FOCUSING ON CHILDREN’S HEALTH

Community Approaches to Addressing Health Disparities

Workshop Summary

Theresa M. Wizemann and Karen M. Anderson, Rapporteurs

Roundtable on Health Disparities

Board on Population Health and Public Health Practice

Board on Children, Youth, and Families

INSTITUTE OF MEDICINE AND NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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FOCUSING ON CHILDREN’S HEALTH Community Approaches to Addressing Health Disparities Workshop Summary Theresa M. Wizemann and Karen M. Anderson, Rapporteurs Roundtable on Health Disparities Board on Population Health and Public Health Practice Board on Children, Youth, and Families

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. This study was supported by multiple contracts and grants between the National Academy of Sciences and the Agency for Healthcare Research and Quality (Contract HHSP23320042509XI, TO#11), California Endowment (Contract 20052634), Cali- fornia Health Care Foundation (Contract 06-1213), Commonwealth Fund (Contract 20060048), Connecticut Health Foundation (unnumbered grant), Ford Foundation (Contract 1050-0152,FF5H003), Healthcare Georgia Foundation (unnumbered grant), the Henry J. Kaiser Family Foundation (Contract 01-1149-810), Kaiser Per- manente (Contract 20072164), Merck (unnumbered grant), Missouri Foundation for Health (Contract 06-0022-HPC), Robert Wood Johnson Foundation (Contract 56387), and the W.K. Kellogg Foundation (Contract P0123822). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-13785-0 International Standard Book Number-10: 0-309-13785-3 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap. edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2009 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2009. Focusing on children’s health: Community approaches to addressing health disparities: Workshop sum- mary. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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ROUNDTABLE ON HEALTH DISPARITIES1 Nicole Lurie (Chair), Senior Natural Scientist, RAND Corporation, Arlington, VA Victoria H. Barbosa, President, Dermal Insights, Inc., Chicago, IL Anne C. Beal, Senior Program Officer, Quality of Care of Underserved Population, Commonwealth Fund, New York Cheryl A. Boyce, Executive Director, Ohio Commission on Minority Health, Vern Riffe Center for Government and the Performing Arts, Columbus, OH America Bracho, CEO, Latino Health Access, Anaheim, CA Francis D. Chesley, Director, Office of Extramural Research, Education, and Priority Populations, Agency for Healthcare Research and Quality, Rockville, MD Todd Cox, Program Officer, Racial Justice and Minority Rights, Ford Foundation, New York William F. Crimi, Vice President, Program and Evaluation, Connecticut Health Foundation, New Britain, CT Alicia Dixon, Program Officer, The California Endowment, Los Angeles José J. Escarce, Professor of Medicine, David Geffen School of Medicine, University of California, Los Angeles Garth N. Graham, Deputy Assistant Secretary, Minority Health Department of Health and Human Services, Office of Minority Health, Rockville, MD Tom Granatir, Director, Policy and Communications, Innovation Center Humana, Inc., Chicago, IL Cara V. James, Senior Policy Analyst, Henry J. Kaiser Family Foundation, Washington, DC Jennie R. Joe, Professor, Department of Family and Community Medicine, and Director, NARTC, University of Arizona, College of Medicine, Tucson, AZ James R. Kimmey, President and CEO, Missouri Foundation for Health, St. Louis Howard K. Koh, Associate Dean and Director, Division of Public Health Practice, Harvard School of Public Health, Boston, MA James Krieger, Chief, Epidemiology Planning and Evaluation Unit, Seattle, WA Anne C. Kubisch, Codirector, Roundtable on Community Change, Aspen Institute, New York 1 IOM forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. 

