SUPPLEMENT ARTICLE

Community Engagement and its Impact on Child Health

Disparities: Building Blocks, Examples, and Resources
AUTHORS: Eduardo R. Ochoa Jr, MDa and Creshelle Nash,
MD, MPHb abstract
aDepartment of Pediatrics, University of Arkansas for Medical National attention to racial and ethnic health disparities has increased
Sciences, and bArkansas Minority Health Commission, University
of Arkansas for Medical Sciences, Little Rock, Arkansas over the last decades, but marked improvements in minority health,
KEY WORDS
especially among children, have been slow to emerge. A life-course
child health disparities, community engagement, child advocacy, perspective with sustained community engagement takes into account
community-based public health root causes of poor health in minority and low-income communities.
ABBREVIATIONS This perspective involves a variety of primary care, public health, and
CDC—Centers for Disease Control and Prevention academic stakeholders. A life-course perspective holds great promise
AAP—American Academy of Pediatrics
CBO— community-based organization for having a positive impact on health inequities. In this article we
AMHC—Arkansas Minority Health Commission provide background information on available tools and resources for
REACH—Racial and Ethnic Approaches to Community Health engaging with communities. We also offer examples of community-
The views presented in this article are those of the authors, not primary care provider interventions that have had a positive impact on
the organizations with which they are affiliated.
racial and ethnic health disparities. Common elements of these
www.pediatrics.org/cgi/doi/10.1542/peds.2009-1100L projects are described; additional local and national resources are
doi:10.1542/peds.2009-1100L listed; and future research needs, specifically in communities around
Accepted for publication Jul 20, 2009 issues that are relevant to children, are articulated. Examples through-
Address correspondence to Eduardo R. Ochoa Jr, MD, University out the history of pediatrics show the potential to eliminate racial and
of Arkansas for Medical Sciences, Department of Pediatrics, ethnic health disparities not only for children but also for all popula-
Arkansas Children’s Hospital, 1 Children’s Way, Slot 900, Little
Rock, AR 72202. E-mail: [email protected] tions across the life course. Pediatrics 2009;124:S237–S245
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2009 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.

