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BARRIERS
Local providers, advocates, and consumers who attended a series of
community focus groups identified numerous issues as barriers to reducing
the health disparities that exist in Travis County, to improving access
to health care, and to utilizing wellness and prevention strategies.
The barriers presented here are a direct result of feedback from the
focus groups and have not been researched or confirmed.
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The barriers presented are the
thoughts and feelings of those who provide services and those accessing
local services.
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Rather, they are the thoughts and feelings of those who provide services
and those accessing local services. One key concern of focus group
participants is the lack of trust in the health care system within
various segments of the community. This mistrust has a deep history
of unfortunate mishaps conducted in the name of scientific advancements.
The mistrust also comes from cultural and language differences which
result in the lack of culturally competent health care services. The
perception of many minorities is that providers do not understand the
root causes of health disparities or are even unaware that disparities
exist.
In addition, the health care system is intimidating to many individuals.
Complicated enrollment procedures and diverse criteria for available
services and funding make it difficult for consumers to access needed
care. Once in the health care system, it remains intimidating to consumers,
especially when providers rush through visits without explaining the
rational of their treatment or taking time to listen to the client
in order to fully understand their concerns and their daily life conditions
which would influence the treatment plan. Also, the lack of coordination
and communication between service providers results in duplication
of services and data collection and overall inefficiencies in the provision
of care.
A significant obstacle to obtaining health care, as identified by
the focus groups, is the ability to pay for services. Over 25 percent
of Travis County residents do not have health insurance coverage. There
is also estimated to be a large number of individuals and families
who have some medical coverage but still can not afford co-payments
for medical care and prescription medications. While Austin is a relatively
prosperous community, with unemployment rate at about two percent,
the number of uninsured individuals in the Central Texas region is
estimated to be 200,000. This means that one in 100 residents are unemployed
while one in every five has no health insurance. Employment, therefore,
does not guarantee health insurance; in fact, 14,000 small businesses
in Texas dropped their health care insurance plans in 1997.
Access to health care is not only related to the ability to pay for
services but also relates to location, hours of operation, and availability
of services. While there are sufficient health care providers in the
over all Central Texas region, four counties (Bastrop, Blanco, Caldwell,
and Lee) in the adjacent area are designated as having an acute shortage
of health care personnel by the U.S. Department of Health and Human
Services (HHS). In Travis County, the Dove Springs neighborhood has
two census tracks designated as a Health Professional Shortage Area
(HPSA), East Austin has twelve census tracks designated as HPSA, and
South Austin has four census tracks designated as HPSA.
An additional barrier identified by the community focus groups is
that opportunities for improving healthy behavior are not as readily
available in some neighborhoods as in others. For example, grocery
stores in less affluent neighborhoods do not offer the same services
of promoting healthier eating as other larger markets do. Less nutritional
fast food establishments are more prevalent in some neighborhoods than
establishments providing wholesome heart healthy foods.
One barrier regarding the utilization of wellness and prevention services
identified by focus group participants is the expectation and demand
of funders, policy makers, administrations, and even consumers for
short-term, highly visible outcomes. The improvements in health made
through wellness and prevention activities are gradual which means
that they are not readily measurable in a short period of time and
often get overlooked. The untrained observer frequently would not make
the connection between wellness and prevention measures and improvements
in a community's health status. For example, an individual may revel
in the immediate results of weight loss from a healthy diet but fail
to see the longer-term effects of reduced risk for heart disease. Thus,
it is difficult to rally support to maintain or enhance activities
without immediate visible impacts. Unfortunately, the prevention system
generally goes unnoticed until a catastrophe is imminent.
A related barrier is an underlying lack of education, specifically
around the concepts of wellness and prevention. For example, some parents
believe that they immunize their children so that "they can attend
school" and do not make the connection between vaccinations and preventing
disease. Many of the population will never consciously seek prevention
services therefore giving little attention to their importance. These
same healthy individuals are the ones that gain the most from the prevention
strategies that keep less healthy at-risk populations from spreading
infection throughout the community. This lack of understanding of wellness
and prevention is common among many community members.