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Jeffrey Levi, Executive Director, Trust for America’s Health, Washington, DC John C. Lewin, Chief Executive Officer, American College of Cardiology, Washington, DC Jane I. Lowe, Senior Program Officer, Robert Wood Johnson Foundation, Princeton, NJ Richard K. Murray, Vice President, External Medical and Scientific Affairs, U.S. Human Health, Merck and Company, Inc., North Wales, PA Gary D. Nelson, President, Healthcare Georgia Foundation, Atlanta, GA Samuel Nussbaum, Executive Vice President and Chief Medical Officer, WellPoint, Inc., Indianapolis, IN Michael W. Painter, Senior Program Officer, Robert Wood Johnson Foundation, Princeton, NJ David P. Pryor, Medical Director, Aetna Founder, www. blackwomenshealth.com, Thousand Oaks, CA Steve M. Pu, General Surgeon, Missouri Foundation for Health, Kennett, MO Kyu Rhee, Medical Officer and Director of the Office of Innovation, Program Coordination, National Center on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD Mark D. Smith, President and CEO, California Health Care Foundation, Oakland Mildred Thompson, Senior Director, PolicyLink, Center for Health and Place, Oakland, CA Pattie Tucker, Lead Health Scientist, Community and Health Program, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA Winston F. Wong, Medical Director, Community Benefit Director, Disparities Improvement and Quality Initiatives, Kaiser Permanente Federation, Oakland, CA Terri D. Wright, Program Director, Health Policy, W.K. Kellogg Foundation, Battle Creek, MI IOM Board on Population and Public Health Practices Board Liaisons Samuel So, Professor, School of Medicine, Stanford University, Palo Alto, CA William A. Vega, Professor, Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles i

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Study Staff Karen M. Anderson, Senior Program Officer (April 2008 through present) Jennifer A. Cohen, Program Officer (July 2007 through April 2008) Rose Marie Martinez, Board Director Thelma L. Cox, Senior Program Assistant (April 2008 through January 2009) Pamela Lighter, Program Assistant (February 2009 through present) Patrick Burke, Financial Officer Hope Hare, Administrative Assistant Yi Cai, Intern (May 2009 through July 2009) ii

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confiden- tial to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Maxine Hayes, Department of Health, Washington Cara James, Kaiser Family Foundation Barbara Starfield, Johns Hopkins University Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by Dr. Bobbie Berkowitz. Appointed by the Institute of Medicine, she was respon- sible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the rapporteurs and the institution. ix

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Contents PREFACE xvii 1 INTRODUCTION 1 Scope of the Workshop, 2 Key Themes, 3 Organization of the Report, 4 2 DISPARITIES IN CHILDREN’S HEALTH: MAJOR CHALLENGES AND OPPORTUNITIES 7 References, 11 3 INVESTING IN CHILDREN’S HEALTH 13 Investments to Promote Children’s Health: A Systematic Literature Review and Economic Analysis of Interventions in the Preschool Period, 14 Study Objectives and Approach, 14 Tobacco, 15 Obesity, 15 Injuries, 17 Mental Health, 17 Conclusions, 18 Clinical Practice and Community Building: Addressing Racial Disparities in Healthy Child Development, 18 Common Factors and Consequences, 18 The Role of Clinical Practice in Addressing Disparities, 20 xi

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xii CONTENTS The Importance and Prevalence of Place, 20 Help Me Grow: A Model for Clinical Practice, 23 Implications for Practice and Research, 25 Open Discussion, 25 References, 26 4 FROM POLICY TO PRACTICE: HOW POLICY CHANGES CAN AFFECT CHILDREN’S LIVES 27 Changing Health Policy, Impacting Lives, 27 Rhode Island RIte Care, 28 Challenges, 29 Next Steps, 30 Healthy Kids, Smart Kids, 31 Discussion, 33 References, 34 5 COMMUNITY DEVELOPMENT APPROACHES: OVERCOMING CHALLENGES, STRIVING FOR CHANGE 35 Whitefoord Community Program: Caring for Children in the Context of Family, Home, and Community, 35 Community Needs, 36 Planning and Implementation, 37 Services and Staffing, 37 Funding, 38 Programwide Accomplishments and Individual Success Stories, 38 Accountable Communities: Healthy Together, 39 Health Data Collection and Community Listening Sessions, 40 Social Determinants of Health, 41 Establishing Priorities and Pilot Interventions, 46 Accomplishments and Challenges, 48 Racial and Ethnic Approaches to Community Health (REACH), 48 Health Disparities Can Be Overcome, 49 Why REACH Works, 50 REACH-ing Further, 51 Open Discussion, 52 References, 53 6 DO BUSINESSES HAVE A ROLE IMPROVING COMMUNITIES OR IMPROVING CHILDREN’S LIVES? 55 WellPoint, Inc., Blue Cross/Blue Shield, 56 Measuring Success: The Member Health Index, 56 Measuring Success: The State Health Index, 57

