essay on health equity

Health Equity: What It Means and Why It Matters

BY KATHY KATELLA February 2, 2021

The pandemic has been relentless for everyone, but it’s hitting some of us harder. For instance, there is the man whose grocery store job puts him at higher risk for exposure to COVID-19 ; if he gets the virus, his diabetes could lead to complications. Working at home is not an option for him, and his family depends on his income. A pregnant woman is missing her prenatal visits because going to the doctor means taking two buses to the clinic and bringing along her two other children. She is worried that would mean exposing the whole family to COVID-19—especially concerning since she lives with and cares for her elderly mother, who has dementia.

There are many stories like this that illustrate why health equity matters. When it comes to health, many factors affect how the odds are stacked. If you’ve noticed that the phrase “health equity” is in the news much more of late, you’re right. It’s because the events of last year—not only COVID-19, but also issues around systemic racism and social justice—have highlighted the fact that some people face more struggles in life due to their background, culture, race, financial status, type of employment, whether or not they live with a disability, or other distinguishing factors.

As the topic of health equity gains traction in national conversations, Yale School of Medicine is emerging as a leader in the area. Marcella Nunez-Smith, MD, MHS , associate professor of internal medicine, public health, and management at Yale, has been an advisor to President Biden since the campaign, and she was then tapped to co-chair the Biden-Harris Transition COVID-19 Advisory Board to ensure that the response to (and treatment for) COVID-19 is distributed equitably.

In December, it was announced that she will serve as a senior advisor in the Biden-Harris White House as the inaugural chair of a federal COVID-19 Health Equity Task Force. Already a national leader in the field, Dr. Nunez-Smith occupies multiple roles at Yale, including serving as director of the Center for Community Engagement and Health Equity, the inaugural associate dean for Health Equity Research, and founding director of the Equity Research and Innovation Center (ERIC) , which will be incorporated as a center within a newly formed trans-institutional Office for Health Equity Research that aligns resources and programs focused on health equity across Yale School of Medicine.

In addition to her professional work, Dr. Nunez-Smith has shared some of her personal experiences with health inequities. In the U.S. Virgin Islands, where she grew up, “people too often died too young from preventable conditions,” she says. “My own father had his first stroke in his 40s and was left paralyzed. I learned there was a term for what we were: an underserved community, marginalized by place and by race.”

What is health equity?

As a term, health equity is broad. According to the Centers for Disease Control and Prevention (CDC), as a society we’ll achieve health equity “when everyone has the opportunity to be as healthy as possible.” Focusing on the pandemic, the CDC notes that “longstanding systemic health and social inequities have put many racial and ethnic minority groups at increased risk of getting sick and dying.” Black and Latinx Americans, for example, are roughly four times more likely to be hospitalized with complications from COVID-19 than non-Hispanic white people. In response, the CDC calls for addressing the situation by making sure everyone can maintain and manage physical and mental health, which requires easy access to information, affordable testing, and medical and mental health care.

“Sometimes, when we aggregate data, we fail to realize that it's not uniformly distributed, that some parts of the country face even greater disparities in health outcomes for racial and ethnic minorities.” Yale infectious diseases specialist Onyema Ogbuagu, MBBCh

Health equity is a complex challenge, says Kristen Nwanyanwu, MD, MBA, MHS , a Yale Medicine ophthalmologist and a member of ERIC. “It’s bigger than a roster of things to check off a to-do list,” she says. “It’s a good development that conversations are happening in many different settings on this topic, as simply raising awareness is a key step toward serving the needs of people who have traditionally been underserved.”

Health equity versus health equality

Onyema Ogbuagu, MBBCh , an infectious diseases specialist who is leading Yale’s clinical studies around COVID-19, says there is an important distinction between “equality” and “equity.” “Imagine there's a high fence, and the goal is to look over the fence,” he says. “A tall adult can see easily, a shorter adult may need a boost, and a child will need to be lifted up to see over it.”

If given three blocks of equal height to stand on, the shorter adult would still need to stretch to see, and the child wouldn’t see at all—each needs a block of the appropriate size, he says. “So, equity means that people have to get what they need to achieve the same results. It’s less about the quantity of what to do and more about the end result in outcomes.”

Which groups face the greatest pandemic challenges?

Health equity issues have hit Black and Latinx communities especially hard in the pandemic. Data from the CDC shows that, in the U.S., people in these two groups who contract COVID-19 are roughly three times more likely to die from it than non-Hispanic white people. Asian Americans and Native Americans are at higher risk as well.

This statistic for Black and Latinx Americans may reflect the broad pattern across the country, but in some places it’s even worse. “In some pockets of the U.S., it's four times greater mortality than for their white counterparts and in other parts, it’s less than one,” Dr. Ogbuagu says. “Sometimes, when we aggregate data, we fail to realize that it's not uniformly distributed, that some parts of the country face even greater disparities in health outcomes for racial and ethnic minorities.”

How does ‘structural marginalization’ play out in real life?

A phrase like “structurally marginalized” (sometimes referred to as “underserved” or “disadvantaged” or "vulnerable populations") refers directly to the connection between social and economic factors (such as education, employment, and housing) and health. It’s well-documented that many people in structurally marginalized situations have underlying health conditions that are influenced by their socioeconomic status, and that these conditions put them at a higher risk for complications from a number of diseases, including COVID-19. This explains why, as Dr. Ogbuagu points out, the death rate for Black Americans is generally higher than whites for heart disease, stroke , cancer, asthma , influenza , pneumonia , diabetes , and HIV/AIDS; Puerto Ricans suffer disproportionately from asthma and HIV/AIDS; and Mexican Americans from diabetes.

Marcella Nunez-Smith, MD, will serve as a senior advisor in the Biden-Harris White House as the inaugural chair of a federal COVID-19 Health Equity Task Force. “People too often died too young from preventable conditions,” she says. “My own father had his first stroke in his 40s and was left paralyzed. I learned there was a term for what we were: an underserved community, marginalized by place and by race.”

These figures are influenced by factors that, at first, might seem unrelated to health and medicine but, in fact, are closely intertwined. In the case of COVID-19, Dr. Nwanyanwu notes that many people of color live together with several generations of family members; when you live in a crowded house, isolation is difficult. “We’re always telling people they need to quarantine and what that should look like,” she says. “But if you have a family in a one-bedroom apartment in a city as opposed to a five-bedroom house in a suburban town, that might not be possible. If someone in your house gets COVID-19, everyone else could get it, because there is no place to quarantine.”

Other factors fueling the discrepancies in health outcomes include racial discrimination, difficulty accessing health care, and gaps in education and income. Workers whose jobs can’t be performed at home—such as those who work in factories, nursing homes, and grocery stores—are far likelier to be exposed to COVID-19 and other infectious diseases.  

These issues affect health in more ways than one might guess, including—for example—vision. As an ophthalmologist, Dr. Nwanyanwu sees this play out in her practice. Diabetic retinopathy, for instance, is preventable if diagnosed and treated early, but it remains the leading cause of blindness in adults. Here in the U.S., this condition affects more than one-third of Black and Mexican Americans, because, says Dr. Nwanyanwu, “we aren’t screening some patients at the appropriate time.”

Even those with loved ones who have lost their sight because of the disease haven’t seen an ophthalmologist, she says. To figure out why, she enlisted a team to go into the community and ask questions. Housing, transportation, and challenging life circumstances turned out to be major factors. “Health care lives among a list of one’s priorities. If there are barriers to health care in someone’s life, it is going to be more difficult to practice preventive care, like getting an eye exam for diabetes,” says Dr. Nwanyanwu. “These issues, compounded by systemic racism, become insurmountable for some of our community members.”

Telehealth, which should make it easier to see a doctor, turns out to be another roadblock for some people. Many don’t have the technology to access telehealth—or knowledge about how to use it, Dr. Nwanyanwu says. “If they had the proper technology, they could stay home, which is probably better for their safety, but instead they have to come into the office.”

And others can’t afford to pay for the care they need. For example, Dr. Nwanyanwu has learned to make sure patients get their eye drops on the day of surgery so they will avoid developing eye irritation when they go home. Even though insurance pays the majority of the cost for the drops, there is still an out-of-pocket cost barrier, she says. “It’s the difference between eye drops being given to a patient on the day of surgery—with the costs bundled into the procedure—and the barriers that come with having to get to the pharmacy and pay the co-pay necessary to purchase the medication,” says Dr. Nwanyanwu.          

Fear and mistrust play a role

Mistrust of the medical establishment is well-earned among people of color, given the extensive legacy of unfair treatment and abuse documented in the U.S. An example that is often cited is the Tuskegee syphilis study , a 40-year experiment carried out in Macon County, Alabama, from 1932 to 1972. Public Health Service officials followed 600 Black men (399 with syphilis and 201 who did not have it at the time) throughout their lives without giving them an accurate diagnosis of their disease (or information about the real purpose of the study). They also withheld treatment, even though it became available. Instead of receiving penicillin, which was established as the treatment of choice for syphilis in 1945, participants were given placebos, including aspirin and mineral supplements. Many of the men developed severe health complications of syphilis and died, and a number of their wives and children contracted the disease.

Dr. Nwanyanwu says she has seen patients who avoid seeking care for diabetic retinopathy partly because of stories like this. “Fear is an emotion that can affect people in different ways. Some don’t want to come for an exam because they are afraid we would find something,” she says. “But in marginalized communities, it can be hard to parse the effects of years of racism from general fear. I’ve heard people say, ‘I don’t want to be a guinea pig.’ They aren’t wrong. We have to address the legacy of racism in research and prove to historically abused communities that we are doing a better job.” 

Still others have different reasons for their attitudes toward medical advice. Early on during the pandemic, the message was to avoid the emergency room, if possible, Dr. Nwanyanwu says. “I have a patient who had a really bad eye problem, but he waited because he didn’t want to go to the ER,” she says. “So, we’re looking at rules, and how rules are followed by different communities. For his health, it would have been better if he went to the emergency room."

How can we move things forward?

All these stories give some insight into what Dr. Nunez-Smith will be addressing on a national level with the health equity task force, the doctors say. Work she has done at Yale may provide some clues about how she will do that.

For instance, ERIC, the organization she heads at Yale, promotes population health and health equity through research, much of which has been funded through National Institutes of Health (NIH) research grants. “ERIC is the true North that is really trying to use science to move our population to be healthier,” says Dr. Nwanyanwu.

Dr. Ogbuagu says that participating in clinical research helps ensure the needs of all kinds of people are met. “We are dying more, we are being affected more, and if we don't get the care we need—if we don’t participate in either research or in the outcomes of research—we will never truly know or experience the impact these opportunities can have in our communities,” he says.

For example, a study published in the Journal of General Internal Medicine and cited on the ERIC website highlights the importance of including marginalized populations in health-related data. According to the study, only 28 states and New York City reported on race and ethnicity-stratified COVID-19 death rates. “The availability of high-quality and comprehensive race and ethnicity data is necessary to address factors contributing to inequity in COVID-19 mortality,” wrote the study’s authors, who include Yale Medicine internist Cary Gross, MD , as well as Dr. Nunez-Smith.

Meanwhile, Dr. Ogbuagu highlights the work of a Yale Center for Clinical Investigation program in New Haven called Cultural Ambassadors . The group partners with the community-based organization Junta for Progressive Action and the African Methodist Episcopal Zion (AME Zion) Church to encourage people to enroll in clinical trials so that diverse groups will be represented. “We worked together for our COVID-19 vaccine trial,” he says. Cultural Ambassadors helped develop recruitment materials and messaging within the communities, and participated in research themselves. “It's been an effective model,” Dr. Ogbuagu says. “And it's not just about COVID-19 research. They’ve used this model for cancer and other forms of research. That's at least one way to do this.”

But there is much more be done, he adds. A priority is to reassure people that decades of efforts have been directed toward ensuring that situations like Tuskegee never happen again. Clinical trials are now heavily monitored, the research is safe, and the risks are minimized. Unfortunately, “even in the backdrop of movements like Black Lives Matter, people of color feel that if something bad happens to them, no one will care as much as they would for the person who is not of color,” he says, noting that the result is that they won’t participate in a trial. “We had to work extra hard to be able to achieve minority recruitment goals with regard to the Pfizer vaccine.”

Similar challenges are emerging now that the COVID-19 vaccination program is underway. In early December, 60% of all American adults said they would definitely or probably get the vaccine when it becomes available, while only 42% of Black adults said they would do the same, according to the PEW Research Center. The government is examining how to support minority acceptance of the vaccine, with efforts such as a special ad campaign to encourage people of color to take the vaccine.

What do people need to know?

In addition to the work taking place in the government and community, individuals can also help shape change by advocating among their friends and family members. Participating in clinical research helps ensure the needs of all kinds of people are met. “We are dying more, we are being affected more, and if we don't get the care we need—if we don’t participate in either research or in the outcomes of research—we will never truly know or experience the impact these opportunities can have in our communities,” Dr. Ogbuagu says.

More news from Yale Medicine

Communities in Action: Pathways to Health Equity (2017)

Chapter: 1 the need to promote health equity, 1 the need to promote health equity, introduction.

In the United States, health equity and equal opportunity are inextricably linked, and the burdens of disease and poor health and the benefits of wellness and good health are inequitably distributed among groups of people.

Although biology, genetics, and individual behaviors play a role in these differences, many health outcomes are more substantially affected by social, economic, and environmental factors. Understanding the social determinants of health requires a shift toward a more “upstream” perspective—that is, the conditions that constitute the context in which an individual’s behaviors are shaped. To put this more simply, Keyes and Galea (2016) describe the relationship between an individual and the conditions in which one lives using the metaphor of a fishbowl. If the bowl in which a fish lives is dirty, or the glass is cracked and the water is leaking, the fish will never reach its full health potential, despite any individual effort. Although the life of a person is clearly more complex than that of a fish, this metaphor illustrates the futility of only addressing individual behaviors without considering the context. People inhabit environments shaped by policies, forces, and actions that influence their individual choices and behaviors over a lifetime and over generations. Community-wide and national problems like poverty, unemployment, poor education, inadequate housing, poor public transportation, exposure to violence, and neighborhood deterioration (social or physical) are among the factors that shape people’s health, and they do so in unequal ways, thus contributing

to health inequities. The historic and ongoing interplay of structures, policies, norms, and demographic/geographic patterns shapes the life of every individual across the country. These factors are not intractable, and inequities in these factors can be mitigated by policies and community action in powerful ways (see Chapter 3 for a discussion of the evidence). Community assets can be built, leveraged, and modified to create a context to achieve health equity.

People are heavily influenced by the communities they work and live in, and the diverse actors that make up the community ecosystem can be powerful producers of health and well-being. Therefore, this report focuses on the promise of communities to create opportunities for their members to achieve their full health potential. By showcasing many creative, forward-looking, and bold community-led solutions for achieving health equity, this report aims to provide a new narrative about health in the United States. In addition to actors in communities, the report examines other elements that address the structures, policies, and norms needed to promote health equity.

DEFINING HEALTH EQUITY

This report makes frequent reference to a number of terms with meanings that vary depending on the context and the community of users. Such terms include “disparities,” “inequities,” “equity,” “racism,” and “bias,” and they are defined in the glossary of key terms and when first introduced in the report.

It is difficult to fully separate the concepts of equity and equality because they are intertwined. Different fields have used varying terminology in legal, public health, government, and other contexts. This report uses the term “health equity” by applying the term equity to the field of public health. Health equity is the state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance. In this report promoting health equity means creating the conditions where individuals and communities have what they need to enjoy full, healthy lives. Health equity requires focused and sustained societal efforts to confront historical and contemporary injustices and eliminate health disparities ( Brennan Ramirez et al., 2008 ; HHS, n.d. ). Health disparities are differences that exist among specific population groups in the attainment of full health potential and in incidence, prevalence, mortality, and burden of disease and other adverse health conditions ( NIH, 2010 ), and they stem from systematic differences—that are preventable and unjust—among groups and communities occupying unequal positions in society ( Graham, 2004 ).