An additional barrier is competition for resources between non-prevention
and prevention activities and between the various programs providing
wellness and prevention services. Resources allocated for wellness
and prevention are tiny in relation to the whole health care system
and they continue to shrink. Services themselves are less efficient
as categorical services, which do not take advantage of the access
they have to those in need. By providing comprehensive wellness and
prevention services, a greater number of people will receive broader,
more complete health services. These issues, coupled with a relatively
healthy community as a whole, make it difficult to justify the need
for services that are generally invisible to the public.
Lastly, there is a lack of specific data collection methods related
to some populations and certain types of services. The current data
collection systems are generic to all populations and do not take into
account determining factors that directly or indirectly relate to disparities
in health and affect specific neighborhoods differently. In addition,
processes for tracking some of the more easily measured wellness and
prevention services are lacking. For example, the county's data register
for tracking immunization rates has had limited success, confined only
to public health providers who serve a fraction of the children.
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BEST PRACTICES
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These are not services developed
for a community; rather they are developed from within the community.
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The practices that have been identified by local community participants
through focus group sessions as being successful in improving the lifestyles
and health outcomes in most minority populations are grassroots programs
with direct neighborhood connection. These are not services developed
for a community; rather they are developed from within the community.
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Essential to the success of this type of program is support from leadership
and resources from the broader area who are committed to listening
and understanding the issues and concerns of the neighborhood. Examples
of successful local programs include:
- Faith ministry programs such as the Parish Health Ministry, Central
Texas Nurses Parish Health Ministry, and Health Ministry Teen Projects
are successfully serving local neighborhoods with a variety of health
promotional services. While these programs do not reach large numbers,
their connectiveness to the community gives the community a sense
of ownership and pride in their success.
- Thurmond Heights Wellness Center serves neighborhoods in the 78753
and 78758 zip code areas of Travis County, providing wellness and
health promotion services. A public health nurse and two community
health workers staff the Center. Some of the specific services provided
are immunizations, blood pressure and blood glucose checks, pregnancy
testing, and counseling on healthy behaviors. This is not a medical
care facility but provides services to help individuals improve their
lifestyle for an overall better health outcome.
- St. David's Root Cause Project is a new project started in 1999
serving a mixed neighborhood of about 50,000 people in North Central
Austin. This is a long-term project to work with a specific community
to help them improve their health by identifying and addressing the
root cause(s) of their major health issues. The community residents
themselves work with project leadership to design the activities
of this project.
- The annual Flu Fight campaign is a collaboration of public and
private entities joining forces to deliver flu vaccines to people
at various locations around the community.
- Skippy Express Mobile Health Clinic is an outreach project from
Children's Hospital of Austin. The unit travels to various neighborhoods
providing comprehensive health services to medically under-served
children. The unit provides free immunizations, low cost well child
exams, sports physicals, vision and hearing exams, and minor illness
treatments.
- Programs that employ one-on-one prevention counseling and case
management services, such as used in communicable disease prevention
programs, are successful in preventing the spread of infectious diseases.
However, this practice should be limited for those at greatest risk
to unhealthy behaviors because it is labor intensive and serves a
limited number of people.
- Proactive food safety programs where sanitarians take advantage
of the opportunity during food establishments inspections to coach
and problem solve with operators on ways to improve operations and
reducing the risk of foodborne illness are also successful. The Austin/Travis
County HHSD sanitarians are well adapted to this process, which builds
cooperation and expectance from within the food service community.
In addition to the local programs identified by the community focus
groups, other initiatives and programs have been developed in other
areas of the United States that can serve as models of successful approaches.
For example, to improve access to health services:
- The Robert Wood Johnson Foundation initiative "Communities in
Charge" assists local communities interested in improving access
to health care services for low-income uninsured individuals. The
program is designed for local communities interested in improving
access to care for low-income, uninsured individuals by rethinking
the organization and financing of local care delivery. The initiative
will help broad-based community consortia design and implement sustainable
new delivery systems that manage care, promote prevention and early
intervention, and integrate services. This program is open to communities
with a minimum population of 250,000 and at least 37,500 low-income,
uninsured individuals.
