INTRODUCTION

A major national enterprise has grown up since the Institute of Medicine (IOM) report devoted to documenting health disparities; understanding their clinical, service, and social determinants; and mounting specific projects that address particular combinations of health status and racial and ethnic populations. This work has given extraordinary visibility to the existence of significant and stubborn disparities and mobilized an impressive number of university centers, provider groups, and community partners. Significant federal and private foundation funding has mapped onto this agenda. A great deal of innovation and adaptation has been spawned in this field, most notably the establishment and federal support for a broad body of community-based participatory research. Important state policy initiatives, such as the recently enacted Massachusetts Health Reform, have specific governance and accountability for disparities reductions.

Despite the number and variety of health disparities initiatives, there is growing restlessness that this enterprise is not yielding effective and scalable approaches and, most importantly, evidence of significant outcomes (Lurie and Fremont, 2006). For example, the Centers for Disease Control and Prevention’s (CDC’s) recent interim report on Healthy People 2010 worried that among the 195 disparities objectives there has only been measurable improvements in 24 categories, declines in 14, and no change in 157 (CDC, 2007).

A number of concerns underlie this restlessness:

• Many initiatives do not embody the kind of community voice, support, and participation that is necessary for sustainable long-term results.
• Many initiatives are divorced from other significant community-development strategies that have the potential to influence the known determinants of health disparities (e.g., housing, safety, education, and civic engagement).
• Many initiatives are not built on a platform of governance, management, and adequate stable financing that assures a continuity of response from prevention, to early detection, to treatment, and to evaluation.

In simple terms, these initiatives have developed along two different paths. One broad approach to disparity reduction involves essential clinical services and interventions, generally developed by health status or diagnostic categories and supported by categorically clinical funding streams. Thus, a huge number of specific health disparities programs have emerged to address asthma, diabetes, breast and cervical cancers, cardiovascular disease, and other conditions. These programs have the advantage of being targeted to known disparities, can be tailored to provider and community resources, and have the potential to pursue evidence-based strategies. Often these programs are mounted by academic medical centers, health systems, or other provider organizations.

At the other end of the spectrum, an alternative set of community programs and policies proceed instead to address the socioeconomic “fundamentals” of community development and health. These initiatives, generally not on the radar of disparities researchers, are designed to enhance the strengths and assets that already exist in communities; to increase human, physical, and social capital; and to navigate complex processes of economic change (such as gentrification) in communities. These programs fall under the rubric of community building, community economic development, comprehensive community collaborations, and others in the so-called community-development field. Examples include the Local Initiative Support Corporation (LISC) and Community Builders.

For our purposes, however, many of these community-development approaches have significant health aspirations (sometimes explicit and sometimes implicit), often command huge investments and resources, as well as involve the same institutions—churches, schools, hospitals—and community leaders as community-based disparities programs. There is much to be learned about the overall impacts of these approaches, as well as their specific health consequences.

The thesis of this review for the IOM is that the “action” in community approaches to addressing health disparities lies in better understanding, design, and implementation of “hybrid” approaches to community development and health disparities. We define hybrid approaches as those derived from a combination of clinical, community, and other heterogeneous sources such as public health and policy. The best of these approaches have the virtue of empowering and mobilizing community resources and residents, but at the same time implementing systematic, sustainable, and clinically sound approaches to health behavior, screening, prevention and promotion, and treatment. Admittedly, the knowledge base for this assertion is thin; in fact, we believe one of the key frontiers in this field lies in creating an evidence-based approach, yielding results for community development that build off of the knowledge base about both community and health disparities that is more purposeful about evaluation and accomplishes better sharing and translation of information across disciplines and stakeholders.

DISPARITIES IN A COMMUNITY CONTEXT

Although many concepts and constructs of community abound, this paper treats communities as largely geographical or spatial units, though only as the best proxy for capturing a set of social relations and social institutions.³ This means that we are largely concerned with so-called place-based approaches to health disparities and aligned with the literature on neighborhood or area effects on health (Diez Roux, 2001; Sampson, 2003).