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Few topics in health, from individual diabetes interventions16 and the role faculty members meeting the needs of
health care to population health and of cultural leverage in health care– uninsured adolescents,20 and a resi-
from social determinants of health1 to disparities interventions17 point to dent targeting the negative effects of
health policy, demand a more compre- the promise of community partner- juice consumption in young children.21
hensive examination than racial and ships for bridging systems and pop- These examples involve advocacy
ethnic health disparities. Health dis- ulations. Pediatrics is particularly projects with realizable goals focused
parities are significant differences in well suited to being the bridging on a particular issue and offer poten-
health, health care, and developmental force at the intersection of public tial approaches to community advo-
outcomes between populations, to health, advocacy, and community. In cacy and engagement.20,22 Projects
modify a definition from the Eunice fact, “promoting community rela- such as these can form the basis for
Kennedy Shriver National Institute of tionships and resources” is 1 of 10 building lasting relationships with com-
Child Health and Human Development health-promotion themes in the Bright munity members, community-based
(NICHD). National awareness of health Futures: Guidelines for Health Supervi- organizations (CBOs), state agencies,
disparities has progressed over the sion of Infants, Children, and Adoles- schools, and other community-based as-
last 25 years from the Centers for Dis- cents,18 a publication of the American sociations. These relationships require
ease Control and Prevention2 (CDC) Academy of Pediatrics (AAP). Pediatri- effort, nurturing, and true partnership.
and the US Department of Health and cians and a host of child health providers These relationships are essential for a
Human Services3 reports in the mid- build relationships every day with fami- multilevel approach toward performing
1980s to the Institute of Medicine re- lies, often across several generations. research, sharing resources, imple-
port in 2003,4 but the pace of progress This experience with children and fami- menting interventions, disseminating re-
in eliminating these disparities has lies makes community engagement less sults, evaluating results, and, ultimately,
been slow.5 daunting for pediatricians and as re- reducing health disparities.14,23
In addition, the health-disparities liter- warding as individual doctor-patient Developing provider-community rela-
ature tends to focus on mortality, mor- interactions. tionships is time consuming at first.
bidity, and health care interventions In this article we describe the lessons However, these relationships have the
related to chronic diseases in adults. that pediatricians can learn from the potential to last much longer than
This does not mean that little is known community-based public health move- grant cycles and allow for creativity in
about child health disparities, as shown ment about the building blocks of com- developing networks, resources, sus-
by the annual editions of the Annie E. munity partnerships. We also provide tainability, and buy-in. Fortunately,
Casey Foundation’s Kids Count Data examples of what has been and what child health providers can learn more
Book,6 which review racial and ethnic can be done through these partner- about community engagement from
disparities in child deaths, teen births, ships to reduce child health dispari- many sources. For example, Mc-
infant mortality, and low birth weight, ties. Finally, we describe resources Knight’s24 succinct and rich explora-
among many other indicators. Further- and models that can be adapted to lo- tion of the differences and interactions
more, disparities by race and ethnicity cal and regional communities. between communities and systems
are well documented for childhood lays the groundwork for understand-
asthma,7 obesity,8,9 immunizations,10,11 SETTING THE STAGE FOR ing social capital and asset-based
and health insurance coverage.12 Health COMMUNITY ENGAGEMENT ON community development, which Pan et
insurance disparities are particularly HEALTH DISPARITIES al25 nicely described. The Community-
severe in Latino children.13 The first foray of a physician or other Based Public Health Initiative offers
The concept of partnering with com- health provider into a community-level practice principles and model ap-
munities to improve health is not a issue often results from the realization proaches,26 research principles,27 and
new one, especially in the public health that a particular problem identified examples of community impact.28
world, but it has recently gained mo- while caring for a patient is large and With these tools, primary care provid-
mentum in more traditional medical requires a group effort to resolve. Ex- ers can convene community members
settings as physicians come to realize amples in the literature of physicians to discuss areas of common concern,
that all nonbiomedical influences on who have engaged the community and preferably outside a major health care
individual health are not easily ad- the focus areas of this engagement institution, and begin to build consensus
dressed in a clinic or hospital room.14,15 include private practitioners address- and form strategies for addressing iden-
Recent reviews of the literature on ing fragmentation of care,19 academic tified issues. The physician-community

