 Research Insights Addressing Disparities Through Public Health Systems & Services Research and Adaptations to Public Health Practice Summary with important public health system partners to get at the root of Healthy People 2010 prescribed a set of health objectives for the disparities and make lasting impact.1 nation to achieve over the first decade of the new century. As the decade concludes, public health professionals are reflecting on An emerging science, public health systems and services research whether the national health goals, and their associated objectives, (PHSSR), has the potential to inform our understanding of the have been met. public health system’s contribution to disparity elimination. As this area of inquiry develops, there is hope that best organizational Eliminating health disparities is one of two overarching goals practices for impacting disparities will be identified and that the set forth in Healthy People 2010. State and local public health relationship between health disparities and various public health departments are key stakeholders in achieving this goal. Currently, system characteristics will be better understood. there is a move to develop a national accreditation system for governmental public health agencies in order to promote quality Changing public health priorities and emerging public health and performance. It is anticipated that this standards-setting issues are currently being considered in the development of a program will support priority public health initiatives, such as framework for Healthy People 2020. At the same time, health disparity elimination. The challenge lies in the complex nature disparities remain. To ultimately reach the goal set forth in of disparities and in the wide array of social determinants that Health People 2010, the elimination of health disparities will influence them. Thus, public health agencies must collaborate continue to require broad-based public engagement and a nationwide commitment. Genesis of This Brief: AcademyHealth’s Annual Research Meeting 2009 As part of its efforts to support the burgeoning field of public health systems and services research (PHSSR), the Robert Wood Johnson Foun- dation sponsored an invited panel at the 2009 AcademyHealth Annual Research Meeting to discuss the ways in which PHSSR can contribute to efforts to measure, assess, and reduce disparities in health and health care. The panel, Addressing Disparities Through Public Health Sys- tems & Services Research, featured presentations from Harold Cox, M.S.S.W., associate dean of public health practice at Boston University, Claudia Schur, Ph.D., vice president and director of the Center for Health Research and Policy at Social & Scientific Systems, Inc., and Marsha Gold, Sc.D., M.P.H, senior fellow, Mathmatica Policy Research. It was moderated by Debra J. Pérez, Ph.D., M.P.A., M.A., senior program of- ficer, Robert Wood Johnson Foundation. This brief summarizes that discussion. Addressing Disparities Through Public Health Systems & Services Research and Adaptations to Public Health Practice Introduction expenditures require substantially more work. In addition, the measures In 2000, the Department of Health and Human Services laid out its for assessing performance and quality in public health practice are still vision for Healthy People 2010 with two primary goals, “increase quality relatively rudimentary (based largely on self assessment) and more and years of healthy life” and “eliminate health disparities.” Although research is needed to identify the most appropriate methodological notable progress has been made, significant disparities persist and the approaches and instrumentation for the field. goal of eliminating health disparities remains largely unmet. Research conducted to date tends to focus on readily observable inputs, Disadvantaged communities have greater exposure to toxins, limited outputs and outcomes. But what happens in the middle4 remains access to healthful choices, and limited access to preventative and largely unexplored. Determining what it is it about the practice clinical services. Public health departments are one vehicle for of public health that has an impact on service delivery and health addressing disparities, yet their resources for and commitment to outcomes is a useful line of inquiry. As PHSSR evolves, and its ability disparities reduction can vary widely. Accreditation and public health to get at more complex issues, such as disparities, improves, it may systems and services research (PHSSR)∗ hold promise as a means to provide valuable insights into what particular structures, processes, and address these disparities.3 practices could lead to improvements in quality and outcomes. According to Debra J. Pérez, Ph.D., M.P.A., M.A., senior program The Potential of PHSSR to Address Disparities officer at the Robert Wood Johnson Foundation, accreditation of Healthy People 2010 set eliminating health disparities as one of two public health agencies, if properly implemented to define a core set overarching national goals, along with increasing quality and years of minimum standards that even the smallest health department of healthy life. Yet, because of the complexity of health disparities, could attain, is seen as a means of “leveling the playing field” for eliminating them is not a goal that the federal government can disadvantaged communities. Beyond that, PHSSR, provides research- address on its own. It requires a multidisciplinary approach from the based understanding of the scope of disparities, the resources and national, state, and