Susan R. Hochman University Health Services

1. Mind the Gap: How college health services can use assessment to identify health disparities, health inequities, and barriers to accessing care Susan R. Hochman University Health Services

2. Learning Objectives 1. Identify quantitative measures for determining health disparities and inequities. 2. Identify qualitative measures for determining health disparities and inequities. 3. Discuss strategies for using data to reduce identified barriers to access and create health equity on college campuses.

3. Definitions • Health Disparities: • Preventabledifferences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. (The United States Centers for Disease Control and Prevention) • Health Inequities: • Differences in health status or in the distribution of healthdeterminantsbetween different population groups. (The World Health Organization)

4. Why is this important? • Health disparities and inequities are well documented in the general population • A relationship exists between health and educational attainment • Higher education was once considered the great equalizer

5. Why is this important? • “Health care disparities persist in the college setting despite improved access and nearly universal insurance coverage.” (Hunt, J.; Eisenber, D.; Lu, L.; and Gathright, M. 2014) • College students who are "members of traditionally stigmatized groups continue to experience relatively poorer health, lower achievement outcomes, and greater psychological alienation than members of non-stigmatized groups." (London, Downey, Bolger, and Viella, 2005) • Despite equality of education, conceptually meaningful group differences in health behaviors were revealed, pointing toward future research on modifying the psychosocial aspects of ethnic health disparities (Despues, D. and Friedman, A. 2007)

6. What we don’t know • Most literature on health disparities and inequities is conducted outside of the college population. • What little literature does exist tends to be limited to a single health variable such as mental health, weight or substance use.

7. Quantitative Measures

8. Analyzing Existing Data • Electronic Health Record • Population health surveys & climate surveys

9. Simple Data Inquiry • Who is accessing health services? • Why are they accessing health services?

10. Electronic Health Record • Patient Demographics: • Does your patient population reflect your campus demographics? • Differences in top diagnoses: • Do top reason codes and diagnoses differ among patient populations?

11. EHR Comparison of Students Enrolled vs. Students Seen at Health Services Based on Race

12. ICD-10 codes by population *international students are included in the racial identities above

13. ICD-10 codes by population (medical and injury only) • *international students are included in the racial identities above

14. What other variables may you consider? • Gender • Insurance status • Age • Veteran status (if known)

15. Limitations to this method • Cannot capture: • Non-binary gender • Sexual orientation • Difficult to capture: • Socioeconomic status • Veteran status • We don’t know what access would look like if we take into account differences in health status • No information on students who sought care off campus

16. Complex EHR Data Inquiry Matching EHR data with institutional data • GPA • Gym usage • Proximity of classes to UHS • Proximity of housing to UHS • Parental education • Home town • And more…

17. Population Level Surveys • National College Health Assessment • Published studies can be found at www.acha-ncha.org • Demographic measures allow us to look at self-reported health outcomes by: • Age, Sex Assigned at Birth, Transgender Identity, Gender Identity, Sexual Orientation, Weight/BMI, Race/Ethnicity, International Student Status, Primary Source of Health Insurance, among others • “Experienced discrimination” variable • Supplemental questions

18. Example Supplemental Question: During the past 12 months, have you personally experienced bias and/or discrimination based on any of the following? • Ability, Age, Body Size or Shape, Economic Status, Education, English Language Skills, Gender, Health Status, Personal Appearance, Race, Religion or Spiritual Beliefs, Sex, Sexual Orientation, Skin Color, Social Class Research Questions: • To what extent are there differences between races in reports of bias? • To what extent are there differences between races in reports of academic impacts due to health conditions? • To what extent are there differences between races in the effect of reports bias on reports of academic impacts due to health concerns?

19. Results • A significantly larger percentage of Black, Hispanic/Latino/a, and Multiracial/Other students reported experiencing an academic impact due to a health concern than White and Asian/Pacific Islander students. • A significantly larger percentage of Black, Hispanic/Latino/a, and Multiracial/Other students reported experiencing bias than White and Asian/Pacific Islander students. • Of students who reported experiencing bias, Black, Hispanic/Latino/a, and Multiracial/Other students reported experiencing significantly more acts of bias than White and Asian/Pacific Islander students. • Students who reported experiencing bias had significantly higher odds of reporting an academic impact due to a health concern.

20. Collecting new quantitative data • Non-user survey • One-time user survey • Health literacy study

21. Health Literacy • The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions

22. Mackert et. al Health Literacy Study New Vital Signs (NVS; Weiss et al., 2005)

23. Mackert et. al Health Literacy Study • Race/ethnicity of college students was found to be negatively associated with health literacy. • In comparison to White participants, Hispanic participants displayed a 0.504 point lower mean NVS score (SE = 0.11, p < .001) • African American participants were 0.957 points lower (SE = 0.23, p < .001) • Asian participants were 0.360 points lower (SE = 0.14, p < .01) • Participants who indicated multiple races or “other” showed a 0.707 point lower mean NVS score than White participants (SE = 0.28, p < .05)

24. Mackert, M., Champlin, S., & Mabry, A.

25. Qualitative Approaches

26. Qualitative • Focus groups • Environmental scan • Diversity and Inclusivity interviews • Community-based participatory research

27. Interviews • How do your social identities (including, but not limited to socioeconomic class, gender, ethnicity, race, sexual orientation, ability, first language, etc.) influence or shape your health or wellness? • In your opinion, what are some major barriers to health or wellness on this campus?  • How can the university better address the health needs of under-represented or marginalized communities through programming, advocacy, and research? 