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 SUPPLEMENT ARTICLE

alliance enhances the community’s so- might have occurred over generations, whether these interventions eliminated
cial capital, providing an opportunity to avoid similar harms to the community health disparities,39 and most did not fol-
to engage potential agents of systems from the partnership. All too often, re- low participants for long enough to show
change safely, and enables the physi- searchers have had a “helicopter,”32 “hit- a sustained effect.
cian to work cooperatively with people and-run,” or “parachute” relationship A model might help pediatricians and
instead of serving as an ombudsman with communities, visiting the commu- other child health providers visualize
for a system. As the relationship ma- nity only to obtain grant funding to sus- the factors that influence the develop-
tures, the pediatrician and community tain their research and not to help the ment of efforts to shape health policy.
can identify other assets within or out- community over the long-term. Again, Richmond and Kotelchuck40 have de-
side the community (including in the child health care providers can turn to scribed a 3-factor approach (Fig 1) to
health care system) that can be used several sources to learn about concep- developing and implementing public
to execute a strategy. Furthermore, as tual frameworks for engaging in and policy and, subsequently, health policy.
pediatric and other primary care resi- evaluating community-based efforts,33 This model shows how a knowledge
dents,21 academic departments, and proposed models for university- or base, political will, and social strategy
children’s hospitals join the broad ef- agency-community collaborations,34 interrelate and shape the development
fort, the community’s access to re- and guidelines21 or strategies34 for of public policy. Although initially pos-
sources improves, and the potential creating and maintaining community tulated as a vehicle for examining the
for building trusting relationships with partnerships. health care delivery system, this model
large institutions increases. is applicable to several public and
While establishing consensus and APPROACHES TO COMMUNITY community health issues, including ad-
identifying issues to address, col- ENGAGEMENT TO REDUCE HEALTH vocacy and health inequalities.
leagues in public health agencies and DISPARITIES
In this model, a knowledge base that
academic institutions can be valuable Pediatricians at all stages of training encompasses social, economic, and
partners as new assets and resources and practice have a rich history of behavioral factors to help understand
are used to address areas of common community engagement to improve health issues is necessary for provid-
concern. Goldhagen29 has provided child health.35 Several AAP programs, ing sufficient evidence on which to
several examples of pediatric–public including Community Access to Child base health-improvement strategies. A
health partnerships and listed several Health (CATCH)36 and the Community public or professional constituency,
potential assets for these partnerships. Pediatrics Training Initiative (CPTI),37 fully engaged and ready to support
In the process of community engage- as well as an AAP policy statement on change, can then influence the political
ment, pediatricians and their com- the pediatrician’s role in community will in favor of new program develop-
munity partners might find that pediatrics,38 have promoted commu- ment. State agencies, CBOs, and other
community- or neighborhood-level nity engagement. child health advocates (including phy-
data on racial and ethnic minorities, Several projects funded by these pro- sicians and other child health provid-
particularly with regard to child health grams are directed toward child health ers) would be appropriate constitu-
disparities, are unavailable. This is es- disparities. A search of AAP’s commun- ents. Lastly, a social strategy can be
pecially likely in emerging immigrant ity pediatrics grants database (www. developed by using information from
communities, geographically or lin- aap.org/commpeds/grantsdatabase/ the first 2 components; this strategy
guistically isolated communities,30 grantsdb.cfm) for the term “health forms the base or infrastructure for
and small communities. In these disparities” returned 202 records for health policy. Such a strategy could be
cases, the partners might need to projects in 1993–2008. disseminated through community-
conduct assessments with involve- However, no systematic review has organizing approaches with CBOs and
ment from the community to further been conducted of community-based community-based associations.
define an issue. child health interventions20 and, by Two examples from Arkansas illus-
The community-engagement process extension, of child health disparity– trate this model in action. In the first
might also reveal the community’s past focused, community-based interven- example, the Coalition for a Healthy
negative experiences with physicians,31 tions. Most of the many health disparity– Arkansas Today (CHART) (which in-
researchers, or government agencies. focused community-based interventions cluded ⬎100 health-related organiza-
The community must have a safe space in the literature have focused on adults, tions from around the state) advo-
to describe these experiences, which few studies were large enough to show cated for spending all of Arkansas’

