The prevention and management of multiple chronic conditions, defined as the occurrence of two or more chronic physical or mental health conditions, is one of the most important challenges that we face in clinical and community care in the United States. National data estimate that 42% of adults live with two or more chronic conditions. About 11% of all adults reported at least three chronic conditions (https://bit.ly/42T346s), such as cancer, heart disease, stroke, diabetes, chronic kidney disease, arthritis, chronic obstructive pulmonary disease, asthma, and depression. The management of multiple chronic conditions accounts for nearly 90% of the $4.5 trillion annual health care expenditure nationally (https://www.cdc.gov/chronic-disease/data-research/facts-stats/index.html).
Many chronic conditions are caused by modifiable risk factors and social, structural, and political determinants that increase the risk of an unhealthy diet, physical inactivity, tobacco use, excessive alcohol intake, poor weight management, inadequate sleep, and untimely preventive health screenings. There is increasing acknowledgment that healthy behaviors are challenging to adopt and sustain in a sociopolitical context that facilitates poor health outcomes. Social determinants of health are “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (https://bit.ly/42Q4PRV). These societal factors are differentially distributed by race and ethnicity, as well as by geography—including rural versus nonrural settings. In turn, social, structural, and political determinants drive disparities in the incidence, morbidity, and mortality of multiple chronic diseases.
To address and reduce the burden of multiple chronic diseases and factors that contribute to longstanding disparities, in 2021, the National Institute on Minority Health and Health Disparities funded 11 regional research centers, collectively known as the Health Equity Action Network (HEAN). The centers were charged with developing and implementing interventional studies to reduce multiple chronic disease disparities and address the social and structural determinants at one or more levels of influence. The National Institute on Minority Health and Health Disparities also funded the Research Coordinating Center to ensure that the efforts of the HEAN were greater than the sum of its parts. The Research Coordinating Center spearheaded developing and collecting common and harmonized data elements, sharing best practices in community-engaged efforts across the centers, and providing training for early-stage investigators and community partners in community-engaged and community-based participatory research.
Within HEAN, a working group of community-engaged researchers and community partners met monthly as the Community Engagement Working Group. In the first year of collaboration, the Community Engagement Working Group adopted the National Academy of Medicine’s conceptual model to advance health equity through transformed systems for health as a guiding framework for HEAN. The model was infused into all units in the Research Coordinating Center and played a key role in the design of the HEAN annual meeting and its associated training sessions for early-stage investigators, center staff, and community partners. The model also serves as the basis of this special issue of AJPH.
This special issue on “Meaningful Community Engagement” includes articles that represent projects from across the network, highlighting the processes and effects of centering community views, voices, concerns, and contributions to research to reduce multiple chronic conditions. The authors demonstrate a deep understanding about the need for interventions that reduce disparities by incorporating the lived experiences and histories of the community collaborators into the research process. In some instances, the authors themselves come from backgrounds that produce intimate knowledge about the barriers to achieving optimal health that many of the community partners across HEAN face daily. Each article provides insights and best practices for sharing power, cocreating scientific knowledge, developing sustainable community-aligned solutions, and supporting thriving communities, while implementing research to reduce multiple chronic disease disparities. Because of these shared experiences, the authors show a level of humility and compassion that is required for successful and meaningful community engagement. We were fortunate to have engaged members of the National Academy of Medicine’s working group, who developed the conceptual model. Their analytic essay, included in this special issue, underscores the impact of the work of the National Institute on Minority Health and Health Disparities’s HEAN presented in this collection.
25 Years Ago
To mitigate, resist, or undo: addressing structural influences on the health of urban population
By 1990, African American youths in some urban areas faced lower probabilities of surviving to 45 years of age than White youths nationwide faced of surviving to 65 years. Popularized images emphasize the role of homicide among urban youth, although chronic diseases in early and middle adulthood are key contributors to these health inequalities and to their growth. For example, among young and middle-aged men in Harlem, the number of excess deaths attributed to homicide per 100 000 persons remained stable between 1980 and 1990 and then began to decline. In contrast, throughout the 1980s, excess deaths attributed to circulatory disease or cancer each doubled among young and middle-aged Harlem men. Attempts to understand, and to reverse, these growing health inequalities will be partial without consideration of the socioeconomic factors and, even more critical, the historical and structural factors that have produced modern ghettos in central cities with predominantly minority populations. . . . In the wake of these policies, un-less public health professionals take poverty and race/ethnicity into account, they risk exaggerating the returns that can be expected of narrow or conventional public health campaigns or overlooking important targets, approaches, and resources for mounting successful interventions.
From AJPH, June 2000, pp. 867–868
14 Years Ago
Ongoing Coverage for Ongoing Care: Access, Utilization, and Out-of-Pocket Spending Among Uninsured Working-Aged Adults with Chronic Health Care Needs
Unlike individuals who require simple routine care and screenings, adults with chronic health care needs have conditions that persist over time, sometimes necessitating the continuing use of a range of costly health care services. In addition, persons with chronic conditions frequently have multiple long-term conditions and may also develop additional acute conditions over time. Although this accumulation of medical conditions is well documented in elderly populations, roughly half of the working-aged population also has at least 1 chronic condition. About a quarter of these persons will also report some degree of disability that may affect work and other types of community participation, as well as such fundamental activities as independently dressing, bathing, or preparing a meal. . . . Among those with chronic conditions, persons with disabilities were just as vulnerable (or slightly more vulnerable) to coverage gaps as were persons without disabilities. In particular, persons with chronic conditions and disabilities that did not affect ADL or IADL were less likely to report a full 12 months of coverage during the year than were individuals with chronic conditions who did not report a disability.
From AJPH, February 2011, pp. 368–370
Biography