A large literature focused on the role of socioeconomic and community factors in health outcomes has grown up in social science, public health, and the field of community organization and development. The backdrop to this literature on community effects is an even larger literature on the socioeconomic determinants of racial and ethnic health disparities. The pathways by which socioeconomic position and resources affect health status are well understood in concept, but more difficult to attribute empirically. Education, for example, provides opportunities for certain occupational pathways, which in turn produce different income streams, occupational exposure to health hazards, wherewithal to engage in positive health behaviors, and access to communities and social networks that are believed to reinforce health behaviors. Perceptions of racial discrimination, for example, have been linked across a large body of studies to health behavior, physical health, and mental health, although the precise mechanisms for how discrimination translates into physical or behavioral outcomes via stress or other pathways is less well established empirically (Williams et al., 2003).

The state of the evidence about these socioeconomic pathways to health disparities is crucial to the justification of community approaches. If policy and programs can in fact systematically affect social variables such as education, employment, or housing, and these improvements translate into health outcomes, then we have the beginnings of a model for influencing significant health disparities at the community level. However, the empirical understanding of how these socioeconomic mechanisms work at the community level is still quite limited. Nonetheless, many observers believe that research and policy experimentation specifically devoted to influencing these indirect socioeconomic pathways to health disparities should proceed apace. Alegría et al. (2003), for example, have argued that interventions in schooling, housing, and income support (earned income tax credits) are empirically defensible and justified in the field of mental health disparities. Adler and Newman’s conclusion about the role of social capital in generating health outcomes is similar: “The literature on social capital has not yet explained why neighborhoods with similar demographics differ on social cohesion and trust, or established whether social capital is stable. But the associational evidence between social trust and health outcomes is striking and suggests that these are complementary frontiers worthy of exploration for addressing health issues along with raising income or educational attainment” (Adler and Newman, 2002, p. 67).

The literature on community effects on health disparities demonstrates that many community factors contribute to differential health outcomes by race and ethnicity, over and above individual characteristics (Bigby, 2007). A recent annotated bibliography of this literature by itself runs 93 pages long.⁴ The sources of these community influences are numerous and complex, including risks created by the built environment such as lead in housing, access to the “ingredients” of healthy living such as affordable healthy foods, lack of community resources such as parks and green spaces that promote activity, ambient levels of stressors such as violence that may have physical and psychological sequlae, and disadvantages in access and in quality of health services and public health supports.

Despite the extent of this literature, again there is relatively little rigorous empirical evidence that demonstrates the mechanisms by which community characteristics or the ways in which community interventions produce observable differences in health outcomes. In part, this stems from the daunting statistical and data requirements for sorting out the multiple influences on health—the selection of individuals (with given health characteristics) into neighborhoods in the first place, the necessity for broad and multiple levels of data, and the substantial need for statistical variation across communities and groups, especially in nonexperimental data (Duncan and Raudenbush, 2001; Kawachi and Berkman, 2003).

The most intriguing recent empirical evidence of community-level effects per se comes from the Move to Opportunity (MTO) demonstration, in which 4,600 families in public housing in five cities were randomly assigned to different treatment groups of housing options and community environments. Adults in the experiment showed significant improvements in mental health and reductions in obesity with moves to new and higher-income communities; teenage girls showed improvements in mental health and reductions in risky behavior. Interestingly, teenage boys exhibited increases in risky behaviors relative to the control group (Kling and Liebman, 2004). Residents in individual MTO sites have shown substantial declines in specific health outcomes that need medical attention, such as injuries and asthma attacks. Other studies involving movers to new communities from distressed public housing, the so-called HOPE VI studies, however, have not yet shown improvements in health status, despite extraordinarily high rates of chronic and mental health conditions at baseline in this population. (Harris and Kaye, 2004; Manjarrez et al., 2007).

