North Carolina’s Strategic Plan on Tobacco Related Health Disparities - Identifying the Data

Scott K. Proescholdbell, MPH; Felicia Snipes-Dixon, MPH; Laurie Mettam-Rude, MEd; Sheri Scott, MPH

N.C. Dept. of Health and Human Services Division of Public HealthTobacco Prevention and Control Branch

Problem

North Carolina (NC) is composed of a number of diverse groups many of which are affected by tobacco use. In order to better address tobacco-related problems, identification of populations with the highest tobacco burden is critical. The North Carolina Tobacco Prevention and Control Branch (TPCB) was funded by the CDC to conduct a one year pilot planning project focusing tobacco-related disparities. In conjunction with the state health department, an array of health professionals and community members formed the NC Tobacco Diversity Workgroup (Workgroup) to develop a plan for NC to address tobacco-related health disparities based on valid and

reliable data.

North Carolina Demographics

Total Population: 8 million

Gender: Male (49%) Female (51%)

Age: Under 5 yrs (6.7%) 65+ (12.0%)

Education: College degree or

higher (22.5) Less than High

School education (21.9%)

Poverty: Individuals below

poverty level (12.3%)

Source: Census 2000

North Carolina Demographics, Cont.

Race/ethnicity White 72.1% 5.8 mill African American 21.6% 1.7 mill American Indian 01.2% 99,551 Asian 01.4% 113,689 Other 03.7% 293,872

Hispanic 04.7% 378,963

Source: Census 2000 and adults (ages 18+) reporting one race

Diversity Workgroup

El Pueblo NC Commission on Indian

Affairs American Cancer Society NC Office on Minority Health Old North State Medical

Society African-American Action

Team Dispute Settlement Center NC State Center for Health

Statistics

NC Office on Rural Health Development

NC Council for Women HBCU Health Alliance Cancer Information Service UNC Health Promotions NC Asian American and

Pacific Islander Association Faith Action International

House

Established in Jan. 2001

Six CDC Sub-Goals to be Addressed

Lower tobacco use prevalence rates among highest groups

Eliminate gaps in data

Raise awareness of tobacco-related health issues

Change tobacco-related social norms

Develop capacity among community leaders

Secure sustainable funding to move plans forward

Methods

The Workgroup identified and assessed all existing NC specific data sources available to gain insight on specific population groups. Populations that did not have valid data but were considered at risk were noted and methods identified for the future to collect valid and reliable data. A standard process was then applied to all data sources to identify and prioritize groups.

Data Sources

NC BRFSSNC YTSNC YRBSSNC PRAMSNC Asthma SurveyNC Six County CVH

SurveyBirth & Death

Certificate data

Current Population Survey (CPS)

SAMMECUNC Recreational

Facility Policy StudyLocal dataKey Informant

InterviewsSWOT Analysis

Description of Selection Process

Data Forums held whereby everyone in the Workgroup reviewed and discussed all potential data sources

Oral and visual presentations were prepared to accommodate multiple learning styles

“Critical Issues and Questions” were identified and discussed at length

Validity and reliability of data source measured

Attention Is the issue already

being addressed?

Impact What impact will

addressing the issue have?

Feasibility Is it possible to

implement?

Integration Does it link with other

critical issues?

Time Frame Can it be

accomplished in 1-5 years?

Innovation Does the issue

consider the unique culture of NC?

Critical Issues and Questions

Results

The priority populations that emerged from this assessment included people identified as American Indian, Hispanic, low SES, and blue-collar workers. Furthermore, gaps in surveillance were recognized for American Indians specific tribes, Lesbian, Gay, Bisexual and Transgender (LGBT), Asian sub-groups and farm worker populations. Critically important was that the Workgroup reached consensus on each group and understood the rationale for them becoming a priority population.

Priority Populations

Low SES education income

American IndiansService and Blue Collar WorkersHispanic/Latinos

NC Adult Current Smoking by Race/ethnicity, NC BRFSS 1997-2001

25.823.3

35.5

13.3

31.9

0

5

10

15

20

25

30

35

40

45

50

White African American American Indian Asian & PacificIslander

Hispanic

NC Adult Current Smoking by Educational Attainment, NC BRFSS 2001

37.4

31.1

24.5

13.6

0

5

10

15

20

25

30

35

40

45

50

<High School HS/GED Some post-HS College graduate

NC Adult Current Smoking by Household Income, NC BRFSS 2001

30.1

33.9

29.3 28.8

19.5

0

5

10

15

20

25

30

35

40

45

50

<15k 15-24k 25-34k 35-49k >49k

NC Adult Current Smoking by Occupation, Current Population Study 1998-1999

20.7

32.1

27.7

30.7

0

5

10

15

20

25

30

35

40

45

50

White collar Blue collar Farm Service

Pe

rce

nt

(%)

Potential Data Needs/Gaps

Lesbian, Gay, Bisexual & Transgender (LGBT)

American Indian by specific tribe

Low SES by sub-populations

Rural/urban sub-populations

Cigar use among African Americans

Hispanic/LatinoSubstance Abuse

ClinicsFarm workersRefugees and

ImmigrantsAsian subgroups

Actions Needed to Fill Gaps

Modify NC BRFSS to over-sample counties with high proportion of American Indians

Consideration of innovative special study focusing on LGBT sampling

Adding questions to BRFSS related to Spanish Speaking and recent arriving immigrants. Interviews in Spanish.

Developing regional criteria for urban/rural

www.communityhealth.dhhs.state.nc.us/tobacco.htm

The Diversity Workgroup spent one year in an inclusive and open strategic planning process. The resulting plan, “Achieving Parity” describes the process and outlines a framework for eliminating tobacco related disparities.

Conclusions

Although the Workgroup was composed of a number of organizations representing specific populations, they agreed to assess the valid data and give priority to those populations that had the greatest tobacco burden. As a result, NC’s strategic plan provides a more comprehensive approach to reducing tobacco disparities. Programs seeking to identify and eliminate disparities should consider the lessons learned from NC in identifying key groups.

Recommendations

Include "Data 101" educational session that helps participants understand key data issues, e.g., surveillance, sampling concepts, confidence intervals, etc.

Non- statistical members need continual, but gentle, reminders of "what the data really said" as the process continues. Statisticians on the working group can bring the group back to "grounding in the data" as discussion becomes personalized and "anecdotal".

Recommendations

At the same time, statisticians need to remember that quantitative data are only one source of knowledge. Community members have other "ways of knowing", including personal stories that contribute critical information to the strategic planning process and should be included later in the process.

Workgroup members with specific ethnic advocacy backgrounds rose to the challenge and set aside their personal affiliations during the data review process to prioritize disparities among "crosscutting" populations, specifically youth aged 18-24, low income individuals, new immigrants and lesbian/gays.