Conclusion and Future Directions: CDC Health Disparities and Inequalities Report — United States, 2013

Pamela A. Meyer, PhD1,

Ana Penman-Aguilar, PhD2,

Vincent A. Campbell. PhD3,

Corinne Graffunder, DrPH4,

Ann E. O'Connor, MPA5,

Paula W. Yoon, ScD6

1 Office for State, Tribal, Local and Territorial Support, CDC

2Office of Minority Health and Health Equity, CDC

3National Center on Birth Defects and Developmental Disabilities, CDC

4Office of the Associate Director of Policy, CDC

5Office of the Associate Director for Program, CDC

6Center for Surveillance, Epidemiology and Laboratory Services, CDC

The reports in this supplement document persistent disparities between some population groups in health outcomes, access to health care, adoption of health promoting behaviors, and exposure to health-promoting environments. Some improvements in overall rates and even reductions in some health disparities are noted; however, many gaps persist. These finding highlight the importance of monitoring health status, outcomes, behaviors, and exposures by population groups to assess trends and target interventions. In this report, disparities were found between race and ethnic groups across all of the health topics examined. Differences also were observed by other population characteristics. For example, persons with low socioeconomic status were more likely to be affected by diabetes, hypertension, and human immunodeficiency virus (HIV) infection and were less likely to be screened for colorectal cancer and vaccinated against influenza.

CDC plays a key role in addressing disparities by collecting and analyzing data and identifying, monitoring, and reporting differences and trends. CDC's national survey data and some state level data are used by the Healthy People initiative to monitor trends in health outcomes and determinants. The Healthy People initiative provides goals and objectives with 10-year targets designed to guide national health promotion and disease prevention efforts to improve the health of all persons in the United States. It is grounded in the principle that setting national objectives and monitoring progress can prompt action and improve health. The Healthy People 2000 initiative had goals to reduce health disparities among persons in the United States. Healthy People 2010 added elimination, not just reduction, of health disparities, and Healthy People 2020 goes even further to achieve health equity, eliminate disparities, and improve the health of all population groups (1). State and local health departments use the Healthy People program as a way to track the effectiveness of local health initiatives.

This supplement provides decision makers with information that they can use to select interventions for certain populations to reduce health disparities. There is a growing awareness that limited health-care coverage and lack of access are only part of the reason why health disparities exist. Many of the strongest predictors of health are social, economic, and environmental factors. Reducing disparities requires national leadership to engage a diverse array of stakeholders; facilitate coordination and alignment among federal departments, agencies, offices, and nonfederal partners; champion the implementation of effective policies and programs; and ensure accountability (2). In addition, a complementary national strategy is required that focuses on a comprehensive, community-driven approach to reduce health disparities in the United States and achieve health equity through collaboration and synergy (3).

Data to Identify Health Disparities

A persistent barrier to documenting health disparities is the lack of data on certain population characteristics. All of the reports in this supplement (n=29) examined differences by race/ethnicity. The next most frequent population characteristics that were examined were age (n=24), sex (n=24), education (n=17), poverty (n=14), place of birth (n=11), and disability (n=nine). The least frequently reported characteristics were the language spoken at home (n=four) and sexual orientation (n=one). Only the paper on HIV infection reported rates by sexual orientation. Some data sources used in this report have very limited information on social and demographic characteristics. For example, death certificates do not have information on sexual orientation, poverty level, or disability (4). Some national health surveys have begun to collect data on sexual orientation, but there are issues that affect the usability of this data. In many instances, the sample sizes are too small to provide meaningful estimates for categories other than heterosexual, and the response rate to the questions on sexual identity is often low. In addition, lack of familiarity with terminology used to describe sexual orientation might have resulted in some misclassification (5).