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 children on the same day with the same
symptoms as a white co-worker’s chil-
dren, the white children were diag-
nosed with the flu and given prescrip-
tions, whereas the black children were
diagnosed with “the crud” and sent
home.42 After releasing its report, the
AMHC initiated activities, such as exer-
cise programs, hypertension school
screenings, and further study of car-
diovascular risk factors, in counties
that had held focus groups to continue
engaging with local communities.
Nationally, policy and programmatic
efforts to eliminate racial and ethnic
health disparities include Healthy Peo-
ple 2010, which articulated health out-
FIGURE 1 come objectives, many with origins in
Three-factor approach to developing and implementing public policy. (Reproduced with permission childhood,14 and had the goal of elimi-
from Richmond JB, Kotelchuck M. Political influences: rethinking health policy. In: McGuire CH, Foley
RP, Gorr A, Richards RW. The Handbook of Health Professions Education: Responding to New Realities
nating disparities,44 and the CDC’s Ra-
in Medicine, Dentistry, Pharmacy, Nursing, Allied Health, and Public Health. San Francisco, CA: Jossey- cial and Ethnic Approaches to Commu-
Bass; 1983:386 – 404.) nity Health (REACH) 2010.45 REACH 2010
promoted the creation of coalitions
through a planning year that required
master tobacco settlement agreement base) and collected focus-group data43 CBOs to partner with other research,
funds on health improvement. The ma- throughout the state (social strategy). public health, health care, or academic
jor focus areas of the CHART plan were This information served as the basis
organizations.46 Each REACH 2010 site
tobacco-prevention and -cessation for several multilevel recommenda-
focused on 1 of 6 areas (immuniza-
programs, expanded Medicaid ser- tions for addressing health dispari-
tions, diabetes, cardiovascular dis-
vices, public health and biomedical re- ties. The incorporation of community
ease, HIV/AIDS, infant mortality, and
search projects, targeted state-needs voices to contextualize the secondary
breast and cervical cancer screening
programs, and a trust fund to provide data enabled the articulation of com-
secured program funding for the fu- munity experiences in the search for and management) and targeted 1 or
ture. The details of this process have health care services. more racial or ethnic communities.
been described in the literature.41 In The CDC originally funded 42 of these
The data collected allowed stakehold-
this example, funding went directly to coalitions. By 2005, 40 of these projects
ers outside the community to under-
address minority health concerns and remained and an evaluation logic
stand how past interactions with the
support Medicaid, which dispropor- model was used to report progress
health care system contributed to
tionately benefits minority individuals health disparities in minority and low- across sites.45 In addition, aggregate
and communities. income communities. For example, in 1 evaluations were completed through
In the second example, the Arkansas community, black people recounted the REACH 2010 risk-factor survey,
Minority Health Commission (AMHC) such negative experiences with the which showed, for example, increased
used some of its minority health initia- only community hospital over several cholesterol-screening rates among
tive funds to conduct a descriptive generations that 1 participant disclosed Hispanic and black people in REACH
study of racial and ethnic health dis- complete avoidance of the facility, 2010 communities and reduced dis-
parities in the state.42 The researchers whereas white people in a different fo- parities compared with national rates,
evaluated existing secondary data on cus group in the same community de- as well as decreased smoking among
social determinants of health, morbid- scribed positive experiences with the Asian males.39 By 2007, the program’s
ity, behavioral risk factors, mortality, hospital. In another county, when the name had changed to REACH US, and
and hospital discharges (knowledge same doctor saw a black participant’s another round of funding had estab-

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TABLE 1 Representative Community-Based Projects That Address Health Disparities

Name Location REACH Goal(s) Procedure(s) Result(s) Reference(s)
Project
Northern Manhattan Start New York, NY ⻫ Improve immunization Trained community health Immunization rates were 49, 50
Right Coalition rates among workers for outreach; higher than national
minority children partnered with average rates after 2 y
academic center
United South and Eastern Nashville, TN ⻫ Improve immunization Implemented disease- Ongoing 51
Tribes rates among Native surveillance system
American children;
analyze factors that
contribute to infant
death
Vietnamese REACH for Santa Clara County, ⻫ Increase screening Developed action plan; Improved screening rates; 52, 53
Health Initiative CA for cervical cancer partnered with created registry and
Coalition in Vietnamese academic center reminder system;
women established
Papanicolaou-smear
clinic
REACH Detroit Partnership Detroit, MI ⻫ Improve diabetes Reduced risk factors; 54
management improved glycemic
control and diabetes
self-management
Bronx Health REACH New York, NY ⻫ Improve diabetes and Community leaders Ongoing 55–57
cardiovascular participated, developed
management policy interventions
Harlem Children’s Zone New York, NY Improve childhood Provided community Decreased hospitalizations, 58–61
asthma health worker training emergency department
management for in-home screening; visits, and school
partnered with absences; increased use
academic center of spacer devices;
increased compliance
with medication
SCHIP/Medicaid Boston, MA, area Compare SCHIP and Conducted randomized, Increased insurance 62
randomized, controlled Medicaid to controlled trial enrollment through
trial community-based community-based
advocacies in entities
insuring Latino
children
Chicago-area consortium Chicago, IL Identify needs of Identified intervention Changed legislation, 63
and American Lung children with plans increased education
Association of asthma
Metropolitan Chicago
Border Health Strategic Yuma and Santa Cruz, Develop diabetes Identified intervention Identified community-based 64
Initiative AZ outreach education plans entities to provide
programs for medical care for the
Hispanics special population;
increased education
opportunities; identified
agencies to assist
patients with payment
for clinical care and
medication
SCHIP indicates State Children’s Health Insurance Program.