As discussed later in this chapter, studies of health inequities have focused largely on health disparities across racial and ethnic populations. Although such studies have uncovered patterns of discrimination and inequitable health outcomes, enlarging this work to assess the effects of poverty, unemployment, toxic stress, and the many secondary unintended consequences (e.g., drug use and violence) for minority and other disproportionately impacted populations is needed. It is well documented that low socioeconomic status (SES) hampers an individual’s ability to achieve optimal health by limiting access to health-preserving resources ( Williams and Purdie-Vaughns, 2015 ; Woolf and Braveman, 2011 ). However, SES does not fully explain health disparities based on race and ethnicity, sexual orientation and gender identity ( Williams and Purdie-Vaughns, 2015 ).

In the following sections, the nature and implications of disparities on three key health indicators and for health care are discussed. This discussion is followed by a brief introduction to the social determinants of health and the impacts of health inequities on society. Next, the changing social and environmental context and the role of communities in addressing health inequity are described. Finally, this chapter highlights the ongoing support for accelerating the progress to achieve health equity before providing an overview of the rest of the report.

DISPARITIES IN HEALTH OUTCOMES

The existence of racial and ethnic disparities in morbidity, mortality, and many indicators of health for African Americans, Native Americans, Hispanics, 1 and Asians/Pacific Islanders was first acknowledged by the federal government in the 1985 Report of the Secretary’s Task Force on Black and Minority Health ( Heckler, 1985 ). Since then, research has sought to identify additional disparities and explain the mechanisms by which these disparities occur.

Three indicators provide summary information about the overall health of a population or subpopulation: infant mortality , age-adjusted death rates , and life expectancy . The United States ranks lower than most peer nations on these indicators; moreover, racial and ethnic disparities exist in quality and length of life among U.S. residents. The failure to address growing income inequality, along with health inequities by race

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1 Hispanic/Latino identification with country of origin: Four decades after the U.S. government mandated the use of Hispanic or Latino for data collection (e.g., in the decennial census), most Americans with roots in Spanish-speaking countries prefer to be identified by their country (51 percent versus 24 percent who prefer a pan-ethnic term). Also, 69 percent respond that they believe there are multiple cultures, not one monolithic “Hispanic” or “Latino” culture ( Taylor et al., 2012 ).

and ethnicity, contributes to the United States’ low health ranking among peer nations ( Davis et al., 2014 ).

Infant mortality rates reflect the number of infants in a population who die before their first birthday per 1,000 live births. U.S. infant mortality rates have decreased since 2005 for the overall population and within each racial and ethnic group; however, sharp racial and ethnic disparities persist. In 2013, as in previous years, the infant mortality rate among African Americans (11.1 per 1,000 live births) was double the rate among whites (5.06 per 1,000 live births) ( Mathews et al., 2015 ). American Indians/Alaska Natives and Puerto Ricans also experienced higher infant mortality rates (of 7.61 and 5.93 per 1,000 live births, respectively) than whites ( Mathews et al., 2015 ). Infant mortality rates among Asians/Pacific Islanders and non-Puerto Rican Hispanics were lower than those of whites. If white America and black America were two separate nations, white America’s infant mortality rate would rank 49th in the world, while black America’s would be ranked 95th out of 224 nations listed by the U.S. Central Intelligence Agency’s World Factbook, following Botswana, Sri Lanka, the United Arab Emirates, and Turks and Caicos Islands ( WHO, 2015 ).

Life expectancy, the average number of years a person is expected to live based on current mortality rates (typically reported as life expectancy at birth or average number of years a newborn would be expected to live), captures the degree to which all of the individual-level socioeconomic, environmental, and health care–related resources in a society enable members of that society to achieve a long and healthy life. Better living conditions and better access to health care–related resources throughout the lifespan extend longevity. From 1980 to 2014, U.S. life expectancy (at birth) increased by approximately 6 years for males, reaching 76.4 years, and increased 3 years for females, reaching 81.2 years. Racial and ethnic disparities decreased, but they were not eliminated. In 2014, the life expectancy for African American males was 72.0 years, while that for white males was 76.5 years and that for Latino males was 79.2 years. In the same year, life expectancy was 78.1 years for African American females, 81.1 years for white females, and 84.0 years for Latina females ( Arias, 2016 ). Childhood obesity, which disproportionately affects Hispanic and African American youth ( Asieba, 2016 ; Taveras et al., 2013 ), has been projected to reduce the steady increase in overall life expectancy in this century ( Olshansky et al., 2005 ).

Age-adjusted mortality rates capture population deaths due to all causes, and especially those not due to old age. High death rates suggest that a population not only faces serious threats to health but also lacks the resources needed to address them. The 2012 to 2014 U.S. age-adjusted rates ranged considerably. By race and ethnicity, they ranged from 399.8

per 100,000 people among Asian/Pacific Islanders to 858.1 among African Americans. From 2007 to 2009, the rate was even higher (943.0 per 100,000) among American Indian/Alaska Natives ( IHS, 2016 ). Although the overall death rate among whites (729.1 per 100,000) was substantially lower than the rate among African Americans, it exceeded that of Asian/Pacific Islanders and American Indian/Alaska Natives ( NCHS, 2014 ) for causes including liver disease, suicide, and unintentional injury ( Kochanek et al., 2016 ). Looking at more distal causes, research indicates that age-adjusted death rates among whites are higher for those who live in rural settings ( Caldwell et al., 2016 ) and have lower incomes ( HRSA, 2015 ).

The patterns of health disparities among immigrants and their children that emerge from available data are not straightforward. More than half of U.S. citizens of Asian/Pacific Islander and Hispanic background come from families that emigrated to the United States since 1965. Considerable socioeconomic and cultural heterogeneity exists within these groups, and some subpopulations (e.g., the Hmong population of Asian descent) experience particularly severe health disparities ( Cho and Hummer, 2001 ; de Souza and Anand, 2014 ; Vang et al., 2015 ). However, recent immigrant status has also shown positive health impact in some populations ( Hummer et al., 2007 ; Lee et al., 2013 ; Markides and Coreil, 1986 ).

Along with race and ethnicity, sexual orientation and gender identity have emerged as important factors in the study of health disparities. Recent epidemiologic surveys have attempted to comprehensively assess the physical and mental health of lesbian, gay, bisexual, and transgender (LGBT) persons ( Hsieh and Ruther, 2016 ; IOM, 2011 ). The available evidence shows that the LGBT population does experience health disparities and that the disparities are exacerbated for those who hold multiple minority statuses: this “intersectional” perspective describes the recognition that when multiple identities intersect, they represent overlapping inequalities or types of disadvantage ( IOM, 2011 ). Thus, LGBT persons who are also racial/ethnic minorities have worse outcomes than do white LGBT individuals ( Hsieh and Ruther, 2016 ).

Health Care

It is becoming clearer that health insurance coverage alone will not address health disparities associated with race, ethnicity, SES, and geography ( Kenney and Huntress, 2012 ; Ubri and Artiga, 2016 ). The Patient Protection and Affordable Care Act (ACA), passed in 2010, has accelerated progress toward improved health equity by expanding health insurance coverage to about 20 million Americans ( Uberoi et al., 2016 ). However, challenges remain in fully addressing health care inequity, including policy hurdles affecting subgroups of the population (e.g., lack of coverage

for some immigrants and asylum seekers, or those subject to Deferred Action for Childhood Arrivals) ( HealthCare.gov, n.d. ); limited system capacity or competence to care for some populations, such as LGBT persons (e.g., newly covered partners of insured LGBT individuals); and the lack of health data to monitor the health needs of some populations (e.g., for American Indians, of whom approximately 20 percent live on rural reservations) ( Kruse et al., 2016 ).

Merely increasing the availability of health care services does not necessarily reduce health care disparities. Consider how the availability of effective antiretroviral therapies has not reduced the rate of acquired immune deficiency syndrome (AIDS) equally across groups. In the U.S. context, the progression to AIDS may signal a failure to access treatment in a timely and appropriate manner as indicated by racial and ethnic trends that have been followed since the beginning of the epidemic, as shown in Figure 1-1 .

Though AIDS diagnoses have decreased over time for all groups since the introduction of antiretroviral therapy, the proportion of diagnoses among whites has decreased substantially, while the percentage has increased for other groups, and most substantially for African Americans. Another striking example is found in the domain of clinical research,

where clinical trials of drugs and devices are not always carried out in diverse populations; therefore, the outcomes of trials may be biased toward the populations studied and fail to account for cultural or other factors that may influence effectiveness ( George et al., 2014 ).

From a policy standpoint, the ACA has achieved its primary goal: the proportion of people who lack health insurance is lower than it has ever been. In the 29 states that have to date elected to participate in the ACA, Medicaid expansion has resulted in more than 10 million low-income individuals now being insured; furthermore, the associated reduction of cost-shifting for uncompensated care has benefited hospital budgets, particularly for disproportionate share hospitals ( CMS, 2016 ; Cunningham et al., 2015 ). However, the costs of care for these patients are often greater than expected, and Medicaid’s reimbursement rates are a small fraction of the reimbursement rates from commercial payers; therefore, cost-shifting persists. The ACA has increased the availability of outpatient care for low-income persons through increased funding for the operation, expansion, and construction of community health centers.

Challenges remain, however. As noted above, access to insurance does not directly translate into health equity. The traditional fee-for-service system persists and influences utilization patterns more heavily than patient need or evidence-based practice guidelines ( The National Commission on Physician Payment Reform, 2013 ; Page, 2013 ; Robinson, 2001 ). Patients need only to receive the care they want and need. Also, there is still a subset of people without adequate insurance, and some commercial payers are leaving the exchanges, premiums are on the rise again, and pharmaceuticals and specialty drugs are increasing in complexity and pricing, untouched by the ACA.

A significant group of workers earn too much to qualify for Medicaid, but too little to afford health insurance. Also, the law does not address the needs of undocumented residents who are among the poorest people in the United States. Nearly one-third of all noncitizen immigrants lack insurance ( Barry-Jester and Casselman, 2015 ). Underutilization of health care services among subpopulations of Hispanic and Asian immigrants has been documented ( Alegria et al., 2006 ). The reasons for underutilization are complex and include an inability to speak the language, differences in the circumstances of immigration (e.g., refugees versus recruited professionals), and the fear of inadvertently outing family members who are in the country without documentation ( Ortega et al., 2015 ).

Because the law is still relatively new, researchers are investigating its outcomes, but there are concerns that some lower-income working class individuals remain underinsured but have had more cost of health care shifted to them ( Saloner et al., 2014 ), and the variations in use and cost persist.

SOCIAL DETERMINANTS OF HEALTH

Although most of the research being conducted at the time of the Heckler Report sought to explain how behavioral and other individual-level factors contribute to health and health care disparities, the evidence accrued since 1985 has led the field toward examining the social, environmental, economic, and cultural determinants of health. These determinants are the conditions in which one lives, learns, works, plays, worships, and ages, and these conditions are shaped by historical and contemporary policies, law, governance, investments, culture, and norms. Addressing the root causes of health inequities, such as the social determinants of health, is important in part to help enable sustainable interventions by engaging multiple sectors and addressing multiple health outcomes simultaneously. The solutions highlighted in this report recognize that national and state leadership are important to effect change in these determinants, but the report specifically addresses these interrelated determinants at the community level (see Chapter 3 for a detailed discussion of the root causes of health disparities, including the social determinants of health).

IMPACTS OF HEALTH INEQUITY IN THE UNITED STATES

Although moral arguments to promote health equity exist 2 advancing progress toward health equity could produce economic, national security, and other benefits for the nation. The premise that social mobility, opportunity to succeed with hard work, and opportunity to achieve prosperity exist is fundamental to the American Dream ( Carr and Wiemers, 2016 ). However, recent literature demonstrates that worsening social, economic, and environmental factors are affecting health in serious ways that compromise opportunity for all ( Chetty et al., 2016 ; Rudolph et al., 2015 ; Woolf et al., 2015 ). Health is more than life expectancy, infant health, and fitness and nutrition—it is the ability to lead a full and productive life. Additionally, an opportunity to achieve good health is crucial to U.S. democracy, national security, and economic vitality, as described below. The burden

2 For example, Jones and colleagues cite valuing all people equally as foundational to the concept of equity, noting that the equal worth of all people is at the core of the human rights principle that all human beings equally possess certain rights ( Jones, 2009 ). Braveman and colleagues point out that health differences adversely affecting socially disadvantaged groups are particularly unacceptable because ill health can be an obstacle to overcoming social disadvantage. They further note that this “consideration resonates with common sense notions of fairness, as well as with ethical concepts of justice” ( Braveman et al., 2011 ). Daniels argues for the moral importance of health by exploring the necessities for justice as it relates to health care and the social determinants of health ( Daniels, 2008 ).

of disparities lowers the nation’s overall health status and its ranking relative to other nations.

Political and Economic Impacts of Health Disparities

In addition to the dollar cost of health care, because health inequities contribute to overall poor health for the nation, health inequity has consequences for the U.S. economy, national security, business workforce, and public finances.

Consequences for the Next Generation

American children rank behind their peers in most Organisation for Economic Co-operation and Development (OECD) nations in health status and on key determinants of health, and they experience growing disparities on multiple measures of child well-being ( OECD, 2009 ; Seith and Isakson, 2011 ). Poverty, food insecurity, lack of stable housing, and lack of access to high-quality and developmentally optimal early childhood education are among the childhood factors that contribute to “chronic adult illnesses and to the intergenerational perpetuation of poverty and ill health found in many communities (e.g., obesity, diabetes, cardiovascular disease, poor educational outcomes, unemployment, poverty, early death)” ( AAP, 2010 , p. 839). Young children are most likely to live in poverty, and children from low-income and minority communities are most vulnerable ( Burd-Sharps and Lewis, 2015 ). The nation’s growing racial and ethnic diversity, coupled with the conditions that lead to serious early life disadvantage, have serious implications for health and health disparities in later life, leading to squandering human lives and their potential ( OECD, 2009 ).

Consequences for the Economy

The economic effects of health inequity are the result of both unsustainable and wasteful health care spending and diminished productivity in the business sector. Health care spending accounted for 17.5 percent of gross domestic product (GDP) in 2014, and health disparities contribute to a significant amount of financial waste in the health care system.

LaVeist and colleagues (2009) calculated that eliminating health disparities for minorities would have reduced indirect costs associated with illness and premature death by more than $1 trillion between 2003 and 2006. In 2009, the Urban Institute projected that from 2009 to 2018, racial disparities in health will cost U.S. health insurers approximately $337 billion in total ( Waidmann, 2009 ). Disparities in access to health care and

in the quality of care can be costly to individuals, health care providers, health insurers, and taxpayers. Obtaining care late in the course of disease (i.e., delayed care) and inadequate health care coverage may increase the cost of care exponentially due to the exacerbation of complications, the need for more expensive care (e.g., emergency department services), and the need for more extensive care; furthermore, such treatment can increase longer-term reliance on the health care system for the management of unintended consequences on one hand and preventable chronic diseases on the other ( IOM, 2009 ).

Consequences for National Security

For a nation that prizes military readiness, the effects of poor health status on entrance to military service and the readiness of the force matter. Military leaders reported that more than 75 percent of 17- to 24-year-olds—more than 26 million young adults—in the United States cannot qualify to serve in the armed forces because they have health problems ranging from obesity to dependencies on prescription and nonprescription drugs, are poorly educated, or are involved in crime ( Christeson et al., 2009 ). According to more than 500 retired admirals, generals, and other senior military leaders, the health of our nation’s youth represents a serious national security concern ( Christeson et al., 2009 , 2010 ). Individuals who are not healthy enough to participate in the workforce will not be afforded the same employment opportunities as their healthy counterparts. Rear Admiral Robert Besal (ret.) has asserted that young people who are physically unfit for “productive employment or military service represent a staggering loss of individual potential and collective strength for the nation as well” ( Council for a Strong America, 2016 ).