The critical role of community-level factors in addressing health disparities has led some commentators to argue that communities should become the “unit of analysis” for interventions, and community development should become the broad framework for implementing approaches (Robinson, 2005). Failure to make communities the unit of analysis means that a number of opportunities to design innovative and effective approaches are lost. First, most disparities of interest have important “nonhealth” community predispositions—environment, levels of community violence, and so on. Second, many disparities represent mixtures of social and health factors that cannot be easily disentangled into a simple clinical intervention. High rates of obesity and diabetes in communities reflect such a complex bundle of medical, health behavior, mental health, community resources, and access to health care. Third, many interventions require the active participation of community residents in order to be effective; this participation cannot be imposed. Fourth, many disadvantaged communities simultaneously exhibit health disparities because of the coexistence of poverty, racial concentration and segregation, and lack of access to health and other key supports. In the city of Chicago, for example, a relatively small number of disadvantaged neighborhoods on the south and west sides exhibit the highest rates of asthma, cancer, heart disease, sexually transmitted infections, diabetes, deaths from injuries and violence, and other critical health outcomes. Even in the face of this overlapping epidemiology, “siloed” approaches to health disparities miss the opportunity to marshal large-scale community participation and resources to design approaches that sweep at least across interrelated health-related conditions—for example, substance use, violence, high-risk sexual behavior—in a community.

A MULTILEVEL FRAMEWORK

As shown in Figure D-1, there have historically been two paths toward addressing the health needs of individuals in communities. In the clinical setting, interventions improve health care processes and outcomes, but there is limited evidence of their impact on health disparities. In the community setting, interventions improve community status, but there is limited evidence of their impact on health. Policy and public health interventions can influence health through clinical or community settings, and may address health directly.

FIGURE D-1

Clinical and community approaches to health.

Over the past decade, in recognition of the inadequate improvements in minority health, clinical, policy, public health, and community leaders have begun to consider what we will call a hybrid approach to health improvement, namely integrating features of clinical, community, and other (i.e., public health) approaches to address both biological and social determinants of health. These hybrid approaches can be focused in communities or in clinical settings, but the expertise of both is brought to bear on the problem, the solution, the evaluation, and plans for dissemination and sustainability. We compare their features in Table D-1. Following the table, we provide an overview of clinical and community approaches to disparities. We then discuss the issues and opportunities for advancing hybrid approaches. Finally, we conclude with a set of ideas about how hybrid approaches might be organized and implemented at scale.

TABLE D-1

Characteristics of Clinical, Hybrid, and Community Interventions to Improve Health.

CLINICALLY DRIVEN APPROACHES

Without question, the effective therapies developed and tested using basic science, clinical, and health services research have significantly contributed to improving the life expectancy of Americans of all racial and ethnic backgrounds. Yet, these diagnostic and therapeutic breakthroughs and unprecedented health care spending have not resulted in elimination of health care or health disparities for the majority of health conditions, even among populations with equal access to care. Several shortcomings of the current approach may help explain this disconnect. Table D-2 shows the building blocks of clinically oriented research to improve health. After each are descriptions of potential missteps that may occur if clinical interven tions are conducted in isolation from the wider sociocultural context where patients spend the vast majority of their lives.

TABLE D-2

Steps in Isolated Clinical Research Addressing Health Disparities and Their Pitfalls.

Two examples of the incomplete impact of clinical research merit further description: breast cancer treatment and diabetes prevention. Breast cancer is an area where disparities in processes, namely screening, often using community-centered education, appear to be narrowing, yet disparities in breast cancer deaths persist (Dietrich et al., 2006; Earp et al., 2002; Erwin et al., 1999; Smith-Bindman et al., 2006; Weir et al., 2003). Minority women with early-stage breast cancer are far less likely to receive necessary adjuvant treatments, even when equally referred to oncologists (Bickell et al., 2006). Perhaps the simpler process (mammography) is easier to address than is breast cancer treatment, which requires a multidisciplinary approach. Perhaps women of color also face disproportionate nonclinical barriers to treatment.