lished 18 “centers of excellence in the ment, or a combination of clinical, pub- designed to reduce disparities, and
elimination of health disparities” and lic health, policy, and community- some focused primarily on children.
22 “action communities.”47 oriented approaches to this national
These successful community-based in-
The REACH 2010 and REACH US model of problem.48 Table 1 lists examples of
terventions offer the following lessons:
community engagement to address several hybrid projects from the liter-
health disparities is an example of a ature, including some that are funded ● Community collaboration, from the
“hybrid” model for health improve- by REACH. All of these projects were earliest possible moment, is a key to

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 building sustainable partnerships, athletic coaches, CBOs, and Medicaid ● The federal Office of Minority Health
establishing trust, and ensuring ap- officials.66 (www.omhrc.gov) has information
propriateness of interventions and Several partners in this health insur- on the recently formed National
strategies. The community must be ance effort in Arkansas, as well as new Partnership for Action to End Health
involved in all facets of the partner- ones, are now working on a statewide Disparities.
ship to increase buy-in and ensure effort to improve child health. Over 2 ● An environmental scan of the state
that the project’s interventions and years, the Natural Wonders Partner- or region can identify institutions
strategies meet their needs. ship Council gathered secondary data that have received federal funds
● Partners must be diverse. The over- on child health indicators and social through such programs as the Clin-
all partnership and the community determinants; collected primary data ical Translational Science Award
can benefit from the assets that through a telephone survey, commu- from the National Institutes of
each group brings to the effort. nity health provider roundtables, and Health, Prevention Research Cen-
community discussion groups; and is- ters or the Steps to a Healthier US
● Lay health advisors (also known as
sued 2 reports. The council includes program from the CDC, and Centers
community health workers) were
health care provider groups and orga- of Excellence awards from the Na-
valuable in eliminating health dis- nizations, public health and human tional Center on Minority Health and
parities from the inception of the service agency representatives, repre- Health Disparities. These programs
REACH 2010 projects.44 These advi- sentatives of state education agencies, frequently require community en-
sors can serve as referral sources, nongovernment insurers, the AMHC, gagement and might present oppor-
advocates, recruiters, connectors, and academic pediatric and public tunities for involvement by primary
navigators, coaches, or data collec- health faculty members. care providers and communities.
tors. Other nonphysician health work-
● Community-Campus Partnerships
ers, such as public health nurses or COMMUNITY-ENGAGEMENT
for Health promotes health through
case managers, have important roles RESOURCES
collaborations between communi-
in community outreach. A recent re- Several authors have described many ties and higher education institu-
view identified several studies in resources that child health providers tions. The collaborations conduct
which community health worker in- can use to engage communities,48 de- service learning, community-based
volvement in health-promotion or velop projects of mutual interest,14,20 participatory research, and coali-
disease-prevention interventions in evaluate the projects,20 and pose fur- tion building to improve community
Latino communities produced statisti- ther research questions33 to improve health. The organization brings
cally significant, positive community child health in a community. These re- groups together, provides technical
outcomes.65 sources include the following: assistance, and offers a wealth of
Another example from Arkansas in- ● Bright Futures: Guidelines for information on its Web site (www.
cluded many of these elements. A Health Supervision of Infants, Chil- ccph.info).
child advocacy organization pro- dren, and Adolescents has many ● The AAP Community Pediatrics grants
moted health care coverage of chil- resources.18 database (www.aap.org/commpeds)
dren in families with incomes up to ● Many state AAP chapters have char- describes projects funded by the
200% of the federal poverty level itable foundations that issue grants AAP. In addition, AAP fellows should
through the state’s Medicaid program. to support projects that improve consider joining the Council on
The state passed its legislation several child health. Community Pediatrics.
months before the federal State Chil- ● Most states have a stand-alone mi-
dren’s Health Insurance Program RESEARCH PRIORITIES
nority health commission or a dedi-
(SCHIP) was enacted and extensive co- cated minority health office in a As momentum builds to address
alition building with community-based public health department or other health disparities in all populations,
outreach began. The organization’s ef- state agency. These organizations additional attention must be paid to
forts reduced the percentage of unin- can often provide access to federal child health-disparities research.
sured children in Arkansas from funding for health-disparities pro- ● Additional research is needed to ex-
⬎19% to 10% between 1996 and 2003. grams or help providers locate amine the impact of community-
Partners in the effort included health state and local partnerships that based interventions on health
care organizations, school nurses, address health disparities. disparities.