Consequences for Business

A healthy, productive workforce is a prerequisite to a thriving economy ( HERO, 2015 ; IOM, 2015 ). The impact of poor health on private businesses is significant. Research from the Urban Institute shows that those young adults with health problems who can find jobs in the mainstream economy are less productive and generate higher health care costs for businesses than those without health problems ( Woolf et al., 2015 ).

Consequences for Income Inequality

Research finds that people in counties with an inequitable distribution of opportunities for good health are more likely to die before the age of 75 than people in counties with more equitable opportunities for

health (health status), even if the average incomes are the same ( University of Wisconsin Population Health Institute, 2015 ). Political scientists at Princeton and Georgetown University are finding that crippling political polarization and gridlock are linked to income and wealth inequality ( Ferejohn, 2009 ; Voorheis et al., 2015 ). But income and wealth are not what worries Americans. Instead, it is what can be obtained with income and wealth that worries them most, and, of these, Gallup reports that health care is at the top of the list ( Swift, 2015 ). Health problems often reduce personal income in ways that worsen inequity, which in turn may lead to further inequity. For states, it is well understood that as health care spending through state Medicaid increases, the funds available to support state universities decrease ( Orszag and Kane, 2003 ).

CHANGING SOCIAL AND ENVIRONMENTAL CONTEXT

There are significant changes in the sociocultural (including demographic, economic, and political) and environmental landscapes affecting health disparities and the determinants of health.

The changing economic context is characterized by growing income inequality. According to an analysis performed by the Institute for Policy Studies, the income gap between higher- and lower-income individuals has increased substantially over the past 30 years, to the point that those with incomes in the top 10 percent average nine times the income of those in the bottom 90 percent, and those with incomes in the top 0.1 percent have incomes that are more than 184 times that of the bottom 90 percent ( Asante-Muhammad et al., 2016 ). This income inequality has a remarkable impact on individual health, as higher-income earners have longer life expectancies than lower-income earners in every region of the United States. There are significant economic changes that affect other social determinants as well. For instance, urban centers across the country are dealing with shifting demographics that can result in the displacement of long-term residents. The economic advantages of changing land value due to these shifts largely benefit those who are already in higher-income brackets. In contrast, dislocated low-income households face overwhelming challenges in efforts to find new housing with access to high-quality schools, jobs, and other essential social services that are vital to optimal health. The lasting effects of the 2008 recession and the resulting displacement of vulnerable populations exacerbated the impact on both their health and their economic well-being—resulting in greater income inequality and wealth inequality ( Smeeding, 2012 ).

Recent changes in U.S. demographics underscore the urgency of finding ways to attain health equity. For example, from 2000 to 2010 the African American population increased by 11 percent ( Rastogi et al., 2010 ),

and the Hispanic population increased by 43 percent ( Ennis et al., 2011 ), while the white population increased by only 1.2 percent ( Hixson et al., 2011 ). By 2040 the number of U.S. counties in which the majority of the population is comprised of people of color is expected to more than double; those counties will then represent about one-third of the United States ( Frey, 2015 ). Without significant and fundamental policy changes, these changes in the racial and ethnic composition of U.S. communities can be expected to further widen health inequities associated with race and class. Disparities in health, income, and education have also all been increasing over time (see Chapters 2 and 3 for more information).

Climate change will increasingly affect health. In 2015, at the United Nations Climate Change Conference—also known as COP 21—multiple nations, including the United States, came together to create an agreement to combat climate change and attempt to prevent the global temperature from rising more than 2 degrees Celsius. Health representatives played an integral role in the conference, as health is and will continue to be significantly affected by climate change. Climate change is happening in all areas, but its impacts are not distributed equally. It exacerbates vulnerabilities in communities that are already disproportionately affected by preexisting social, economic, and environmental factors. Extreme weather events are one of the many examples of the ways in which climate change will impact health. Hurricane Katrina was not necessarily the direct result of climate change. However, it offers many important lessons on mitigating risk and increasing resiliency in making plans to help the entire population, especially the most vulnerable. Although there is a risk that climate change could worsen health inequities, there is also great opportunity to integrate efforts to promote health into mitigation and adaptation efforts to support more resilient, healthy, and equitable communities ( Rudolph et al., 2015 ).

Finally, recent events involving race and law enforcement relations have elucidated systematically unequal treatment in the criminal justice system ( The President’s Task Force on 21st Century Policing, 2015 ). Moreover, there is a growing and bipartisan recognition that mass incarceration, which affects individuals of color disproportionately, plays a major role in the breakdown of families and communities, constitutes an unsustainable use of taxpayer dollars, and leads, in connection with the larger policy milieu in both the private and the public sector, to poor employment prospects and voter disenfranchisement ( Clear, 2008 ; NRC, 2014 ). These current realities serve as reminders that the vision of an equitable society will be challenging to reach, but community-driven solutions, such as those this report highlights, can help move in that direction on a local scale.

WHY COMMUNITIES?

Individuals and families are part of communities, and the role of communities is crucial to promoting health equity for several reasons. First, as discussed earlier, medical interventions are insufficient to address health equity, and behavioral health promotion continues to show little success in reducing disparities ( Baum and Fisher, 2014 ). Community-based and -driven efforts are needed to alter environmental, socioeconomic, and cultural conditions in ways that promote health equity. Community health refers to the overall well-being of a community at all levels (including the individuals within the community and the physical setting), which may involve multi-sector and multidisciplinary collaborative approaches to optimizing the health and quality of life of all persons who live, work, or are otherwise active in a defined community ( Goodman et al., 2014 ). A healthy community is the foundation for achieving all other goals, as it is essential for a productive society. (For example, a community with a healthy workforce has a good base upon which to build its economy, and healthier students are more equipped to learn and be successful academically.) Furthermore, communities differ in the local quality and availability of health care providers, the affordability and quality of housing, employment opportunities, transportation systems, the availability of parks, green space, and other aspects of the physical environment. Communities are uniquely positioned to drive solutions tailored to their needs that target the multiple determinants of health.

MOMENTUM FOR ACHIEVING HEALTH EQUITY

There is a clear urgency for the nation to fully address health inequity. An analysis of current trends provides evidence of persistent health inequity, but there are reasons for optimism. Turning the tide is not only possible, it is imperative; many organizations in the public and private sectors have recognized this, making health equity an explicit or implicit priority. These organizations span the sectors of finance, philanthropy, public health, community development, academia, and beyond. Local, regional, and state governments have also taken on issues essential to achieving health equity. For example, the Federal Reserve Bank and community development financial institutions are engaging in improving community development, employment, and housing—which drive health improvement—and they are making investments that expand access to healthy and affordable foods and neighborhoods with open space to promote physical activity and community safety ( Andrews and Erickson, 2012 ). Health equity is a guiding priority for the American Public Health Association in its initiative to make the United States the healthiest nation in a generation, with 2030 as a goalpost ( APHA, n.d. ). In

2016 the Association of State and Territorial Health Officials’ President’s Challenge is to “Advance health equity and optimal health for all,” and “Cultivating a culture of health equity” was the theme for the National Association of County and City Health Officials’ annual meeting. Numerous states, including California, Colorado, Massachusetts, Pennsylvania, and Wyoming, have created statewide offices of health equity that work in collaboration with other agencies and departments to inform policies that promote health equity. Health equity has become central to the goals of some of the nation’s largest philanthropic organizations, including The California Endowment, Ford Foundation, Kresge, and Kellogg. Advancing health equity is at the core of the Robert Wood Johnson Foundation’s (RWJF’s) new push for a culture of health ( RWJF, 2015 ). The federal government is investing heavily in health equity as well, and it recently established a National Institutes of Health research program to address health disparities in chronic disease as well as the National Partnership for Action to End Health Disparities. These investments seek to “transform lives and places for disinvested people” ( The Housing Fund, 2015 ), and at their core they are investments to create opportunity for all to achieve optimal health.

Conclusion 1-1: The persistent state of health disparities and health inequity in the United States has profound implications for the country’s overall health standing, economic vitality, and national security. Thus, addressing health inequities is a critical need that requires this issue to be among our nation’s foremost priorities.

ABOUT THIS REPORT

RWJF, as part of its Culture of Health Initiative, 3 asked the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine to help delineate the causes of and the solutions to health inequities in the United States. The charge to the committee is provided below (see Box 1-1 for the full statement of task). To respond to the charge, the Committee on Community-Based Solutions to Promote Health Equity in the United States was formed.

The focus of this report is on what communities can do to promote health equity and on the broader policy context and contributions of stakeholders that can support communities. In addition to the root causes and structural barriers that need to be overcome, the committee also examined levers and policies to support change, some of which span

3 For more information, see http://www.rwjf.org/en/culture-of-health.html (accessed October 28, 2016).

national, state, regional, and other contexts for the work of communities. To address its charge, the committee reviewed examples of community efforts across the country and was inspired by how these communities are rising to the challenge to address the difficult challenges and barriers to health and well-being.

Culture of Health Lens

RWJF defines a culture of health broadly “as one in which good health and well-being flourish across geographic, demographic, and social sectors; fostering healthy equitable communities guides public and private decision making; and everyone has the opportunity to make choices that lead to healthy lifestyles” ( RWJF, n.d. ). RWJF also says that “the exact definition of a culture of health can look very different to different people. A national culture of health must embrace a wide variety of beliefs, customs and values. Ultimately it will be as diverse and multifaceted as the population it serves” ( RWJF, n.d. ). The culture of health framework was developed by the foundation in collaboration with RAND Corporation through a combination of literature review and structured discussions with stakeholders ( Chandra et al., 2016 ). The framework includes four action areas that are interdependent—none can be achieved alone ( Plough and Chandra, 2016 ). The four action areas are

• Making health a shared value
• Fostering cross-sector collaboration to improve well-being
• Creating healthier, more equitable communities
• Strengthening the integration of health systems and services

The committee used the framework as a guide for this report and adapted it to apply specifically to its statement of task and at the community level.

The committee also referred to the ecological model illustrated in the 2003 Institute of Medicine (IOM) 4 report The Future of the Public’s Health in the 21st Century. This figure shows the multiple determinants of health, beginning with an individual’s biology (and the biology of diseases) at the center, followed by individual behavior, and in the outermost layer, the highest level of social, economic, cultural, health, and environmental conditions and policy ( IOM, 2003 ). The committee was charged with examining community-based solutions, and it developed a simple model to show what it concluded are three important elements of community-based efforts to promote health equity. The community-based level of intervention is situated in the second and third outermost circles of Figure 1-2 (i.e., social, family, and community networks; living and working conditions). As Figure 1-2 clearly indicates, community effort is necessary, but it is not a sufficient contributor to population health and, by extension, health equity. The outermost ring—the broad milieu of social,

4 As of March 15, 2016, the Health and Medicine Division (HMD) carries out the work previously undertaken by the IOM.

economic, and environmental conditions and policies—is crucial to support community-level efforts.

Report Conceptual Model

Figure 1-3 is a conceptual model that grounds the committee’s report. The model adapts elements of the Culture of Health Action Framework

( RWJF, 2015 ) and the Prevention Institute’s Systems Framework to Achieve an Equitable Culture of Health ( Prevention Institute, 2016 ). The model applies the culture of health lens to the committee’s understanding of the underlying causes and conditions of health inequity in addition to the community-based solutions that promote health equity.

The model begins with the outer circle and background as the context in which health inequities and community-driven 5 solutions exist.

5 The committee chose the term “community-driven solutions” because the community will be the driving force behind the solutions in this report.

The “socioeconomic and political context” was adapted from the World Health Organization Conceptual Framework for Action on the Social Determinants of Health ( WHO, 2010 ) and encompasses policies, law, governance, and culture. In the report conceptual model, this socioeconomic and political context includes structural inequities and biases that are produced along the axes of race, gender, class, sexual orientation, and other social domains. These inequities are manifested in systematic disadvantages that lead to inequitable access to or experience of the determinants of health. The committee adapted the determinants of health identified by the Achieving Health Equity Team at the RWJF, separating the social and physical environments, and adding transportation. Although the framework incorporates transportation as part of the “physical and social environment,” transportation is vital to many areas of health (e.g., the ability to travel to health care facilities, community events, accessing jobs) and, alternatively, can have detrimental impacts on health (e.g., air pollution, unintentional injuries), and thus it has been highlighted in the model. (See Chapter 3 for a more detailed description of each determinant of health and the ways in which they affect health and well-being.)

The committee adapted two of the Culture of Health Action Framework Action Areas for community-level solutions: “Making health equity a shared vision and value” and “Fostering multi-sector collaboration.” Based on the committee’s information-gathering sessions, relevant literature, and committee deliberations, the committee also identified a third action area of importance for the framework when proposing solutions at the community level: “Increasing community capacity to shape outcomes.” This is a process that has emerged as essential for communities to have the power to address inequities and to sustain their efforts. (These three elements are discussed in more detail in Chapter 4 .) To align with its statement of task, the committee incorporated equity at the community level in its conceptual model. The Culture of Health action area “Creating healthier, more equitable communities” has been incorporated into the conceptual model as the outcome of the community-driven solutions in the center of the diagram.

The community examples featured in this report will highlight solutions that have been implemented at the community level to target one or more of the nine determinants of health using the processes identified in the conceptual model (see Chapter 5 ). By making health equity a shared vision and value, increasing community capacity to shape outcomes, and fostering multi-sector collaboration, these solutions foster equal opportunity for health, which is the foundation for a vibrant, healthy community.

Community Health

This report does not focus on interventions that target a single health condition, but on community-level changes and impacts on health through a holistic lens. The development of a community-based solution is a community-driven process that includes fair participation by the community in the decision-making process, in which all people have access to the information necessary to understand the matter and the process and which produces outcomes that the people accept as fair, equitable, and nondiscriminatory in the context of addressing health disparities. Therefore, the terms “community-driven solutions” and “community-based solutions” will be used interchangeably for the remainder of this report (see Box 1-2 for definitions). The importance of communities and their role and potential to promote health equity is discussed in Chapter 4 .

Overview of the Study Process

To address its charge, the committee gathered information through a variety of means. It held three information-gathering meetings that were open to the public and webcast live. The first, held in January 2016, focused on obtaining information on health disparities and their root causes, including an overview from the report sponsor. The second, held in March 2016, focused on many of the social determinants of health and

included presentations on how transportation, planning, environmental justice, and civil rights law affect health. The third meeting was held in April 2016, and presentation topics included faith-based community organizing, community-based participatory research, place-based factors and policy at the community level, and the economics of community development (meeting agendas are in Appendix C ). The committee met in executive sessions for deliberative discussion throughout the study process. The committee received public submissions of materials for its consideration at the meetings and by e-mail throughout the course of the study. 6 A website was created to provide information to the public about the committee’s work and to facilitate communication between the public and the committee. 7 The process used to identify the community examples highlighted is outlined in the Chapter 5 Annex .

Overview of Report

Chapter 2 begins with a description of the state of health disparities in the United States by geography, income, race and ethnicity, and other categories. Chapter 3 discusses how structural and institutional inequities have led to disparate health outcomes and highlights historical issues that continue to affect health outcomes today, as well as the ways in which current and emerging issues ultimately affect communities. This is followed by a discussion on the multiple determinants of health and how they affect health equity. Chapter 4 discusses the role and capacity of communities to promote health equity and explains the larger context in which communities are situated, as well as the types of evidence needed to support communities. Chapter 5 provides nine examples of communities that are tackling health inequity and the lessons learned from these efforts. Chapter 6 addresses the policies that ultimately affect communities and that could either hinder or promote solutions at the level of individual communities. Chapter 7 discusses the roles of various stakeholders and the actions that these actors could undertake in their communities, with an emphasis on multi-sector collaboration. Chapter 8 is geared toward communities and provides an array of strategies, tools, and activities available to communities to help them promote health equity. Chapter 9 provides brief summarizing thoughts.

6 Public access materials can be requested from http://www8.nationalacademies.org/cp/projectview.aspx?key=IOM-BPH-15-15 (accessed December 23, 2016).

