+ (n=1534)

51% 51% 62% 70%

76%

Had Pap smear in the last 3 yrs Women, 18+ (n=3438)

78% 82% 95% 79%

81%

Ever had a colonoscopy Men & women, 50+ (n=923)

50% 44% 48% 62%

65%

Received HPV vaccination (self) Women, 18-26 (n=641)

19% 9% 19% 15%

17%

Received HPV vaccination (daughter)

Have daughters, 9-17 (n=888)

42% 55% 55% 38%

44%

Current cigarette smoker All (n=3824) 24% 6% 6% 18%

19%

**BRFSS 2010, n/a=not available

*How To Get Started

* Your Research/Knowing Your Community

*How your 211 data can help*Knowing the needs of your community*Health Department Priorities*Internet Research

*Ways to Make Contact with Educational Institutions

*Calling or Visiting *Schools of Public Health*Prevention Research Centers*Cancer Prevention and Control Research Networks*Community Network Programs*Clinical and Translational Science Award (CTSA) Community

Engagement leaders*Community Organizations*Inviting University Professors to sit on boards, committees*Sending out “Calls for Proposals”

*An Example

*Activity / Discussion

*Let’s Practice

*Make a list of the major universities in your service area.*Google search –

university + “health disparities research”*Yes, it’s that easy.

*Getting Your Foot in the Door

*Brown Bag Meetings*211 Open House *Educate the community*Thought leader in the work

*Community Committees*Networking

* Strategies for Collaboration

* Pre-Grant Proposal* Letters of Support* State and nation-wide partnerships (CNP, CPCRN)

*During Grant-Writing Process* Sharing approach and previous work

* First year of the study* Intervention Development/Training* Kick-off Meeting*Capacity Assessment/ Capacity Building

* Implementation*Weekly meetings at 2-1-1 Houston/ weekly update e-mail* Transparent Protocols & Processes/ Ongoing Quality Assurance*Collaboration: meetings, events, conferences and publications

*Challenges

From the academic perspective

*Challenges & Lessons Learned *Lower acceptance and retention rate

*Site Differences*Tailor strategies based on organizational culture

*Research-based vs. Service-oriented*Balance each party’s interests: reciprocal relationships

*Change in Site personnel*Need to “Over-train”

*Variation in staff morale*Introduce different incentives

* Implementation Challenges for Further Investigation

*2-1-1 Competing responsibilities

*Commitment of collaborators

*Implementation practices

*Quality control

*Support & Continuity

*2-1-1 Challenges

*Know Your Pricing Strategy

This is not unique to academic research, but pricing is an area where many struggle – effort versus results. Our Approach

* Make a commitment based upon # of FTEs * 1 FTE -- coach/navigator* 2 FTE -- Recruiters* 10% of a manager’s time.

* Convert to an hourly rate. * Expand out over the project timeline.

* X # of hours for helpline specialists at $Y per hour* X # of hours of manager at $Y per hour.

*Selecting Staff

Make a commitment based upon # of FTEs

1 FTE -- coach/navigator2 FTE -- Recruiters10% of a manager’s time.

*Build an org chart that doubles the FTE commitment*2 coaches*4 recruiters

*Selecting Staff

*Not Everyone Was a Successful Recruiter*Questions are too intrusive – we should not be asking.*Attached to the outcomes*Trouble switching gears/focus from a 3 to 5 minute I&R

call to a 20 to 30 minute survey call.*Result : Burn out lead to “taking breaks”

*Longest Documented Call

*Francis Potakey*Time: 2 hours 0 minutes*Comments : “Very Talkative

Caller. Digresses a lot for every question that you ask.”*Runner-Up*Vallery Arnold: 1 hour 26

minutes.

*Training

*All participants have to be certified in Human Subjects Research training. (Ethics)*Takes 8 hours to complete, plus 2 hours refresher every

two years.*Project start-up training will vary, but ours have been

averaging an additional 20 hours from selection to the start of recruiting.

*Ethics

*Have to be able to provide informed consent *IRB will not approve attempts to based upon age (under

18) or vulnerable populations (mental illnesses or intellectual disabilities) without additional safeguards. *Researchers will generally exclude from study

recruitment, unless they have a specific interest.*AIRS Standards = we are ethically obligated to provide

information and referral services to all of these populations.*Need to discuss at the start of the contract.

*Pareto Principle – 80/20 in action

Recruiter Results %1 14 15%2 13 14%3 12 13%4 51 55%5 3 3%

93 100%

*Opportunity : Smoke Free

Homes

*Potential Public Health Impact

2-1-1 Systems take an estimated 16 million calls annually

With the potential of reaching 5 million smokers,

3.1 million women in need of Pap tests,

2.6 million women needing mammograms,

2.3 million women needing the HPV vaccination,

1.9 million with daughters in need of the HPV vaccination,

1.9 million in need of colonoscopies