Designing and Implementing a Curriculum to Support Health Equity Research Leaders: The Interdisciplinary Research Leaders Experience.

Health inequities in the United States are well-documented. However, research that is focused on solutions, rather than just describing the problem, and research that is designed explicitly to inform needed policy and practice change, is still too rare. The Robert Wood Johnson Foundation Interdisciplinary Research Leaders (IRL) program launched in 2016 with the goal of filling this gap: to generate community-engaged research to catalyze policy action in communities, while promoting leadership among researchers and community partners. In this paper, we describe the creation and implementation of a curriculum for IRL program participants over the first 5 years of the program. The curriculum-spanning domains of leadership, policy, communication, community engagement, and research methodologies-was designed to cultivate leaders who use research evidence in their efforts to promote change to advance health equity in their communities. The curriculum components implemented by IRL might be applied to other educational programs or fellowships to amplify and accelerate the growth of leaders nationwide who can use research and action to respond to grave and ongoing threats to community health.

Integrating Community Health Workers Into Medical Homes.

PURPOSE: Though evidence supports the value of community health workers (CHWs) in chronic disease self-management support, and authorities have called for expanding their roles within patient-centered medical homes (PCMHs), few PCMHs in Minnesota have incorporated these health workers into their care teams. We undertook a qualitative study to (1) identify facilitators and barriers to utilizing a CHW model among PCMHs in Minnesota, and (2) define roles played by this workforce within the PCMH team. METHODS: We conducted 51 semistructured, key-informant interviews of clinic leaders, clinicians, care coordinators, CHWs, and staff from 9 clinics (5 with community health workers, 4 without). Qualitative analysis consisted of thematic coding aligned with interview topics. RESULTS: Four key conceptual themes emerged as facilitators and barriers to utilizing a CHW model: the presence of leaders with knowledge of CHWs who championed the model, a clinic culture that favored piloting innovation vs maintaining established care models, clinic prioritization of patients' nonmedical needs, and leadership perceptions of sustainability. These health care workers performed common and clinic-specific roles that included outreach, health education and coaching, community resource linkage, system navigation, and facilitating communication between clinician and patient. CONCLUSIONS: We identified facilitators and barriers to adopting CHW roles as part of PCMH care teams in Minnesota and documented their roles being played in these settings. Our findings can be used when considering strategies to enhance utilization and integration of this emerging workforce.

The Development of Culturally Appropriate Tobacco Prevention Videos Targeted Toward Somali Youth.

BACKGROUND: Approximately 18% of Somali youth in Minnesota intend to use tobacco in the next year and youth perceive that 64% of their peers smoke. High perceived prevalence increases tobacco use intentions and initiation, indicating that Somali youth-targeted tobacco prevention efforts are needed. OBJECTIVES: To develop a Somali youth-targeted tobacco prevention intervention using a community-based participatory research (CBPR) approach. METHODS: Three focus groups were conducted to inform the development of a tobacco prevention intervention. Three tobacco prevention videos were developed. Twenty interviews were conducted to evaluate the videos. LESSONS LEARNED: It was essential to partner with Somali youth to develop the videos. Recruitment and development of the videos were facilitated through collaborating with trusted, existing community programs. CONCLUSIONS: A CBPR approach can be used to develop a culturally tailored intervention. It was important to involve academic and community partners in all stages of the research project.

Barriers to Care and Health Care Utilization Among the Publicly Insured.

BACKGROUND: Although the Affordable Care Act has been successful in expanding Medicaid to >17 million people, insurance alone may not translate into access to health care. Even among the insured, substantial barriers to accessing services inhibit health care utilization. OBJECTIVES: We examined the effect of selected barriers to health care access and the magnitude of those barriers on health care utilization. RESEARCH DESIGN: Data come from a 2008 survey of adult enrollees in Minnesota's public health care programs. We used multivariate logistic regression to estimate the effects of perceived patient, provider, and system-level barriers on past year delayed, foregone, and lack of preventive care. SUBJECTS: A total of 2194 adults enrolled in Minnesota Health Care Programs who were mostly female (66%), high school graduates (76%), unemployed (62%), and living in metro areas (67%) were included in the analysis. RESULTS: Reporting problems across all barriers increased the odds of delayed care from 2 times for provider-related barriers (OR=2.0; 95% CI, 1.2-3.3) to >6 times for access barriers (OR=6.2; 95% CI, 3.8-10.2) and foregone care from 2.6 times for family/work barriers (OR=2.6; 95% CI, 1.3-5.1) to >7 times for access barriers (OR=7.1; 95% CI, 3.9-13.1). Perceived discrimination was the only barrier consistently associated with all 3 utilization outcomes. CONCLUSIONS: Multiple types of barriers are associated with delayed and foregone care. System-level barriers and discrimination have the greatest effect on health care seeking behavior.

