CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 15 • Number 3 • Fall 2002

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Special Focus: Eliminating Health Disparities

Interventions to Eliminate Health Disparities Are Innovative

To help the people hurt the most by disparities, public health workers are trying creative approaches that engage community members and new partners. Across the country, churches, schools, public housing authorities, hospitals, and health departments are teaming up to fight health disparities. 

Helping Black Teens Eat Healthier Foods and Be More Active
Children’s eating habits and physical activity decline during the early teen years, and the decline is especially acute for black teens. To counter this trend, CDC’s Division of Nutrition and Physical Activity has partnered with 100 Black Men of America (100 BMOA), the U.S. Department of Agriculture’s (USDA) Food and Nutrition Service, and the California Adolescent Nutrition and Fitness Program (CANFit) to work with 11– 18-year-old African American boys. They developed a curriculum-based program that teaches young people the benefits of good nutrition and physical activity, with the goal of preventing cardiovascular disease, diabetes, and hypertension.

CDC developed the curriculum to complement 100 BMOA’s existing guide, "Mentoring the 100 Way." The curriculum was revised after being tested in 100 BMOA’s chapters in Dallas, Los Angeles, and Atlanta. The extensive testing process included gathering feedback from the young people. It has since been expanded to include girls and is again being revised for use nationwide. A few professional men who are members of 100 BMOA were trained to use the curriculum. The training was conducted in Los Angeles by CANFit, which specifically addresses the needs of youth of color and also combines physical activity with nutrition. 

"One lesson learned is that it takes time, patience, and endurance to work with volunteer organizations," said Annie Carr, MS, RD, CDC Public Health Nutritionist. "We had to defer to their schedules and priorities." 

The interventions are culturally sensitive. For example, the chapter in DeKalb County, Georgia, integrated this curriculum into their program, which is based on Kwanzaa principles. The program empowers young men to conduct community environmental assessments. At one meeting site, for instance, participants created a directory of places where young people could be physically active. 

"The basis of the nutrition piece is teaching young people how to assess the fat and sugar content of foods," said Refilwe Moeti, MA, CDC Public Health Advisor. "For example, they learn to measure the equivalent of the grams of fat and sugar in particular foods." Because focus group results showed that these young people were frequent customers of fast food restaurants, they also learn how to assess the nutritional values of fast food items and select healthier foods from the menus. 

Another nutritional benefit is that the young people, about 12 to 15 per site, are served snacks. Meetings are after school or on Saturdays. At sites where the snacks are funded by USDA, the food and the serving sizes must meet USDA standards. Pure juice, not a juice drink, must be served, for instance. Making sure the snacks were healthy was a challenge when the meetings were held at youth clubs that had soda contracts. 

 
Reaching Boston’s Poorest Residents 
The Boston University School of Public Health (BUSPH) Prevention Research Center (PRC) is working with public housing residents, the Boston Housing Authority, and the Boston Public Health Commission to improve the health of the city’s 26,000 public housing residents. Boston’s public housing residents are some of the city’s poorest, having an average income of $11,000. They are 35% Hispanic, 30% black, 23% white, and 8% Asian. Robert Meenan, MD, MPH, MBA, BUSPH dean and the PRC’s principal investigator, said that 40% of Boston’s public housing residents are children and 15% are elderly. 

In addition, noted Dr. Meenan, their health status is poor. Black infant mortality rates have remained high despite improved access to care. Half the residents are current smokers, three times the rate found in the rest of Boston. Because the city’s 64 developments are in poor, often industrial locations, residents are exposed to environmental hazards as well. They also face high stress related to crime, isolation, and lack of adequate nutrition. 

Projects under way in the BUSPH Prevention Research Center are designed to promote physical activity and self-esteem among young girls, prevent domestic violence, increase breast and cervical cancer screening, and establish a new database on the health status of public housing residents. 

Boston University School of Public Health has a history of working with housing authorities that precedes the existence of the Prevention Research Center. In one program, returning Peace Corps volunteers received a BUSPH Health and Housing scholarship toward their MPH degree, were provided an apartment by the housing authority, and worked to coordinate public health-related services for residents. Services included flu shots, tobacco control programs, and computer labs. That program is no longer active, but another program has since been started, with funding from the Department of Housing and Urban Development (HUD), that focuses on improving indoor air quality in Boston public housing and reducing the health impacts of asthma on residents. 

Dr. Meenan hopes to expand the PRC program to involve public housing authorities in nearby cities. 

Reaching the Border Population 
The University of Arizona Prevention Research Center is searching for practical interventions that will improve the health of border populations. Special Action Groups that include key community members are formed to address problems like finding places for people to walk. Some groups have designed paths for walking and biking and had them approved by the city. Another group convinced the county to award it a Community Development Block Grant for a new park. 

In Nogales, one of the Special Action Group’s goals was getting rid of school vending machines or radically changing their contents. One school now offers students fresh fruits and carrot sticks as rewards rather than the snack foods given at many other schools. 

The Arizona PRC (known as the Southwest Center for Community Health Promotion) also has offered nutrition classes in communities and food demonstrations at supermarkets. One intervention was so successful that some stores had to begin ordering more low-fat dairy products. 

In clinics, the PRC aims to change the behavior of providers, partnering with the clinic to set benchmarks for critical services, tracking the services being provided to diabetic patients and providing feedback on the providers’ effectiveness in meeting their own goals. With patients, they try to increase and improve self-management practices. One strategy targets family members so they can be supportive of the patient. The whole family gets support and education. 

"Our chronic disease prevention strategy is to fully engage the community as partners, mount comprehensive interventions, and emphasize policy change at the community, state, or even national levels," said Joel Meister, PhD, Co-Director for Community Programs. "And so far it’s working!" 

REACH 2010 
Communities participating in CDC’s Racial and Ethnic Approaches to Community Health (REACH 2010) project are encouraged to be creative in their search for successful programs to end health disparities, particularly interventions that can be replicated in other settings. "Racial and ethnic disparities have been resistant to traditional change strategies," noted Pattie J. Tucker, DrPH, RN. She is responsible for data collection and evaluation activities for REACH 2010, which oversees 37 demonstration projects across the country. 

Grantees include universities, hospitals, community-based organizations, and health departments. To spur new partnerships, community-based organizations are required to form coalitions with three other organizations, one of which must be a health department, university, or other research organization. 

The coalitions are urged to form new relationships that can strengthen the community. In Chicago, for example, REACH 2010 staffers worked with churches to encourage low-income women to seek screening for breast and cervical cancer. This effort brought together members of the African American and Hispanic communities. 

Coalitions also have been successful in finding new ways to engage community members. In Lowell, Massachusetts, where cardiovascular disease and diabetes among the Cambodian community is targeted, older refugees were influential but isolated by language barriers. Forming a council of Cambodian elders has been an important step in increased community involvement. 

The program’s strong evaluation component adds value to project activities. "For example, in the Texas migrant health project, promotores [lay health workers] are being used," said Imani Ma’at, EdD, Director of REACH 2010. "It’s not a new idea, but it may not have been documented and evaluated as we are doing." 

Making REACH 2010 results useful to others is just as important as developing strategies specific to communities. A data warehouse is being established to identify similarities among projects. "This will make it easier to pull out similar activities by topic or racial/ethnic group," noted Dr. Ma’at. 

The next step is to develop a plan for translating and disseminating the REACH 2010 research findings so that others can use the information to develop effective interventions. Community involvement is an important part of the plan, said Dr. Ma’at, because REACH 2010 is "very much about community empowerment."

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