7 See http://www.nationalacademies.org/hmd/Activities/PublicHealth/Culture-ofHealth.aspx (accessed December 23, 2016).

CONCLUDING OBSERVATIONS

There are systemic root causes of health inequities in this country that can be overwhelming and that will take considerable time to address. It will require system-level changes to eliminate structural racism, reduce poverty, improve income equality, increase educational opportunity, and fix the laws and policies that perpetuate structural inequities. Until these root causes are addressed nationally, health equity will not be fully realized. However, actors at the community level—policy makers, businesses, state and local governments, anchor institutions, and community residents—are agents of local change who have the power to change the narrative and take action that will promote health equity. The latter is what this report will focus on, although, where possible, it will provide promising strategies to address these hard-to-tackle root causes at higher levels.

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Olshansky, S. J., D. J. Passaro, R. C. Hershow, J. Layden, B. A. Carnes, J. Brody, L. Hayflick, R. N. Butler, D. B. Allison, and D. S. Ludwig. 2005. A potential decline in life expectancy in the United States in the 21st century. New England Journal of Medicine 352(11):1138–1145.

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In the United States, some populations suffer from far greater disparities in health than others. Those disparities are caused not only by fundamental differences in health status across segments of the population, but also because of inequities in factors that impact health status, so-called determinants of health.

Only part of an individual's health status depends on his or her behavior and choice; community-wide problems like poverty, unemployment, poor education, inadequate housing, poor public transportation, interpersonal violence, and decaying neighborhoods also contribute to health inequities, as well as the historic and ongoing interplay of structures, policies, and norms that shape lives. When these factors are not optimal in a community, it does not mean they are intractable: such inequities can be mitigated by social policies that can shape health in powerful ways.

Communities in Action: Pathways to Health Equity seeks to delineate the causes of and the solutions to health inequities in the United States. This report focuses on what communities can do to promote health equity, what actions are needed by the many and varied stakeholders that are part of communities or support them, as well as the root causes and structural barriers that need to be overcome.

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• Achieving Health Equity

Achieving Health Equity in the United States

• Policy Statements and Advocacy
• Policy Statement Database
• Development Process
• Archiving Process
• Proposed Policy Statements
• Date: Nov 13 2018
• Policy Number: 20189

Key Words: Health Equity, Health Disparities, Social Determinants of Health

Abstract Decades of surveillance and research in the United States have documented health disparities in morbidity and mortality, particularly among racial/ethnic minority groups and those of lower socioeconomic status. Moreover, it is estimated that from 2003 to 2006 the combined costs of health inequities and premature deaths in the United States totaled $1.24 trillion and that elimination of health disparities among racial/ethnic minorities would have reduced these costs, including direct medical care, by $229.4 billion. In response to health inequities, national initiatives have been undertaken such as Healthy People 2020 and the National Partnership for Action to End Health Disparities. Despite Healthy People goals and objectives over several decades and modest reductions in health disparities in the United States, there are still persistent and pervasive disparities. Thus, more intentional, comprehensive, system-oriented, and coordinated strategies should be employed to achieve health equity in the United States. The action items presented in this policy statement call on national, state, and local governments, as well as nonprofit and philanthropic organizations and individuals, to implement policies, practices, surveillance, and research that include a health equity lens and framework across all sectors of society such that everyone can live a long life in optimal health.

Relationship to Existing APHA Policy Statements The following are some relevant APHA policies that are more narrowly focused on individual social determinants of health and health disparities.

• APHA Policy Statement 20179: Reducing Income Inequality to Advance Health
• APHA Policy Statement 20178: Housing and Homelessness a Public Health Issue
• APHA Policy Statement 201710: Protecting Children’s Environmental Health: A Comprehensive Framework
• APHA Policy Statement 20173: Public Health and Early Childhood Education: Support for Universal Preschool in the United States
• APHA Policy Statement 20101: Public Health and Education: Working Collaboratively Across Sectors to Improve High School Graduation as a Means to Eliminate Health Disparities 
• APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health
• APHA Policy Statement 20165: Addressing Social Determinants to Ensure On-Time Graduation
• APHA Policy Statement 20167: Improving Health by Increasing the Minimum Wage
• APHA Policy Statement 20091: Support for Community Health Workers to Increase Health Access and to Reduce Health Inequities
• APHA Policy Statement 20073: Environmental Injustices: Research and Action to Reduce Obesity Disparities
• APHA Policy Statement 200311: Opposition to Eliminating or Compromising the Collection of Racial and Ethnic Data by State and Local Public Institutions
• APHA Policy Statement 20017: Research and Intervention on Racism as a Fundamental Cause of Ethnic Disparities in Health
• APHA Policy Statement 20005: Effective Interventions for Reducing Racial and Ethnic Disparities in Health 
• APHA Policy Statement 9612: Threats to Affirmative Action Are Threats to Health
• APHA Policy Statement 8325: Access of Minority Medical Colleges to Public Hospitals
• APHA Policy Statement 7424: Racism in the Health Care Delivery System
• APHA Policy Statement 20062: Reducing Racial/Ethnic and Socioeconomic Disparities in Preterm and Low Birthweight Births

Problem Statement A major public health problem in the United States is that a baby born today is expected to have a shorter life span and live in poorer health than a baby born in other high-income countries.[1] Likely explanations for babies in the United States experiencing a poorer quality of life and dying earlier are that, relative to other high-income, democratic countries, the United States lacks organized and coordinated health and social systems and does not invest as many of its resources in social services. These circumstances translate to limited access to primary care, a larger uninsured population, increases in certain health risk behaviors (drug abuse and firearm violence), a greater population in poverty, less quality education of children, and less investment in safety net social programs. Furthermore, an  outcome of these circumstances for U.S. babies during their life spans is that their health status varies by race/ethnicity; gender; income; education; cognitive, sensory, or physical disability; sexual orientation or gender identity; and place of residence (geography).[2–4]

There have been efforts at the community, state, and national levels to address these “unnatural” health differences by population and place across the United States. National initiatives have created measurable goals and objectives for the nation to monitor health outcomes and determinants of health. Healthy People, a science-based, 10-year health agenda, has measured national health promotion and disease prevention progress since 1979, and more recently is measuring not only health outcomes and risk behaviors but also the social determinants of health for the decade from 2010 to 2020.  Currently, plans are under way for measuring health outcomes and determinants for 2020 to 2030.[2–4] Eliminating health disparities and achieving health equity such that everyone has optimal health (well-being) remains a foundational principle that guides the development of Healthy People 2030.[4]  The purpose of Healthy People 2020 is to engage communities and every sector of society to act in improving health across the United States. The vision of Healthy People is that its goals and objectives in communities across the nation will be applied through engaging multiple sectors to take action as described in the National Academy of Medicine’s report Communities in Action: Pathways to Health Equity.[5] This report highlights the role of communities in driving action, policy, programs, or laws to promote health equity in communities. Partnerships between governments at every level and nongovernmental organizations (including not-for-profit organizations, foundations, and the private sector) are also envisioned through active participation of the entire nation working locally to implement effective policies and programs across all sectors in society.

The goals of Healthy People 2020 include achievement of health equity and creation of social and physical environments that promote good health for all.[2,3] Healthy People 2020 defines health equity as the “attainment of the highest level of health for all people.”[2,6,7] Moreover, “[a]chieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.”[4,8] Other definitions of health equity, for example the definition offered by Dr. Camara Jones (APHA past president), posit that health equity is the assurance that conditions for optimal health are available for all people, based on the premise that all people are valued equally and injustice is both recognized and rectified.[9]

To assess health equity, a major measure is elimination of health disparities.[1] Healthy People 2020 defines health disparities as “a particular type of health difference that is closely linked with social, economic, and environmental disadvantage.”[1] As such, health disparities are rooted in sociopolitical and economic history. Health disparities adversely affect populations that have systematically experienced greater obstacles to health based on their race or ethnicity, religion, socioeconomic status, gender, age, mental health, disability status, sexual orientation, geographic location, or other characteristics historically linked to discrimination or exclusion.[3]

Despite Healthy People goals and objectives over several decades,[7] and although there have been some health improvements, there are still persistent and pervasive health disparities in the United States. For example, pervasive disparities were reported in the 2015 midcourse review of national health progress toward Healthy People targets.[10] Only modest reductions were found in health disparities among the widespread health and social objectives examined.[10] Of the up to 492 trackable objectives by race/ethnicity, the Healthy People target was met or exceeded for 36.9% of non-Hispanic Whites, 27.2% of non-Hispanic African Americans, 34.8% of Hispanics, 26.6% of American Indians/Alaska Natives, 47.8% of Asians, and 43.9% of Native Hawaiians or other Pacific Islanders.[10]

Examples of persistent health disparities include infant mortality, all-cause mortality, and life expectancy. In fact, U.S. life expectancy in all populations dropped from 78.9 years in 2014 to 78.7 years in 2015 and 78.6 years in 2016.[11] It is well known that infant mortality, all-cause mortality, and life expectancy differ by race/ethnicity, and these disparities have been documented over the past three decades. Trends in infant mortality from the 1980s to 2016 show disparities for African American infants relative to White infants; infant mortality among African American infants, on average, continues to be twice as high as mortality among White infants.[12,13] These disparities have worsened over time despite declines in overall U.S. infant mortality,[12] and more recent adverse trends have been found among Puerto Rican, American Indian/Alaska Native, and Pacific Islander infants.[2] Likewise, disparities persist in all-cause mortality and life expectancy at birth for African Americans relative to Whites, even though there have been overall improvements in both indicators of health.[12]  Furthermore, despite overall declines in cardiovascular disease (CVD) mortality, marked population and geographical inequities persist. A recent study showed a widening of the rural-urban disparity in CVD mortality, with mortality continuing to be higher in rural than urban communities.[14] From 1969 to 2011, the decline in CVD mortality was largest in New England and the Mid-Atlantic region and smallest in the Southeast and Southwestern regions. In 1969, the mortality differential in the Southeast relative to New England was 9%, and this differential increased to 48% in 2011.[14]

Other health outcomes such as obesity and diabetes, which have increased by epidemic proportions over the past few decades, show marked adverse disparities among African American and Hispanic populations in comparison with the White population at all time points during the 1980s to 2000s.[12] In addition, the legacy of slavery, racism, current oppression, and violence has impacted the mental health of African American populations. Several studies show that there is a relationship between self-reported experiences of racial discrimination and poor mental health among African Americans (as an example), including increased risk of depression, anxiety, substance use, and psychological distress.[15–17] Although the proportion of individuals receiving mental health treatment has increased, racial/ethnic disparities with respect to access to mental health treatment still persist among both children and adults.[18] In fact, this circumstance leads to members of racial/ethnic minority groups being less likely to achieve symptom remission and more likely to be chronically impaired after a diagnosis of a mental health disorder.[19]

Healthy People 2020 findings of persistent disparities in health outcomes and behavioral risk factors by socioeconomic status and education suggest that solutions to improve health outcomes for racial/ethnic and other disadvantaged populations point to upstream social determinants of health, including health care access, utilization, and quality.[20,21] These social and economic conditions, which are the “causes of the causes” of health disparities, vary not only by population characteristics but also by geography.[20] As such, inequities in certain social determinants of health are also assessed in Healthy People 2020 to understand what gives rise to disparities and to identify effective interventions so that all people are given the opportunity to realize the benefits of optimal health. Because of the U.S. political economy (the driver), which structures opportunities (advantages) and disadvantages for individuals, social determinants have been often described by race/ethnicity and income, which are measures of racism and classism, major drivers of social conditions.[3,7,22

Racism is defined as “institutional and individual practices that create and reinforce oppressive systems of race relations whereby people and institutions engaging in discrimination adversely restrict, by judgement and action, the lives of those against whom they discriminate.”[23] Racism is a major social determinant of health disparities. According to Jones, racism occurs on three levels: institutional, personally mediated, and internalized. Institutional racism is defined as “differential access to goods, services and opportunities of society by race.”[24] Personally mediated racism is defined as “prejudice and discrimination where prejudice means differential assumptions about the abilities, motives and intentions of others by race and discrimination is the differential actions toward others according to their race.” An unfortunate consequence of these two forms of racism is internalized racism, which is the “acceptance by members of stigmatized races of negative messages about their own abilities and intrinsic worth.”[24] APHA has recently begun a campaign against racism initiated by Jones.

Disparities in poor health outcomes described by racial/ethnic populations (of which racism is a contributor) place a substantial health burden on the nation and its workforce and give rise to an extreme economic burden.[25] This economic burden, which concerns communities of color but also can spark concern throughout the entire nation, has been quantified and calculated.[26] It is estimated that between 2003 and 2006, eliminating health disparities among racial/ethnic minority populations would have reduced direct medical care expenditures by $230 billion and indirect costs to society (due to loss of productivity from illness and premature death) by more than $1 trillion.[26] This evidence illustrates the cost effectiveness of eliminating racial/ethnic health disparities.

Along with the important health, social, and economic burdens to society based on the existence of health inequities, government and private sectors have a number of legal obligations related to racial equity, disability accessibility, and avoidance of gender-based discrimination. In addition, there is a growing body of legislation designed to prohibit discrimination based on sexual orientation or gender identity.[1] Examples of legal obligations and extent of implementation are described below for housing and education.

Housing: To build healthy communities as outlined in the National Prevention Strategy, all people must have access to safe, affordable, and stable housing. Access to housing has a direct and tangible impact on people’s ability to access quality education as well as on other social determinants of health. Specifically, housing segregation has a direct connection with student poverty rates and inadequate school resources, among other indicators of poor academic outcomes.[27] The federal government passed the Civil Rights Act of 1968 to specifically respond to various ways that American life had been divided based on race. Title VIII of the Civil Rights Act, known as the Fair Housing Act, prohibits race-based discrimination in housing with the express goal of “replacing ghettos” and creating truly integrated neighborhoods.

More recently, potential renters have come up against a new iteration of housing discrimination in the form of online ads. Yet, section 3604(c) of the Fair Housing Act specifically targets media postings (e.g., Craigslist) and prohibits racial discrimination using media platforms. Even with these clear legal obligations prohibiting racial discrimination in renting and home buying, housing segregation persists. Moreover, this systematic grouping of resource-rich and resource-poor neighborhoods[28] has a ripple effect on the ability of certain communities to access stable housing and, in turn, on their access to quality services.

Education: Access to education is a crucial social determinant of health.[29] It has been shown that “[p]eople with less education have higher rates of illness, higher rates of disability, and shorter life expectancies.”[30] However, in the United States, even decades after the landmark civil rights decision by the U.S. Supreme Court in Brown v. Board of Education, education is largely segregated on the basis of race and socioeconomic status.[31] Furthermore, there is no federal or constitutional right to education, and communities must rely primarily on state constitutions and special education laws to ensure equitable access to educational opportunities. K–12 education access is tightly interwoven with access to housing, as in most places students are assigned to schools based on their residence and school districts are divided along the same racial and socioeconomic lines as housing. The Supreme Court has unfortunately held that interdistrict integration is an inappropriate remedy where there has been no finding that wealthier (usually suburban) districts directly contributed to the harm suffered in less affluent districts (Milliken v. Bradley, 1974). In addition to the harm caused by racially segregated school districts, students’ access to quality education is hampered by exclusionary discipline policies that unfairly remove students of color, students with disabilities, and LGBTQ (lesbian, gay, bisexual, transgender, and queer) and non-gender-conforming (GNC) students from the classroom.[32] However, students do have some protections through the Individuals with Disabilities in Education Act, a federal law requiring that students with disabilities receive a free appropriate public education and that parents have a private right of action to demand that their child’s school district develop an educational plan that will allow the student to make meaningful educational progress.

