The Role of Communities in Eliminating Health Disparities: Getting Down to the Grass Roots

Abstract

Racial disparities in health status and health care have been documented for decades, yet the exact causes of these disparities are unknown. It is known that an array of factors including personal risk, interaction with the physical and social environment in communities, and interaction with the health-care system influence health status. Efforts to eliminate health disparities will not succeed unless they include multipronged approaches focused on the multiple levels of causation. Much attention has been focused on causes of health-care disparities that operate primarily at the level of the individual and emphasize personal behaviors and individuals’ access to and experience in the health-care system. In addition, the role of individual health-care providers’ biased attitudes, stereotyping, and discrimination toward people of color is often offered as an explanation of health-care disparities. Barriers to accessing care and poorer quality of health care for minority populations have also received significant attention. Addressing individual patient or provider behavior can help to reduce but will not be sufficient to eliminate disparities. Individual characteristics and biology (e.g., race, sex, genes) contribute to health, but health status is largely determined by other factors including those that exist outside the health-care system. The health of individuals is determined by multiple factors including the extent and quality of health care, individual characteristics, family factors, exposure in communities, and by social and political factors. These factors influence access to health care and risk and personal health behaviors. The decision to engage in specific ­personal health behaviors (smoking or regular exercise, for example) is not made in isolation but is influenced by community characteristics, environmental conditions, and social and economic factors (McGinniss and Foege, JAMA 270:2207–2212, 1993; Flournoy and Yen, The influence of community factors on health: an ­annotated ­bibliography. Oakland: PolicyLink and The California Endowment, 2004). Access to affordable food, tobacco products, and illicit drugs vary ­significantly in ­communities across the USA and have been demonstrated to influence personal health behaviors. Asthma, heart disease, diabetes, HIV and AIDS, and poor birth outcomes such as low birth weight are some of the conditions that are highly prevalent in communities of color. Communities that suffer disproportionately from disparities in health also bear a higher burden of physical and mental illness, disability, and mortality. This burden has an immense influence on economic and educational opportunities, leading to a vicious cycle of socioeconomic inequality and poor health. This chapter provides an overview of the relationship between health and community conditions, specifically related to understanding disparities in health. The chapter will also describe community-based and community-driven efforts that can help to make substantial progress toward improving the health of populations that experience the greatest health disparities.