Transcript Addressing Health disp through community and system change 2009

Addressing Social
Determinants through
Community & System Change
By
Aida L. Giachello, Ph.D.
Associate Professor & Director
Midwest Latino Health Research, Training
and Policy Center
University of Illinois at Chicago
[email protected]
Presentation at the State Workshop on Latino Health,
Columbia, MD
Objectives
 Briefly list selected health disparities
of Hispanics/Latinos (H/L) and the
sources of the disparities
 Share some strategies on how to
address the health and social needs
of the growing Hispanic/Latino
population through community and
system change
2
Public Interest in Hispanic/Latino
Health Disparities in Montgomery
County & in Maryland
1. Dramatic population growth
 In 2006, 128,365 H/L lives in
Montgomery Country representing the 2nd
largest minority in the County
 MC has the largest concentration of H/L in
MD
 Most H/L are from Central America
(44%), followed by South America
(22.4%)
 65% of H/L are foreign born
3
Interest in H/L Health
Disparities issues…….
2. Mobilization of H/L groups and
forming partnership with the
Montgomery Dept of HHS and
other sectors
 Hispanic Health Initiatives
 BluePrints for Latino Health in
Montgomery County
4
Public Interest in H/L health Disparities
3. Increased Research & Data
National Mortality Data:
1. Heart Disease (65+)
2. Cancer (particularly
breast, cervical (45+)
and lung (25-44) cancer)
3. Injuries-- leading cause
of death: 24-44 yrs
4. Cerebrovascular diseases
5. Diabetes- 3rd cause of
death for persons 45+
6. Homicide-- leading cause
of death: 15-24 yrs
7. Pneumonia and
influenza (65+)
8. Liver diseases
(cirrhosis)
9. Pulmonary
diseases
10.HIV/AIDS (25-64)
11.Kidney failure
(65+)
12.Maternal deaths
5
Interest in H/L Health
Disparities issues…Res & Data…
Montgomery County
 HIV/AIDS
 In 2005, H/L accounted for 1.6 times as
many new HIV diagnoses as non H/L whites
(MD Dept of PH, 2007).
 Tuberculosis
 TB for H/L in Maryland is 3.5 times
 Foreign-born Latinos in Maryland is 12.5
higher than for the US
6
Interest in H/L Health
Disparities issues…Res & data...
 Type 2 Diabetes
 Leading cause of death
 Latinos are diagnosed after the age of 38
 New cases are emerging among children
and adolescents and young adults
 Diabetes complications serious problems
 Diabetic end-stage renal disease among
55+ is 10%-20% higher than whites
 Hypertensive end-stage renal disease rates
is 1.5 to 5 times higher than whites
7
Interest in H/L Health
Disparities issues…Res & Data…
 Over-weight and obesity
 In 2005, 3 out of 4 H/L 40 years of age
were overweight (46%) or obese (30%)
 Community Safety issues discourage
physical activity
 Limited income lead to limited access to
healthy food options
 Communities designated food dessert
 Occupation injuries & fatalities
 Social stress, violence, suicide/homicide,
social discrimination & anti-immigrant
sentiment
8
Hispanic/Latino Health Vary By
Age
Socio-economic status
Place of birth
National origin
Acculturation and assimilation
“Push” and “pull” factors related to
immigration
 Neighborhood, place of employment, etc






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High acculturation impact negatively
Latino Health
 +Infant mortality
 +Low birth weight
babies
 +blood pressure
 +Obesity





+Teen pregnancy
+Smoking
+Alcohol use
+Other drug use
-breast-feeding
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TRUE SOURCES OF
DISPARITIES
1. Poverty & Low SES
•
Neighborhoods and school segregation and neighborhood
quality
• Poor neighborhood becomes market for tobacco, alcohol
and fast food
 Large families, average size of 3.96
 44% have more than 4 members
 H/L has the lowest per capita income in Montgomery
Country ($20,165), representing 37.4% of whites
($53,926).
