The paucity of research on interventions to reduce child disparities: Most intervention research has focused on adults, and most medical or clinical care research has focused on general quality improvement rather than disparities.
The need to directly or indirectly address disparities in health status and in health care. Addressing health care disparities will not eliminate health-status disparities, but failure to address health care disparities could worsen health-status disparities.
Addressing disparities in health care is, in part, about equity goals, but it is also about accountability in the health system. Third-party payers in the public and private sectors expect that people with similar needs will receive similar treatment. This is a matter of basic fairness.
The articles point out that disparities related to race/ethnicity, socioeconomic status, generation, and geography are closely intertwined. Disentangling this web could be useful for developing more tailored interventions, but it is not critical for making progress in reducing racial disparities. For example, Ochoa and Nash3 discuss their work with the statewide Coalition for Health of Arkansans Today, which advocated spending tobacco settlement agreement funds on health programs. These programs included tobacco-prevention and -cessation programs, Medicaid expansions, public health infrastructure, and a hypertension initiative for minority residents. Only 1 of these efforts focused on minority residents, but most of the investments will serve the health needs of low-income minority residents.
Although many of the causes of health disparities are fundamentally linked to forces outside the health system, some of the remedies are within the health system's domain.1,2 For example, Currie4 discusses how nutrition supplement programs, such as the Supplemental Nutrition Program for Women, Infants, and Children (WIC), can reduce disparities by improving maternal nutrition and infant health outcomes in underserved communities. Although the causes of poor maternal health are primarily socioeconomic and intergenerational, 1 of the solutions to this problem is within the health system's reach.
Interventions designed to eliminate disparities have focused largely on efforts to change individual behaviors (such as diet, exercise, and substance use). However, broader policy changes are probably more effective and can reach more people, at least for some of the changes needed. Flores1 points out that many children who are eligible for Medicaid and the State Children's Health Insurance Program (SCHIP), for example, are not enrolled in these programs. Currie4 argues that enrollment in these programs would increase if all children were enrolled automatically unless their parents opted out by choosing private coverage. The effectiveness of such a strategy has been demonstrated by the success of automatic enrollment in Medicare Part B for US residents when they turn 65 years old. Health insurance can make a difference in providing children with timely and high-quality care. Although expanding insurance to all children who need it will not eliminate disparities, it will move the country in the right direction.
The use of media and new technologies to provide public education messages to the public and policy makers can expand the reach of interventions to reduce disparities, and often do so at a lower cost. Flores1 provides an example of a community intervention that used mass communication–based strategies to increase breastfeeding in a Navajo community.
NEW RESEARCH DIRECTIONS
Chin et al2 recommend, on the basis of the adult health-disparities literature, making reductions in care inequities for vulnerable populations an integral part of quality-improvement efforts. We then must measure, analyze, and report on our findings, because the issue of disparities needs to stay visible. This is not a new recommendation, but it is not gaining traction in the rapidly expanding quality-improvement world. Many quality-improvement experts believe that improving quality will reduce disparities. However, not all interventions that improve quality have an impact on the gap in care. Researchers and practitioners are moving along the quality-improvement and health-care-disparities tracks on 2 parallel trains. It is time for these tracks to connect with one another.
Since the 1960s, efforts to improve health and access to care have focused largely on strengthening the safety net to keep low-income populations and communities of color from “falling through the cracks.” It is time to expand our perspective beyond building a sturdier safety net for vulnerable populations to refining our parachute for vulnerable populations. This new framework emphasizes interventions and related research focused on lifting people up and reducing the likelihood that they will need a safety net.
Research on strategies for maintaining and improving health will help move the field of health-disparities research further away from the health care system (which is largely focused on treatment for individuals who are ill and injured) to approaches that address the causes of health disparities, such as how to end child poverty. Reframing the research agenda will encourage cross-disciplinary collaboration among researchers and practitioners in health, education, income support, tax policies, and city planning. Including the community as a partner when implanting a research, quality-improvement, or health-improvement activity in practice or in a more broad scope was also highlighted in several of the articles presented. These collaborations will enable us to address a broad array of factors in ways that can truly make a difference in children's lives.
- Accepted July 20, 2009.
- Address correspondence to Marsha Lillie-Blanton, DrPH, George Washington University School of Public Health and Health Services, Department of Health Policy, Ross Hall, Washington, DC 20010. E-mail:
The views presented in this commentary are those of the author, not the organizations with which she is affiliated.
Financial Disclosure: The author has indicated she has no financial relationships relevant to this article to disclose.
- ↵Flores G. Devising, implementing, and evaluating interventions to eliminate health care disparities in minority children. Pediatrics.2009;124 (2 suppl):S214– S223
- ↵Chin MH, Alexander-Young M, Burnet DL. Health care quality-improvement approaches to reducing child health disparities. Pediatrics.2009;124 (3 suppl):S224– S236
- ↵Ochoa ER Jr, Nash C. Can sustained community engagement have an impact on child health disparities? Important building blocks, promising examples, and resources for pediatricians. Pediatrics.2009;124 (3 suppl):S237– S245
- ↵Currie J. Policy interventions to address child health disparities: moving beyond health insurance. Pediatrics.2009;124 (3 suppl):S246– S254
- Copyright © 2009 by the American Academy of Pediatrics