To ensure equitable access to public education, cities and states across the country must commit to redistributing school funding in ways that are equitable and that undo the past and present harm caused by racial housing segregation. Furthermore, communities and districts must commit to eliminating “zero-tolerance policies,” which have been shown to disproportionately exclude youths of color, youths with disabilities, and LGBTQ and GNC students. The American Academy of Pediatrics has released a policy statement detailing that students who have been suspended or expelled are more likely to drop out of high school and calling for a reduction in zero-tolerance policies and an increase of prevention efforts, including early intervention for preschool students and positive behavioral support and interventions within schools.[32] In addition, the American Bar Association’s Joint Task Force on Reversing the School-to-Prison Pipeline called for the removal of zero-tolerance policies from schools and for legislation designed to eliminate criminalization of students for behavior that does not harm others.[33]

Summary: Unfulfilled legal obligations and persistent and pervasive health inequities are major public health problems because inequities cause tremendous health, economic, and ethical burdens for U.S. society, and there is a need for enforcement of legal protections from discrimination. Elimination of health disparities is cost effective, and if nothing is done these societal burdens are projected to worsen as the U.S. population becomes more diverse and multicultural. By 2044, the United States is projected to become a majority-minority country.[34] Furthermore, racial/ethnic minority and low-income populations combined now represent nearly one half of the U.S. population.[34,35]

Evidence-Based Strategies to Address the Problem While there is not a comprehensive, coordinated strategy for the nation to achieve health equity, there are science- and evidence-based national strategies and initiatives that have demonstrated success in reducing or eliminating some health disparities at the local level and in communities because they have effectively addressed the social determinants of health, including racism and classism. Many are discussed in an Institute of Medicine report titled How Far Have We Come in Reducing Health Disparities? Progress Since 2000: Workshop Summary.[36] Although national initiatives are emphasized as key opportunities, it is realized that their success involves multisector partnerships at every level of government and with nongovernmental, nonprofit organizations. These initiatives are discussed in the context of the Patient Protection and Affordable Care Act and include but are not limited to the following:  the dual vaccination strategy, the recommendations of the Community Preventive Services Task Force (CPSTF), Healthy People 2020 goals and objectives, the National Prevention Strategy (NPS),  the National Partnership for Action to End Health Disparities (NPA), the Environmental Justice Strategy and Implementation Plan, the Public Health Accreditation Board standards for public health agencies,  the Culture of Health initiative of the Robert Wood Johnson Foundation, Association of State and Territorial Health Officials (ASTHO) and National Association of County and City Health Officials (NACCHO) programs and initiatives to achieve health equity, and APHA efforts to achieve the healthiest nation in a generation.

The dual vaccination strategy includes multicomponent, evidence-based interventions designed to reach the general population of children in U.S. communities and targeted interventions designed to reach the most vulnerable children (e.g., those from underserved, low-income, and racial/ethnic minority populations) and high-risk communities (those at risk of vaccine-preventable illnesses because of low vaccination coverage).[37,38] Universal interventions include regular assessments of vaccination services for children at the local, state, and national levels and in health care practices.[37,38] At the health care practice level, the focus is on provision of high-quality vaccination services through practice standards, standing orders, and assessment of services.[39] Targeted interventions, based on the needs of the most vulnerable children, have enabled low-income and racial/ethnic minority children and high-risk communities to gain routine access to health care services via the Vaccines for Children Program. In addition, there is increased awareness of the need for and availability of vaccination services through strategic partnerships between public health agencies and community organizations at all levels of governmental public health, particularly faith-based organizations.[37,38] The Vaccines for Children program specifically provides free vaccines to uninsured and underinsured children.[40]

The evidence-based recommendations of the CPSTF represent examples of interventions proven to improve the quality of health care service delivery. Evidence-based recommendations also exist for communities in reducing risk behaviors for chronic diseases and injuries.[39] These recommendations, when applied to communities, have been proven to improve health.[39]

As mentioned, Healthy People 2020 provides achievable and measurable objectives for improving the health of all that are applicable at the national, state, and local levels.[2,3] Regular and routine monitoring of objectives requires assessments of the overall population at these levels as well as assessments of different groups by education, race/ethnicity, income, disability, and geographic location.[3] This strategy of monitoring the health objectives of individuals in communities, counties, states, and the nation reflects the adage “what gets measured, gets done.”[41]

The NPS, a key national initiative that includes targeted interventions as components, is designed to improve the resilience of all populations by addressing the social determinants of health.[42] The NPS goal is to increase the number of Americans who are healthy at every stage of life.[42] This goal is accomplished via four strategic directions: eliminating health disparities, building healthy and safe communities (e.g., through provision of clean air and water and affordable housing), integrating community and clinical preventive services and enhancing the quality of both, and empowering people to make healthy choices. Elimination of health disparities is applied across the other three directions and nine priority areas to reduce the burden of the leading causes of preventable deaths and major illnesses in the United States.[42] An example of integration of community and clinical preventive services is enabling access to clinical services by providing transportation, child care, and patient navigation interventions.[42] The nine priorities, which include tobacco-free living, prevention of drug abuse and excessive alcohol use, healthy eating, active living, and mental and emotional well-being, can reduce poor health outcomes.[42] Full implementation of the NPS in all communities, including those with substantial racial/ethnic minority and low-income populations, should improve community health.

While education and housing are important social determinants of health, racism (as mentioned) plays a dynamic role in shaping the health and well-being of individuals and populations alike. Throughout the nation, there are a number of efforts taking place at the state and local levels, particularly around building capacity to address racism. Training, webinars, and coalitions and committees formed by national and local organizations provide health departments, hospitals, businesses, and communities with tools and resources to recognize, address, and eliminate racism. Anti-racism training sessions, such as those taught by the Racial Equity Institute, the Center for Racial Justice Innovation, Clear Impact, and the Race Matters Institute, focus on creating racial equity and challenging the status quo.[43–46] These training sessions equip communities and the workforce with knowledge, skills, and resources regarding racial equity. Webinars such as those sponsored by APHA,[47] the Latino Medical Student Association,[48] and Human Impact Partners[49] offer an opportunity to examine the structural barriers that preserve racism while advancing racial and health equity. Coalitions and committees such as Organizing Against Racism, the Interfaith Coalition Against Racism, the United Nations Human Rights Committee on the Elimination of Racial Discrimination, and the International Justice Resource Center’s Committee on the Elimination of Racial Discrimination focus on disassembling racism while promoting justice.[50–53] In addition, organizations such as the National Collaborative for Health Equity, CommonHealth ACTION, the Aspen Institute, the W.K. Kellogg Foundation, and the Center for Ethical Leadership provide funding and resources to organizations in an effort to address the impact of racism.[54–56]

Interventions and initiatives targeting upstream social determinants of health are likely most effective in improving health equity. The NPA, a targeted umbrella initiative led by the Office of Minority Health of the U.S. Department of Health and Human Services (DHHS), is expected to mobilize a nationwide, comprehensive, community-driven, and sustained approach for combating health disparities and for moving the nation toward achieving health equity.[8] Systems-oriented, cross-sector, partnership-based, and community-driven approaches to eliminating health disparities include a national stakeholder strategy for achieving health equity. The goals of this strategy are to increase awareness of the impact of health disparities and actions needed for improving health among racial, ethnic, and underserved populations; to strengthen leadership in addressing health disparities; to improve health and health care outcomes for racial, ethnic, and underserved populations; to improve cultural and linguistic competency and the diversity of the health workforce; and to improve data, research, and diffusion of research and evaluation outcomes.[57] To accomplish the stakeholder plan, there are regional health councils in place. All public health agencies and the private sector could benefit from the guidance of the NPA regional health equity councils and state minority health directors, and they should engage in efforts with community health workers to educate and empower communities and individuals.[58,59] These councils and directors have established trusted partnerships in underserved and minority communities, and they can assist public health agencies in developing community improvement plans.

An example of such endeavors can be seen in the work accomplished by the National Indian Health Board and the National Partnership for Action. To build capacity and improve outcomes for tribal communities, these two organizations have collaborated in a joint effort sponsored by the Office of Minority Health.[60] This effort has provided resources to tribal public health departments surrounding public health accreditation and bolstered “use of the social determinants of health and health equity frameworks in programming and in community health needs assessments.

The 2012 DHHS Environmental Justice Strategy and Implementation Plan delineates actions to address environmental health disparities experienced by minority and low-income populations and American Indian tribes.[36] Environmental justice is defined as fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income in the development, implementation, and enforcement of environmental laws, regulations, and policies.[61] This definition was developed in response to a body of science and community advocacy indicating a disproportionate burden of environmental pollution among minority, low-income, and tribal populations in the United States.[61] The Environmental Justice Strategy and Implementation Plan builds on an earlier strategy from 1995 to protect the health and advance the economic potential of communities overburdened by pollution and other environmental hazards.[61] The four interrelated parts of the 2012 strategy are linked to climate change polices and directives such as policy development and dissemination; education and training; research and data collection, analysis, and utilization; and services.[61] The plan provides a roadmap for DHHS agencies to develop their own environmental justice strategies and plans, to enhance accountability, and to promote collaboration and meaningful community partnerships.

To strengthen the public health infrastructure and improve routine public health agency performance, the Public Health Accreditation Board offers an accreditation process for state, local, tribal, and territorial public health agencies.[62] As of August 2016, 150 local, tribal, and state agencies and one integrated state system of 67 local agencies were accredited.[62] An accredited public health agency meets national standards based on the 10 essential public health services. The accreditation standards drive public health agencies to develop and use documents such as community-driven health improvement plans, agency strategic plans, and emergency operations plans. With accreditation standards, there is strong attention to understanding emerging trends, using assessment data and identifying jurisdiction-specific needs and issues, and addressing health equity, cultural competency, and vulnerable populations. As such, the accreditation process and national standards are driving attention to important topics and actions, which could strengthen the preparedness and response of communities to the health impacts of climate change and improve efforts to address threats faced by vulnerable populations by more strongly motivating public health agencies to take actions required to address their needs. In addition to meeting overall standards, accredited agencies meet specific cultural competency standards.[62]

As mentioned in the problem statement, the health status of individuals in the United States is poor relative to those living in other high-income countries, and life expectancy is shorter. A major explanation for shorter life expectancy is that countries with the best health outcomes provide the strongest social services for their populations.[1] There is a need for social supports to improve health status and reduce health inequities in the United States.

The APHA goal is for the United States to become the healthiest nation in a generation by 2030. To accomplish this goal, APHA calls for the conduct of eight science-based key actions[63]:

• Build safe, healthy communities
• Help all young children graduate from high school
• Reverse growing income inequalities
• Remove barriers to good health for everyone
• Provide affordable, nutritious food for everyone
• Effectively prepare for and respond to the health impacts of climate change
• Provide quality health care to everyone
• Strengthen public health infrastructure

Furthermore, considerable literature exists denoting additional specific strategies in smaller localities that have led to improvements in health equity through addressing the social determinants of health. These strategies include, but are not limited to, research strategies (such as community-based participatory research), housing program and policy strategies (such as tenant-based rental assistance programs), and educational program and policy strategies (such as center-based early childhood education, full-day kindergarten programs, and high school completion programs).[64]

Also, critical state and local strategies to improve health equity are being led by nonprofit organizations. APHA has implemented case studies, as have NACCHO, ASTHO, and the Robert Wood Johnson Foundation.[9,65–67] In addition, a community of practice in North Carolina, which has the shortest life expectancies in the nation, has developed a health equity framework.[68,69] North Carolina has its own Office of Minority Health and Health Disparities, which generates health equity reports evaluating the state’s progress in eliminating health disparities.[68] The Chronic Disease and Injury Section of the North Carolina Department of Health and Human Services strives to decrease death and disability by way of education, policy change, and health services.[69] Within that section are communities of practice that aim to further the section’s work.[69] One community of practice developed a health equity framework that encompasses priorities, key activities, and terminologies surrounding health disparities, health inequities, and the social determinants of health. This framework offers an approach to advancing health equity while providing strategies and a common language that can be used to inform the policies of decision makers and increase funding for health equity in grant applications.[68,69]

In prioritizing multisectoral approaches to achieving health equity, the “health in all policies” approach provides an opportunity for multifaceted collaboration focusing on the social determinants of health.[70] This upstream approach also promotes the importance of considering health in developing every decision and throughout a wide range of sectors.[70] ASTHO asserts that “by taking a broader view of what creates health, we can better understand how policies related to transportation, housing, education, public safety or environmental protection can affect health outcomes.”[71]

Building safe communities also requires aggressive enforcement of existing civil rights protections and active work to undo the past harms caused by redlining, predatory lending, and other forms of discrimination in housing. Continued research and aggressive policy changes to hold financial institutions, landlords, and other actors accountable for fighting racial inequity in housing are absolutely necessary to combat inequity in housing.

In the journey toward achieving health equity in the United States, effective interventions to address the social determinants of health continue to be needed at the nonprofit and philanthropic organizational- levels.[5] It is estimated that 45% to 57% of the drivers of health determinants are outside of health care, supporting the need for intentional, collaborative, coordinated, and innovative efforts to address the social determinants of health.[72] Nongovernmental organizations play a critical role in stimulation of innovation; for example, the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation work through programs and grants to engage communities, policymakers, business leaders, and other stakeholders to set a standard for health equity in communities and to provide evidence for the business case for racial equity.[67,73] In addition, there are numerous other foundations that impact health, are thought leaders, and provide funding to impact decisions, policies, and programs that can address health equity, including the Henry J. Kaiser Family Foundation, Kaiser Permanente, the Ford Foundation, the California Healthcare Foundation, the Commonwealth Fund, and the California Endowment.

The Institute of Medicine’s report Communities in Action: Pathways to Health Equity further supports the notion that health is shaped by community context and is the product of multiple determinants.[5] This report provides examples of innovative evidence-based strategies and recommendations for closing equity gaps. In addition, the report acknowledges that both governmental and community actors are necessary but are independent of one another and are not sufficient for the advancement of equity. The community-driven initiatives included in the report illustrate several promising cross-cutting elements that promote equity, including creating a shared vision and building trust in the community, developing leadership, and building diverse partners through relationship building and mutual accountability.[5] By developing strategic partnerships/collaborations and building community capacity for equity, communities can successfully impact socioeconomic and political frameworks accounting for a range of factors such as employment, public safety, housing, transportation, and education.[5] It is evident through these examples that community-based organizations and subsequent partnerships are drivers of change and are a fundamental component in the implementation of effective strategies in pursuit of health equity. To further strengthen the success of this work, communities need evidence (from research), tools, supportive policies, resources, and political will that will nurture local efforts.[5]

Opposing Arguments/Evidence There are fundamental opposing arguments used against attaining health equity that are underlying values of decision makers and policymakers (e.g., capitalism, xenophobia, and sexism). These opposing arguments are as follows: (1) personal health choices are the responsibility of the individual and (2) the scarcity of resources leads to a need for a balance between health rationing and what is acceptable as redistribution of resources.[74]

Credence given to these fundamental opposing arguments, however, is difficult because during the public meetings for Healthy People 2010, when elimination of health disparities became a national health goal, the public expressed concern that differences in health status by race/ethnicity and income were unacceptable.[75] In addition, as previously mentioned, the cost effectiveness of eliminating health inequities[26] and the business case for racial equity[73,76] are strong economic arguments in support of achieving health equity.

Moral and ethical arguments have also been used to refute other opposing arguments. For example, Dr. Cynthia Jones has offered ethical arguments refuting specific prevailing opposing arguments against the elimination of health disparities.[77] She describes the following three prevailing opposing arguments to elimination of disparities: “The first opposing argument is that it is not necessarily wrong that some people are ‘less healthy’ than others. The second opposing argument holds that different cultural groups may exhibit cultural habits that perpetuate health disparities and the third opposing argument is that addressing health disparities is a waste of resources, as substantial resources have already been spent studying the problem of health disparities, yet the disparities persist.”[77] Jones then refutes these opposing arguments as follows.