 52% work in the Service or Construction industries
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Factors affecting poverty rates
 High teen
 Low education
pregnancy
 Low earnings
& parenthood
 High
 High no. of
unemployment
families
headed by
 High poverty
women
among
married couple
families
12
Public Response to Health
Disparities: Blaming the Victim
Don’t be poor
Don’t be unemployed
Change jobs
Change neighborhood
etc
13
True Sources of Disparities:
2. Access to Care Barriers
 No regular source of care—in MC
Over 50% have no medical home)
 Lack of health insurance (50-58%)
[2005 and 2007 cancer study]
 System barriers
 Limited bilingual and bicultural staff
 Long traveling time to go to healthcare
facility
 Lack/limited transportation
14
True Source of Health Disparities…Access to
care…
Lack
Systems- barriers
of capacity of health care facilities
Long
waiting time between calling for an
appointment and the actual visit
Long
office
waiting time once you get to doctor’s
Lack
of hours of services during evening or
weekends
15
Other Healthcare Systemslevel barriers
•In managed care organizations, financial
incentives to providers tend to limit
services
• “Fragmentation” of services and poor
coordination
16
True Source of Health Disparities…Access
care…System Barriers.
to
 Lack of interpreters
– For example 1 out 5 have Gone Without Care
When Needed Due to Language Obstacles
 Poor pt-doctor communication
 NO interpreter services available
 Only 1 out of 4 requests received
interpreter in MC
 1 of 6 failed to make an appt due to
language barrier in MC
 1 in 5 could not complete their phone calls in
MC
17
True Source of Health
Disparities…Access to Care…
 Low use of health and medical care
 Delays seeking care and using
preventive services
 Limited familiarity with the health care
system and low health literacy
 Uses home remedies and OTC
 Uses medication from their country of
origin
 Seek non professionals (e.g., faith
healers)
18
True Source of
Disparities…Access to care…
 Eligibility issues
 1996 Immigration reform made eligibility
for public funder programs more
restrictive for more immigrants
 Concerns about deportation
19
July 29 – August 6
Source: Kaiser Health Tracking Poll, Election 2008:
August 2008
The Obama Plan
 Mandated coverage for kids
 Pay-or-play for employers
 New public plan offered
 No tax credits/changes
 Expansion of Medicaid/SCHIP
 Invest $10 B in HIT
 Cost: estimates range from
$50-110 B a year
3. Sources of Health Disparities:
Poor Quality of Medical Care
 Most of the improvements in health in
the last 100 years have been the
results of improvement in public
health, sanitation, nutrition and living
conditions
 Physicians and other health
professionals are not familiarized with
clinical guidelines for the management
and control of chronic diseases
23
•Racial and ethnic
minorities and women
receive poor care due to
physicians’ biases and
stereotypes
24
3. Source of Health Disparities:
Poor medical care…
 Due to long history of race/ethnic
and gender bias in the medical care
system
 Mexican Americans received 38% fewer
medications (antiarrhythmics) than
whites
 Hispanics in a Los Angeles hospital ER,
were least likely to receive no analgesia
for their injuries
Source: Goldberg et al. 1992; Herholz et al. 1996; Blustein et al, 1995; Todd
et al, 1993
25
3. Source of Disparities: Poor Medical Care…
Conclusions of IOM Report
 “Across virtually every therapeutic
intervention, ranging from high
technology procedures to the most
elementary forms of diagnostic and
treatment interventions, minorities
receive fewer procedures and poorer
quality medical care than whites
 Differences persist after controlling for
health insurance, SES, stage and severity
of disease, comobidity, and the type of
medical facility”
26
Disparities in the Clinical
Encounter: The Core Paradox
(Williams, 2004)
How could well-meaning and highly
educated health professionals, working in
their usual circumstances with diverse
patient populations, create a pattern of care
that appears to be discriminatory?
Williams argues that it has to due with
stereotyping
27
Unconscious Discrimination
 When one holds a negative stereotype
about a group and meets someone who
fits the stereotype s/he will discriminate
against that individual
 It is automatic and unconscious process
 It occurs even among persons who are
not prejudiced
 “I am not racist: I know I don’t
stereotype”
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Factors that Increase Stereotype
Usage in Medical Care






Time Pressure
Need for Quick Judgments
High Cognitive demands
Task Complexity
Resource constraints
Anger or Anxiety
Source: Williams, 2004; Van Ryan 2002
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Conclusions
 Many sources are responsible for health
disparities
• Socioeconomic and environmental
conditions
• Financial, linguistic, cultural and system
barriers to access to care;
• Poor medical care as a result of Medical
Professional behaviors in clinical settings
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STRATEGIES &
RECOMMENDATIONS
FOR ACTION
To address the social determinants of
health we must work at different levels:
Individual
Empowerment of H/L
Family
Neighborhood
Macro:
 Health and other systems
 Other systems
32
Long term institutional/structural
changes
This calls for an improvement in the levels
of education and income, and better
distribution of resources and services for all
Hispanics/Latinos
H/L health must be viewed within a broader
societal context
33
Stronger Government & Private
Sector Commitment at all Levels
For Example:
To eliminate health disparities, in addition to the
DHHS, you need to involve the Depts. of
Education, housing, Commerce,
Environmental Protection Agencies, etc.
