Racial/ethnic health disparities in chronic disease interventions and services across the socio-ecological model

Thesis (Ph.D.)--University of Washington, 2014Many chronic disease interventions have focused on individual-level services, such as one-on-one behavioral counseling, education or self-management classes, or direct clinical care. However, a growing body of research indicates that social factors play critical roles in shaping health and are "root causes" of health disparities. The socio-ecological model (SEM) suggests that factors across the socio-ecological spectrum, from individual genetics and behavior to environmental conditions and policies across one's lifespan, all contribute to individual health. The three studies presented in this dissertation examine the role or impact of chronic disease interventions across the socio-ecological model and racial/ethnic disparities in relation to each intervention. Study 1 monitors trends in individual-level diabetes services and care from 2001 to 2010 using national survey data, to examine if and to what extent individuals diagnosed with diabetes receive appropriate standards of clinical diabetes care or self-manage their condition over time, and the extent of racial/ethnic disparities in care. Moving toward the outer rings of the SEM, Study 2 uses King County survey data to measure the impact of obesity-related policy change, specifically menu-labeling policy, on calorie information awareness and use in the region. It also examines whether there were disparities in outcomes by race/ethnicity and other socioeconomic factors. Study 3 takes a broader look at the practical issues confronting public health practitioners and partnerships in their progression from direct service interventions to activities addressing policies and social and environmental conditions. This qualitative, exploratory case study examines the experiences of a local community coalition, whose focus shifted from a direct-service orientation to impacting broader social determinants of health to address racial and ethnic health disparities. Findings from the three studies have policy implications regarding gaps that may exist in the receipt of appropriate clinical and self-care for people of color with diabetes, whether population-level policy changes are positively impacting higher risk groups, identifies factors that may facilitate or hinder community coalitions' shift to address broader social determinants, and highlight lessons learned and areas for technical assistance in making this transition