Diabetes is another area in which clinicians and clinical researchers are making strides and yet persons of color do not appear to reap sufficient benefits. Minority individuals are more likely to develop and die from diabetes, and disparities in death between whites and blacks/Latinos are widening (Mokdad et al., 2003). If prevention efforts are not developed and widely implemented, one in two black and Latino children born this decade will develop diabetes, as opposed to one in four whites (Narayan et al., 2003). Several clinically based programs, most notably the large, multisite Diabetes Prevention Program, found that weight loss among overweight adults with pre-diabetes can prevent or delay diabetes (Knowler et al., 2002). In this program, weight loss even eliminated racial and ethnic disparities in incident diabetes. Despite this unusually promising result, the program has been neither expanded, nor continued, even at the sites where its effectiveness was proven. Less expensive methods are needed to achieve the degree of weight loss and diabetes prevention seen in this costly, time-consuming efficacy trial (Eddy et al., 2005).

COMPREHENSIVE COMMUNITY-DEVELOPMENT APPROACHES

Community-development and community-building approaches emphasize the development of community capacity and community connections as the means to producing better outcomes such as economic opportunity, safety, housing conditions, and health status (Chaskin et al., 2001). Community-building approaches tend to emphasize local leadership development, promotion of collaborations, strengthening the capacity of community-based organizations, strengthening of social capital, and generation of new resources for housing and economic development.

A classic example of a comprehensive community-development approach based on a community-building philosophy would be initiatives supported by the LISC:

LISC helps resident-led, community-based development organizations transform distressed communities and neighborhoods into healthy ones—good places to live, do business, work and raise families. By providing capital, technical expertise, training and information, LISC supports the development of local leadership and the creation of affordable housing, commercial, industrial and community facilities, businesses and jobs. (LISC, 2006)

These community-building programs individually and collectively represent substantial commitments of public and private resources, as well as community leadership and effort. LISC alone claims to have mobilized over $7.8 billion for projects in 300 urban and rural communities (LISC, 2006). Development banks, such as ShoreBank, or commercial banks with large community-development portfolios, represent significant sources of capital and expertise. Bank of America, for example, expects to invest $750 billion in community economic development over the next 10 years. Major foundations, such as Ford, McArthur, and Kellogg, have also built their strategy and funding priorities around these comprehensive community-development initiatives, in most cases leveraging an additional set of federal and state development resources. These sums dwarf the scale of most disparities interventions, yet there seems to be little effort devoted to capture and leverage these resources to strategically improve environment and community capacity in ways that produce measurable health outcomes.

On the whole, these comprehensive community-building initiatives and the national health disparities agendas have proceeded on largely separate tracks. While the connections of community-building initiatives and the efforts of public health and disparities programs operating in communities may seem self-evident, a recent review by Kieffer and Reischman (2004) concludes that the “reality is that many public health interventions are not coupled with community building strategies; and many groups undertaking community building do not include measures of improved public health as an outcome of their activities” (p. 2).

The implications of this disconnect are significant. Health disparities initiatives by themselves cannot command the level of resources and community attention necessary to impact the myriad of physical, social, and economic factors that underlie community health outcomes. Since community leadership and institutions are critical to the success of any health intervention, it may be necessary for community health interventions to become aligned with these larger community-development efforts to be able to capture the necessary time and attention.

There are a number of good reasons why community health approaches to disparities reduction have not been built on this platform of comprehensive community building. First, these approaches tend to emphasize the community process over interventions and implementation. In this world, collaborations, connections, relationship building, partnerships, and process often take precedence over specific interventions and implementation. Second, these approaches vest enormous control with community residents and stakeholders to define their own assets and approaches, whatever the views of experts may be. Particular health disparities may or may not rise to the top of the community hierarchy of priorities and needs for attention and resources. Third, by the very nature of comprehensive community approaches, these initiatives may have low target efficiency for a particular health condition. Efforts to improve employment, education, safety, and other community factors may have marginal or indirect effects on a particular health condition of interest. Finally, these comprehensive collaborations are often slow and halting in their progress and observable outcomes.