To promote uniform collection of data on sex, race, ethnicity, primary language, and disability status, in October 2011, the U.S. Department of Health and Human Services (HHS) promulgated standards pursuant to Sec. 4302 of the Patient Protection and Affordable Care Act (ACA) (6). The standards were developed by the Section 4302 Workgroup organized by the HHS Data Council in collaboration with the Office of Management and Budget (OMB) and the U.S. Census Bureau. These data standards apply to all population health surveys conducted or supported by the federal government that use self- or proxy-reported data "to the extent practicable." The recommended data standards require that questions be tested and demonstrate adequate performance in national surveys and comply with any existing mandates by OMB (7). The recommended questions are considered to be a minimum set, and additional questions can be asked in surveys "provided that the additional detail could be aggregated back to the minimum standard and the sample design and sample size support estimates at that level of granularity" (7). The purpose of this provision of ACA is to provide standard approaches for collecting, analyzing, and reporting on health disparities that might exist between various demographic segments of the U.S. population. A standard set of questions to be asked in all national population surveys will improve understanding of the role of certain conditions as a risk factor for preventable poor health. CDC is evaluating the feasibility of incorporating the new data standards into many of its surveys and public health surveillance systems. Some modes of questionnaire administration might not readily support elements of the data standards because of the length of time needed to collect the data. For example, the 2011 data standard for classifying race establishes 14 categories that can be collapsed into the five categories established in 1997 by OMB. The 14 categories are preferred when sample sizes can support the increased detail. More than one race can be specified but there is no "multiracial" category.

Although a mandatory minimum set of six questions was established for determining disability status, no provision exists for modifying data collection modes to accommodate the new questions. One of the questions is, "Are you deaf or do you have serious difficulty hearing?" Notably, persons with serious hearing difficulties might not be able to participate in telephone surveys without the assistance of a Telecommunications Relay Service or other adaptive telephone equipment or services, making it problematic to collect reliable information on the prevalence of this disability and health outcomes for which they might be at risk. Another option for gathering data on persons with serious hearing difficulty is internet panel surveys.

CDC Initiatives to Reduce and Prevent Health Disparities

CDC is conducting many activities that support reducing health disparities and promoting health equity. For example, CDC provides technical support to the independent Community Preventive Services Task Force (Task Force). The Task Force makes recommendations based on systematic reviews of published studies on many important public health topics (8). These recommendations identify programs, services, and policies proven effective in a variety of real-world settings (e.g., communities, worksites, schools, and health plans). One topic the Task Force considered was effectiveness of interventions to improve colorectal, breast, and cervical cancer screening. After reviewing the evidence, the Task Force recommended nine strategies for helping bring those who are eligible for colorectal, breast, and cervical cancer screening to the point of care, including such services and programs as client reminders, one-on-one education, reducing structural barriers (e.g., providing scheduling assistance and transportation and offering extended hours), and provider reminders to screen patients. Many of these services have been effective for underserved populations and communities that are at greatest risks for cancer (9).

CDC's Office of Minority Health and Health Equity (OMHHE) advances policy, scientific, and programmatic efforts to eliminate health disparities affecting populations at social, economic, or environmental disadvantage and achieve health equity in the U.S. population. For example, OMHHE provides leadership in the development and promotion of Healthy People 2020 Social Determinants of Health objectives and is leading an effort to compile promising practices and strategies used by CDC-funded programs to address health disparities. Through all of its activities, OMHHE focuses attention on efforts to achieve health equity, facilitating implementation of relevant policies, furthering the science of health equity and its application, and building and strengthening national and global partnerships for health equity.

CDC provides scientific and technical support to the National Prevention Council. Created by ACA, the National Prevention Council developed the National Prevention Strategy (NPS) to realize the benefits of prevention for all persons in the United States. Eliminating health disparities is one of four strategic directions identified in NPS (2). NPS recommends five approaches to reducing disparities: 1) focus on communities at greatest risk, 2) increase access to quality health care, 3) increase workforce capacity to address disparities, 4) support research to identify effective strategies to eliminate disparities, and 5) standardize and collect data to better identify and address disparities. Recognizing that disparities are closely linked with social, economic, and environmental disadvantage (e.g., lack of access to quality affordable health care, healthy food, safe opportunities for physical activity, and educational and employment opportunities), the National Prevention Council has representation from 20 federal departments including Agriculture, Housing and Urban Development, Defense, Education and Transportation, and is chaired by the Surgeon General.

