Working Toward Social Justice: Center for Research on Minority Health Summer Workshop on Health Disparities

Health disparities research encompasses a complex web of areas of cross-disciplinary expertise from fields such as health policy, public health, economics, sociology, psychology, anthropology, communications, genetics, biology, environmental science, ethics, and law. Dissemination of health disparities research is paramount to educating and training professionals, academics, community leaders, students and others about the subject area, and providing them with the necessary tools to affect change and eliminate health disparities. This paper chronicles the development of a unique health disparities and social justice research educational program held annually by The University of Texas M. D. Anderson Cancer Center, Center for Research on Minority Health. The program is composed of a college semester course and summer workshop, which in the past five years, has become a preeminent program in the United States. The program's impetus, premise, evaluation, and future directions are discussed. © 2007 Californian Journal of Health Promotion. All rights reserved.


Introduction
Long-time human rights activist, Dr. Jack Geiger, asserted that the disenfranchised would be relegated to "lives less worthy of life" if health professionals and practitioners were to abort the mission of ameliorating health disparities (Geiger, 2002).In 2002, in a sobering and pivotal report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, The Institute of Medicine (IOM) identified the overwhelming evidence that racial and ethnic disparities in healthcare exist and are frequently irrespective of socioeconomic status.The IOM went on to declare that because such disparities are associated with worse health outcomes, they are unacceptable (Smedley, Stith, & Nelson, 2003).It appears that healthcare professionals, researchers and policymakers have begun to address health disparities, as evinced by the growing number of conferences, initiatives, and research studies on health disparities, sponsored by government and private institutions alike.
Health disparities are most frequently reported in the framework of race, ethnicity and socioeconomic status.Research in health disparities, however, has appreciably evolved to include the association between gender, geographic location, age, disability, and sexual orientation and health outcomes and equal access to quality care.Health disparities exist across the continuum of primary, secondary, and tertiary care, and stem from the interplay of multiple factors, including access to care and quality of health care; increased risk of disease posed by the physical environment; genetics; culturally prescribed attitudes; and family or social networks.
The reduction and ultimate elimination of health disparities in the United States will require multilevel approaches, all of which will emanate from the initial advancement of our knowledge base.Structural or policy changes will need to be made to reduce institutional barriers to equitable health outcomes, including issues related to health insurance coverage and the under-representation of minorities in health fields.Numerous reports have in fact cited the necessity of increasing the pool of ethnic minorities entering the health professions as a means for reducing health disparities (Aguirre-Molina & Pond, 2002;Smedley et al., 2003).Cultural competency training for health care professionals, as well as hospital accreditation that includes health disparities as a criterion could also be major steps in addressing and preventing inequities in access to services (Smedley et al., 2003).Health disparities, however, cannot be adequately and effectively addressed if communities and policy makers lack the information needed to affect change.The purpose of health disparities research is therefore to advance the knowledge base that contributes toward the reduction and elimination of disparities by narrowing the knowledge gaps and rectifying the limitations associated with previous sources of information on ethnic minority communities (Gibbs, Nsiah-Jefferson, McHugh, Trivedi & Prothrow-Stith, 2006;Ver Ploeg & Perrin, 2004).
The Institute of Medicine has evaluated health system-level factors such as health financing, cultural and linguistic barriers, patient-level factors, biological factors, and disparities arising from the clinical encounter and structure of care.Recent examples of how system-level factors potentially contribute to health disparities are several health policy initiatives that have further limited immigrants' access to care as a result of the highly politicized disputes on immigration reform and the wide array of inequities that became evident during the aftermath of Hurricane Katrina.Anti-immigrant sentiments fueling some legislative health policies have in fact hampered progress in reducing health disparities for all Latinos in the U. S. (Leichter, 2004;Palinkas & Arciniega, 1999).The devastation witnessed across the country when Hurricane Katrina struck the Gulf Coast in September of 2005 is a vivid representation of how preexisting social infrastructures shaped disparities in health outcomes that ensued, and ultimately dictated who survived and who died (Atkins & Moy, 2005).The elderly disproportionately affected were impoverished, frail, immobile, and susceptible to dehydration with chronic illnesses aggravated under the harsh conditions (Wallace, 2006).African Americans who died or were left behind were overwhelmingly poor residents in areas of New Orleans such as the Lower Ninth Ward, in what resembled apartheid (Holtz, Holmes, Stonington, & Eisenberg, 2006).
In order to more comprehensively address health disparities, additional cross-disciplinary research encompassing the political, socioeconomic and cultural dimensions of health disparities must be conducted and disseminated.Further research is also needed on methods to effectively resolve such inequities, including the development and evaluation of culturally tailored interventions.A greater understanding of the role of medical mistrust and health-related behavior and decision making among ethnic minorities will also provide practitioners, researchers and policy makers with valuable information needed to develop interventions and effectively address issues that prevent minority and underserved groups from accessing critical services and participating in research.
Finally, more collaboration is needed between academic and health-related institutions to access and utilize the expertise in these institutions in comprehensively addressing health disparities through education, awareness, research and training.A comprehensive approach to addressing and reducing health disparities cuts across multiple spherespolitical, social, cultural, human genomics, and economic.It is also vital to disseminate the work and progress in these various areas and to create and train a cadre of professionals dedicated to social justice through quality courses such as the Disparities in Health in America: Working Toward Social Justice fall undergraduate and graduate courses and Summer Workshop.Courses such as these that encompass the numerous aspects of health disparities may indeed one day soon form part of academic degree/certificate-granting programs in health disparities -an imperative step towards achieving equity in health in the United States.The development and evolution of this course represents a first step in this direction.