HYBRID APPROACHES (MIXED APPROACHES)

Hybrid approaches imply that community and clinical and other resources are both deployed and coordinated in developing and implementing programs to address health disparities. Interventions can be centered or grounded in one of five disciplines or areas: clinical, public health, policy, community, and research. We review existing approaches from these perspectives in the following sections.

Clinically Centered Hybrid Approaches

These approaches invite community, public health, policy, and research experts into the clinical setting in order to make clinical care more responsive to vulnerable populations (i.e., low-income individuals, or persons of color) and to make clinical interventions more effective in improving their health. Two approaches are gaining favor: systems redesign to make systems more culturally competent and effective, and health management and support to facilitate patient self-management and navigation.

Health Systems Redesign

Health systems leaders can look outside their clinical boundaries to find expertise and models to improve the care they deliver. Efforts are well under way to make health centers meet current standards for culturally and linguistically appropriate services (CLAS). Some translate materials into common languages and offer brief cultural sensitivity trainings. More comprehensive efforts also aim to include a well-trained and diverse staff and gain a deeper understanding of the populations they serve, and they use this understanding and active community input, creating a welcoming, educational, health-promoting clinical environment (Horowitz et al., 2000; National Standards for Culturally and Linguistically Appropriate Services in Health Care, 2001). Data on the impact of CLAS on health outcomes is scarce, although providing such basic services should not be considered controversial.

Broader approaches to providing health care in communities of color have been under way for decades. The community health center model that emerged as part of the war on poverty in fact targeted the roots of poverty by combining the resources of local communities with federal funds to establish neighborhood clinics. Because these centers are governed by community boards, and provide access regardless of ability to pay, there is some evidence that patients in these centers receive more timely screening and preventive services.

To combat the continued heavy burden of chronic illnesses at these centers, the Health Disparities Collaboratives of the Health Resources and Services Administration (HRSA) employed Wagner’s Chronic Care Model, a system that encourages high-quality disease management (Landon et al., 2007; Wagner, 1998). The collaboratives significantly improved the processes of care for two of the three conditions studied (diabetes and asthma), but there was no improvement in the clinical outcomes studied. The authors reflect that “achieving improvements in both longer-term and intermediate outcomes may require more intensive interventions in order to overcome environmental factors that pose particular challenges for patients.” As shown in Figure D-2, this model asserts that to improve the health of the population, health systems organizations reach out to form community alliances and partnerships with state programs, local agencies, schools, faith organizations, and businesses, a step those implementing the model may not have focused on adequately.

FIGURE D-2

Chronic care model. SOURCE: Modified from Wagner (1998).

Health Management and Support

Health management and support reforms are often built around new professional and paraprofessional roles that connect with community residents. Examples include clinical disease managers, community health workers who are usually employed by health systems, and more independent peer educators. Each straddles the clinical and community realms with the goal of helping patients better manage their health.