local level. And because public health authority systems required to provide services to disadvantaged communities, and activity rests heavily at the state and local levels, and public and the most efficient organization and delivery of those services, and private sectors are also involved, public health is a key stakeholder. insight into which interventions are most effective in reducing disparities and improving public health. States Perez, “disadvantaged PHSSR is uniquely suited to advancing this goal because it investigates populations stand to gain the most from improvements in the programs, direct services, policies, laws, and regulations designed effectiveness and efficiencies” in public health, yet the realities and to protect and promote the public’s health and prevent disease and challenges facing public health departments are great. disability at the population level.5 As a growing and relatively young field, PHSSR also has the promise of attracting a new and diverse On June 29, 2009, the Robert Wood Johnson Foundation sponsored a workforce of researchers who can contribute to the reduction of panel discussion at the 2009 AcademyHealth Annual Research Meeting disparities by asking unique questions about population health. to discuss the potential for PHSSR to address disparities in public health practice. This brief provides a summary of that discussion and Despite this promise and the progress made to date, challenges provides recommendations on data needs and collaborative strategies exist. The potential for the current public health system to for researchers and policymakers. eliminate disparities is understudied and the workforce is underfunded and overtaxed. Background PHSSR is a relatively new field. Much of the early research has been Challenges and Realities descriptive in nature, measuring the availability of services and the As stated previously, addressing disparities is heavily weighted to state organization and financing of public health systems. Though that work and local effort. Yet states and communities have widely disparate levels is ongoing, it has established an important foundation for the next of response in addressing disparities and equally variable resources phase of inquiry, which has begun to examine the degree of variation in available to do this work. public health practice across communities and variation’s influence on health outcomes. According to Harold Cox, M.S.S.W., associate dean of public health practice at Boston University, who offered a provider’s perspective to Existing research has made headway in defining public health system the panel, efforts to reduce disparities at the state and local levels are organization and agency structure, yet our knowledge of financing impeded by the limitations of financial and workforce resources, an is relatively limited and the systems for tracking public health already expansive list of responsibilities competing for those resources, 2 and the knowledge that a department might have to shift priorities to some useful information, but are limited in their ability to deliver new, pressing needs (such as emergency preparedness or H1N1 virus) information on subgroups and subjurisdictions. For example, these as they emerge. surveys may allow a certain level of analysis on African American and, to a lesser degree, Hispanic communities, yet gaps exist and Resources and competing needs researchers and policymakers have very little ability to establish Many health departments struggle amid limited financial and estimates for many other relevant subgroups or subjurisdictions. workforce resources to deliver the basic services under their Measurement is also challenged by the timeliness and sample sizes purview, let alone supporting additional initiatives to reduce of surveys – which can vary widely from state to state – as well as by disparities. According to preliminary research presented by differences in the state’s abilities to use the data effectively. Claudia Schur, Ph.D., vice president and director of the Center for Health Research and Policy at Social & Scientific Systems, Inc., In support of this notion, NACCHO’s 2008 Profile of Local Health up to 71 percent of local health departments report inadequate Departments revealed that only 52 percent of LHDs “describe health funding as a barrier to addressing health disparities. According disparities in jurisdiction using data.”9 Lack of data, at the state and to Schur, most local health departments are quite small, serving local level, and the absence of reliable centralized data sources is a communities of less than 50,000 persons, and one-third having constraint for policymakers and researchers. annual expenditures of less than $500,000.6 Many have fewer than 10 full-time employees. The research was supported by Literacy and Language Barriers the experience of Cox who cited Massachusetts data indicating As part of their work to study the populations who LHDs serve and that local health departments in that state had budgets as low as the ways in which LHDs meet population needs, Schur and colleagues $1,000 to address populations of up to 40,000 persons. are conducting an evaluation of the extent of diversity in LHD jurisdictions, the variations in structure and capacity to deal with Human resources are also limiting. According to Cox, 80 percent disparities, and promising strategies to improve service. of health departments in Massachusetts have inadequate staffing. In addition, a lack of consistency in training and preparation The researchers began with the NACCHO 2005 National Profile of for