Collaborating to End Health Disparities in Our Lifetime

The issue of health disparities has national implications both retrospectively and prospectively. In 1985, the Department of Health and Human Services released a report from the Secretary's Task Force on Black and Minority Health.¹ This report was one of the first federal documents to extensively highlight the existence of disparities in health and health care for racial and ethnic minority populations. Since then, minority populations have grown. Recent US Census Bureau data indicate that the minority population of the United States totals more than 100 million, or 34% of the US population, and this group will likely become the majority population in less than 30 years.² Despite all the medical advances made over the more than two decades since the task force report, disparities in health outcomes for many Americans persist, as shown by continued higher disease incidence, morbidity, and mortality.³

Disparities persist not just for racial and ethnic minorities but also for women, individuals with disabilities, and other medically underserved populations, including the socioeconomically disadvantaged. Disparities also occur as a result of sociodemographic factors such as poverty, education, environment, culture, and geographic and language differences. Medically underserved populations face additional obstacles to accessing and receiving health services, including health promotion, disease prevention, early detection, and high-quality medical treatment, which contribute to less than optimal health outcomes.⁴ Thus, the promise of optimal health and access to health care still eludes millions of Americans.

CHALLENGES AHEAD

Although health disparities have been documented for more than a century, efforts to eliminate them, as indicated by the nation's closely tracked Healthy People 2010 ⁵ and the annual disparities report from the Agency for Healthcare Research and Quality,⁶ have demonstrated less than satisfactory progress. Nevertheless, eliminating disparities in health and health care remains a top priority for the federal government and many state and local entities. The goal of eliminating health disparities cannot be accomplished by any one entity.⁷ Sustainable partnerships between government, nongovernment partners, communities, and individuals are needed for the elimination of health disparities.⁸ The need for such collaborative engagement is the focus of analytical papers included in this special issue on the scientific collaboration conducted by the Federal Collaboration on Health Disparities Research (FCHDR).

Federal agencies have historically collaborated in many areas, but in recent years the government has increased attention to the extent, the depth, and the limited use of collaboration. Increased attention to health disparities has led to enhanced collaboration across governmental departments and agencies. The FCHDR is a leader in efforts to facilitate and encourage collaboration across federal agencies and departments on health disparities research to achieve more rapid progress toward elimination of disparities. Under the leadership of the Department of Health and Human Services and the Department of Education Interagency Committee on Disabilities Research, the FCHDR is not only promoting federal department and interagency collaboration but also working to establish partnerships between the public and private sectors.

BUILDING STRONGER PARTNERSHIPS

These new collaborative approaches encourage researchers not only to work more collaboratively across governmental departments and agencies and state, local, tribal, and territorial entities but also to include nontraditional community partners to ensure concrete and lasting accomplishments. In addition, community groups, academic institutions, and other nongovernmental organizations are using collaborative engagement to achieve common research and scientific goals. In their study of collaborative research and behavior change theory, Jordan et al. clearly showed that their research was able to “transcend disciplinary boundaries by developing a collaborative framework that fused scholarship and creativity to explore research problems in the area of health behavior change theory and intervention.”^9(p7) Moreover, some research collaborations have resulted in scholarly publications jointly authored by academe and the community, demonstrating the value and effectiveness of these partnerships.¹⁰

Given the history of efforts to address disparities, the persistence of these disparities, and the need for more efficient application of resources, it is imperative that government agencies enhance their efforts to collaborate with other federal departments and agencies, academe, and professional, minority, and community partners to identify and rapidly apply proven solutions. Current efforts to coordinate involvement of federal and nonfederal partners are promising and are being supported and encouraged.

The importance of working across sectors to eliminate disparities has become clear to many both inside and outside government and was highlighted by President Obama, who declared soon after taking office, “Government should be collaborative.”^11(p1) In his memorandum to the heads of executive departments and agencies, the president said,

Collaboration actively engages Americans in the work of their Government. Executive departments and agencies should use innovative tools, methods, and systems to cooperate among themselves, across all levels of government, and with nonprofit organizations, business, and individuals in the private sector.^10(p1)

Because of its sheer size, the US government is a complex system. Large initiatives with broad population impact generally involve multiple entities, often reaching across the executive, legislative, and judicial branches. Efforts to eliminate racial and ethnic disparities in health and health care are no exception. Among the many contributors to health disparities, individual-, environmental-, and system-level factors will all need concerted attention.¹² Collaborative efforts must be grounded in the best available science. Evidence derived from the science should be translated into effective large-scale community and national interventions with proven effectiveness in eliminating health and health care disparities.

NEW FOCUSES FOR RESEARCH

Collaborative research is needed to address individual- and system-level concerns. Some examples are studies on capacity building, improvement of measurements and estimation of disease burden at the community and neighborhood level, enhancement of surveillance to better measure progress and new causes and determinants, development of evaluation methods and strategies that are more sensitive to measuring changes in disparities, and improvement of health workers' knowledge of the causes of health disparities and capacity to effect change in health care systems and policies. Collaborative work is also needed to improve resources and infrastructure for promoting public health programs and practice, improve mechanisms for knowledge dissemination and translation, and develop evidence-based intervention strategies and large-scale community interventions with known capability to improve health outcomes.¹² Given the current thrust toward collaboration and the growing evidence that system factors play a significant role in the persistent differences in health outcomes, addressing these factors will need to be one of several major priorities for collaboration.

The vision behind the FCHDR acknowledges that several conditions need to be met to eliminate disparities. Ultimately, this approach will involve a comprehensive examination of what we are doing in relation to stakeholder needs; what is working; and what we must do differently to make greater progress. We also will need to agree on a clear and well-defined guide we can follow to help us get there. All of this will best be achieved by creating new mechanisms that allow for pooling scientific and programmatic expertise and resources among governmental departments and agencies and nongovernmental organizations. This effort will require the support of communities and of state and local partners. Achievement of these objectives is within our reach if we use best-practice guidelines and technologies to support effective communication, coordination, and collaboration. To achieve our goals we must apply the best-available collaboration science, which suggests that success increases when the collaboration builds on critical factors that encourage groups to work together toward a common goal. Within the FCHDR, this work has begun around four priority topic areas: obesity, culturally competent mental health services, the built environment, and comorbidities. This special issue includes an overview paper¹³ describing the history, collaborative structure, and strategic approach of the FCHDR. It also includes another paper¹⁴ describing the need for research into the relationship between the built environment and the health of vulnerable populations and for effective strategies to increase access to culturally appropriate mental health services.

Ultimately, our team efforts and research partnerships should be organized around the goals of effectively disseminating research findings and establishing effective knowledge translation plans that help the federal government, communities, clinicians, and other partners in the field to eliminate health disparities. As we enter this paradigm shift to improved coordination, collaboration, and communication, if we keep the populations we serve at the forefront of everything that we do, health disparities can be eliminated in our lifetime.