• Disease managers or nurse case managers work with patients who have specific, often chronic, health problems and they use information systems to track and monitor patients and clinical guidelines for care to improve both clinical and self-management (Norris et al., 2002). Initially developed to cut costs and resources, a new generation of these programs is culturally tailored to better educate, motivate, and support patients (Sisk et al., 2006). The programs have some strong effectiveness data in their favor, but current non-managed care payment structures that do not lead to cost savings for health systems if these relatively costly managers prevent hospitalizations may make it difficult to sustain these programs beyond the studies that prove their beneficial impact (Carryerou, 2006).
• Community health workers (CHWs) are lay community members who work with the local health care system, and usually sharee thnicity, language, socioeconomic status, and life experiences with the community members they serve (HRSA, 2007). They can be members of the care delivery team (largely subordinate to a lead provider); navigators who assist individuals and families in negotiating complex service systems and bolster their clients’ confidence when dealing with providers; screeners and health educators, often working with hard-to-reach populations; outreach workers, who reach individuals and families eligible for benefits or services and persuade them to apply for help or come to a provider location for care; advocates for individual and community health needs; and organizers who become active in a community over a specific health issue, promoting self-directed change and community development. There are myriad evaluations of CHWs and the meta-analyses of these studies. CHW trials reveal significantly increased access to health care, improved asthma symptoms and decreased use of urgent care, blood pressure control, breast feeding, and decreased high-risk sexual behavior (Andrews et al., 2004; Brownstein et al., 2005; HRSA, 1998; Krieger et al., 2005; Lavery et al., 2005; Lewin et al., 2005; National Fund for Medical Education, 2006; Rosenthal, 1998). The CHW workforce is likely to increase in the forthcoming years (HRSA, 2007).
• Peer educators are distinguished from CHWs because they are more independent of the health care system. Lay-led, community-based peer-group sessions are an effective and cost-effective method to improve patients’ self-management skills, health outcomes, and hospitalization rates. They use trained lay leaders with backgrounds and health problems similar to those of the participants, incorporating evidence of the effectiveness of role models in increasing patients’ confidence in their ability to manage their conditions, and recognizing patient education should be inexpensive and widely available and that lay leaders from the community can impart information that may not be accepted from outsiders. These programs have significant health benefits in diabetes, asthma, seniors with heart disease, and with heterogeneous groups of persons with chronic conditions (Brown, 1999; Center for the Advancement of Health, 1996; Fries et al., 1998; Ladhenuso et al., 1996; Lorig and Gonzalez, 1992; Lorig et al., 1999, 2001; Mazzuca et al., 1986).

MODELS AND IDEAS FOR HYBRID COMMUNITY APPROACHES

In order to bring these hybrid approaches to scale, new community infrastructure and resources will need to be developed. Current approaches are typically small in scale, do not leverage significant resources, and do not capitalize on information and technical expertise. Creating scalable community approaches will require solutions to the financing problems inherent in many disparities initiatives. Community approaches that can be evaluated and that demonstrate statistical impact on disparities will also need to account for much larger populations and bring much greater analytic sophistication than most current community examples. Five models or heuristics are presented to give examples of how new hybrid approaches might be configured in ways that address many of the shortcomings identified in this paper.

1.

Regional Health Authorities: A number of regional authorities already exist at different levels of aggregation. The Westside Health Authority in Chicago, for example, has led a number of community-development and health disparities initiatives with full community participation and advocacy. The Regional Health Commission in St. Louis addresses a range of data, provider, and policy functions from the perspective of the region as a whole. Regional Health Authorities effectively configured for addressing disparities would need to capture a financing stream (most likely though a Medicaid assessment or all-payer program), and adopt a dedicated focus on disparities reductions for particular communities to be effective.

2.

Community Development Banks/Corporations: While improvement of community health is one of the stated initiatives of many comprehensive community-development initiatives, in practice the goals and resources are more tightly defined by housing and economic-development measures. However, these institutions and investments represent large flows of capital and often intensive community involvement. Bank of America, for example, will invest $750 billion in the next 10 years in community development. Many of these investments occur in exactly the same communities with a high prevalence of health disparities conditions. To organize this combined health/community-development approach, new partnerships would need to be struck with institutions such as Shorebank, LISC, Bank of America, the Department of Housing and Urban Development (HUD); as well as other regional investors and developers. Many of these initiatives are organized around community-development corporations that provide an initial infrastructure and governance of these collaborations.

3.

University–Community Partnerships: A number of successful university–community partnerships have been built in recent years, some with the formal support of HUD and other federal agencies. The major examples, the University of Pennsylvania and the University of Chicago, have largely focused on community economic development and urban schools. While there certainly are examples of academic medical centers and schools of public health that have significant community partnerships, they have not been organized and disciplined by a systematic approach to addressing disparities in particular communities. The emergence of CPBR, the emphasis on CTSAs, the community interest of academic public health, and the community training needs of many medical school make this an opportune time to consider scaling up and organizing university–community partnerships specifically for addressing disparities. To the extent that these partnerships can leverage the health care delivery system at major academic centers, there is also the potential to create more seamless structures of financing and health care service in these neighborhoods. These urban community models have the potential for not only addressing urban disparities but also utilizing university networks in rural health.