 You need Strong commitment from
businesses, foundations, and many other key
players
 For example, MC DHHS should establish a
multi-sectorial council across departments
34
For Example: Structural
Conditions Impacting
Health
 Type and location of employment
within the economic structure (i.e.,
services industry)
 Environmental and occupational
hazards.
By not addressing the origins of the
problems we are treating the most
costly symptoms
We need to Recognize
Health Inequities
 Systematic and unjust distribution of
social, economic, and environmental
conditions needed for health
 Access to healthcare
 Employment
 Education
 Access to resources (e.g. grocery
stores, car seats)
 Housing
 Transportation
 Freedom from discrimination
Source: Whitehead M. et al
Social Determinants of Health:
Socio-ecological Model
Source: Institute of Medicine, 2003
Social Determinants of Health
Social Determinants of
Health:
Refers to…
Life-enhancing resources, such as food
supply, housing, economic and
social relationships, transportation,
education, and health care, whose
distribution across populations
effectively determines length and
quality of life.
Source: James S., 2002
Adopt Population based approach including
multiple determinants of Health
For example:
Public Health Working with the Business
Community
 Why should business care about diabetes
prevention and control?
 Loss productivity
 Increased health care expenditures
 Poorer quality of life for employees
 Consequences related to permanent
disability
 What can the food industry do?:
 Educate its members, make available
fruits and vegetables
40
5. Adopt a Population-level Approach,
including Multiple Determinants of Health…
 Work with the school system to change the
School Environment
 Changing School Environment Curbs Weight
Gain In Children, Study Shows (Apr. 7,
2008)
 Public Health Law Reform (federal, state,
local)
 Arkansas Act 1220, An Act to Combat Childhood
Obesity Act 1220 is now codified, in part, at Ark.
Code Ann. 20-7-135 (2005)
41
Population approach to address
multiple determinants of health
 New York - The Board of Health voted to make
New York the nation’s first city to ban arteryclogging artificial trans fats at restaurants-MSNBC News Services, Dec. 5, 2006
 U. S. District Court for the Southern District of
New York upheld the constitutionality of New
York City’s calorie-posting requirement for
restaurants of a certain size and type. Apr. 16,
2007)
42
Develop & Sustain different
partners
 Role of the Workplace
 What can employers do
 Employee risk assessments
 Employee education
 Health plan benefit design/disease
management vendors
 Environmental change (supportive
environment)
43
Sustaining partnerships
Partnerships will require:
 Forging a common language and
understanding
 Exchange of information and data
 Learning together about effective
strategies for the workplace
 Recognizing efforts
44
Increase accountability
Review the regulatory authorities of DHHS agencies to
maximize effectiveness and collaboration across
departments, and with other state and local health
agencies
 How can WIC be used to impact on the childhood obesity
epidemic?
 How can the DOT integrate health and physical activity
goals into transportation planning?
 What is the role of DOE in supporting implementation of
K-12 Health Education Standards?
 Is there a body that coordinates activities across
agencies to address the obesity epidemic? Do we need
one?
