PLAGIARISM FREE "A" WORK IN 18 HOURS

CHE 6305, Issues and Trends in Community Health 1

Course Learning Outcomes for Unit II Upon completion of this unit, students should be able to:

2. Assess public health problem-solving methodologies to propose new interventions and policy alternatives. 2.1 Apply a model or theory of social and behavioral sciences to the challenges of community

health.

5. Discuss the methods used to solve current public health problems. 5.1 Identify a public health problem that needs to be addressed in a specific community. 5.2 Combine health promotion theory and practice models to create all-inclusive methods in

community health science.

Course/Unit Learning Outcomes

Learning Activity

2.1

Unit Lesson EBook: Using Theory to Guide Change at the Individual Level. In Health

Promotion Theory (2nd ed., pp. 65–78) Unit II Scholarly Activity

5.1

Unit Lesson Chapter 2, pp. 46–48 Chapter 8, pp. 140–145 Video: Minority Health Disparities | Michelle’s Story Unit II Scholarly Activity

5.2

Unit Lesson Video: Minority Health Disparities | Michelle’s Story EBook: Using Theory to Guide Change at the Community Level. In Health

Promotion Theory (2nd ed., pp. 79–96) Unit II Scholarly Activity

Required Unit Resources Chapter 2: What Are Health Disparities?, pp. 46–48 Chapter 8: Reducing Healthcare Disparities Through Physician–Patient Partnerships, pp. 140–145 In order to access the following resources, click the links below. Davies, M., Macdowall, W., & Cragg, L. (2013). Using theory to guide change at the individual level. In Health

promotion theory (2nd ed., pp. 65–78). McGraw-Hill Education. https://libraryresources.columbiasouthern.edu/login?url=http://search.ebscohost.com/login.aspx?direc t=true&db=e000xna&AN=666066&site=ehost-live&scope=site

Davies, M., Macdowall, W., & Cragg, L. (2013). Using theory to guide change at the community level.

In Health promotion theory (2nd ed., pp. 79–96). McGraw-Hill Education. https://libraryresources.columbiasouthern.edu/login?url=http://search.ebscohost.com/login.aspx?direc t=true&db=e000xna&AN=666066&site=ehost-live&scope=site

UNIT II STUDY GUIDE

Community Health Theories, Models, Disparities, and Social Determinants

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John Hopkins Medicine. (2017, April 18). Minority health disparities | Michelle’s story [Video]. Cielo24. https://c24.page/vgpmn99szerkc57pjm89d7p596

Unit Lesson

Introduction Understanding both disparities and the social determinants of health is critical because they explain the inequalities and other issues that exist in community health today. They also give background knowledge on how the overall health for a particular population is affected by these disparities. For example, minorities generally receive limited access to health care due to a lack of insurance coverage. Another example would be that patients who have state insurance such as Medicaid may not be able to receive the services they need because they are not covered, or they are subjected to a longer wait list when compared to patients who have private or commercial insurance such as Blue Cross Blue Shield or Medicare. Health promotion theories, models, and frameworks collectively provide an explanation to the health behavior seen in the community and amongst its members. They can provide clarification as to why these issues and trends are occurring. In order to remedy some of these issues, a needs assessment must be completed, followed by program planning and an intervention. In this unit, we will discuss the definition of disparity. We will examine how disparities affect different populations including those based on gender, geographic regions, and ethnicity. Lastly, we will discuss common theories, models and frameworks used for behavioral change, the role of a needs assessment, and the importance of program planning and interventions.

Disparity Defined The term health disparity has had several definitions throughout the years. It has repeatedly been changed or updated, depending on the organization defining it. In 2008, the U.S. Department of Health and Human Services defined health disparity as a difference in health care related to one’s social, environmental, and economic status, which negatively affects people based on their demographics, gender, and much more (The Secretary’s Advisory Committee, 2008). The National Institutes of Health (2010) suggests health disparities are health conditions, only existing in certain groups, which results in a higher rate of diseases and death. Conversely, in 2011, the Centers for Disease Control (CDC) presented a more recent definition and defined health disparities as “…differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental, and geographic attributes” (p. 3). It has continued to evolve as the populations and communities change. For the purpose of this course, we will use the CDC’s definition.