4.

CBPR Practice Networks: As this appendix describes, one of the exciting developments in addressing disparities has been the number of projects and community relationships stimulated by CBPR. Despite the apparent early successes of this movement, it is operating at small scales and with little opportunity for cross-fertilization, data development, and comparative analysis. A structure that organizes and supports this movement across community sites has the potential to create a multiplier from these projects. A potential model for collaboration, data collection, and technical assistance are the national practice networks that are emerging in other areas of health services research. The extension of this idea to communities would involve the creation of comprehensive practice network structures and data and information systems at the community level. Even better, a consortium of community-based practice networks would allow better systematic and comparative evaluation of community-based disparities initiatives.

5.

Provider Networks or Systems to Address Disparities: Many of the current priority conditions have a heavy reliance on improvements in access and quality of health services in low-income and minority neighborhoods. As a practical matter, sufficient funding and sufficient “market penetration” to create a statistical impact will require multiple health care plans, systems, and providers operating in consort. Versions of these arrangements have been created in cities to address ambulatory care provision, indigent care, and special service needs such as trauma care. These networks of systems typically require dedicated payment streams and some governance from the local health departments, state public health, or other public agent. Payment streams have included Medicaid provider assessment schemes, use of Disproportionate Share dollars, or allocations of city, county, or state revenues. A model for organizing these networks to address place-based disparities would be the creation of special health disparities districts, analogous to medical districts, that would provide incentives for health plans to create new community-based programs as well as access and quality improvement in relevant services.

SUMMARY AND RECOMMENDATIONS

The central problem for building community approaches to reducing health disparities is to knit together community, provider, funding, and academic resources at such a scale that there is the potential to have statistical effects on population health outcomes. Many of the initiatives to date have demonstrated good will, effective community collaborations, and reasoned approaches to addressing disparities, but they tend to be fragmented, small in scale, and inadequately or transiently funded. Considering realistically the magnitude of behavioral change and service provision that is necessary to have a statistical impact on disparities, at the community level much less nationally, it will require a level of commitment and organization that far outstrips current models of intervention. In effect, the disparities initiatives need to be upsized from a cottage industry to substantial organization and scale.

Hybrid approaches to improving health outcomes and reducing disparities have the advantage of being clinically centered in the community, but they leverage the community participation, resources, and environmental agenda that are associated with broader community-development strategies. In principle these hybrid approaches have greater potential for sustainability and scale. They have the disadvantage of being diffuse, community process oriented, and difficult to target narrowly on specific disparities interventions. Many varieties of these hybrid approaches exist, such as the REACH 2010 and CBPR projects, but little empirical evidence about outcomes and little analysis of strategies are available for making these approaches successful, scalable, and sustainable.

Our analysis of current hybrid community approaches has identified a number of issues that need to be addressed to advance these clinical and community models. The goal of these hybrid models should be that they are simultaneously clinically excellent as well as community-responsive ini tiatives. Significant adaptation will need to occur in the clinical enterprise in order to have mutuality and successful collaboration in the community. Innovation in the forms and utilization of data will be necessary. New commitments to community-level evaluation, including some version of social return on investment, will be necessary to learn from and advocate for these community-level initiatives. A new cadre of appropriately trained community-based researchers, with expertise in the community disciplines and experience with the cultural, social, and political realities of working in communities will need to be trained. CTSA opportunities will need to be seized, so that that the community side of this roadmap is highly responsive to community values and interests, not merely an appendage to the traditional clinical research enterprise. The resources of public health—both governmental and academic—will need to be reassessed and more effectively deployed to advance this agenda of hybrid approaches. Finally, solutions to the organizational and financing gaps in disparities programs will need to be fashioned.

