Clinical, Community, and Epidemiologic Considerations for Addressing Racial/Ethnic Disparities in Chronic Disease

Abstract

Advancing health equity requires explicit consideration of the factors that prevent the attainment of the highest level of health for all people. Racial/ethnic and socioeconomic disparities in chronic conditions such as obesity and hypertension persist. The U.S. Department of Health and Human Services’ Action Plan to Reduce Racial and Ethnic Health Disparities acknowledged the need to consider disparities in 1) health care access and quality, 2) community conditions that provide access to resources which support health, and in 3) adequate scientific data on race, ethnicity, and other factors that would help in understanding the barriers faced by groups experiencing disparities. This dissertation explores chronic disease disparities spanning clinical practice, community intervention, and epidemiologic surveillance. Chapter 1 answers the call of the Action Plan, by examining disparities in health care quality. Given well-documented racial/ethnic disparities in health care quality, and emerging evidence exploring the influence of weight bias and stigma on quality of care, we examined differences in obesity-related care in pediatric care settings by race/ethnicity and parent weight status. We found no evidence of consistent differences in obesity-related care by race/ethnicity or parent weight status after accounting for predictors that could influence care received. Chapter 2 examined the effectiveness of a community-level intervention in reducing the percent of high sodium (>200mg) prepackaged products in 21 institutions serving those disproportionately burdened by hypertension. After the intervention, the percent of high sodium prepackaged foods decreased significantly from 29.0% at baseline to 21.5% at follow-up. The change was primarily driven by sodium reductions in hospital cafeterias and kiosks. This study adds to the evidence-base of community-level sodium reduction initiatives. Chapter 3 examines trends and gaps in diet quality at the intersection of race/ethnicity with education and nativity. Diet quality scores have been low overall, with small improvements only for some population subgroups between 1999-2012. U.S.-born Blacks, regardless of education status, and others with lower levels of education experience the lowest diet quality scores, and are seeing the least amount of improvement over time. Nativity was also found to be an important factor that reveals distinct patterns in diet quality regardless of race/ethnicity.