The Major Health Disparities and Their Determinants As mentioned above, disparities measure the effects of health disparities amongst populations created by the major determinants such as “…conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (Office of Disease Prevention and Health Promotion [ODPHP], n.d. para. 4). The ODPHP (n.d.) also lists, in Healthy People 2020, five areas affected by these determinants, including “economic stability, education, social and community context, health and health care, and neighborhood and built environments” (para. 6). Disparities occur as a result of social determinants.

Economic Stability When economic stability is visible in a community, there will be steady output growth as well as minimal fluctuations coupled with low inflation. When this happens, it results in more purchasing power, meaning the dollar is worth more. The United States has experienced instability, such as during the COVID-19 pandemic. During the first few months of the pandemic, the federal government injected trillions of dollars received from the federal reserves, which is a loan, to help stimulate the economy. This pandemic caused a higher demand on goods and services. Hundreds of companies across the United States had to reduce their staffing levels, and, in some cases, shut down all together. When this occurs, it creates a high demand for the products they

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manufacture, but the lower production output creates inflated costs. For example, toilet paper would cost $1.99, pre-pandemic, but during the pandemic, that same product doubles in price. For this reason, regulations were put in place to prevent price gauging. On the other hand, products may stay the same price, but the quantity shrinks. For example, prior to the pandemic, there were no restrictions on purchase amounts for cases of water or hand sanitizer. However, during the pandemic, customers are limited to one case or bottle per visit. When social determinants are present in the community, it causes disparities in employment, food security, housing, and poverty levels. Only certain groups of people will be able to attain ideal jobs, live in adequate housing, and live above poverty levels. There is also a clear link between employment and health. Those who are categorized as having low income tend to have a higher risk of developing health related issues.

Education The Constitution of the United States (Article 25) establishes that education is a basic human right, and it must be made available for all. However, disparities in the quality of education occur across the country. This can be seen with low graduation rates, unequal resources, and funding in underprivileged communities or populations. For example, schools in poverty-stricken areas tend to consistently have lower graduation rates coupled with higher dropout rates when compared to higher socioeconomic areas (Baydu et al., 2013). They also receive fewer resources needed for success, including fewer supplies, outdated materials, and limited or no access to technology. They also contend with oversized classrooms. All of these factors result in a gap in the quality of education for the students in these areas. Due to the COVID-19 pandemic, many schools were shut down and transitioned to a virtual learning platform. Many schools in the Detroit Public Community School District (DPCSD) were ill-equipped due to the lack of technological resources. They have since recently announced the acquisition of laptops and internet access for all of their students due to several businesses donating to DPCSD. However, students will not receive these tools until June, after the official school year ends, which puts these students even further behind. Disparities in health lead to poor education. Reciprocally, poor education results in poor health. The lack of a well-rounded education can lead to bad decision-making that revolves around all aspects of one’s health. For example, something as simple as preparing a balanced meal can be challenging for those who do not understand proper nutrition. This can lead to health-related diseases such as obesity or diabetes.

Social and Community Context The social and community context refers to the social setting where people live and also include how they interact in the community. This can be a social gathering, churches, and places of work. Healthy People 2020 suggests discrimination and incarceration are also factors. For example, poverty-stricken communities tend to have higher incarceration rates of Blacks when compared to Whites. According to Weidner and Schultz (2019) Black people are incarcerated at a rate six times higher than Whites. They also suggest poor education levels and poverty as possible factors for incarceration.