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xiii CONTENTS The WellPoint Foundation, 60 WellPoint Health Plan Programs: Reducing Disparities, 60 Bank of America, 62 The Employee Community, 62 Traditional Community Outreach, 62 Investing in Health, 63 Strategic Corporate Community Involvement, 64 ING Foundation, 65 Benefiting the Community and the Business, 66 Open Discussion, 66 7 CLOSING COMMENTS 69 Open Discussion, 69 Sustainability, 69 Total Health: Spirituality and Education, 70 Creating a Health Movement, 71 Conclusion, 72 APPENDIXES A WORKSHOP AGENDA 73 B BIOSKETCHES OF PRESENTERS AND AUTHORS 77 C RESOURCES 83 D SPECIAL PRESENTATION: UNNATURAL CAUSES 85 E CLINICAL HEALTH CARE PRACTICE AND COMMUNITY BUILDING: ADDRESSING RACIAL DISPARITIES IN HEALTHY CHILD DEVELOPMENT 87

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Tables, Figures, and Boxes TABLES 3-1 Examples of Reviewed Interventions, 16 E-1 Child Health Disparities in Context, 90 E-2 Racial Composition of Census Tracts by Child-Raising Vulnerability Status, 95 FIGURES 2-1 Determinants of health, 9 2-2 Population model of health promotion, 10 3-1 Comparison of selected disparities, 19 3-2 Outcomes of well-child care, 21 3-3 Child-raising vulnerability factors, 2000 Census data, 22 3-4 The importance/prevalence of place and race, 23 3-5 A model for clinical practice: Help Me Grow in Hartford, Connecticut, 24 5-1 All cancer deaths among males in Atlanta, Georgia, neighborhood planning units V and F, 1998–2002, 42 5-2 Type II diabetes prevalence among males in Atlanta, Georgia, neighborhood planning units V and F, 2002–2004, 43 xi

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x TABLES, FIGURES, AND BOXES 5-3 Type II diabetes prevalence among females in Atlanta, Georgia, neighborhood planning units V and F, 2002–2004, 44 5-4 Breast cancer incidence among females in Atlanta, Georgia, neighborhood planning units V and F, 1999–2002, 45 5-5 NPU-V resident ballot to establish community priorities, 47 5-6 REACH communities in the United States, 52 6-1 Mammography screening rates for Georgia, by ZIP code, 61 E-1 Children’s healthy development: Who sees young children?, 98 BOXES 6-1 WellPoint Member Health Index: Domains of Health Care and Clini- cal Areas, 57 6-2 WellPoint State Health Index: Activities Focused on Children, 59 E-1 Theory of Change Set of Testable Assumptions for Strengthening Pediatric Practices to Reduce Disparities in Healthy Child Development, 97