CDC supports the implementation of the National Prevention Council Action Plan (10). The plan outlines the Federal commitment to implementing the vision, goal, and recommendations of NPS. CDC is working with the U.S. Department of Housing and Urban Development and the Environmental Protection Agency on Health Impact Assessments (HIAs). HIAs examine ways to create healthy communities, provide health protection, and promote health.

CDC also works to reinforce cross-sector collaborations that can advance CDC programs, priorities, and initiatives. CDC's Community Transformation Grant (CTG) program seeks to improve health and wellness by implementing strategies included in NPS. CTG communities are engaging partners from multiple sectors, such as education, transportation, housing, and business, to create healthier communities where persons work, live, learn, and play. CDC's grant programs strive to achieve the greatest possible health impact and eliminate health disparities. Since October 1, 2012, all CDC domestic nonresearch funding opportunity announcements require that grantees describe how health disparities will be addressed, where relevant. When addressing health disparities, CDC programs might require grantees to identify existing health disparities in their communities and develop or implement evidence-based strategies to address those disparities.

Future Directions

Despite persistent racial, ethnic, and socioeconomic gaps in health care and health status, awareness of such disparities remains low among the general public (11). Much can be accomplished within the health and public health arena; however, the multiple and complex web of causes of health disparities can be fully addressed only with the involvement of many partners in fields that influence health such as housing, transportation, education and business. Identifying disparities and monitoring them over time is a necessary first step toward the development and evaluation of evidence-based interventions that can reduce disparities. CDC will continue to document health disparities and promote awareness of disparities as part of its contribution to the national goal to eliminate health disparities for vulnerable populations as defined by race/ethnicity, socioeconomic status, geography, sex, age, disability status, sexual orientation, and primary language, and among other populations identified to be at-risk for health disparities.

References

1. U.S. Department of Health and Human Services. Office of Disease and Prevention and Health Promotion. Healthy People 2020. Washington, DC. Available at http://www.healthypeople.gov/2020.
2. National Prevention Council. National Prevention Strategy, Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011. Available at http://www.surgeongeneral.gov/initiatives/prevention/strategy/report.pdf.
3. U.S. Department of Health and Human Services. HHS Action plan to reduce Racial and ethnic health disparities: a nation free of disparities in health and health care. Available at http://minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf.
4. CDC. 2003 Revisions of the U.S. standard certificates of live birth and death and the fetal death report. Available at http://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htm.
5. Miller K, Ryan JM. Design, development and testing of the NHIS sexual identity question. October 2011. Available at http://wwwn.cdc.gov/qbank/report/Miller_NCHS_2011_NHIS%20Sexual%20Identity.pdf.
6. Patient Protection and Affordable Care Act (Pub.L. 111-148, 124 Stat. 119, March 23, 2010). Data Collection to Support Standards Related to Essential Health Benefits; Recognition of Entities for the Accreditation of Qualified Health Plans. Federal Register, July 2012.
7. U.S Department of Health and Human Services. Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status. Available at http://aspe.hhs.gov/datacncl/standards/ACA/4302/index.pdf.
8. The Guide to Community Preventive Services. Available at http://www.thecommunityguide.org/index.html.
9. The Guide to Community Preventive Services. Cancer Prevention and Control. National Prevention Council, National Prevention Strategy, Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011. Available at http://www.healthcare.gov/prevention/nphpphc/2012-npc-action-plan.pdf.
10. National Prevention Council, National Prevention Strategy, Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011. Available at http://www.healthcare.gov/prevention/nphpphc/2012-npc-action-plan.pdf.
11. Benz JK, Espinosa O, Welsh V, Fontes A. Awareness of racial and ethnic health disparities has improved only modestly over a decade. Health Aff 2011;30:1860-7.