• Refuting the first opposing argument: Even if individuals are responsible for their own health and, more important, the health disparities with which we are concerned are disparities that follow racial/ethnic lines and socioeconomic distinctions, it would be a strange leap to suppose that the members of a particular ethnic population are responsible for their lower health outcomes or that the poor are responsible for their lack of access to adequate medical care. Even if we assume, for the sake of argument, that this is indeed the case, we may still argue that the high rate of diabetes and heart disease in minority populations, for example, is a problem that should be addressed through education, even if the population as a whole exhibits habits that are unhealthy and are somewhat within their control. Public health programs designed to educate the public about the dangers of smoking are an example of this logic at work.[77] Furthermore, individuals’ choices are strongly influenced by options and opportunities in their environments, and in some communities, geographic areas, and socioeconomic groups individuals are limited by their access to making healthy choices.
• Refuting the second opposing argument: Cultural practices that result in significant health risks should be addressed, albeit as sensitively as possible. If a cultural practice results in harm to the individual or to others, then it would be morally problematic to ignore such harm. It may be that we can educate individuals about potential harm while presenting healthier alternatives that are not antithetical to a group’s ethnic and cultural practices.[77]
• Refuting the third opposing argument: We should not abandon efforts to address a problem because past efforts have been unsuccessful. Efforts to address diseases such as Alzheimer’s disease and breast cancer and social problems such as domestic violence and poverty should not be curtailed because these diseases and problems persist. There is also no clear evidence that the problem is indeed “unfixable.” At best, this objection points to the need to rethink approaches to addressing health disparities. Numerous factors, such as health literacy, housing, environmental toxins, mistrust of health care professionals, and lack of insurance, affect health and can perpetuate or increase health disparities. Clearly, a complex tangle of factors is at work to affect health and contribute to significant health disparities in the United States. We need to develop creative, broad-based approaches to address these inequities. Rather than pulling health disparities out of the social context in which they are entrenched and attempting to address them narrowly, researchers should find ways to address health disparities within the social context, which may require “fixing” more than just the health disparities. Perhaps increasing public awareness of health disparities as a moral issue can contribute to addressing this problem.[77]

Action Steps The action steps outlined below are based on the science- and evidence-based strategies described previously and are structured at the national, state, local, and nongovernmental levels, with ultimate impacts at the individual and community levels. It is recognized that nongovernmental partners also play a major role in fostering healthy communities.

National Level

• Congress should fund fully, and the federal government should implement fully, the Affordable Care Act, including (1) providing access to health services for everyone (through health insurance and promotion of Medicaid expansion by states on the path to universal access to health care), (2) implementing the recommendations of the U.S. Preventive Services Task Force and the CPSTF, (3) collecting required data, and (4) implementing value-based health care.
• Congress should fund fully the National Prevention Strategy and Implementation Plan and the National Partnership for Action to End Health Disparities, including implementation of the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care.
• Congress should continue to fund research on elimination of health inequities through the National Institute on Minority Health and Health Disparities as well as other institutes at the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), the Agency for Healthcare Research and Quality (AHRQ), the Substance Abuse and Mental Health Services Administration, and the Patient-Centered Outcomes Research Institute (PCORI).
• The CDC, ASTHO, NAACHO, the Robert Wood Johnson Foundation, and other organizations should develop and implement evidence-based toolkits for communities to implement interventions that include the dual strategy approach of universal interventions and targeted interventions to reach society’s most vulnerable populations
• Congress should fund and implement fully social safety net services such as quality education, housing, jobs, and transportation.
• Congress should permanently reauthorize special provisions of the 1965 Voting Rights Act to prevent further reauthorizations.
• Federal, state, and local governments should enforce civil rights laws to achieve health equity.
• The CDC should continue to monitor progress on eliminating health disparities and health inequities and consider new methods to expand monitoring of health outcomes by socioeconomic status in addition to race/ethnicity.
• The CDC, NIH, AHRQ, and PCORI should continue and expand community research to identify models to reduce health disparities in communities across the United States.
• The CDC and the W.K. Kellogg Foundation should engage in efforts to reduce breastfeeding disparities across the United States.[78]

State/Local Level

• State governments should expand Medicaid to improve universal access to health care.
• State and local public health agencies should create broad coalitions with regional and state health equity councils and minority health directors to reach the most vulnerable populations (racial/ethnic minority and low-income populations) through health in all policies initiatives and other evidenced-based efforts to improve population health.
• State and local governments should fund state and local public health agency accreditation efforts.
• State and local governments should implement evidence-based interventions and identify practice-based interventions found to eliminate health disparities (e.g., communities of practice).
• State and local governments should support social policies to improve education, income, housing, jobs, and transportation.
• State and local governments should work with urban planners and health professionals to foster incorporation of health in planning, policy, and decision-making frameworks to create healthy communities.
• >State and local public health agencies should include the most vulnerable populations in developing, implementing, and evaluating community improvement plans and training.
• State and local governments should implement a dual strategy approach of public health programs and prevention programs.

Nongovernmental Organizations

• Nongovernmental organizations such as the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation should continue to introduce paradigm shifts such as the Culture of Health initiative and the business case for racial equity.
• Nongovernmental organizations should work with partners to create healthy communities.
• Nongovernmental organizations such as the Kellogg Foundation, the Satcher Institute, and the American Medical Students Association should enhance scholarship and fellowship programs seeking to develop public health leaders in academia and health policy who are focused on eliminating health disparities and advancing health equity.
• Academic institutions, in the major role of identifying effective interventions in communities to achieve health equity, should focus research particularly on the discovery of interventions that intervene on the social determinants of health in communities across the United States.
• Academic institutions should focus on training members of the public health workforce with the specific knowledge and skills they need to prepare them for leadership roles in developing, promoting, and implementing research and policies to advance health equity. Moreover, these institutions should enhance and develop centers and curriculums focused on advancing health equity, specifically providing graduates with the necessary training to work effectively with disadvantaged communities to develop sustainable programs and critically analyze issues, programs, and policies that impact health disparities and advance health equity.

Individuals/Communities

• Individuals and communities should advocate for political, social, and economic policies and programs that will improve health for the most vulnerable populations, families, and communities, as well as policies that support health advancement of multicultural populations.
• Individuals and communities should understand their legal rights and obligations to uphold civil rights laws and disability laws and advocate for enforcement of such laws.

Cross Cutting

• Federal, state, and local governments; professional organizations; and businesses should create a pipeline of public health and preventive medicine physicians and professionals made up of members of the most vulnerable populations in U.S. society.
• Federal, state, and local governments should adopt a “health in all polices approach” to ensure that health issues are addressed broadly, especially with respect to social policies that affect vulnerable populations.

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Available at: https://www.apha.org/topics-and-issues/health-equity. Accessed January 18, 2019. 66. Association of State and Territorial Health Officials. Programs. Available at: http://www.astho.org/Programs/Health-Equity/. Accessed January 18, 2019. 67. Robert Wood Johnson Foundation. Building a culture of health. Available at: https://www.rwjf.org/en/how-we-work/building-a-culture-of-health.html. Accessed January 18, 2019. 68. North Carolina Office of Minority Health and Health Disparities. Health equity report. Available at: http://www.ncminorityhealth.org. Accessed January 18, 2019. 69. North Carolina Department of Health and Human Services. Chronic Disease and Injury Section. Available at: https://publichealth.nc.gov/chronicdiseaseandinjury/. Accessed January 18, 2019. 70. American Public Health Association. Health in all policies. Available at: https://www.apha.org/topics-and-issues/health-in-all-policies. Accessed January 18, 2019. 71. Association of State and Territorial Health Officials. Implementing a “health in all policies” approach with health equity as the goal. Available at: http://www.astho.org/Health-Equity/2016-Challenge/Implementing-a-health-in-all-policies-approach-with-health-equity-as-the-goal/. Accessed January 18, 2019. 72. Marmot M, Allen JJ. Social determinants of health equity. Am J Public Health. 2014;104:S517–S519. 73. W.K. Kellogg Foundation. Growth, productivity, revenues, output: the business case for racial equity. Available at: http://www.nationalcivicleague.org/wp-content/uploads/2018/04/RacialEquityNationalReport-kellogg.pdf. Accessed January 18, 2019. 74. Robert Wood Johnson Foundation. A new way to talk about the social determinants of health. Available at: https://www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf63023. Accessed January 18, 2019. 75. U.S. Department of Health and Human Services. Healthy People 2010: understanding and improving health. Available at: https://www.healthypeople.gov/2010/document/pdf/uih/2010uih.pdf. Accessed January 18, 2019. 76. Turner A. The business case for racial equity. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1002/ncr.21263. Accessed January 18, 2019. 77. Jones CM. The moral problem of health disparities. Am J Public Health. 2010;100:S47–S51. 78. Bartick MC, Jegier BJ, Green BD, Schwarz EB, Reinhold AG, Stuebe AM. Disparities in breastfeeding: impact on maternal and child health outcomes and costs. J Pediatr. 2017;181:49–55.

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Advancing Health Equity, Eliminating Health Disparities, and Improving Population Health

EDITORIAL — Volume 18 — August 12, 2021

Leonard Jack Jr, PhD, MSc 1 ( View author affiliations )

Suggested citation for this article: Jack L Jr. Advancing Health Equity, Eliminating Health Disparities, and Improving Population Health. Prev Chronic Dis 2021;18:210264. DOI: http://dx.doi.org/10.5888/pcd18.210264 .

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Author Information

In June 2017, Preventing Chronic Disease (PCD) invited a panel of 7 nationally recognized experts in scientific publishing to respond to key questions about the journal’s mission, quality of scientific content, scope of operations, intended audience, and future direction (1). PCD and the panel of experts recognized that chronic disease is a major contributor to poor health outcomes, an increase in health care costs, and a reduction in quality of life. Reducing the burden of chronic disease is a challenge requiring diverse collaborations and dissemination and adoption of effective interventions in multiple settings. The expert panel strongly encouraged the journal to focus more on complementing its rich body of published work on epidemiological studies with content that is attentive to evaluating population-based interventions and policies.

Since its inception in 2004, PCD’s mission has been to promote dialogue among researchers, practitioners, and policy makers worldwide on the integration and application of research findings and practical experience to address health disparities, advance health equity, and improve population health. To better advance that mission, PCD used the panel’s recommendations to refine the journal’s focus, addressing 4 main areas of public health research, evaluation, and practice:

Behavioral, psychological, genetic, environmental, biological, and social factors that influence health

Development, implementation, and evaluation of population-based interventions to prevent chronic diseases and control their effect on quality of life, illness, and death

Interventions that reduce the disproportionate incidence of chronic diseases among at-risk populations

Development, implementation, and evaluation of public health law and health policy–driven interventions

Refining the focus on these 4 areas has allowed PCD to receive a wide range of content from authors around the world. In addition to manuscripts received through the journal’s regular submission process, PCD has issued calls for papers on topics that bring to the forefront timely public health issues and targeted public health responses to improve population health.

Advancing health equity and eliminating health disparities have been and continue to be critical factors to PCD in addressing these topic areas. Healthy People 2020 defines health equity as the attainment of the highest level of health for all people (2). According to Healthy People 2020, “Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities” (2). Healthy People 2020 defines health disparities as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage” (2).

As part of its mission to address these important issues, PCD is excited to release this collection, “Advancing Health Equity, Eliminating Health Disparities, and Improving Population Health.” Of the 17 articles in the collection, 10 were submitted in response to PCD’s call for papers for the collection and 7 were previously published in the journal. All articles underwent the journal’s rigorous peer-review process. In addition, this collection features a position statement on the journal’s commitment to advancing diversity, equity, and inclusion in its scientific leadership, peer review process, research focus, training, and continuing education (3).

Over the past decade, there has been a range of community-based, technically innovative, and clinically driven prevention strategies in public health to prevent and reduce the burden of chronic conditions among diverse populations worldwide. Articles in this collection describe innovative and successful work to address factors contributing to advancing health equity, eliminating health disparities, and improving population health. They provide the latest information on ways to better understand contextual factors responsible for influencing health outcomes (both negatively and positively) and effective approaches to improve population health among diverse populations in various settings. The 18 articles address these core themes from multiple perspectives:

PCD’s Commitment to Advancing Diversity, Equity, and Inclusion in Its Scientific Leadership, Peer Review Process, Research Focus, Training, and Continuing Education (3)

Engaging With Communities — Lessons (Re)Learned From COVID-19 (4)

Global Perspectives on Improving Chronic Disease Prevention and Management in Diverse Settings (5)

Reaching the Hispanic Community About COVID-19 Through Existing Chronic Disease Prevention Programs (6)

Community Engagement of African Americans in the Era of COVID-19: Considerations, Challenges, Implications, and Recommendations for Public Health (7)

Addressing Racial and Ethnic Disparities in COVID-19 Among School-Aged Children: Are We Doing Enough? (8)

A Framework for Mobilizing Health Care to Respond to the Community Within the COVID-19 Pandemic (9)

Addressing Emotional Wellness During the COVID-19 Pandemic: The Role of Promotores in Delivering Integrated Mental Health Care and Social Services (10)

COVID-19 and Chronic Disease: The Impact Now and in the Future (11)

Screening and Referral Care Delivery Services and Unmet Health-Related Social Needs: A Systematic Review (12)

Community and Research Perspectives on Cancer Disparities in Wisconsin (13)

Urban–Rural Disparities in Access to Low-Dose Computed Tomography Lung Cancer Screening in Missouri and Illinois (14)

Quantification of Potential Inequities in Breast Cancer Incidence in New Mexico Through Bayesian Disease Mapping (15)

HbA 1c Performance in African Descent Populations in the United States With Normal Glucose Tolerance, Prediabetes, or Diabetes: A Scoping Review (16)

Reducing Tobacco Use in Oregon Through Multisector Collaboration: Aligning Medicaid and Public Health Programs (17)

“We’re, Like, the Most Unhealthy People in the Country”: Using an Equity Lens to Reduce Barriers to Healthy Food Access in Rural Appalachia (18)

Oral Health Behaviors in Very Young Children in Low-Income Urban Areas in Chicago, Illinois, 2018–2019 (19)

A Randomized Trial to Improve Adherence to Follow-up Eye Examinations Among People With Glaucoma (20)

Positioning a scientific journal to address matters related to diversity, equity, and inclusion requires careful and intentional thinking and action. Going back to PCD’s inaugural issue in 2004, featuring an essay on social determinants of health by Dr Leonard Symes, professor emeritus of epidemiology at the University of California, Berkeley, the journal has created a space to highlight the importance of these topics in chronic disease prevention and health promotion. Since that first issue, PCD has continued to demonstrate a dedication to these issues at all levels: through its leadership and staff, the content it publishes, its expanding pool of talented volunteers (PCD’s external review panel, editorial board, associate editors, statistics review committee), the rigorous peer-review process, a comprehensive and inclusive variety of article types, calls for papers related to these issues, and more. In its 18 years of publication, PCD has consistently worked to assure the public of its commitment to achieving diversity, equity, and inclusion.

Peer-reviewed journals around the world are also focusing attention on these issues. In keeping with this movement, as PCD’s editor in chief I have authored the first article featured in this collection, which is a position statement on the steps already taken by the journal, steps planned for the next 5 years, and key measurable outcomes (3). PCD hopes to serve as a model in identifying and implementing best practices for diversity, equity, and inclusion to build an even stronger trust with the public.

And trust is needed: mistrust of the health care system has emerged as a primary barrier among members of communities of color to seeking care in health care systems (21). Mistrust stems from historical events, including the Tuskegee syphilis study, and is reinforced by health system issues and discriminatory events that continue to this day (21). This collection includes an article by Michener and colleagues, which posits that COVID-19 has underscored long-standing societal differences in drivers of health (4). The authors offer insights into this historical reality and suggest using a health equity lens to engage communities at risk of poor health outcomes, improve bidirectional communication, establish data sharing, and improve involvement in program implementation, dissemination, and evaluation. Authors share concrete ways these can be achieved by presenting successful examples around the US.

The global impact of COVID-19 among people at risk or living with a chronic condition in multicultural communities necessitates that health communication messages are created and delivered from a health equity perspective (22). Airhihenbuwa and coauthors, in their commentary, discuss the importance of culture in unpacking messages that may be the same globally (eg, physical/social distancing) yet different across cultures and communities (individualist vs collectivist) (5). Authors discuss how use of the PEN-3 framework can facilitate a community-engaged communication response to COVID-19.