 Can we eliminate tobacco use in public housing
45
Advocate & Support Health Care
reform and Single-payer System
 Health care is a right and not a
privilege
 Sooner or later we must have a
national solution
 Without health we cannot work, we
cannot take care of our families, and
we cannot be productive citizens
46
Need for close monitoring of
Managed-care Networks
Concerns exist with
 Access to specialists and/or
hospitalization
 Marketing strategies
 Limited support services and follow-up
 Possible violations of patients’ rights
 Assure that Health insurance
plans/managed care cover preventive
services according to guidances
47
Improve H/L Access and use of
Health and mental health
services &
Advocate for better quality of
health/medical care, mental
health & Human services
48
Develop and implement Creative
Public Health Solutions and Models
Example:
 Racial and Ethnic Approaches
to Community Health (REACH)
2010, a CDC Initiative
 & Center of Excellence for the
Elimination of Disparities
49
REACH 2010: Building
partnerships
 Calls for community mobilization and
system change
 Encourage coalition building and
establishing partners with nontraditional sectors
 Chamber of Commerce, food industry
 Faith communities
 etc
50
Increase data and Research on
Hispanics/Latinos
Issues
 Health data systems are poorly equipped to
provide information on the health status of
Hispanic groups (GAO Report, 1992)
 Insufficient Identifiers for subgroups
 Incompleteness
 Ethics (informed consent is often violated)
 Managed-care systems do not collect data
on demographic and socioeconomic
characteristics of participants enrolled in the
plans
51
Community Participatory
Action Research Model &
Action Planning
52
UIC – CSDCAC
Phase I: Participatory Action Research &
Coalition Building Model
1
Process
Activities
Community
Dialogue
Problem
Definition
2
3
4
Coalition
Formation
CapacityBuilding
(Training)
Assessment,
Data
Collection &
Analysis
Orientation
Community
Organizing &
Coalition-building
Telephone
Survey
Giachello, 2003)
Dissemination
of findings &
Community
Consultation
Community
Forums/Town
Meetings
6
Finalize
ACTION PLAN
(logic Model)
Values
Goals &
Objectives
Strategies
Community
Involvement
Strengthening
Establishing
Com. Action
coalition
Topic
area 101 &
201
Focus
Groups
APPLIED
Research
Methods
Analyses of
Epidemiological
Data
Formations
of
Committees
Resource
Survey &
Community. mapping
Strengths &
limitations
Resources
Needed
Evaluation
CEED@Chicago Model: Systemic Links Across Socio-ecological Levels
SEM level
Political/
Economic
System
Health-Social
Service
System
Organizational
Community/
Interpersonal
Activity/ Target
Involve
nonhealth
sectors
Develop
Policy
Agenda
CapacityBuilding
Workshops
Trainers
Trained
Effects
Influence
Powerbrokers
Strengthen
Coalition
Practice
Change
Training
delivered
in Comm.
Intermediate
Outcomes
Long-term
Outcomes
Policy
Change
Crossorganizational policy
change
<Socioeconomic
Barriers
to Health
Equity
>Access
minority
clients
>Resources
at Local
Level
Change
in Local
Norms
Obesity
Reduc
tion
CEED REACH-US
HEALTHY EATING & PHYSICAL ACTIVITY PROGRAM
TRAINING &
TECHNICAL
ASSISTANCE
PUBLIC
POLICY
INITIATIVES
MULTI-SECTORAL PARTNERSHIPS
NEIGHBORHOOD
BLOCK CLUBS
EMPLOYERS
APPOINTED
& ELECTED
OFFICIALS
PARK DISTRICT
GROCERY STORES
SCHOOLS
PROFESSIONAL
ORGANIZATIONS
e.g. ADA
CHAMBER OF
COMMERCE
FAITH COMMUNITY
RESTAURANTS
CBOs
CDOH
WIC
FOOD INSPECTION
MEDIA
Create Capacity and Engage in Workforce
Development by Training Community
Residents as Health Promoters
Effectiveness of Health Promoter as diabetes educators
Changes Hb A1c Wave I
17
16.5
16
HbA1c3 Range
15
14.7
14
Hb A1c
13
12.4
12
11.8
11
10
Class #1
Class #12
6 Months after class #12
Time of Intervention
12 Months after class #12
56
Integration of Health in
Human Services delivery
 Establishing Health Promotion & Wellness
Center in the community managed by
Health Promoters
 These centers have walking clubs, and
engages in policy and advocacy
activities in addition to health education
and support
 Integrating health promoters in primary
care settings
 Integrate health promotion programs in
social services organizations
Examination of the impact of
recent social & health Policies
 Welfare Reform on health status and
on access to health care
 Immigration Reform
 Children’s Health Insurance Program
(CHIP)
 Affirmative Action
 Child Care Legislation
 Medicaid and Medicare Managed-Care
 Medicare Prescription Drug Plan
58
Increase Latino representation in
health and human services
Professions
 Between 60% to 75% of Latinos never go
to college
 Those that do go, less than 10 will graduate
 90% of our students are in urban public
schools which suffer from a limited tax base
 School segregation has increased for
Hispanics/Latinos
 Only 3% of all teachers in US are Hispanics
59
increase/encourage H/L