Historical Development of the Fall Course and Summer Workshop
Issuance of the IOM report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, culminated from a series of historical efforts to bring into focus a problem that for decades had been termed the "unequal burden" of disease among racial and ethnic populations.It is difficult to pinpoint the catalyst that led the U. S. to turn from observation and discussion to research and funding to address and alleviate health disparities in this country.Roundtable discussions among health care professionals and researchers, the rising voice of minority health care consumers and advocates and a projected increase in the number of ethnic minorities that could potentially cripple the U.S. health care system, were among the factors that pushed the issue of health disparities to the forefront -disparities that by the Year 2000 were substantial (Williams and Jackson, 2005).
Among the many individuals who sought to advocate change in a broken health care system that sustained disparities in health care was Lovell A. Jones, PhD, Professor of Health Disparities Research and the Director of the Center for Research on Minority Health (CRMH).In 2000, Dr. Jones established the CRMH, at The University of Texas M. D. Anderson Cancer Center in Houston, Texas.The CRMH was one of the first centers of its kind to seek to address disparities in cancer patient care, research, education and prevention, and to be housed at a comprehensive cancer center, and the first congressionally mandated center on minority health and health disparities outside of the federal government.
By 2002, the CRMH had become a multidisciplinary center, with a diverse staff of researchers, community outreach coordinators, educators, fellows, and students working together to achieve equity in health for all ethnic and racial minorities.The mission of the CRMH is to reduce the prevalence of cancer in ethnic minority and medically underserved populations through outstanding, integrated programs in patient care, research, education and prevention.The goals of the CRMH are to: a) foster research that addresses the causes of health disparities and translates scientific results back to the communities affected by those disparities; b) encourage minority students to pursue careers in the biomedical sciences; and c) increase recruitment and retention of minority and medically underserved populations into clinical trials.CRMH collaborators include academic and health care institutions, private and volunteer organizations, government agencies, and community leaders and advisory and advocacy groups.The first CRMH course, Disparities in Health in America: Working Towards Social Justice was offered as a full semester course in the fall of 2002 and was held at the University of Houston.This initial cross-institutional "anchor course" included collaborations from The University of Texas M. D. Anderson Cancer Center (CRMH), The University of Houston, The University of Texas Health Science Center at Houston, Baylor College of Medicine, Texas Southern University, and Rice University.Established in the summer of 2003, the workshop, Disparities in Health in America: Working Toward Social Justice, emanated from the original semesterlong anchor course, yet was modified as a one week Summer Workshop to accommodate not only students, but health professionals, policy experts, clinicians, school administrators, community members and researchers nationwide who had an interest in health disparities.These Workshops have had similar formats.Nationally recognized authorities in the field of genomics, policy, law, ethics, public health, culture, science education, epidemiology, anthropology, health communication, economics, politics, international health, research and science have presented from their respective fields providing their attendant perspectives on health disparities.
Since 2003, the number of participants has steadily increased with a cumulative total of 959 individuals from the Texas Medical Center and the U.S. attending the annual Workshop.The number of graduate students, particularly public health students, attending the Workshop has also risen each year.Finally, the breadth of topics covered in the Summer Workshop has expanded over the past five years in response to course evaluations and participant recommendations and to accommodate new areas of interest.

Evaluation of Summer Workshop: Disparities in Health in America: Working Toward Social Justice
Course Goals The goal of the Summer Workshop is to provide a comprehensive approach to the issue of health disparities and to provide the attendee with a broad base of knowledge so that they may address health disparities with a biopsychosocial approach.

