Achieving the Healthy People 2010 goal of elimination of health disparities: what will it take?
The second national goal for Healthy People 2010 is the elimination of health disparities related to social disadvantage in the United States. Unfortunately, progress to date has been limited. Our national strategy to achieve this goal has been too narrowly focused on public health. Success will require a broader strategy including alignment of existing national policies in non-health areas that affect the health of the socially disadvantaged such as education, health care, labor, welfare, housing, criminal justice, the environment, and taxation if it is to succeed. Key criteria are needed to begin to prioritize areas for federal investment to achieve this goal. These include the impact of the targeted condition on disparities, evidence base for the intervention, potential impact of the policy on disparities, economic impact, and federal politics. Two "big ideas" offer promise including federal investment in early child education and enhanced primary care within federally qualified community health centers. The proposed criteria are applied to each proposed policy.
Available from: Mona Duggal
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ABSTRACT: Rural persons with human immunodeficiency virus (HIV) face many barriers to care, but little is known about rural-urban variation in HIV outcomes.
To determine the association between rural residence and HIV outcomes.
Retrospective cohort study of mortality among persons initiating HIV care in Veterans Administration (VA) during 1998-2006, with mortality follow-up through 2008. Rural residence was determined using Rural Urban Commuting Area codes. We identified 8489 persons initiating HIV care in VA with no evidence of combination antiretroviral therapy (cART) use at care entry, of whom 705 (8.3%) were rural.
At care entry, rural persons were less likely than urban persons to have drug use problems (10.6% vs. 19.5%, P < 0.001) or hepatitis C (34.3% vs. 41.2%, P = 0.001), but had more advanced HIV infection (median CD4: 186 vs. 246, P < 0.001). By 2 years after care entry, 5874 persons had initiated cART (528 rural [74.9%] and 5346 urban [68.7%], P = 0.001), and there were 1022 deaths (108 rural [15.3%] and 914 urban [11.7%], P = 0.004). The mortality hazard ratio for rural persons compared with urban was 1.34 (95% confidence interval: 1.05-1.69). The hazard ratio decreased to 1.18 (95% confidence interval: 0.93-1.50) after adjustment for HIV severity (CD4 and AIDS-defining illnesses) at care entry, and was 1.17 (95% confidence interval: 0.92-1.50) in a model adjusting for age, HIV severity at care entry, substance use, hepatitis B or C diagnoses, and cART initiation.
Later entry into care drives increased mortality for rural compared with urban veterans with HIV. Future studies should explore the person, care system, and community-level determinants of late care entry for rural persons with HIV.
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ABSTRACT: BACKGROUND: To address public health risk factors, governments conduct interventions in many different ministries, including non-health ministries. In order to understand the scope and cost of public health in Alberta, we developed a survey of government public health interventions. We included any government ministry or public organization, which includes health as a stated objective. METHODS: A grey literature search was initially conducted, followed by 69 consultations with federal, provincial and municipal organizations. We captured information related to (i) the type of public health service provided; (ii) the associated costs (if available); and (iii) any additional ministry that may collaborate on the initiative. This information was then presented to lead ministry personnel for validation and verification. RESULTS: We covered 15 areas of public health and identified 23 federal and 21 provincial agencies and departments that were providing these services. Public health spending on current operations amounted to $327 per capita, of which 60.5% came from provincial non-health ministries. Capital expenditures were $256 per capita, of which 32.5% were from the federal government. CONCLUSIONS: Public health expenses by non-health ministries were greater than those for health ministries. Capital expenses were much greater than non-capital expenses. In order to measure the full impact of government public health, it is necessary to take a cross-ministerial approach.
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