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Preface I n early 2007, the Institute of Medicine (IOM) of the National Acad- emies convened the Roundtable on Health Disparities to increase the visibility of racial and ethnic health disparities as a national problem, further the development of programs and strategies to reduce disparities, and track promising activities and developments in health care that could lead to dramatically reducing or eliminating disparities. The Roundtable on Health Disparities includes representatives from the health professions, state and local government, foundations, philanthropy, academia, advocacy groups, and community-based organizations. Its mission is to facilitate communication across sectors and—above all—to generate action. Through national and local activities, the Roundtable strives to advance the goal of eliminating health disparities. On January 24, 2008, the Roundtable on Health Disparities, in col- laboration with the Board on Children, Youth, and Families of the National Research Council and the IOM, held a workshop at the Morehouse School of Medicine’s Louis W. Sullivan National Center for Primary Care Audi- torium in Atlanta, Georgia. The Roundtable brought together a diverse group of experts from a variety of fields to discuss the relationship between socioeconomic conditions early in life and later health outcomes. Life course epidemiology has added a further dimension to our understanding of the social determinants of health by showing an association between early socioeconomic conditions and adult health related behaviors as well as adult morbidity and mortality. Realizing that the foundations of adult health and adult health behaviors are laid prenatally and early in child- hood, the Roundtable’s workshop focused on (1) describing the evidence xii

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xiii PREFACE linking early childhood life conditions and adult health outcomes; (2) dis- cussing the contribution of early childhood conditions to observed racial and ethnic disparities in health; (3) highlighting successful models that engage both community factors and health care factors that affect life course development; and (4) facilitating discussion of these issues among stakeholders in academia, community development, health care, business, and philanthropy. The workshop provided the Roundtable members with an opportunity to hear from a diverse set of people from across the country and to engage in an open dialogue about the relevant issues and concerns related to reducing health disparities. Additionally, workshop attendees offered differing perspec- tives and unique approaches to these issues. Together, research, experiences, evidence, and knowledge were shared across the two groups. ACKNOWLEDGMENTS The Roundtable on Health Disparities thanks all workshop partici- pants for their individual contributions to this workshop. Their willingness to share their time and expertise led to frank discussions about the long- term effects of social conditions during childhood. We especially want to extend thanks to Dr. David Satcher of the More- house School of Medicine and his staff for sponsoring and hosting the workshop in the Louis W. Sullivan National Center for Primary Care Audi- torium. Deborah Jones, in particular, was incredibly helpful at every step of the way as we organized the workshop. We are also indebted to Dr. Gary Nelson and Janette Blackburn from the Healthcare Georgia Foundation for sponsoring this workshop and for assisting with all aspects of the workshop planning. We also want to thank Dr. Charles Bruner and Dr. Edward Schor for their collaboration on the background paper that was commissioned by the Roundtable for this workshop. Their paper, “Clinical Health Care Practice and Community Building: Addressing Racial Disparities in Healthy Child Development,” is in Appendix E. We also want to thank Dr. Bernard Guyer for sharing his paper “Investments to Promote Children’s Health: A Sys- tematic Literature Review and Economic Analysis of Interventions in the Preschool Period” with the Roundtable. Biosketches for all presenters are in Appendix B. The Roundtable also thanks IOM staff for their ongoing efforts to sup- port the work of the Roundtable. Sincere gratitude is extended to Dr. Rose Marie Martinez, Director of the Board on Population Health and Public Health Practice; Jennifer Cohen, for planning, organizing, and implement- ing this workshop; and Thelma Cox for managing all of the administrative

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xix PREFACE components of the meeting. We also want to extend thanks to Christie Bell and Hope Hare for their ongoing assistance and support. Finally, special thanks to all of the sponsors who make the Roundtable on Health Disparities a reality. Financial support for the Roundtable and its activities was provided by the Agency for Healthcare Research and Quality in HHS; the Office of Minority Health in HHS; the California Endowment, the California Health Care Foundation; the Commonwealth Fund; the Con- necticut Health Foundation; the Ford Foundation; the Healthcare Georgia Foundation; the Henry J. Kaiser Family Foundation; Kaiser Permanente; Merck; the Missouri Foundation for Health; the Robert Wood Johnson Foundation; and the W.K. Kellogg Foundation. Dr. Nicole Lurie, Chair Roundtable on Health Disparities

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