Health and Health Care Healthy People 2020 indicates health and health care refers to access to health care and primary care as well as health literacy. Health care should be provided for all citizens no matter where they live, how much they earn, or their race; however, this is not the case. Disparities in health care still exist today, particularly in minority groups. These groups disproportionately receive limited health care due to lack of insurance, limited access to health care resulting in higher rates of preventable, and treatable diseases (Jackson & Gracia, 2014). Primary care refers to generalized treatments received from doctors, nurses, and physician assistants. In other words, they do not have a specialty; they are general practitioners (GP). They provide you with knowledge necessary to help you prevent and or treat health related conditions. For example, it is customary to receive an annual check-up. During these visits, basic vitals and conditions are checked, such as blood pressure, weight, temperature, and cholesterol. If there is a problem in any of these areas, the primary care physician implements a plan to improve these areas. However, if there was a concern with a specific area, such as a skin condition, the patient would then be referred to a specialist known as a dermatologist. Primary care also integrates behavioral health into patient treatment. For example, during the annual check-up,

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patients answer a question related to depression. If the score is high, treatment options are discussed. The patient may also then be referred to a behavioral health specialist such as a psychologist or psychiatrist. However, quality primary care is not provided equally for everyone, as disparities occur within underserved communities. Research indicates primary care treatment received by minorities is significantly lower than that received by Whites (Cooper, 2004). This could be due to the limited access to primary care in these particular areas (Brown et al., 2016). Health literacy is defined as one’s ability to obtain, interpret or comprehend, and communicate all aspects related to health. However, when there is limited education or low education levels, it makes it challenging for certain people in disadvantaged communities to be health literate. Conversely, if a person has difficulty understanding health-related information as it pertains to them, then they are also considered to be health illiterate and cannot make informed decisions. For example, calculating medicine dosages would be difficult to accomplish. Research suggests there is a positive correlation between low health literacy and economically disadvantaged communities (Knighton et al., 2017).

Neighborhood Environments Neighborhood environments include the surroundings or conditions in which a person lives or operates. A health community is one with access to healthy and nutritious foods. In contrast, a poor community is one where food deserts exist. A food desert is a locality where access to high quality foods such as fresh fruits and vegetables is limited. Community members are inclined to make food choices based on what is readily available to them. For example, if fast-food restaurants are plentiful and close in proximity, more families will eat there. The same is true with food prices. Healthier foods tend to cost more money. If a family is on a fixed income or receiving government assistance, cheaper and unhealthy foods will be purchased. More food items can be purchased for less. However, cheaper food items tend to be high in fats and sugars while lower in nutritional value, all of which results in an increased risk of obesity.

Theories and Models Theories, models, and frameworks are used to help explain behaviors in the community. They also are used to promote behavior change and disease prevention as well as for the implementation of program planning and interventions. Theories are used in various stages, including planning, implementing, and the evaluation stage of the intervention. Theories are used to not only explain the behavior exhibited in a particular group or community, but they are also used to predict the possible outcomes. Using theories helps the program planner gather critical information from the population that could potentially help the overall success of the intervention, which is hopefully, changed behavior. For example, theories start by identifying a problem such as diabetes in minorities. Theories then delve deeper to trying to answer questions, such as: Why do minorities have a higher rate of diabetes? What can be done to decrease these numbers? How should the problem be approached and implemented? Theories help to really analyze the community health problem. However, theories and models themselves do not offer any topic areas; they only provide a guideline for how the problem should be approached. Models use one or more theories to explain the psychology behind a behavior. Based on the desired outcome of the program, certain elements of these theories, models, and frameworks may be used as strategies to reach certain targets.

Theories Two common theories used in program planning are the Social Cognitive Theory (SCT) and the Theory of Reasoned Action/Planned Behavior. The SCT suggests an individual’s ability to change is contingent on several factors including self-efficacy, reinforcements, expectancies, self-control, observational learning, behavioral capability, and expectations. The SCT is used to create a roadmap to changed behavior. In contrast, the Theory of Reasoned Action/Planned Behavior implies one’s health behavior is indicative of his or her attitude toward the behavior and his or her perceived control over the behavior.

Models Three popular models used to describe behavior include the Ecological Model, the Health Belief Model, and the Stages of Change Model. The Ecological Model proposes multiple levels influence behavioral changes.