leadership development
This calls for
vision
passion
Commitment
team work
Knowledge and skills
Willing to lead and seeking opportunities
to lead
 Risk taking
 Perseverance
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60
Achieve Cultural Competency in
the health care system
At the individual level
Organizational level
61
Cultural Competency at the
Institutional Level
 Refers to practices, norms, value and
policies (written or not) in the health
care delivery system that either
respond or do not respond to the
needs of racial and ethnic minority
(or no- minority) groups, or other
diverse populations (e.g., the poor,
women, gay and lesbians, people with
special needs, etc)
62
63
Cultural Competency strategies at the
Institutional/Organizational level of the
health care Delivery System
Steps
 Commitment from the top
organization leadership (e.g.,
board of directors/Bd of
Trustees, President/CEO, Medical
Director, etc)
 Commitment must be reflected in
budget allocation
 Recruitment of H/L in policy
decision-making positions
64
Steps to achieve CC in the health
care system (2)
 Establishment of a Community
Advisory Committee to the Agency
 They can also contribute to
identifying problems and the
solutions
 Conduct an assessment of needs and
assets
 Within the institution/organization
 Target communities/catchments'
areas
65
Steps to achieve CC in the health care system (3)
From the community assessment of
needs and assets data develop
policies & programs
Suggested Policies and practices
 Board of Directors/bd of Trustees
 Recruitment of minorities in board
 Given minorities leadership roles
 Establishment of a policy on cultural
diversity
 etc
66
Steps to achieve CC in the health care system
(4)
Suggested Policies…..
 Personnel
 When positions are open, qualified H/L
should be recruited with appropriate
salary compensation




Hire Executive Recruiters to assist, if needed
Establish community personnel committee
Promote jobs in ethnic media
Use informal minorities network
67
Steps to achieve CC in the health care system (5)
Suggested Policies…..
 Research & Data
inclusion of ethnic identifiers
partnership with Universities
On-going analyses of agency’s data
On-going collection of data (e.g., pt.
Satisfaction surveys)
 Development and dissemination of reports




68
Steps to achieve CC in the health care system (6)
Suggested Policies…..
 Marketing of programs & services
 Assess channel of health information used
by H/L
 Provide contracts to H/L media
 Develop bilingual educational materials
(e.g., program brochures, newsletters) for
population with low levels of health
literacy
69
Steps to achieve CC in the health care system (7)
Suggested Policies…..
 Plan and implement cultural,
gender and educationalappropriate Diversity Training
 Form a planning committee with members
of staff at different levels
 Assure to conduct training with
administrative staff (particularly middle
management staff and supervisors)
70
Steps to achieve CC in the health care system (8)
Suggested Policies…..
 Cultural Diversity Training….
 Focus on one racial/ethnic group at a time
 Assure that training has group/individual
self-assessment exercises and activities
 Provide a forum for honest discussion and
ventilation of problems, concerns and
identification of solutions
71
Steps to achieve CC in the health care system (9)
Suggested Policies…..
Cultural Diversity Training….
 Provide multiple training sessions so
everyone can attend, including
administrators
 Recognize that CC is an on-going process
 Identify minority vendors as trainers
72
Steps to achieve CC in the health care system (10)
Suggested Policies…..
Cultural Diversity Training….
 You need to have realistic expectations.
Things at times have to get worse before
they get better. Be careful with firms that
assures that they can sensitize everyone in
one-two training session
73
Steps to achieve CC in the health care system (11)
Suggested Policies…..
 Establish translation services
 Establish a telephone hotline for non-English
speaking persons calling in
 Develop an interpreter/translation system with
trained individuals who knows the medical
terminologies
 Hire minority vendor for translation of materials
 Establish patient navigator programs
 Integrate trained health promoters as educators and
to conduct outreach, home visits and follow up with
professional backup
74
Steps to achieve CC in the health care system (11)
Suggested Policies…..
 Establish translation services….
 Use ATT interpreter telephone line, only if
bilingual interpreters are not available
 Do not use bilingual staff with other
assignments
 Do not use bilingual children, other relatives,
neighbors or friend, due to ethical issues (e.g.,
violation of confidentiality)
75
Steps to achieve CC in the health care system (12)
Suggested Policies…..