Populations with low socioeconomic status and certain racial and ethnic groups (eg, Native American, Hispanic, and African American people) have historically been disproportionately affected by chronic disease, COVID-19 diagnosis, hospitalization, and mortality (23). Calo and associates discuss how COVID-19 has disproportionately affected Hispanic communities throughout the US (6). This commentary describes how Better Together REACH, a community–academic coalition promoting chronic disease prevention, and Project ECHO (a telementoring program based at Penn State University), were adopted to support a coordinated COVID-19 response in the Hispanic community in Pennsylvania. Authors provide insights into how the existing infrastructure of chronic disease programs can be used to leverage resources and provide trusted and continuous services to reach Hispanic populations during the pandemic.

African Americans, like the Hispanic population, are more likely to contract COVID-19, be hospitalized, and die of the disease (24). Akintobi et al describe how psychosocial, sociocultural, and environmental vulnerabilities, compounded by preexisting health conditions, exacerbate the burden of COVID-19 among African Americans (7). Authors share important information based on their years of experience on ways to create and implement approaches to intentionally engage African Americans at higher risk of COVID-19. Insights and recommendations can advance community leadership and be used to prepare public health practitioners, researchers, and evaluators for future pandemics — both assisting in advancing health equity and addressing historical aspects of health disparities among African Americans.

The disproportionate impact of COVID-19 and associated disparities among Hispanic, non-Hispanic Black, and non-Hispanic American Indian/Alaska Native children and teenagers has been widely reported (25). Children from some racial and ethnic minority groups have a higher prevalence of obesity, asthma, type 2 diabetes, and hypertension; were diagnosed more frequently with COVID-19; and had more severe outcomes compared with their non-Hispanic White counterparts (26). In addition, a higher proportion of children from some racial and ethnic minority groups, compared with White children, live in families with incomes less than 200% of the federal poverty level or in households lacking secure employment (8). White et al argue that the COVID-19 pandemic reemphasizes the importance of implementing policy, systems, and environmental changes in school systems to support emergency preparedness and recovery, as well as resilience, through collaborations among local health departments, local school systems, and other public and private organizations (8). Topics addressed in this article include disparities in underlying medical conditions and social determinants of health, inequities in social determinants of health, and community-based approaches to reducing COVID-19 disparities. The article concludes by discussing ways to implement strategies to advance health equity through partnership.

It has long been recognized that disparities in health care access and patient outcomes are associated with factors related to race, sex, gender, sexual orientation, primary language, and socioeconomic status (27). Epps and coauthors recognize that African Americans and other underrepresented racial and ethnic groups are often not included in health decision making and policy development (9). As a result, these public health experts describe steps undertaken to improve participation, joint decision making, and capacity building between an integrated academic health system and a community coalition to address complex health challenges with the aim of increasing the capacity of health systems to reduce the burden of COVID-19. This article describes a call to action by the chair of a health care board of trustees to its board members consisting of clinicians, researchers, educators, and health advocates to identify ways to mitigate disparities and determine how the health care system could play a role in advancing and implementing effective strategies to reduce the disproportionate burden of COVID-19 among communities of color. Authors provide insight into the organizational planning process to generate a community outreach and health disparities collaborative with goals for governance, messaging and education, community partnerships, data, and research and evaluation.

COVID-19 has exacted a tremendous toll on the physical, emotional, and psychological well-being of many Americans, thus requiring a population health response (28). The disproportionate impact of the COVID-19 pandemic on Hispanic communities has resulted in a greater burden of depression, anxiety, and stress along with the need for increased assistance with housing, access to food, and supplemental income (29). Moon and colleagues offer original research that reports findings on demographic characteristics and factors associated with service volume, types of services, and referrals in the pre-COVID-19 and COVID-19 periods (10). They report that referrals shifted from primarily mental health services and disease management during the prepandemic period to affordable housing support, food assistance, and supplemental income during the COVID-19 period. This study presents findings on how a community-based organization with a long-standing presence in the Hispanic community effectively expanded its emotional wellness program, using promotores to provide integrated mental health care and social services to clients disproportionately affected by COVID-19.

Hacker et al discuss the problem of COVID-19 and chronic disease in their essay (11). They describe 3 categories of challenges facing public health professionals and identify solutions needed to improve health outcomes and lessen health inequities among people at risk or living with a chronic disease. Authors also discuss the evolving response by the Centers for Disease Control and Prevention’s National Center for Chronic Disease Prevention and Health Promotion to implement a multipronged approach to enhance access to data at the local level, focus on addressing social determinants of health through a health equity lens, and expand partnerships and communication about the impact of COVID-19 on chronic disease.

Unmet health-related social support needs among people being served by health care systems can contribute to high patient morbidity and poor population health (30,31). However, little is known about the overall impact of screening and referral programs that address unmet health-related social needs on outcomes related to experience of care, population health, and cost. Ruiz Escobar et al conducted a systematic review of peer-reviewed articles in PubMed published over the past 10 years (as of March 2020) to determine the impact of screening and referral care delivery services on unmet health-related social needs (12). Thirty-five articles met the systematic review’s inclusion criteria. After conducting their review, the authors concluded that although evidence exists of a positive influence of screening and referral program outcomes related to experience of care and population health, no definitive conclusions could be made on the overall impact on changes in patient connection to resources, patient satisfaction, and patient-reported outcomes because of the potential high risk of bias across studies. Their findings can inform the use of screening and referral programs in health care organizations, including ways to strengthen future studies to examine their effectiveness.

Qualitative research is an important methodological tool that provides critical insights in identifying subjective meaning in the context of health (32). Qualitative research is a necessary exploratory approach that can be used to better understand and improve health equity research and practice. Olson and her team of researchers conducted 10 listening sessions and 28 interviews with people from diverse backgrounds to identify themes in causes, solutions, and opportunities to collaborate across sectors to address cancer disparities (13). Researchers validated the use of qualitative approaches to engage diverse participants representing many different sectors. Qualitative findings identified medical mistrust, the need for equitable multilevel partnerships, influences of environmental threats on cancer burden, and location of cancer disparities as key concerns among people participating in the listening sessions and interviews. The researchers describe how these findings will be used to form multisector teams to address local social, cultural, and biological influences of cancer disparities and achieve health equity in Wisconsin.

Geographic location continues to be an important contributor in shaping access to timely and necessary screening and treatment options (33). Rohatgi et al conducted original research examining relationships among rurality, sociodemographic characteristics, and access to low-dose computed tomography (LDCT) screening for lung cancer and screening access and lung cancer mortality (14). This study revealed that more than 97% of metropolitan residents had access to LCDT screening, compared with just over 40% of nonmetropolitan residents. Researchers learned that residents of southeastern Missouri, a rural and impoverished area, had low screening access, high smoking prevalence, and high lung cancer mortality. Researchers concluded that targeted strategies to implement rural LDCT screening could reduce geographic disparities in access, and future research could help identify factors that increase access to screening to eliminate rural-related disparities in lung cancer mortality.

Breast cancer is the most frequently diagnosed cancer and a leading cause of cancer mortality among American Indian/Alaska Native (AI/AN) women (34). Despite having a lower incidence of breast cancer than White women, AI/AN women are more likely to be diagnosed at younger ages and later stages (35). Breast cancer incidence among non-AI/AN women has largely been quantified in large geographic regions in the US, and substantial regional variation in breast cancer inequities in non-Hispanic AI/AN populations has been reported. Zahrieh and colleagues conducted research to obtain a deeper understanding at a granular level to identify potential inequities in breast cancer incidence by applying county-level Bayesian disease mapping (a model-based approach that offers a means to improve county-level incidence estimates) to population surveillance data from 2005 through 2014 in New Mexico (30). They found a significant overall disparity effect across New Mexico, evidenced by the age-adjusted rate of breast cancer among non-Hispanic AI/AN women being appropriately 0.38 times the corresponding age-adjusted rate among non-Hispanic White women. Researchers also suggest that findings can be used to facilitate targeted statewide and county-level cancer control interventions to mitigate breast cancer disparities among AI/AN women in New Mexico.

Historically, type 2 diabetes has disproportionately affected racial and ethnic minority groups (31). To ensure accurate detection of type 2 diabetes, we must understand the ability of hemoglobin A 1c (HbA 1c ) to correctly classify type 2 diabetes status and evaluate intra-ethnic variation. Toward this end, Khosla et al conducted a scoping review to determine HbA 1c performance in African descent populations in the US with normal glucose tolerance, prediabetes, and diabetes (16). Results included 7 studies that analyzed HbA 1c performance among African Americans, 1 study that analyzed HbA 1c performance in Afro-Caribbean people, and 4 studies that analyzed HbA 1c performance among Africans. Researchers found that current HbA 1c cutoffs for prediabetes and type 2 diabetes may overestimate glycemic status in African Americans and underestimate glycemic status in Afro-Caribbean and African people. Researchers indicated that alternating testing, such as the oral glucose tolerance test, fasting plasma glucose, and other glycated blood proteins in place of or in combination with HbA 1c may better assess glycemic status in populations of African descent.

Tobacco use remains the leading cause of preventable morbidity and mortality in the US (33). Livingston and colleagues evaluated changes in tobacco cessation benefits, patient access, and cigarette smoking prevalence before and after 16 coordinated care organizations began providing comprehensive cessation benefits for reducing tobacco use prevalence among Medicaid members in Oregon (17). This implementation evaluation identified changes in tobacco cessation benefits, patient–provider discussions of smoking cessation, and cigarette smoking prevalence before and after the introduction of statewide incentives for reducing cigarette smoking. Evaluators reported that statewide effort accelerated progress toward tobacco use reduction among members of coordinated care organizations.

Obesity among adults living in Appalachia continues to be a major problem, and policy, systems, and environmental interventions may help to address long-standing underlying factors that have historically contributed to this persistent public health concern (35). Cardarelli and associates reported findings from a qualitative study that used a grounded theory approach to identify barriers and facilitators for healthy food access in a rural county in Kentucky (18). The goal was to design interventions responsive to social, cultural, and historical contexts from an equity perspective. Focus group participants were asked, for example, if it was easy to get fruits and vegetable at locations where they purchase food, if many people in their community purchase food at farmers markets, and what factors in their community make it easier or harder to eat healthy. The authors concluded that efforts to address food access through policy, systems, and environmental interventions must be sensitive to characteristics of the rural setting, acknowledge social inequities in the region, and proactively engage community members throughout all stages of intervention planning, implementation, and evaluation.

Oral health disparities among children have been linked to socioeconomic inequalities, access to care, health systems barriers, and lack of access to foods that promote optimal oral health outcomes (39). Martin et al conducted original research that explored the frequency of tooth brushing among children with a mean age 21.5 months (19). Their results indicated that the frequency of brushing among children, as reported by guardians, was higher when the correct amount of toothpaste was used, brushing occurred for a longer duration, and other family members helped children with brushing. Their findings strongly suggest that parental and family support for brushing are critically important in promoting and sustaining tooth-brushing behaviors.

According to the Lancet Global Health Commission on Global Eye Health, women, rural populations, and racial/ethnic minority groups are more likely to have vision impairment, a pervasive inequality that needs to be addressed (40). This PCD collection on advancing health equity and reducing health disparities concludes with a research study by Leiby et al investigating the effectiveness of an enhanced intervention among people with glaucoma: using patient navigators and social workers to improve patient adherence to follow-up eye care in community settings (20). The study compared the intervention group with a group of patients in usual care. Participants in usual care were provided with a local ophthalmologist’s contact information and a copy of their eye examination results; they were not provided access to patient navigators or social workers. Study participants, who were randomly assigned to either the enhanced or usual care intervention, were a diverse group of participants aged over 40 with a family history of glaucoma or currently diagnosed with diabetes. Only participants who had not seen an ophthalmologist in the previous 12 months were permitted to enroll in the study. Study participants consisted largely of African Americans, followed by White, Asian American, and Hispanic residents of Philadelphia, Pennsylvania. The study found that the use of patient navigators and social workers doubled the rate of adherence to annual recommended eye care follow-up, compared with participants assigned to the study’s usual care intervention. The study highlights that formalized use of social support in partnership with local ophthalmologists can be an effective approach to increasing access to local ophthalmological services.

At the center of this collection of articles is a shared commitment to the goal of eliminating health disparities, particularly those that continue to persist despite aggressive efforts to ameliorate them. The collection describes a range of diverse and timely examples of efforts to eliminate health disparities and advance health equity among racial and ethnic groups in the US. Articles appearing here represent various types of PCD articles that encompass multiple perspectives, from original research and systematic reviews to implementation evaluation to expert commentaries to tools that can be used in public health practice. As a discipline, we have important work to do, not only to better understand how social determinants of health and other contextual factors impact health but also to design, implement, and evaluate effective multilevel systems approaches that create optimal conditions to promote health for all. PCD will continue to move forward in its commitment to these goals, and we encourage authors to visit the journal’s Author’s Corner website (https://www.cdc.gov/pcd/for_authors/index.htm) to learn more about article types that best fit their research addressing population-based approaches to eliminating health disparities and advancing health equity.

Corresponding Author: Leonard Jack, Jr, PhD, MSc, Editor in Chief, Preventing Chronic Disease: Public Health Research, Practice, and Policy, Office of Medicine and Science, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, NE, Mailstop S107–8, Atlanta, GA 30341. Email: [email protected] .

Author Affiliations: 1 Office of Medicine and Science, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

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• Akintobi HT, Jacobs T, Sabbs D, Holden K, Braithwaite R, Johnson LN, et al. Community engagement of African Americans in the era of COVID-19: considerations, challenges, implications, and recommendations for public health. Prev Chronic Dis 2020;17:E83. CrossRef PubMed
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• Zahrieh D, Golafshar MA, Patel SH, DeWees TA. Quantification of potential inequities in breast cancer incidence in New Mexico through Bayesian disease mapping. Prev Chronic Dis 2021;18:E23. CrossRef PubMed
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• Bassett MT, Chen JT, Krieger N. The unequal toll of COVID-19 mortality by age in the United States: quantifying racial/ethnic disparities. Working paper. Cambridge (MA): Harvard T.H. Chang School of Public Health; 2020.https://www.hsph.harvard.edu/social-and-behavioral-sciences/2020/06/23/the-unequal-toll-of-covid-19-mortality-by-age-in-the-united-states-quantifying-racial-ethnic-disparities/. Accessed July 13, 2021.
• Kim L, Whitaker M, O’Halloran A, Kambhampati A, Chai SJ, Reingold A, et al. ; COVID-NET Surveillance Team. Hospitalization rates and characteristics of children aged <18 years hospitalized with laboratory-confirmed COVID-19 — COVID-NET, 14 states, March 1–July 25, 2020. MMWR Morb Mortal Wkly Rep 2020;69(32):1081–8. CrossRef PubMed
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The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

A Path to Achieve Health Equity Essay

• To find inspiration for your paper and overcome writer’s block
• As a source of information (ensure proper referencing)
• As a template for you assignment

Evidence-based nursing practice is an emerging field that aims to improve the efficiency and quality of nurses’ work. Every year the number of responsibilities and the influence of nurses on healthcare change. In the work of each medical institution, such criteria as accountability, emotional stability of nurses and equal treatment of patients are important. Therefore, it is important for nurses to adhere to a fair attitude to all patients and try not to be at work in a state of emotional burnout.

It was found out from the National Academy of Medicine’s 2021 report that nurses work at the intersection of healthcare, education, and society. They are the first people with whom patients of different races, nationalities, and religions interact (Flaubert et al., 2021). Consequently, nurses play one of the main roles in achieving equality and fair treatment of all in health care. The report notes that the next decade will be important for nurses, as the main goal will be to create equal conditions for hospital patients.

Social determinants of health are the environmental conditions in which people are born, live, study, work and lead daily lives, which directly affects their health. These conditions are the cause of many property inequalities (Flaubert et al., 2021). The social determinants of health considered at the societal level include unequal living conditions in early childhood, different educational opportunities, social security and access to health care. One of the most important social determinants of health is financial well-being (Flaubert et al., 2021). The principle of justice in healthcare today is directly related to the human right to health protection within the framework of the social institute of healthcare. In order to ensure fair treatment in the field of health care in accordance with the determinant of health, it is necessary to inform patients about possible budgetary medical programs. The need to address issues related to the social determinants of health means that the activities of nurses should extend to areas such as finance, agriculture, education, transport, energy and housing.