- One nationally recognized community model
is the Hillsborough HealthCare System, a
county-sponsored managed care program in
Hillsborough County, Florida, that was created
in 1992 to provide health care services to
low-income, uninsured individuals. The Hillsborough
HealthCare System enrolls and serves 30,000
uninsured individuals each year, integrating
community-based medical and social services
under a coordinated managed care framework.
The program has reduced per capita monthly
health care costs from $600 to $233 by promoting
prevention and early intervention.
The Hillsborough County program is a
direct result of the county's decision
to restructure services to create a new
enrollment-based safety net program.
Hillsborough County has received national
attention and awards for their achievements,
including the Ford Foundation's prestigious
award for Innovations in Local Government.
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In efforts to address health
disparities:
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- The Centers for Disease Control and Prevention has budgeted
$10 million for support of 30 communities to conduct community
planning activities. The planning activities include establishing
infrastructure for community-level data collection, establishing
collaborative partnerships, establishing linkages with other state
and local agencies, and working with federal agencies and other
partners to identify "best practices". These community planning
projects promote program activities which will underpin intervention
activities, and award community planning cooperative agreements
to community-based demonstration projects testing science-based
approaches to achieve health disparity reduction goals. Results
from these demonstrations will be important in shaping strategies
to eliminate disparities, and for improving the focus and effectiveness
community-based wellness programs (Centers for Disease Control
and Prevention, November 2000).
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In promoting wellness and prevention:
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- There are three comprehensive community-based disease prevention
models that are universally accepted as standards for community
prevention strategies. The Stanford Five-City Project, the Minnesota
Heart Health Program, and the Pawtucket Heart Health Program all
targeted reduction of cardiovascular disease risk but have been
applied to multiple prevention and wellness programs. Each study
lasted from five to eight years and included multifaceted campaigns
of education and risk reduction, simultaneously addressing the
prevention, treatment, and control aspects of hypertension, cigarette
smoking, high dietary fat, obesity, and sedentary lifestyles. The
three projects shared a common intervention strategy of primary
prevention, including direct education of health professionals
and the public through media and personal contact as well as community
organization to foster institutional and environmental support
(Winkleby, Feldman, & Murray, 1997).
- The Pawtucket Heart Health Program, which focused on community
organization, campaigns of risk reduction, and screening, counseling,
and referral activities, was the most successful, producing improvements
in total cholesterol, systolic and diastolic blood pressures, smoking
reduction, and body mass index. The hypothesis that cardiovascular
disease risk can be altered by community-based education was correct
but statistically significant differences were lost after the programs
were discontinued. Accelerating risk factor changes will likely
require a sustained community effort with reinforcement from state,
regional, and national policies and programs (Carleton et al.,
1995).
- Workplace and school wellness programs are a proven strategy
for developing a foundation to improving healthy behaviors. These
programs have also shown to be effective in increasing productivity,
reducing absenteeism, and improving the overall effectiveness of
individuals participating (see figure 4-1: Wellness in the Workplace,
Section IV). There are many different models of varying degrees.
The more inclusive and accessible the more successful the results.
Models that provide onsite services or allow work-time for participation
have demonstrated overall increases in productivity. Recent research
suggests that multiple behavioral risk factors are likely to cluster
among adult workers. For example smokers are more likely to have
multiple other risk factors, and nonsmokers are more likely to
engage in health behaviors such as exercise. Addressing one behavioral
change results in improvements in multiple behaviors. (Campbell
et al., 2000).
- The Centers for Disease Control and Prevention, Guidelines for
School and Community Programs Promoting Lifelong Physical Activity;
and CDC's Guidelines for School and Health Programs Promoting Lifelong
Healthy Eating are excellent standards for school and community
wellness programs. (CDC Guidelines. Online, 2000).
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