Addressing Disparities

By Beti Thompson, Yamile Molina, Kasisomayajula Viswanath, Richard Warnecke, and Michael L. Prelip
doi: 10.1377/hlthaff.2015.1364

Strategies To Empower
HEALTH AFFAIRS 35,
NO. 8 (2016): 1424–1428
©2016 Project HOPE—
The People-to-People Health
Foundation, Inc.

Communities To Reduce Health

Disparities

Beti Thompson (bthompso@

fhcrc.org) is a professor in the ABSTRACT Community-based participatory research is a promising
Cancer Prevention Program at
the Fred Hutchinson Cancer
approach to reducing health disparities. It empowers individuals and
Research Center, in Seattle, communities to become the major players in solving their own health
Washington.
problems. We discuss the use of community-based participatory research
Yamile Molina is a and other strategies to enhance empowerment. We also discuss projects
postdoctoral research fellow
in the Cancer Prevention
from the Centers for Population Health and Health Disparities that have
Program, Fred Hutchinson empowered communities to achieve positive health outcomes aimed at
Cancer Research Center.
reducing disparities. We offer recommendations to policy makers for
Kasisomayajula Viswanath is involving residents in efforts to achieve health equity.
an associate professor of
popular sciences, Department
of Medical Oncology, at the
Dana-Farber Cancer Institute,
and an associate professor of

H
human development and ealth disparities continue to be a findings, and dissemination of results.6 It in-
health at the Harvard T. H. vexing problem in the United creases the relevance of the research to commu-
Chan School of Public Health, States, and the issue has long nity members, balances power among the part-
both in Boston,
Massachusetts.
been a major focus of policy ners, and helps translate research into policy and
and research. The government’s practice.6 It also helps identify community assets
Richard Warnecke is a Healthy People 2000, 2010, and 2020 initiatives on which to build interventions, and it facilitates
professor emeritus at the have aimed to reduce health disparities,1 elimi- the exchange of knowledge between researchers
Health Policy Center,
University of Illinois at
nate disparities,2 and achieve health equity,3 and community members.5
Chicago. respectively. But despite concerted efforts, dis- The approach empowers individuals and com-
parities and inequities persist.4 munities as a whole to address their own health
Michael L. Prelip is a Researchers have recognized the futility of try- issues.9–13 Empowerment can originate from out-
professor of community
health sciences at the Fielding
ing to change communities affected by health side the community (for example, from a re-
School of Public Health at the disparities by intervening at the individual level. searcher, community organizer, or outside sup-
University of California, Los A different approach, community-based partici- porter) or inside it.10–12,14
Angeles. patory research, is based on working with com- In this article we discuss how community
munities. By involving people in identifying and empowerment methods have been and can be
defining their own health problems, this ap- used to reduce disparities, with examples from
proach is most likely to develop sustainable sol- some of the projects of the Centers for Popula-
utions that work for both individuals and com- tion Health and Health Disparities program. We
munities. It has been the focus of a growing body also discuss strategies that policy makers can use
of literature.5–7 to empower communities.
Community-based participatory research is
based on collaboration between and participa-
tion by community members, representatives of Understanding Empowerment
community-based organizations, and research- Power generally refers to unequal relationships
ers to achieve health equity through social ac- among people and the ability of some to influ-
tion.8 The approach involves a long-term part- ence the behavior of others;15 power is often not
nership that is focused on a local health issue and balanced among diverse individuals in a commu-
involves co-learning, capacity building, shared nity.16 In a review of the effectiveness of empow-
decision making, mutual ownership of research erment to improve health and reduce health dis-