Educational Objectives
After attending the Workshop, participants should be able to: 1. Acquire introductory knowledge and experience related to the complex social, behavioral and medical determinants of populations' health, which will enable them to understand the origins of health disparities within a population and to conceptualize programs and policies to reduce and eliminate those disparities.2. Examine and gain an understanding of the latest findings of specific research that demonstrate that there are wide disparities in health among certain populations.3. Demonstrate awareness of factors that currently contribute to wide disparities in health among certain populations.4. Identify the role of (various) health professionals in eliminating disparities.5. Investigate community and state-level resources that can be mobilized for planning, policy development, program interpretation and funding for reduction of health disparities.
The 2006 Summer Workshop, Disparities in Health in America: Working Toward Social Justice was held for seven days, with two speaker sessions each day.Each speaker session consisted of presentations followed by a panel discussion.The panel discussion was included in response to previous evaluations.A total of 53 presentations were given by speakers with expertise in various areas of health disparities research.The breadth of topics covered in the Summer Workshop has expanded to include presentations in the following disciplines: health policy, public health, economics, sociology, biology, health communications, genetics, environmental science, ethics, psychology, anthropology, and law.Participants had the option of registering for the entire Workshop or for a particular day consisting of two speaker sessions.
Workshop Participants and Speakers There were 277 participants in the 2006 Disparities in Health in America Workshop.Of these individuals, approximately 224 participants were "course-goers", that is, individuals who attended at least one presentation and did not contribute as a Workshop speaker.Among the participants, 28% reported doctorate level credentials (e.g., Ph.D., Dr.P.H., D.N., and Ed.D.), and an additional 22% reported the completion of a master's degrees (e.g., MPH, MA, MS, MPA, MHA, and MeD).Six percent of the participants were physicians, 5% were in the nursing profession, and 2% were attorneys.There was also a naturopathic physician in attendance.Although participants traveled from numerous regions of the United States to attend the Workshop, more than half of the participants were from the State of Texas (52.6%), and 75% of Texans were from Houston.Of the attendees, 24.8% were employees of The University of Texas M. D. Anderson Cancer Center.There were 53 speakers for the 2006 Workshop compared to 40 speakers from the previous year.Considerably more students were in attendance at the 2006 Workshop than in the previous year (48 students in 2006 versus 16 students in 2005).

Workshop Evaluation
The instrument used to evaluate the 4th Annual Disparities in Health in America Workshop consisted of both quantitative and open-ended items that assessed for each session the: value and usefulness of the information presented; opportunities for networking; marketing of the course; extent to which participant expectations were met; selection of topics; and whether the participant expected to attend future courses.Items assessing the percentage of information presented that was new to the participant and the potential of bias toward commercial interest were also included.Knowledge and self efficacy questions related to health disparities were also included.The evaluation tool captured information on whether the participants perceived that the sessions increased their understanding and knowledge of health disparities, helped to clarify how to eliminate health disparities, and provided insight on how to positively change interactions with minorities and the medically underserved.The evaluation survey has been modified over the years to provide clearer and more concise feedback from the participants.The completed evaluation tools were collected following the completion of each speaker session.
The number of participants completing the evaluation tool differed for each question and speaker session.Overall, 581 participants rated each speaker, 560 participants assessed the course objectives (clarification on prospective areas, interaction with minorities, understanding, and overall knowledge of health disparities), and 429 participants evaluated the course attributes (publicity, pre-workshop mailings/brochure, website information, and registration).

Speaker Evaluations
Participants completed a 6-point scale to rate each speaker session, where 1 represented "excellent" and 6 represented "poor".Findings from last summer's survey evaluating the 53 speakers indicate that over 94 percent of the speaker sessions were rated as either excellent, good, or above average in terms of providing valuable, current, and useful information, networking opportunities, as well as, a panel of speakers that met individual expectations.Over 61% of the participants rated the sessions as excellent in each category.Very few of the speaker sessions were rated as "fair" or "poor".

Evaluated Course Objectives
Ninety two percent (92%) of the participants "strongly agreed, agreed, or slightly agreed" that the four evaluated course objectives (clarification on prospective areas, interaction with minorities, understanding, and overall knowledge of health disparities) were accomplished.A 6-point scale rating was used to induct answers from "strongly agree to strongly disagree", where 1 represented "strongly agree" and 6 represented "strongly disagree".

Evaluated Course Attributes
In terms of course attributes, a total of 436 session surveys were completed by participants.Of these responses, approximately 95% rated publicity for the Workshop and the preworkshop mailings/brochure as "excellent", "good" or "above average".Finally, over 98% of responses indicated that the website information was either above average, good or excellent and all respondents reported being satisfied overall with the registration procedures.
Center Department of Social Work is also an approved provider of Continuing Education Units (CEU's) by the Texas Board of Social Work Examiners.Course credits offered to undergraduate and graduate students for attending the Summer Workshop vary by institution.More information regarding the 2007 Summer Workshop can be found at the Center's web site.