professionals in the public health workforce and the Local Health Departments, which they linked with 2000 Census data retirement of staffers from the baby boomer generation leave by jurisdiction to create population profiles. In their preliminary many departments with less experienced and prepared teams data, they found considerable diversity in the populations residing through which to provide services. in the LHD service areas— for example, 125 LHDs are located in areas where more than seven percent of households are linguistically Despite funding and staffing constraints, local health departments isolated (no one over 14 speaks English well) and 290 LHDs serve often have a long list of commitments and responsibilities, communities where as many as 38 languages are spoken. While the including everything from restaurant inspections to vaccination diversity is greater in the largest jurisdictions and in certain Census programs. The list is not static. At any time, the department may divisions, Schur notes that it is present in most regions, including have to shift priorities to address an emergent issue, such as the smaller LHD service areas. In addition, while these statistics describe recent H1N1 outbreak. the population of the jurisdictions as a whole, the client populations— those who actually obtain services from the LHDs—are likely to be Data and Measurement more diverse. Building on this analysis, the researchers distributed According to Marsha Gold, Sc.D., M.P.H, senior fellow, Mathmatica surveys to a sample of the most diverse communities. Policy Research, one key determinant of effective policy is the ability to use data to identify priorities and develop solutions. To determine In preliminary results, two-thirds of the LHD survey respondents what data were available to measure disparities at the state level, Gold report serving client populations where more than 10 percent speak and colleagues undertook a two-part study that included a national a primary language other than English. Approximately the same inventory of the capacity to measure disparities in Leading Health number have bilingual staff, and about half use telephone interpreter Indicators (LHIs) at the state and local levels7 and a pair of state level lines. Three-quarters have materials translated. However, that leaves case studies of relevant disparity reduction initiatives.8 another 23 percent with no formal interpretation services available. Gold found that data on LHIs is collected as part of the Behavioral As with the SHDs studied by Gold and colleagues, LHDs found Risk Factor Surveillance System, Youth Risk Behavioral Surveillance some innovative ways to address needs within the constraints System, and National Vital and Health Statistics System, for which of their mission, financial resources and staffing. Approximately the federal government has provided support. These data provide three quarters of respondents provided some services targeted to 3 Addressing Disparities Through Public Health Systems & Services Research and Adaptations to Public Health Practice diverse populations, most often through community outreach, 3. Maintain good and consistent communications – regular translated or culturally appropriate materials and collaboration communication helps establish trust. with minority partners. 4. Acknowledge that there will be mistakes – no collaboration is perfect but acknowledgement allows each party to move on. Lessons PHSSR can learn lessons from the clinical services field and avoid 5. Compromise – working collaboratively requires that you must be research in isolation – focusing early in PHSR’s development able and willing to compromise. on the practice community and practice based research. In 6. Take the long view – Collaboration in PHSSR is not just a short order to do so, Cox and the other panelists stressed the term commitment. importance of communication, collaboration and flexibility in addressing the challenges of diversity and disparities in state and 7. Play nice - Don’t burn your bridges. local health departments. 8. Focus – If you keep your eye on the objective there can and will be ways to work together. According to Gold, it is very difficult to determine what states and localities have done throughout the decade to meet the Healthy People 2010 goal of eliminating health disparities. There is limited centralized Next Steps for PHSSR information to enable researchers to understand historic efforts or Other than the obvious need for more resources at the state and local evaluate the activity and results of state-based initiatives. This lack level for data, workforce, and public health programming, there is of evidence-based best practices means that even when a state or hope that PHSSR can also inform the elimination of health disparities. locality identifies an area for intervention, it isn’t always clear what the evidenced-based intervention would be. Yet, despite a troublesome In the conclusion of her presentation, Gold outlined next steps for lack of data and catalog of proven practices, Healthy People 2010 did public health systems and services researchers to undertake in support serve as a catalyst for state and local champions to act on disparities. of eliminating health disparities. Specifically, she recommended more and better documentation of efforts and the development of syntheses Although state and local structures for addressing disparities will that can analyze those efforts. Gold and colleagues also called for more reflect unique features of the particular environment, Cox identified research on what makes