There are currently a large number of alternative community disciplines, professionals, and organizations laying claim to the community-development and disparities agenda. Community health, community building, community organization and planning, urban planning, public health, environmental health, social work, and others all see themselves as primary professional leaders in this movement. From the perspective of communities, academic centers, health providers, social service organizations, public health agencies, faith-based organizations, and a host of advocacy organizations are all seeking to partner and mount their own versions of disparities programming. Meanwhile, some of the largest players in community development, the banks and developers, are often outside of the discussion, financing, and implementation of disparities programs.

Community collaborations (e.g., CBPRs) show great promise in the struggle to eliminate disparities. They can identify root causes of disparities, build on local assets, devise novel, clinically, and environmentally sensible designs with sustainability in mind, inspire robust research participation, and disseminate results so they inform policy and inspire further introspection and change. They are also community-organizing and -development initiatives in their own right. However, models for partnership in the literature describe years of planning—building relationships and crafting fair rules of engagement before research and interventions begin in earnest. While these processes must not be overlooked and local adaptation may be necessary for many interventions, the CBPR community must challenge itself to move from community-based planning (CBP) to “CBPR” with more efficiency and to find models that are proven to improve health and that can be exported to other communities or within the community, to address other health-related issues.

The solution is not to choose one or another of these community players as primary. Rather, new mechanisms which bring together some of these stakeholders in partnership with community residents and with focus on substantial disparities programming will be necessary. Examples we have considered include regional health authorities, community-development corporations, university–community partnerships, CBPR practice networks, and new forms of health plan districts or networks.

Our analysis has produced a beginning agenda for the IOM Roundtable to pursue in building better linkages between community development and clinical services—hybrid approaches—in the name of reducing disparities.

• Convene community-development organizations and funders, along with health disparities academic and practice leadership to design hybrid approaches.
• Promote the creation of an evidence-based clearinghouse for information and technical assistance in community development for reduction in health disparities (such a clearinghouse could be mounted under the auspices of public, association, university or foundation organizations).
• Convene the major health systems to address staffing, programming, disease management, and community partnerships approaches to disparities.
• Influence the major existing clinical/research mechanisms—CBPR, CTSAs, REACH 2010—to leverage the full spectrum of community resources beyond the traditional scope of the clinical and research requirements of these mechanisms.
• Commission a set of briefing papers that describe replicable models of community finance (e.g., disproportionate share hospital payment approaches), governance (e.g., health authorities), and communications innovations for effective and sustainable disparities reduction in communities.
• Reexamine the framework and recommendations of the IOM report The Future of Public Health with the goal of reinvigorating a public health agenda in community and health disparities.
• Convince a leading public health, health services, or community-development journal to publish a special issue on methods for evaluating community interventions and initiatives to reduce disparities—geographical and Health Impact Analysis, cost benefit and social return on investment analysis, multilevel and social network methods—as well as qualitative approaches.
• Engage a leading foundation in supporting the training and professional development of a new cadre of community-savvy academic leaders in the field of health disparities.
• Identify and encourage a set of universities with the academic mission, resources, and community context to seriously and systematically build hybrid approaches that bring the same sophistication to community engagement and partnership that they brought to other dimensions of translational science.

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Footnotes

1

Assistant Professor, Departments of Health Policy and Medicine, Mount Sinai School of Medicine.

2

Dean and the William E. Gordon Professor, George Warren Brown School of Social Work, Washington University in St. Louis.

3

For a complete discussion and review of different concepts of community see Robert Chaskin (1997).

4

For a review of this literature see Rebecca Flournoy and Irene Yen, The Influence of Community Factors on Health (PolicyLink, 2004).

5

See http://depts​.washington​.edu/ccph/index.html.

6

See http://www​.ncrr.nih.gov​/research_infrastructure.

7

See http://www​.ctsaweb.org/commengage.html.

8

See, for example, Terry Jones, Fragmented by Design (Jones, 2000).