 Establish translation services….
 Train or hire interpreters who knows the
medical terminologies
76
Steps to achieve CC in the health care system (13)
Suggested Policies…..
 Develop benefit package for target
communities. E.g. :
 Support and attend cultural events
 Support and attend community
organizations benefits
 Provide scholarships in health career
development (e.g., nursing) for local
residents
77
Steps to achieve CC in the health care system (13)
Suggested Policies…..
 Have staff to sit in board of directors of
CBOs
 Provide job opportunities to local
residents, including training and
recruitment of community health workers
or health promoters
 Provide uncompensated care for poor
families
78
Steps to achieve CC in the health care system (14)
Suggested Policies…..
 Engage in Effective outreach and community
education strategies
 Use health promoters
 Organize or participate in health fairs and other
community educational events
 Obtain bilingual education, low literacy materials and
have them available for physicians and other health
professionals in direct services delivery
79
Steps to achieve CC in the health care system (16)
Suggested Policies…..
 Use minority vendors for diverse services
within your institution, particularly in you
are working or serving racial/ethnic
minorities
80
Steps to achieve CC in the health care system (17)
Suggested Policies…..
 Develop services delivery policies related
to:
 appointment system
 Walk-ins
 Cost (e.g., sliding scale)
 Translation services
 providing uncompensated emergency care to
those in needs
81
Steps to achieve CC in the health care system (17)
Suggested Policies…..
 Develop services delivery policies….
 Make the doctor office, clinic or hospital
user-friendly places
 Have decorations that reflects the patients
preference
 Have staff trained in customer services
82
Engaging in Cultural Competency
practices at the individual level
 Greet people with smile, handshaking, look at persons eyes. If
he/she looks puzzle, approach the
person and see I they need
assistance
 You need to do your homework about
the specific racial/ethnic population
being served
 It requires
 knowledge on culture & environmental
conditions
83
Engaging in Cultural Competency
practices at the individual level
 Developing awareness/sensitivity
 A deep understanding not only
at the intellectual level but at
an emotional level “empathy”
 Developing cultural competencythe skills to use the cultural
knowledge and sensitivity in an
effective manner in working with
diverse populations
84
Engaging in Cultural Competency
practices at the individual level (2)…..
 Engaging in cultural assessment. Find
out:










Gender roles
Place of birth
Language proficiency (fluency)
Immigration history and experience
# of years in US, as measure of acculturation
# of years of schooling (literacy)
Family composition
Language
Lifestyle practices
Health practices (use of home remedies)
85
Engaging in Cultural Competency
practices at the individual level (3)…..
 Cultural assessment…
 Religion/spirituality
 Socioeconomic status,
poverty/resources
 Gender role
 Urban/rural origin
 Social support systems/networks
 Community participation/civil
engagement
 Previous experience with the health
delivery system
86
Engaging in Cultural Competency
practices at the individual level (4)…..
 Physicians and other providers should greet
the person (s)
 Establish contact with a smile and looking
at person’s eyes.
 Use a word in Spanish: Buenos Dias/Tardes. It
relaxes the patient.
 Do not try to learn Spanish during the encounter
 If you are looking at the medical records—
inform the person what you found (most
pts do not know their diagnosis or results of
lab test and other results
 Explain what will happen doing the clinic
visit
87
Engaging in Cultural Competency
practices at the individual level (5)…..
 Involve the family
 Treat patients/clients with

Respeto (respect)—a internal Latino
value where the elderly, professionals,
and persons in position of authority are
treated with respect and dignity
 Personalismo—person-to-person contact
where the professional demonstrate
interest for the patient (and his family)
well-being while maintaining a
professional image
88
Engaging in Cultural Competency
practices at the individual level (6)….
 Listen attentively to the situational
context surrounding pt. clinical condition
 Explore the fear related to doctor visits
and health conditions
 Give patient specific referrals, when
needed
 Be aware of barriers to seeking &
using services (e.g., lack of health
insurance, inconveniences in
obtaining care, etc.)
89
Conclusion
 There is a sense of urgency to
intervene now in developing and
implementing strategies that will
improve the health and well-being of
H/L and to implement effective
strategies
 To eliminate social and health
disparities we must commit to an
agenda of social action
THANK YOU!
90