for effective interventions and which areas three primary opportunities for PHSSR researchers to work with offer the greatest payoff for the effort. LHDs to reinforce, assist, and improve their ability to address disparities. These include working collaboratively to enhance the work In a commentary co-authored by Perez, Tapping the Potential: that is done in local health departments by: Tackling Health Disparities Through Accreditation and Public Health Services and Systems Research, it is suggested that PHSSR 1. Determining what programs and interventions are tools and datasets might provide a more effective evidence base to actually effective; identify the best organizational practices that will have an impact 2. Evaluating how the built environment impacts health; and on disparities and a means for understanding the relationship between health disparities and various public health system 3. Identifying the impact of health literacy on health status. characteristics.10 Throughout, the importance of collaboration was clear. Both Cox Yet, as noted earlier, PHSSR’s existing body of literature is primarily and Gold cited case studies in which collaboration was a significant descriptive in nature. While it provides an important base for future determinate of success. Gold, in particular, advocated for the use of studies, it offers little specific guidance to public health decision multiple stakeholders inside and outside of government as a means makers concerning how to improve practice. However, recent research to create and solidify political support. Cox offered tips for successful that classifies agencies and systems into homogeneous groups for the collaboration: purpose of analysis and comparison suggests that PHSSR is on its way to conducting rigorous, comparative studies.11 Such studies may lead 1. Clarify the purpose – why are you working together? to the development of a catalog of efficacious public health practice interventions, including those that tackle disparities. 2. Fully engage the stakeholders – practitioners resent academics who swoop in, get their research, and then go home without sharing data. 4 As we await new national health goals with the release of Healthy 5 AcademyHealth’s Public Health Systems Research Interest Group (IG) recently adopted an expanded definition of public health systems research that further People 2020, there is great potential for PHSSR to contribute to the defines public health services. The IG’s statement states: “‘services’ broadly includes elimination of health disparities in this next decade. programs, direct services, policies, laws, and regulations designed to protect and promote the public’s health and prevent disease and disability at the population level.” See http://www.academyhealth.org/files/interestgroups/phsr/PHSR%20 Endnotes Definition%20for%20Web%20site.pdf 1 AcademyHealth’s Public Health Systems Research Interest Group (IG) recently adopted an expanded definition of public health systems research that further 6 According to the 2008 National Profile of Local Health Departments, released by the defines the public health system. The definition states: “The public health system National Association of County and City Health Officials (NACCHO) after Schur’s includes governmental public health agencies engaged in providing the ten panel presentation, 64 percent of local health departments serve populations less essential public health services, along with other public and private sector entities than 50,000 persons and one quarter have annual expenditures of less than $500,000. with missions that affect public health.” See http://www.academyhealth.org/files/ 7 Gold, M., A. Hedley-Dodd, and M. Neuman. “Availability of Data to Measure interestgroups/phsr/PHSR%20Definition%20for%20Web%20site.pdf Disparities in Leading Health Indicators at the State and Local Levels.” Journal of 2 Public Health Systems Research (PHSR) has been defined by Mays et al. as “the field Public Health Management and Practice, 2008, pp. S36-44. of scientific inquiry that examines the organization, financing and delivery of public 8 Conwell, L., M. Neuman, and M. Gold. “State Efforts to Address Healthy People health services in communities, and the impact of those services on public health.” 2010 Goal to Eliminate Health Disparities: Two Case Studies.” September 2008. Recently, it has been suggested that the name and nature of this sibling to Health Available at www.mathematica-mpr.com/publications/pdfs/healthypeople2010.pdf. Services Research be recast to include ‘services.’ Thus, this paper refers to this line of inquiry as Public Health Systems and Services Research (PHSSR). 9 2008 National Profile of Local Health Departments, National Association of County and City Health Officials, p. 69. 3 Mays, G.P. et al. “Behind the Curve? What We Know and Need to Learn from Public Health Systems Research,” Journal of Public Health Management and Practice, 2003, 10 Henry, B. et al. “Tapping the Potential: Tackling Health Disparities Through pp. 179-82 and Scutchfield, F.D. et al. “Public Health Services and Systems Research,” Accreditation and Public Health Services and Systems Research.” Journal of Public American Journal of Preventive Medicine, 2007, pp. 169-71. Health Management and Practice, 2008, pp.S85-87. 4 Mays, G.P. “A Call to Action for Public Health Systems Researchers.” Presentation at 11 Scutchfield, F.D. et al. “Applying Health Services Research to Public Health Practice.” the 2008 Public Health Systems Research Interest Group Meeting, Washington D.C.; HSR, 2009, 44, pp. 1775-87. June 7, 2008. 5