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parities, the World Health Organization con- emerge and become “policy” at the community
cluded that empowerment can lead to better level (for instance, when it becomes the norm to
health outcomes.11 It can help communities and wear a seat belt or get seasonal flu shots).
individuals develop opportunities, capacities, Below we offer three examples of the use of
and tools that benefit them, and it can ensure community-based participatory research and
that communities can mobilize targeted popula- community empowerment to address health dis-
tions to obtain needed health resources by fos- parities.
tering awareness of a given problem.17 It can also
ensure that communities have tools to use in
advocating for their members’ access to preven- Empowerment At Work In
tion, screening, and treatment. Empowerment Communities
often refers to either individual or collective A Media Intervention In 2010 the Harvard
power, but in this article we focus on collective T. H. Chan School of Public Health’s Center for
power that can be engendered in the community. Population Health and Health Disparities initi-
Community empowerment is a process. First, ated a project to modify public views of tobacco
power analyses should be conducted to under- use in a small Massachusetts town. The research-
stand the power relationships in a community ers wished to generate support in the local media
and possibly reveal innovative strategies for for addressing health inequities in general and
equalizing power in the community.18,19 Out- related to tobacco use in particular. Their ap-
lining the distribution of power in a community, proach was based on the assumption that the
referred to as “mapping,” involves describing in media play an important role in identifying the
depth which individuals and groups have the causes of and potential solutions for health in-
power to make decisions in a community. These equities. The researchers felt that changing the
analyses inform the process of strategic relation- public health agenda to support policies and pro-
ship building.20 grams to address health inequities was neces-
Next, the current policies and systemic factors sary; they also believed that such a change re-
that govern community health-related issues, quired mobilizing support from the powerful
and what groups are responsible for the adop- social and institutional forces in the community.
tion of the policies, should be identified. Agents Using a “community reconnaissance method”
of empowerment should also be identified. They to identify major actors in the community who
can be external to the community (such as com- were perceived to play an important role in ad-
munity organizers and academic researchers dressing health, the Harvard center examined
skilled in working with community members) the relationship among the actors.23 This method
or members of the community (such as commu- is designed to identify not only policy makers,
nity health workers and pastors in churches serv- but also the people who influence policy makers.
ing the poor). In the Harvard project, in-depth semistructured
It may be difficult to empower communities to interviews were conducted with policy makers
address health disparities if community partners who were nominated by members of the commu-
appear less concerned than researchers and pol- nity as influential on health issues, to shed light
icy makers with system changes, such as health on how power was distributed in the community.
system or legal system reform. The underserved The reconnaissance approach yielded a rich
are likely to be more worried about addressing and detailed picture of leaders in different power
the social determinants of health, including find- positions in the community, the interactions
ing safe housing, feeding a family, or having among them, and their views on health inequi-
a job, than about preventing cancer.21,22 This ties and how to address them. The analysis guid-
should not be construed as a lack of interest in ed the development of the media intervention,
reforming inequitable systems on the part of the which was intended to change the public health
underserved, however. Many of these people rec- agenda by ensuring that greater attention was
ognize that discrimination and unequal power paid to the social determinants of health in news
are the cause of social inequities that lead to coverage. The intervention consisted of work-
unfavorable social determinants, such as low- shops at which members of the media received
quality housing. Thus, it is important to empow- education about the social determinants of
er communities through interventions that tar- health.
get the social determinants of health.21 The Harvard study is ongoing and has not yet
Researchers working with underserved com- provided evidence that the media intervention
munities are likely to be most successful in has changed the community’s awareness that
empowering the community not only when the poor health is not caused solely by individual
availability of health resources improves, but factors. However, the first necessary steps for
also when norms supporting those changes that change to occur have been taken.

