Ending Unequal Treatment Strategies to Achieve Equitable Health Care and Optimal Health for All (2024) / Chapter Skim
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6 Community-Centered and Community-Engaged Care
6 Community-Centered and Community-Engaged Care
Pages 215-246
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This chapter reviews how the community embedded within the domains of health care law and payment policies, health care service delivery, discovery and evidence generation, and accountability can be a determinant of health and produce mechanisms central to developing and maintaining health equity. Recognizing that racial and ethnic differences structure the life opportunities of individuals, this chapter summarizes promising strategies and interventions for mitigating the health care inequities experienced by racially and ethnically minoritized and Indigenous populations, while acknowledging gaps in the literature.
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were compounded by neighborhoodbased risks to disproportionately produce substantial disparities in COVID-19 infection incidence, morbidity, and mortality in racially and ethnically minoritized counties. 1 See https://www.cms.gov/blog/cms-innovation-centers-strategy-support-high-quality-primary care (accessed April 29, 2024)
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Community members and organizations have firsthand knowledge and lived experience to know what is needed to improve the health and health care of racially and ethnically minoritized communities. Partnerships with communities can lead to interventions at multiple places in the care continuum, such as in individuallevel patient–provider interactions (e.g., community health worker [CHW]
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Some successful interventions have been designed and implemented by community-based participatory research (CBPR) approaches, embedding services within communities with active involvement of community members, and/or codesigning interventions with the community.
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. Successful use of CBPR interventions to improve health and health care outcomes for minoritized populations has been well-documented for various conditions (Afulani et al., 2021; Geronimus et al., 2020; Stokes and Wilson, 2022; Yonas et al., 2013)
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. Promoting Informed Prostate Cancer Screening Decision-Making To increase cancer screening decision making among African Ameri can men, a public health school in St.
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. This proved to be an innovative way to incorporate community health workers and health care technology strategies to enhance community empowerment and capacity to address the social needs of minoritized populations.
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Integrating Health and Social Care As discussed in Chapter 2, health and health care outcomes are driven by multiple factors beyond the health care system. As discussed in Chapter 5, community-based care models are effective to achieve health care equity and optimal health for all.
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Approaches used to engage community members can foster the participation of minoritized populations in identifying resources available to address SDOH, such as food insecurity. One group investigating nutritional resources accessible to African American community members in Los Angeles, for example, conducted surveys of market inventories and store conditions and found that the targeted areas were significantly less likely to carry healthy and quality food items (Sloane et al., 2003)
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Participants also experienced greater blood pressure control compared to those who did not have HRSNs and therefore did not receive support services. Patients requiring medication to lower their low-density lipoproteins also had larger improvements over those who screened negative and did not receive the support services.
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. A 2023 review of 152 studies on social care interventions with multiracial and multiethnic populations found that only 44 included race or ethnicity in the analyses, and only 21 looked for heterogeneous treatment effects among racially and ethnically minoritized populations, which may have differential effectiveness because of structural inequities (e.g., residential segregation)
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Integrating Community Members and Community Health Representatives into Health Care Settings Community members can be integrated into health care settings to bridge the gap between the health care system and the community. Box 6-2 summarizes several ways community members can be included to improve health and health care.
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. A systematic review of navigator interventions targeting minoritized populations, in cluding racially and ethnically minoritized, rural, urban low-income, and mixed-ethnic groups, found that they were correlated with positive health outcomes and effectively increased cancer screening knowledge and behaviors in low-income and racially and ethnically minoritized popula tions (Hou and Roberson, 2015)
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. Peer Support The Veterans Health Administration has implemented a peer support intervention, PARTNER-MH, to improve engagement in mental health care among racially and ethnically minoritized veterans (Eliacin et al., 2023)
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These successful Indigenous models of care demonstrate approaches that can be used more broadly in many Indigenous and non-Indigenous communities to build and maintain relationships between patients, providers, and community members and organizations; center community needs; uplift community voices; and emphasize the central role communities play in achieving health and health care equity. Examples of Models of Care and Approaches to Advance Health Care Equity in Indigenous Populations The Southcentral Foundation Nuka System of Care The Southcentral Foundation in Anchorage created the Nuka model for Alaska Natives living in the southcentral region of Alaska.
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Similar to Alaska Natives, Native Hawaiians experience significant and persistent health disparities (Mokuau et al., 2016)
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. For example, WCCHC implements the Chronic Care and Obesity Care Models to improve health and health care outcomes by linking primary care best practices and community-based programs (Okihiro et al., 2013)
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The Choctaw Nation of Oklahoma is the third largest Tribal Nation and owns and operates CNHS, created to provide health care services specifically for Choctaw people and other AIAN people living on or near the Choctaw Nation reservation.6 It includes a hospital and eight outlying clinics that provide quality-focused and holistic services with an emphasis on dignity, cultural values, and SDOH. The Choctaw Nation took over administration of what was originally an IHS hospital and three medical clinics in 1985.
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Due to the diversity of Indigenous peoples, an official definition has not been established, but the United Nations recognizes Indigenous peoples as those population groups who maintain several characteristics, including historical continuity with precolonial and/or presettler societies.11 Box 6-3 summarizes interventions used to advance health care equity for Indigenous populations in high-income countries with economy structures similar to those in the United States. 8 See https://www.choctawnation.com/services/chat/ (accessed April 29, 2024)
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Program to provide supportive research environments for Indigenous health research driven by and grounded in Indigenous communities in Canada.13 The British Columbia Network Environment for Indigenous Health Research (BC NEIHR) is one of nine Indigenous led networks across Canada that supports research leadership among Indigenous communities, collectives, and organizations (ICCOs)
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. Australia's Closing the Gap Initiative to Achieve Indigenous Health Equity The Australian federal government, prompted by the severe health inequities faced by Indigenous communities (Anderson et al., 2016)
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The new agreement as developed in partnership between the Australian government and the coalition, and the expertise and experience of the coalition and its membership have been central to the commitments. Interventions Designed by and Serving Indigenous Populations Interventions designed to achieve health and health care equity among U.S.-based Indigenous communities have been implemented in a variety of settings that serve a high population of Indigenous people, including through the IHS, Urban Indian Organizations, and IHS and tribally managed service units.15 Regardless of location, all interventions presented are characterized by their efforts to provide culturally centered health care and health promotion practices that are focused on the whole person and address the broader SDOH affecting Indigenous populations (Marmot et al., 2008)
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Community-led care and partnering with communities involves culturally centered health care and health promotion practices focused on the whole person and addressing the broader SDOH affecting communities. CHAPTER SUMMARY Since Unequal Treatment, recognition has been growing that the community is central to health and health care.
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Conclusion 6.4. Indigenous models of care are successful examples of prioritizing building and maintaining relationships between patients, providers, and community members and organizations, center community needs, uplift community voices, and emphasize sovereignty, Indigenous governance, and self-determination.
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drive-through collection site: A community-based participatory research partnership with a Federally Qualified Health Center. American Journal of Public Health 111(4)
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2022. Community based participatory research ap proaches to combat oral health inequities among American Indian and Alaska Native populations.
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2020. Peer support as an ideal solution for racial/ ethnic disparities in colorectal cancer screening: Evidence from a systematic review and meta-analysis.
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2016. On some practical considerations regarding com munity-based participatory research for addressing cancer health disparities.
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2021. Conducting community based participatory research with minority communities to reduce health disparities.
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2017. Reducing disparities in cancer screening and prevention through community-based participatory research partnerships with local libraries: A comprehensive dynamic trial.
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2006. Using community-based participatory research to ad dress health disparities.
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