The poor continue to be challenged by our nation's financially driven healthcare system. In Tennessee with the failure of TennCare, thousands of working and unemployed poor live without health insurance. This compromises individuals' ability to sustain or improve their quality of life, particularly for those who live with chronic disease. Many African Americans and other minorities, who disproportionately represent the poor, must rely on community-based health initiatives such as Racial and Ethnic Approaches to Community Health (REACH) 2010 to benefit from health education and health outreach activities to link to the healthcare system.
Nashville's REACH 2010 project has achieved successes and faced many challenges in the quest to make community-wide environmental and behavioral changes to reduce disparities in cardiovascular disease and diabetes. The articles in this issue share knowledge gained as a result of data collection efforts to understand the problem as well as interventions employed to improve health status. Each reveals unique challenges and offers opportunities to ensure the success of community-based health initiatives. The following describe a few recommendations and lessons learned derived from the information and experiences presented in this issue.
* Recruit non-health-related organizations for participation in community health coalitions: By involving community leaders such as housing developers, community planning officials, or major employers, innovative system-level solutions can be developed that address socioeconomic deprivation alongside health challenges. Schlundt et al. establish that in Nashville, geographic areas of poor health are associated with environmental characteristics indicative of poverty. The authors call forth the need to address factors such as education, job training, community's economic development, and affordable housing while implementing health disparity initiatives.
* Develop initiatives to maximize sustainability: Because the church is a cornerstone of the African American community, it offers itself as a place to reach many in need of health education and screening. After experiencing varied results within individual churches, Pichert et al. demonstrate great potential of impacting widespread behavior change by developing and introducing a Faith and Health course into the curriculum at American Baptist College, the nation's only predominately African American accredited Baptist college. The course teaches ministers to develop health programs for their congregations. This approach offers an attainable systems change to improve health for current and future residents.
* Assess, evaluate, and address community identity: Build a knowledge base that identifies not only the community's sociodemographic characteristics but also extends to characterize its values, priorities, and perceptions of social capital. Belue et al. explore people's perceptions of their own relationship to the area in which they live. The researchers found that African American residents within North Nashville, an impoverished community, had a low sense of belongingness in addition to a low sense of empowerment to effect change in the community, compared to white residents of other geographic areas of the city. This is important for community-based initiatives in that a greater sense of ownership or community identity could increase the communities' acceptance and participation in strategies that are started within the community.
* Coordinate activities and use of resources at the community level: Partnerships between private and public organizations in community-based health initiatives offer opportunities to maximize service to the individuals while creating cost savings for each organization. Greene et al. demonstrate how a diabetes community outreach and education program could be integrated into an existing diabetes care system and can have a positive impact clinic-wide.
* Continue to support prevention efforts: By ensuring access to education and screening (diabetes, blood pressure, cholesterol), there is more opportunity to prevent disease and disparities. On the basis of the results of screening efforts by REACH 2010 staff, Schlundt et al. developed a model that offers a process for assuring that individuals screened are triaged to receive the appropriate level of care, such as treatment for newly identified cases and education for those at high risk. Coordinated activities between organizational partnerships will be important in developing and implementing recruitment strategies.
* Address racism: Dialogue about issues associated with race/ethnicity and class are imperative in addressing health disparity. Measurement is essential to begin to understand the effects of race and class on health and healthcare. The Centers for Disease Control and Prevention has added a 4-question module, Reactions to Race, to Behavioral Risk Factor Surveillance System and it is being used by several states. Larson et al. show that in North Nashville, a greater percentage of individuals who screened positive for depression reported health-related symptoms and perceived that they had worse healthcare experiences as a result of their race.
Celia O. Larson, PhD
Issue Editor, Health Services Research Consultant