The Impact of Gender Differences in Attitudes and Beliefs Concerning HBV Vaccination and Screening in the Lao Community.

Liver cancer incidence is increasing among Asian Americans. Laotians in the US have greater risk of liver cancer death compared to other Asian American groups. However, ethnicity is not the only disparity; Laotian men are at increased risk of liver cancer compared to Laotian women. Use of hepatitis B virus (HBV) vaccination and screening is low among Laotians. The impact of gender differences in attitudes and beliefs concerning HBV vaccination and screening is unknown. This secondary analysis of a cross-sectional community-based participatory research study. Although men were more likely to believe that infection with HBV is preventable, and treatable, causes liver cancer, and that healthy persons should be vaccinated, of those who thought people should get vaccinated, women were four times more likely to receive vaccine than men (adj. OR 4.0, CI 1.2-19). Understanding and addressing gender differences may increase HBV screening and vaccination uptake, thus reducing disparities within the Laotian community.

Barriers to care in an ethnically diverse publicly insured population: is health care reform enough?

BACKGROUND: The Affordable Care Act provides for the expansion of Medicaid, which may result in as many as 16 million people gaining health insurance coverage. Yet it is unclear to what extent this coverage expansion will meaningfully increase access to health care. OBJECTIVE: The objective of the study was to identify barriers that may persist even after individuals are moved to insurance and to explore racial/ethnic variation in problems accessing health care services. RESEARCH DESIGN: Data are from a 2008 cross-sectional mixed-mode survey (mail with telephone follow-up in 4 languages), which is unique in measuring a comprehensive set of barriers and in focusing on several select understudied ethnic groups. We examine racial/ethnic variation in cost and coverage, access, and provider-related barriers. The study adhered to a community-based participatory research process. SUBJECTS: Surveys were obtained from a stratified random sample of adults enrolled in Minnesota Health Care Programs who self-report ethnicity as white, African American, American Indian, Hispanic, Hmong, or Somali (n=1731). RESULTS: All enrollees reported barriers to getting needed care; enrollees from minority cultural groups (Hmong and American Indian in particular) were more likely to experience problems than whites. Barriers associated with cost and coverage were the most prevalent, with 72% of enrollees reporting 1 or more of these problems. Approximately 63% of enrollees reported 1 or more access barriers. Provider-related barriers were the least prevalent (about 29%) yet revealed the most pervasive disparities. CONCLUSIONS: Many challenges to care persist for publicly insured adults, particularly minority racial and ethnic groups. The ACA expansion of Medicaid, although necessary, is not sufficient for achieving improved and equitable access to care.

Survey of high-risk pool enrollees suggests that targeted transition education and outreach should begin soon.

Several provisions of the Affordable Care Act make state and federal high-risk pools unnecessary beginning in January 2014. As a result, thousands of enrollees in those pools will be transferred to Medicaid and the new state and federal insurance exchanges. Our study analyzed new survey data collected from enrollees in the country's oldest and largest state-based high-risk pool, the Minnesota Comprehensive Health Association. We estimate that approximately half of the enrollees in that pool will qualify for Medicaid or premium subsidies in the exchange. More than 60 percent of the enrollees reported being somewhat or very unfamiliar with health care reform and the resulting changes to their current coverage. Their concerns about the expected impact of health reform varied by income, geography, and level of deductible. Targeting education and outreach information to address these concerns will be critical for this population's smooth transition to new coverage.

Comparing errors in Medicaid reporting across surveys: evidence to date.