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These levels include public policy, community, organizational, interpersonal, and individual. Using this model, change occurs when multiple levels are utilized. For example, if there was a need to change activity levels in the community, one may use a strategy that encompasses the organizational level, the interpersonal level, and the individual level collectively. The Health Belief Model is used to predict behavior by focusing on perceived susceptibility, perceived severity, perceived benefits, cues to action, and self-efficacy. The Stages of Change Model suggests change occurs in stages beginning with the pre-contemplation stage, contemplation, preparation, action, and ending with maintenance, and/or relapse. In each stage, a different strategy is used to move them to the next level. For example, if a smoker is in the preparation stage, they are preparing to stop smoking within the next 30 days. During this stage, they have started to make small changes to help them be successful. This will prepare them for the next phase, action, where they have stopped and are trying to continue to not smoke.

Needs Assessments, Program Planning, and Interventions A needs assessment is used in a community to identify and analyze areas of concern. It helps to highlight the health needs of the community (Bani, 2008), which is then used to create and implement a plan. Several tools are used to gather valuable information, including surveys, focus groups, and interviews with stakeholders. Once the needs assessment identifies a problem or areas of concern, program planning can occur. A program plan is similar to a design blueprint. It indicates what should be done from start to finish. The program plan also includes a description of what should be done at each step along with recommended resources; however, an intervention is then taken in order to remedy the problem uncovered in the needs assessment.

Conclusion In conclusion, social determinants affect all aspects of health, which lead to disparities. One way to help close this gap or reduce the disparities is to understand the link between the two and how it negatively affects the health of those living in an underserved community. Utilizing models, theories and needs assessments not only helps to understand the behavior of these individuals, but also highlights areas or concern. It is only at this point where program planning and interventions can begin.

References Bani, I. A. (2008). Health needs assessment. Journal of Family & Community Medicine, 15(1), 13–20. Baydu, M. M., Kaplan, O., & Bayar, A. (2013). Facing the influence of poverty on graduation rates in public

high schools. Procedia – Social and Behavioral Sciences. 84. 233–237. https://www.sciencedirect.com/science/article/pii/S187704281301608X

Brown, E. J., Polsky, D., Barbu, C. M., Seymour, J. W., & Grande, D. (2016). Racial disparities in geographic

access to primary care in Philadelphia. Health Affairs, 35(8). https://doi.org/10.1377/hlthaff.2015.1612

Centers for Disease Control and Prevention. (2011, January 14). CDC health disparities and inequalities

report – Unites States, 2011. Morbidity and Mortality Weekly Report, 60, 1–116. Retrieved from https://www.cdc.gov/mmwr/pdf/other/su6001.pdf

Cooper L. A. (2004, September). Health disparities. Journal of General Internal Medicine, 19, 985–986.

https://doi.org/10.1111/j.1525-1497.2004.46002.x Jackson, C. S., & Gracia, J. N. (2014). Addressing health and health-care disparities: The role of a diverse

workforce and the social determinants of health. Public Health Reports, 129(1, Suppl 2), 57–61. https://doi.org/10.1177/00333549141291S211

Knighton, A. J., Brunisholz, K. D., & Savitz, S. T. (2017). Detecting risk of low health literacy in disadvantaged

populations using area-based measures. eGEMS, 5(3), 7. https://doi.org/10.5334/egems.191

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National Institutes of Health. (2010, September 27). NIH announces institute on minority health and health disparities. https://www.nih.gov/news-events/news-releases/nih-announces-institute-minority-health- health-disparities.

Office of Disease Prevention and Health Promotion. (n.d.) Social determinants of health: Overview. Healthy

People. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for

2020. (2008, October 28). Phase I report: Recommendations for the framework and format of Healthy People 2020. U.S. Department of Health & Human Services. https://www.healthypeople.gov/sites/default/files/PhaseI_0.pdf

Weidner, R. R., & Schultz, J. (2019, December). Examining the relationship between U.S. incarceration rates

and population health at the county level. SSM - Population Health, 9, 100466. https://doi.org/10.1016/j.ssmph.2019.100466

Learning Activities (Nongraded) Nongraded Learning Activities are provided to aid students in their course of study. You do not have to submit them. If you have questions, contact your instructor for further guidance and information. Check your understanding of key terms from this unit by working through the Unit II Flash Cards. Unit II Flash Cards PDF