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Addressing Disparities

Reducing Breast Cancer Mortality A histo- the local public health department because of the
ry of collaborative research with community dearth of availability of healthy food. Research-
partners was key to the success of the Center ers built on existing relationships within the
for Population Health and Health Disparities at community to develop a multilevel, community-
the University of Illinois at Chicago.24,25 In 1995, based participatory research project to convert
mortality from breast cancer among non- small neighborhood corner stores with un-
Hispanic black women in Chicago was 98 percent healthy food options to stores that offered
higher than among white women. Breast cancer healthy food options and by mounting a social
mortality has decreased for white women but has marketing and education campaign.28
remained almost unchanged for black women East Los Angeles and Boyle Heights residents
since the 1990s. In 2007 the Sinai Urban Health were engaged in both program and research ac-
Institute, in response to these data, formed a tivities. Teens from area schools were trained in
consortium of academics, breast cancer experts, store conversion and social marketing, thus em-
public advocacy groups, and community mem- powering them to change their own food envi-
bers as the Metropolitan Chicago Breast Cancer ronment. The approach was quickly accepted by
Task Force, which eventually numbered over a community-based organizations, whose mem-
hundred members. The Center for Population bers were interested in creating opportunities
Health and Health Disparities provided leader- for local youths to become advocates for the com-
ship in assessing access to breast screening and munity as well as to develop leadership skills and
diagnostic services, a key aspect of the task force learn about potential health-related careers.
agenda.24 Early in the project it became evident that the
The task force produced a report26 containing topic of nutrition did not resonate with teens in
specific evidence-based recommendations that these communities. Messages about healthy eat-
culminated in the Reducing Breast Cancer Dis- ing (such as the food pyramid and the US De-
parities Act of 2009. The act provided increased partment of Agriculture’s MyPlate campaign)
Medicaid reimbursement for digital mammo- had been heard repeatedly, and the teens seemed
grams, expanded Medicaid coverage for to have tuned them out. However, when the issue
mammography, eliminated copayments and de- was presented as a food justice and power ineq-
ductibles for mammograms, and created a pilot uity issue, the youths became highly interested
program to help women covered by Medicaid in the topic of food deserts (areas where healthy
navigate health services. Other provisions estab- food options are lacking) and food swamps
lished a Medicaid patient rescreening reminder (areas where unhealthy food options abound).
system, exercised the option of a state panel to They related more to food environment issues
establish quality standards for mammography, and how this affected poor dietary behavior than
developed a Medicaid reimbursement rate for they did to individual factors associated with
mammography, and established a Medicaid dietary behavior.
“pay for performance” bonus for primary care Working with two local high schools, the
providers who refer patients to mammography. YMCA, and an arts and civic engagement orga-
When a subsequent amendment to the legisla- nization, the Center for Population Health and
tion required that the increased Medicaid Health Disparities established a semester-long
reimbursement rates be tied to submission of elective course focused on food environments,
mammography quality data by mammography food justice, health disparities, media literacy,
facilities and radiologists, the task force was con- arts for social change, social advocacy skills, cor-
tracted by Medicaid to implement a mammogra- ner store conversions, social marketing, and nu-
phy quality surveillance program. In 2014 it pub- trition, as a means of creating opportunities for
lished its report on Illinois, noting a 35 percent youth development and youth empowerment.
reduction in breast cancer mortality among The classes provided the students with the skills
black women from 2009 to 2012.26 Recent re- to do something about the problem in their com-
ports indicate that the task force contributed munity. The teens became the face and voice of
to a significant reduction in the mortality dispar- the project: They were responsible for develop-
ity between white women and women of color, ing the brand of the project (Proyecto Mercado-
from 63 percent in 2007 to 40 percent in 2014.27 FRESCO, or fresh market project), creating and
Empowering Teens To Improve Food Envi- disseminating social marketing materials, re-
ronments In East Los Angeles and Boyle modeling and restocking corner stores, present-
Heights—predominantly low-income Latino ing information and performing skits (written
communities in Los Angeles, California—the by the teens) at key community and school
quality of the local food environment became a events, and meeting with community leaders.
key concern of community members, neighbor- Through their efforts, they showed the commu-
hood nonprofit agencies, and staff members of nity, including their teachers and parents, and