28. Interview excerpts: “Gina” • Identifies herself as a Latina cis woman, and was raised in a lower SES • She doesn't always feel comfortable speaking from those places in a professional or healthcare environment, which can lead to her not advocating for herself. • Much of her family have a low literacy level in both English and Spanish, which has led to negative experiences with healthcare providers. As a result, she and her family often mistrust HCPs and avoid going to the doctor. In fact, Gina's grandma gave her a book on alternative medicines so that she wouldn't have to go to the doctor. • In her experience, HCPs don't ask what kind of healing practices she and her family used at home growing up, or if she saw a doctor regularly.

29. Interview quotes: • “More diverse chefs in the dining locations preparing corresponding cultural food” • “As an Asian-American male, there are a lot of things that are taboo in my culture. Death, emotions (its okay to have feelings), etc. Could university set up groups around identity to help support students?” • “My Asian identity leads me to often try home remedies before seeking Western medical care. Also, because of my age I seek limited preventative care except STD testing.” • “Most wellness offerings are in English, which may be inaccessible for Spanish speakers. Social identities may influence what wellness incentives are desired. For example restaurant gift cards as incentives may be appealing to one group, but others may prefer to share food that they made with those they care about.”

30. Strategies for Achieving equity

31. Strategies • Visible Non-discrimination Policy or Diversity Statement* • Hiring and staffing practices-Diversity Coordinators model* • Outreach and communication • Affordability/Advocacy (insurance, etc.)* • Policy review • Staff training • Telemedicine & mobile clinics *Examples on subsequent slides

32. Diversity Coordinators at UT Austin Counseling and Mental Health Center • Team of clinicians who have specialized interests, training, and knowledge for serving a variety of populations. Diversity Coordinators have a unique role in specializing services to reach underserved populations. • Work closely with faculty/staff to offer consultation and support to them as they work directly with students.

34. Diversity Coordinators at UT Austin Counseling and Mental Health Center • Other functions: • Develop open discussion groups for mental health needs in marginalized communities • Outreach programs to students for building awareness of mental health and self-care • Diversity trainings for staff/faculty across campus • Open consultation hours for students interested in mental health services • Systemic changes within CMHC to ensure services are more accessible, inclusive, and affirming • Participate in campus community events

35. Advocacy Campus level example: • Affordability: review charge structure to ensure care is affordable to those without insurance or those with high deductible plans National example: • Student Health Insurance Plans- availability and viability

36. Future research • Deeper understanding of the relationship between health disparities and disparities in academic achievement • ACHA Data Warehouse • Application of the IOM framework using McGuire et al.’s methodology

37. Continue learning with ACHA: ACHA Annual Meeting Sessions: • Dorosin lecture on Discovering Bias: Challenges and Opportunities for Organizational Diversity • Presented by Keith Maddox, PhD • The Impact of Unconscious Bias on Students’ Health and Wellbeing • Presented by Rene Salazar, MD • Beyond ACHA-NCHA Report Documents — Basic Techniques for Evaluating and Analyzing Your Campus Data (precon) • Presented by Mary Hoban, PhD; Pat Ketchum, PhD; and Alyssa Lederer, PhD • Advocacy Skills Training for College Health Professionals (precon) • Presented by Stephanie Maddin Smith, JD • Using Clinical Data and Research Collaborations to Establish the Link Between Health and Success in College • Presented by Susan Hochman, MPH; Jamie Pennebaker, PhD; and Rita Thornton, MEd

38. References • Mackert, M., Champlin, S., & Mabry. (in press) Exploring College Student Health Literacy: Do Methods of Measurement Matter? Journal of Student Affairs Research and Practice. • Hunt, Justin.2014. “Racial/Ethnic Disparities in Mental Health Care Utilization among U.S. College Students: Applying the Institution of Medicine Definition of Health Care Disparities • Pascarella, E., &Terenzini, P. (2005). How College Affects Students (2nd ed.) San Francisco, CA: Jossey Bass. • London, B., Downey, G., Bolger, N., & Velilla, E. (2005). A framework for studying social identity and coping with daily stress during the transition In G. Downey, J. S. Eccles & C. M. • Chatman (Eds.), Navigating the future: Social identity, coping, and life tasks (pp. 45-63). New York: • Russell Sage Foundation • Despues, D.; Friedman, H.S. (2007) Ethnic Differences in Health Behaviors Among College Students. Journal of Applied Social Psychology. 33(1) pp131-142

39. Questions? • Contact me: s.hochman@uhs.utexas.edu