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Introduction

When researchers and policy makers discuss the differential health outcomes for racial and ethnic minorities, what language is appropriate to describe these differences? Are they “disparities”? “Inequalities”? “Inequities”? The definition used depends on how the differences are framed. How people talk about these issues has everything to do with public interest in the topic, what is understandable to people, and what energizes and engages them. The present workshop, then, focused on how these disparities should be framed and how this framework relates to the ways in which disparities are discussed at the community level and across the country.

This workshop follows two earlier workshops convened by the Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities. The first, held in St. Louis, Missouri, focused on the interface between the health care system and the community in which it is based. The second, held in Atlanta, Georgia, looked at disparities in health outcomes across the life span, with a particular emphasis on young children.

SCOPE OF THE WORKSHOP

On July 28, 2008, the Institute of Medicine’s Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities sponsored a public workshop to discuss the role of framing health disparities in diverse communities in reducing health disparities. Because California is a state that has experienced—and that continues to experience—dramatic demographic shifts, the Roundtable thought that it was an important locale to look at the importance of framing health disparities for a range of dif-



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1 Introduction When researchers and policy makers discuss the differential health outcomes for racial and ethnic minorities, what language is appropriate to describe these differences? Are they “disparities”? “Inequalities”? “Inequi- ties”? The definition used depends on how the differences are framed. How people talk about these issues has everything to do with public interest in the topic, what is understandable to people, and what energizes and engages them. The present workshop, then, focused on how these disparities should be framed and how this framework relates to the ways in which disparities are discussed at the community level and across the country. This workshop follows two earlier workshops convened by the Round- table on the Promotion of Health Equity and the Elimination of Health Disparities. The first, held in St. Louis, Missouri, focused on the interface between the health care system and the community in which it is based. The second, held in Atlanta, Georgia, looked at disparities in health outcomes across the life span, with a particular emphasis on young children. SCOPE OF THE WORKSHOP On July 28, 2008, the Institute of Medicine’s Roundtable on the Pro- motion of Health Equity and the Elimination of Health Disparities spon- sored a public workshop to discuss the role of framing health disparities in diverse communities in reducing health disparities. Because California is a state that has experienced—and that continues to experience—dramatic demographic shifts, the Roundtable thought that it was an important locale to look at the importance of framing health disparities for a range of dif- 

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2 DEMOGRAPHIC CHANGES, A VIEW FROM CALIFORNIA ferent racial and ethnic groups. Framing, Roundtable Chair Nicole Lurie noted, is critical in determining how disparities are discussed. The workshop, titled America in Transition, a View from California: Implications for Addressing Health Disparities, was organized to advance the dialogue about health disparities by facilitating a discussion of the topic among stakeholders in the community, including residents, academia, health care, business, policy makers, and philanthropy. The goal of the meeting was to discuss how the framing of health disparities in diverse communi- ties influences the public debate about improving health outcomes. The workshop was also organized to help identify commonalities in community strategies, best practices, and lessons learned from community successes and failures in their attempts to address health disparities. As populations shift across a geographic area, there is often a redis- tribution of health risk factors and health problems that leads to a need to reassess the solutions that will best address these redistributions. By understanding how demographic shifts in communities are affecting health disparities, the strategies that communities develop may differ depending on the racial and ethnic composition of that community. How issues of health disparities are framed may also differ across different racial and ethnic groups. WORKSHOP AgENDA After two keynote speakers talked about the changing face of Ameri- can communities and the implications of these demographic transitions for California in particular, Lori Dorfman described the science of framing health disparities and its use in policy discussions. These three morning presentations were followed by panels from three California communities: East Palo Alto, Fresno, and South Central Los Angeles. Each of these communities is grappling with major demographic transitions. By bringing together a panel of individuals from each commu- nity, the purpose was to learn how different racial and ethnic groups work together to solve health disparities and how they frame health disparities within the community. The afternoon was spent in small breakout sessions facilitated by Roundtable members in which the community representatives talked with workshop attendees and Roundtable members about these issues in more detail and in a smaller setting and reported back on their discussions of the following topics and questions: • riefly talk about the demographic transitions that have occurred B over the past 10 to 15 years in your community. Are there “old”

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 INTRODUCTION versus “new” ethnic groups in your community? What, if any, has been the impact of immigration on your community? • hat assets have your community’s newer ethnic groups brought W to the community? • ave attitudes about race and expressions of racism changed with H the arrival of new community members? • escribe the major health and health disparity concerns in your D community. • ow has the community worked to address these health and health H disparity concerns? Specifically, how has your framing of these issues affected your progress? • ave the different racial and ethnic groups worked together? What H have been your successes in addressing these concerns? What have been your challenges in addressing these concerns? • hat suggestions on how to frame health disparity issues do you W have for other communities? KEy THEMES Throughout the workshop, the speakers and the workshop attendees highlighted several recurring themes: • raming. An understanding of framing is critical to understanding F how health disparities should be addressed. In particular, it needs to be recognized that the default frame in a culture of personal responsibility colors conversations about health disparities. • esidential segregation. The issues of gentrification, urban renewal, R and the historical practice of redlining all affect where low-income people of color can live. This, in turn, affects the health of low- income people of color. • ace and racism. Race interacts with the process of residential R segregation and thus cannot be ignored when health outcomes are being evaluated. • ack of access to health care. A lack of access to health care, L especially to specialty care, is a major problem for low-income individuals of color and their communities. • ack of community infrastructure. A lack of safe places to walk L and exercise and a lack of access to large grocery stores will have an impact on the health of the residents in that community. The skyrocketing obesity rates in some racial and ethnic minority groups are contributing to rising rates of chronic diseases, such as diabetes.

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 DEMOGRAPHIC CHANGES, A VIEW FROM CALIFORNIA • ther community factors. Poverty and violence are major contribu- O tors to health disparities for some racial and ethnic groups. • horter life spans for future generations. As several speakers noted, S if current trends continue, children today will not live as long as their parents do. Studies of foreign-born immigrants and their children who are born in the United States also indicate that the American-born children of immigrants have shorter life spans than their immigrant parents. ORgANIzATION OF THE REPORT The report that follows summarizes the presentations and discussions that occurred during the workshop. Therefore, its scope is limited to the views presented and discussed during the workshop. Chapter 2 reviews the changing demographics in the United States and in California in particular. E. Richard Brown, using data from the California Health Interview Survey, describes a number of health disparities among individuals in different racial and ethnic groups and notes the importance of having good data to document these disparities. Mindy Fullilove focuses on residential segregation and its history in the United States. She concludes that the ongoing problem of residential segregation is a major contributor to health disparities between people of color and other groups in society. The concept of framing is covered in Chapter 3. Lori Dorfman defines the term “framing,” describes its origins, and offers examples of how fram- ing works in news stories. Because the ways in which health disparities are framed have consequences for how people address these disparities, it is important to understand framing. Chapter 4 presents the stories of three different communities in California that have experienced major demographic shifts. Three panels, one for each community, describe how these demographic changes have influenced health outcomes and how framing can lead racial and ethnic subgroups to work together to reduce health disparities. After the presen- tation of the comments of the three panels, Tony Iton offers his reactions and observations. Finally, Chapter 5 describes the reports from the group breakout sessions in which the community representatives talked with workshop attendees and Roundtable members about these issues in more detail and concludes with comments from Roundtable Chair, Nicole Lurie. Several appendixes contain additional information about the work- shop. In addition to the meeting agenda (Appendix A) and biographical information about the speakers (Appendix B), Appendix C provides a list of relevant websites that the speakers mentioned in their presentations.