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themselves that they could have an impact on the less of the resources required to make it happen.5
social determinants of health and social norms As a result of the project, policy makers awarded
(related to healthy eating) that affected them and funding for identifying HIV/AIDS in transgen-
their community. The researchers successfully der individuals.5 A study of youth suicide in First
converted two small corner stores that provided Nations communities (indigenous populations)
primarily unhealthy foods to stores that included in Canada found a strong inverse correlation
a variety of healthy foods, including fresh fruit between empowerment of the communities and
and vegetables that were strategically placed at the rate of youth suicide.29 Similarly, a study of
the stores’ entrances. HIV prevention among sex workers in Calcutta,
India, found that empowerment to make their
own decisions on which prophylactic activities to
Discussion pursue led to a significant decrease in HIV prev-
The Centers for Population Health and Health alence among the sex workers compared to those
Disparities projects described above took a vari- in other Indian cities, and condom use among
ety of approaches to community empowerment. Calcutta sex workers increased from 3 percent in
These included understanding the roots of pow- 1992 to 90 percent in 1999.30
er and how it was manifested in the Harvard Improving the health outcomes of communi-
center’s project, engaging the community in cre- ties through community empowerment relies on
ating recommendations to address black-white ongoing trust and relationship building between
differences in breast cancer rates in Chicago, and the community and researchers. Although it is
empowering teens in Los Angeles to fight for important to begin initiatives at the local level to
food equity by framing it as a social justice issue. engage community members and secure their
Community partnerships have required univer- buy-in, making differences in the health of a
sity-based researchers to explore and consider community often requires policy decisions at
new approaches to understanding community the local, state, or national levels. Community-
empowerment. Paramount among these ap- based participatory research efforts to improve
proaches is understanding and building on the community health outcomes must simulta-
assets that communities bring to research neously develop and maintain partnerships
projects. among key stakeholders (individuals, busi-
In a town in Massachusetts, understanding nesses, media, and others) at different levels
community power was key to developing an in- to influence policies to improve health.
tervention intended to change how the media Policy makers must recognize and facilitate
report on health. The University of Illinois at empowerment at a variety of levels. This can
Chicago also worked with the Metropolitan Chi- be done by involving community members and
cago Breast Cancer Task Force partnership to the underserved in the initiation and implemen-
understand local power issues that had an influ- tation of policy, as well as by relying on people
ence on breast cancer mortality. The task force who hold more traditional power. Decision mak-
was instrumental in changing the policy agenda ing should not be left to policy makers alone: It is
and in revising the policy when gaps between their responsibility, to the underserved and to
black and white women were noted in breast the communities in which they work, to achieve
cancer screening. shared policy making. Involving policy makers
The examples demonstrate one way of measur- in the empowerment of underserved popula-
ing empowerment: through changes in the rela- tions has the potential to reduce health dis-
tionships among people. They illustrate that parities.
changes occurred in the communities that affect-
ed the ability of underserved individuals to take
advantage of health services. This has the poten- Conclusion
tial to change the environment within which If health disparities are to be reduced or elimi-
health disparities occur. As the examples show, nated, the playing field must be leveled. One way
a community-based participatory research ap- to do that is to empower communities so that
proach can redistribute power and subsequently everyone has access to the national, regional,
change health behavior. and local assets that equalize available opportu-
Previous studies confirm that community nities. It is not always easy to empower commu-
empowerment can reduce health disparities. In nity members and the underserved, but without
the Transgender Community Health Project, full participation in a healthful society, a sizable
aimed at assessing HIV/AIDS risk among trans- portion of the US population will be excluded
gender people in San Francisco, empowerment from good health. Empowered communities can
allowed the community to define and work to- work toward the common goal of reducing and
ward a solution that met its own needs, regard- eventually eliminating health inequities. ▪

A u g u s t 201 6 35:8 Health A ffairs 1427

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Addressing Disparities

The authors thank the Centers for and funders, click on the Appendix link position of the National Cancer Institute
Population Health and Health Disparities in the box to the right of the article or the National Heart, Lung, and Blood
Writing Group and funders. For a online. The views expressed in this Institute.
complete list of writing group members article do not reflect any official

NOTES
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