OBJECTIVE: To synthesize evidence on the accuracy of Medicaid reporting across state and federal surveys. DATA SOURCES: All available validation studies. STUDY DESIGN: Compare results from existing research to understand variation in reporting across surveys. DATA COLLECTION METHODS: Synthesize all available studies validating survey reports of Medicaid coverage. PRINCIPAL FINDINGS: Across all surveys, reporting some type of insurance coverage is better than reporting Medicaid specifically. Therefore, estimates of uninsurance are less biased than estimates of specific sources of coverage. The CPS stands out as being particularly inaccurate. CONCLUSIONS: Measuring health insurance coverage is prone to some level of error, yet survey overstatements of uninsurance are modest in most surveys. Accounting for all forms of bias is complex. Researchers should consider adjusting estimates of Medicaid and uninsurance in surveys prone to high levels of misreporting.

Facilitating research faculty participation in CBPR: development of a model based on key informant interviews.

Community-based participatory research (CBPR) may enhance the translational research process; however, this would require increased institutional capacity for community engaged research. In this paper, we fi rst present results of key informant interviews with academic health center faculty regarding facilitators to faculty participation in CBPR partnerships and then propose a model arising from these results describing how increased capacity may be achieved. Participants were 13 key informant faculty of varying levels of expertise in CBPR at a large university academic health center. Interviews were recorded and transcribed. A thematic content analysis of each interview was conducted by research team members. Facilitators reported by faculty representing fi ve health science schools were grouped into fi ve thematic areas: (1) researcher personal attributes including an innate orientation toward working with community, (2) positive attitudes toward collaboration, (3) a partnership-building skill set, (4) community partners who are ready and eager to collaborate, and (5) supportive institutional policies and procedures. We propose a model describing the relationship between personal attributes, learned/environmental factors, and community facilitators that may be utilized to promote increased institutional capacity for CBPR and thus increase the likelihood of the successful translation of research findings into community settings.

Agreement between self-reported and administrative race and ethnicity data among Medicaid enrollees in Minnesota.

OBJECTIVE: This paper measures agreement between survey and administrative measures of race/ethnicity for Medicaid enrollees. Level of agreement and the demographic and health-related characteristics associated with misclassification on the administrative measure are examined. DATA SOURCES: Minnesota Medicaid enrollee files matched to self-report information from a telephone/mail survey of 4,902 enrollees conducted in 2003. STUDY DESIGN: Measures of agreement between the two measures of race/ethnicity are computed. Using logistic regression, we also assess whether misclassification of race/ethnicity on administrative files is associated with demographic factors, health status, health care utilization, or ratings of quality of health care. DATA EXTRACTION: Race/ethnicity fields from administrative Medicaid files were extracted and merged with self-report data. PRINCIPAL FINDINGS: The administrative data correctly classified 94 percent of cases on race/ethnicity. Persons who self-identified as Hispanic and those whose home language was English had the greater odds (compared with persons who self-identified as white and those whose home language was not English) of being misclassified in administrative data. Persons classified as unknown/other on administrative data were more likely to self-identify as white. CONCLUSIONS: In this case study in Minnesota, researchers can be reasonably confident that the racial designations on Medicaid administrative data comport with how enrollees self-identify. Moreover, misclassification is not associated with common measures of health status, utilization, and ratings of quality of care. Further replication is recommended given variation in how race information is collected and coded by Medicaid agencies in different states.

Revisiting crowd-out update.

Crowd-out occurs when the existence of public insurance causes people to shift from private to public coverage, thus stretching scarce government resources to insure those who could access private plans. This update looks at the research published since the 2004 synthesis was released. Key findings include: Some level of crowd-out will always occur with public program expansions. There is a wide range of estimates of crowd-out with lower estimates for low-income children (0 to 15%) and higher rates for higher-income children and longer-term enrollees (35% to 50%). Recent studies confirm the most common anti-crowd-out measures--waiting periods and increased public-plan premiums--discourage both the uninsured and the privately insured from enrolling in public coverage. Crowd-out is more likely when eligibility is expanded to include higher-incomes and entire families. Crowd out can occur based on employers', as well as employees' behaviors, but it appear the recent decline in ESI is more a result of employee take-up rather than employers dropping health benefits. Finally, there is limited research that suggests children with public coverage are better off than those with private insurance.

Providing health care to Latino immigrants: community-based efforts in the rural midwest.

We examined case studies of 3 rural Midwestern communities to assess local health care systems' response to rapidly growing Latino populations. Currently, clinics provide free or low-cost care, and schools, public health, social services, and religious organizations connect Latinos to the health care system. However, many unmet health care needs result from lack of health insurance, limited income, and linguistic and cultural barriers. Targeted safety net funding would help meet Latino health care needs in rural communities with limited resources.