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● Many of the projects reviewed for and change in ways that enrich mother taught them (be respectful)
this article had short-term out- community capacity while advanc- can learn to work in and with the
comes. Although many of these re- ing population health.32,48 community.
sults were positive, researchers To have a meaningful impact on child
need to follow these outcomes over
CONCLUSIONS
health disparities, child health care
a longer period of time. Although the literature has described providers must continue to make the
● Where disparity reductions are many community-based interventions transition from 1-on-1 clinical care and
sustained, researchers and com- that addressed health disparities, focused advocacy to community-based
munities must disseminate results challenges remain in generalizing the partnership building and long-term
and try to apply successful interven- findings, when available, of these inter- strategic initiatives. Pediatrics is a
tions to larger populations. ventions. Notably, most disparity- deeply relational profession, and these
related interventions have focused on relationships give pediatricians an
● Researchers need to describe
adults, few have measured the impact open door into communities. Walking
models in the literature for sus- on disparities, and few have followed
taining disparity reductions in di- through the door might not be easy,
outcomes for enough time to show and what they find in the community
verse organizations and funding lasting change.
environments. might be overwhelming at first. How-
However, the examples we review in ever, the potential for having a lasting
● Community-based interventions this article have shown that sustained effect on health disparities, particu-
among Native American, Asian, and community engagement can have an larly child health disparities, makes
emerging immigrant communities impact on child health disparities. The the journey all the more essential.
should be enhanced and reported. history of pediatrics has many exam-
Because these communities expe- ples of interdisciplinary collabora- ACKNOWLEDGMENTS
rience some of the largest health tions and public health interventions We thank Drs Renee Jenkins and Tina
disparities, engaging them and for improving child health on a broad Cheng for their thoughtful review of
addressing their disparities is scale and has much to offer primary the manuscript, as well as the panel-
particularly urgent. care providers, who are uniquely ists, moderators, and respondents at
● Research must approach each side suited to cultivate relationships with the 2008 conference “Starting Early: A
of the equation in health system– families. To paraphrase Paulson,22 phy- Life-Course Perspective on Child
community partnerships to under- sicians who can take a thorough his- Health Disparities—Developing a Re-
stand markers of trust, success, tory (listen) and remember what their search Action Agenda.”
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Community Engagement and its Impact on Child Health Disparities: Building
Blocks, Examples, and Resources
Eduardo R. Ochoa, Jr and Creshelle Nash
Pediatrics 2009;124;S237
DOI: 10.1542/peds.2009-1100L

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Community Engagement and its Impact on Child Health Disparities: Building
Blocks, Examples, and Resources
Eduardo R. Ochoa, Jr and Creshelle Nash
Pediatrics 2009;124;S237
DOI: 10.1542/peds.2009-1100L

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/124/Supplement_3/S237

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