The International Council of Nurses (ICM) considers the human right to equity in the availability of medical services as an integral part of nursing ethics. This is enshrined in the MSM Code of Ethics preamble, which states that nursing is characterized by respect for human rights, including the right to life, dignity, and respect (Flaubert et al., 2021). The availability of nursing care is not affected by the patient’s age, skin color, beliefs, culture, disability, or illness. Nurses must constantly improve their skills to ensure equitable access to medical services.

The cultural competence of employees is an important condition for ensuring fair access to services. It helps improve service quality by developing communication between medical professionals and patients (Flaubert et al., 2021). Nurses play an important role in developing strategies, actively participating in political activities, and conducting scientific research, especially in medical care (Oldland et al., 2020). The ability to adapt to a new situation is an important strategy for improving access to medical services. Increasing the function of nurses demonstrated the possibility of improving the quality of service and reducing organizational costs.

Introducing appropriate new personnel is an effective way to reduce costs without compromising the quality of service. It is important that managers, including nurse managers and employers, provide their employees with information about the possibility of training on issues related to the needs and preferences of the local population (Flaubert et al., 2021). The recruitment of employees from among persons belonging to national minorities and their support in the workplace affect the receipt by minority representatives of medical care of the same quality as the majority (De Groot et al., 2019). Nurses, with their experience of direct patient care, should ensure that patients have the most reliable information and that research protocols are designed in such a way as to ensure proper representation and participation in research of all population groups.

In current conditions, a person meets on his way with a sufficiently large number of stressful factors that undoubtedly affect his personality and professional activity. It is especially important to study the syndrome of emotional burnout in the professional activity of a nurse during the period of reforms that lead to the intensification of the professional activity of a specialist. To prevent the syndrome, it is advisable to conduct psychological training, which masters the exercises of auto-training – the main method of mental self-regulation. It is emphasized that the prevention of emotional burnout should be comprehensive, considering the individual personality characteristics of each health worker (Flaubert et al., 2021). The class of physical methods is often used because it is simple and accessible: exposure to the body through different temperatures and light therapy. To combat emotional burnout, pharmaceuticals, herbal remedies, and aromatherapy are used.

Thus, the National Academy of Medicine’s 2021 report made clear the key responsibilities of a nurse and the importance of this profession in ensuring equality in the field of health care. The criterion for evaluating the effectiveness of nursing care is the improvement of the patient’s health indicators and earlier rehabilitation, which is achieved through compliance with the standards of nursing practice. Nurses today should have deep theoretical knowledge about the application of innovative techniques and manipulations in accordance with the standards of medical practice. Nurses play an essential function in achieving health equity and defining strategies for the health sector’s impact on reducing inequities in this area. For effective work, nurses should monitor their emotional state and consult a doctor during emotional burnout.

De Groot, K., Triemstra, M., Paans, W., & Francke, A. L. (2019). Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews . Journal of Advanced Nursing , 75 (7), 1379-1393. Web.

Flaubert, J. L., Le Menestrel, S., Williams, D. R., & Wakefield, M. K. (2021). The future of nursing 2020-2030: Charting a path to achieve health equity . Web.

Oldland, E., Botti, M., Hutchinson, A. M., & Redley, B. (2020). A framework of nurses’ responsibilities for quality healthcare—Exploration of content validity . Collegian , 27 (2), 150-163. Web.

• Journey to Nursing: A Personal Reflection on Passion, Influence, and Aspirations
• The Concept of Cultural Relativism in Nursing
• Burnout in Professional Therapists
• The Nursing Burnout: Causes and Consequences
• Nursing Burnout and Implications for Nursing Profession
• Older Adults Patient Education Issues
• Evaluation and Testing in Nursing Education
• Mindfulness Meditation to Reduce Nursing Stress Levels
• Critique of Quantitative Research Article in Nursing
• Nursing Diagnosis: Poor Visual Acuity in an Eye
• Chicago (A-D)
• Chicago (N-B)

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Raine R, Fitzpatrick R, Barratt H, et al. Challenges, solutions and future directions in the evaluation of service innovations in health care and public health. Southampton (UK): NIHR Journals Library; 2016 May. (Health Services and Delivery Research, No. 4.16.) doi: 10.3310/hsdr04160-69

Challenges, solutions and future directions in the evaluation of service innovations in health care and public health.

Essay 5 evaluating health-care equity.

Rosalind Raine , Zeynep Or , Stephanie Prady , and Gywn Bevan .

Affiliations

The evaluation of health-care equity necessitates measuring both horizontal and vertical equity components to establish whether or not patients receive the health care across levels of need. Examining interactions between social factors of concern and need, or stratifying analyses according to different levels of need, can be used to identify horizontal and vertical equity. Increased data linkage across sectors and settings is vital for identification of sources of inequity and, crucially, to ascertain whether or not any identified variation has clinical relevance. Macro-, meso- and micro-level determinants of equity should always, ideally, be considered. However, examination of the ‘gap’ or the ‘gradient’ will depend on the intervention studied. Emerging techniques should be harnessed, for example machine learning to more completely exploit data sources on need, case mix and outcomes; and interactive multimedia techniques to examine social variations in clinical decision-making.

• Scientific summary

Universal health-care systems aim to provide care for all, solely according to clinical need. Despite this, the ‘inverse care law’ has been demonstrated to operate in these systems. In this essay we discuss key methodological challenges in the measurement of health-care equity and propose ways forward.

The ascertainment of equity in health care requires the evaluation of both horizontal and vertical components: horizontal equity refers to the equal treatment of those with equal needs and vertical equity recognises that people with greater clinical needs should have more intervention. Methods to examine varying levels of need include stratifying analyses according to different levels of need or examining interactions between the social factor of concern and a measure of need.

Data on the population in need of care and case-mix data may be poorly recorded or available only as free text. Emerging innovations in machine learning enable extraction of valuable information from both existing and hitherto unused data sources. Data linkage of data from different settings is also required to identify source(s) of inequity and whether or not it matters in terms of outcomes.

Careful consideration should be given on whether it is most appropriate to examine the gap or the gradient in sociodemographic differences in the uptake of health-care/public health interventions. Statistical techniques are now available to calculate the sample size needed for gradient analyses.

In addition to examining equity at the intervention level, innovative methods are now being developed to examine the impact of national policies. Evidence from North America is that dismantling universal systems will not only create greater inequities in access but also mean increases in total costs of health care. Researching inequalities at the individual level and in clinical encounter are also beginning to be addressed. Recent approaches include the use of web-based interactive multimedia vignettes with actor ‘patients’ to simulate key features of health-care consultations. Qualitative, longitudinal study designs which allow the exploration of decision-making at different points of a patient’s health-care journey could also yield valuable insights.

The development of innovative techniques and application of emerging methods for collecting and analysing data will enable equity to be measured with greater accuracy, precision, relevance and comprehensiveness. This will, in turn, better inform interventions for their remediation.

• Introduction

Universal health-care systems, whether publicly funded or insurance based, aim to provide health care for all, according to clinical need, and undistorted by social or economic factors, geographical location or ability to pay. Yet observers have long recognised the presence of the so-called ‘inverse care law’ operating in these systems. 1 This term was first coined in 1971 by Dr Julian Tudor Hart, a general practitioner (GP) who worked in socially deprived mining communities in the Welsh valleys. His observation that ‘the availability of good medical care tends to vary inversely with the need for it in the population served’ was largely based on his personal experiences rather than on empirical research. However, a wealth of confirmatory data has since been published internationally. In England, this led the Chief Medical Officer to observe in 2005 that, in the publicly funded NHS:

. . . healthcare [. . .] is to some extent inequitable at present: the preference of clinicians, the socioeconomic status and empowerment of patients, and decisions regarding specific local resource allocation may influence clinical practice as much as the actual health needs of patients, the behaviour of any pathological process or the scientific evidence base. p. 22 (reproduced under the terms of the Open Government Licence for Public Sector Information) 2

For those health-care systems which aim to provide universal coverage based solely on clinical need, health-care inequity matters because it undermines the capacity of the system to remain true to its core values or its constitution. The robust measurement of equity is, therefore, crucial.

In this essay we discuss key methodological challenges in the measurement of health-care equity and propose some ways forward. We also briefly review evidence on policies to achieve equity using the method of the natural experiment.

• Equality, equity and its horizontal and vertical components

Equity is about fairness and justice and implies that everyone should have an equal opportunity to attain their full potential for health or for the use of health care. 3 It should be distinguished from the related concept of equality. Equality is about the equal distribution of shares (of health or health care) so that each individual receives the same amount. The notion of equity transcends equality. Some inequalities may be unavoidable and therefore are not generally considered unjust. Others, for example associated with one’s area of residency, ethnic group, sex, age, socioeconomic circumstances (SEC) or disability, might be avoided and so are considered inequitable. They may be unfair or unjust as well as unequal and, because they are not solely determined by need, they may lead to differences in outcomes.

We recognise that definitions of fairness vary according to libertarian, liberal and collectivist perspectives. However, universal health-care systems define fairness in terms of needs. Mooney 4 pointed out that equitable distribution according to clinical need might refer to the distribution of expenditure, access, use or health. With respect to expenditure distribution, in the UK, the NHS uses formulae to promote equitable allocation of funding for care. The Resource Allocation Working Party (RAWP) and its successors have developed different methods of formula funding for the four countries of the UK (England, Scotland, Northern Ireland and Wales) which recommend that money should be distributed on the basis of population size, weighted for relative need and accounting for variations in unavoidable costs of providers (e.g. higher living costs in London, excess costs for delivering services in remote areas in Scotland). 5 The components of the RAWP formula have been reviewed and revised for over 30 years and they continue to be subject to reanalysis. For example, although the RAWP recommendation to account for relative need by weighting for age and sex using national average rates of utilisation is relatively uncontroversial, their use of the standardised mortality ratio to account for additional need has raised many questions, which are discussed by Bevan. 5 In 1999, a new objective for the allocation of resources in the English NHS was introduced to contribute to the reduction in avoidable health inequalities. 6 As a consequence, a health inequalities component was introduced into the allocation formula and increases in allocations have since favoured more deprived areas. Local NHS commissioners were free to use these additional funds to purchase primary or secondary health care or public health services, to better meet their population’s needs and improve the quality of care received. The underlying rationale is that additional health-care expenditure translates into improved population health outcomes. A recent analysis of this policy found that geographical inequalities in mortality from causes amenable to health care declined in absolute terms during the 10-year period in which this allocation policy was applied. 7 Moreover, the association between additional NHS funds and reduced mortality was stronger in deprived areas than in more affluent areas. Analyses such as these, using aggregated, routinely available data, cannot exclude the possibility that the associations observed were attributable to unmeasured confounders, such as smoking, or to other, concurrent non-NHS policies implemented to tackle social exclusion in disadvantaged areas. Moreover, they do not tell us about the types and content of services received and their relative contributions to outcomes.

Indicators of access include the availability of resources, waiting times, user charges and others barriers to care. Thus, equity of access is a purely supply-side phenomenon, in the sense that equal services are made available to patients in equal need. The difficulty with measuring equity according to this definition is that individuals may not use services to which they have access. Their reasons for non-use are socially patterned and are, at least in part, because of structural and environmental barriers which are proportionately greater for the socioeconomically disadvantaged, older people, people with disabilities or those for whom English is not their first language. Routine data such as medical records may not, therefore, strictly give a measure of access, because they can supply information only about services which have been taken up.

The definition of equity which takes this into account is equal use for equal need. This definition recognises the influence of both demand and supply factors on the pursuit of equity. These factors are influenced by the preferences, perceptions and prejudices of both patient and health-care provider. Most studies on equity and access analyse utilisation rates (often adjusted by sociodemographic and clinical indicators of need) as a proxy measure of access.

The final definition is equal health for equal need. This definition addresses the fact that there are inequalities in health arising from the level of resources, housing conditions, exposure to environmental hazards and different lifestyles and behaviours. It is an ideal rather than an operational definition, as both avoidable and unavoidable influences affect our health. Neighbourhood renewal 8 and Sure Start 9 are examples of initiatives in the UK that move towards this ideal.

There is another issue surrounding distribution according to need which should be considered. This is that distribution on the basis of need comes in two versions: a horizontal version (people with equal needs should be treated the same) and a vertical version [people with greater clinical needs should have more intervention (provided it is effective) than those with lesser needs (unequal use for unequal need)]. From a macroeconomic perspective, Mooney and Jan 10 defined vertical equity in terms of positive discrimination, arguing that achievement of horizontal equity is rarely enough. They propose differential weighting of the level of need by socioeconomic group in order to more thoroughly investigate the distribution of health and health care and to facilitate the movement of disadvantaged people up to the level of the advantaged. 10 Mooney and Jan 10 do not provide the differential weights that would allow examination of the presence of vertical equity. Sutton 11 takes the approach forward by specifying a target level of use for people at different levels of need and then comparing whether or not actual use equals the target.

An alternative way of operationalising vertical equity is generated by the understanding that the demonstration of equal use for equal need does not necessarily indicate unequal use for unequal need. 12 For example, although male and female patients with a mild form of a disease may be treated equally (horizontal equity), it cannot be assumed that the likelihood of treatment varies according to the degree of abnormality in both men and women. Men with severe disease may be more likely to receive treatment than men with mild disease (vertical equity), but the likelihood of treatment for women may not differ with disease severity (vertical inequity). The vertical component is often overlooked by researchers and policy-makers, and this prevents the comprehensive measurement of equity, the likely consequence of which is overestimation of fair use of care. Unless both components of equity are measured, it cannot be concluded that patients are receiving the health care that they need. Studies that use multivariable analysis alone to adjust for need assume that social differences in use are the same at every level of need, which may not be the case. Other analysis strategies should be employed to examine varying levels of need, such as stratifying analyses according to different levels of need or examining interactions between the social factor of concern and a measure of need. 12

• Identifying the population in need of care

To examine the equitable distribution of health care and public health interventions, we need to understand how interventions are distributed across the social factors of concern. This requires identification of both the complete population in need and their sociodemographic characteristics.

This is not always straightforward. Many of the social factors of interest, such as ethnicity, language skill or religion, are poorly recorded in national data sets or available only as free text (which is unstandardised). These data may not always be missing at random, potentially leading to selection bias. An emerging innovation is to apply machine learning techniques to ‘code’ free-text data in medical records. Thoughtful application of these methods has the potential to increase our ability to extract valuable information from both existing and hitherto unused or underused data sources. Machine learning could revolutionise systematic data collection in terms of comprehensiveness, completeness, timeliness and accuracy.

There are many sources of data that can be used to characterise socioeconomically disadvantaged groups. Area-based measures of SEC are often freely available and readily linked with postcode data; for example, in England the Index of Multiple Deprivation (IMD) scores and ranks areas containing approximately 650 households across several domains of deprivation. 13 Relying on area-based measures to ascertain SEC for individuals, however, can result in ecological fallacy, where lack of precision or incorrect inference stems from within-area pockets of relative advantage and disadvantage masked by the ‘average’ area score. In the absence of individual-level data, such effects can potentially be reduced by adding in data from commercially available data sets at smaller geographic units which provide information on consumer habits. Such data may distinguish the advantaged from the disadvantaged within an area and provide greater resolution on SEC when used in combination with the IMD. 14 The method is not bias free, however, as relatively high levels of consumerism may be the result of high debt, not affluence. Health and health-care researchers are perhaps less familiar with using sources such as local and national taxation information and education data, but forging links with data providers to explore such sources has the potential to reap benefits for future equity research.

Some relationships between health and measures of SEC are best characterised by J-shaped curves, meaning that the most disadvantaged group may not be where you expect to find them. For example, in the USA, health insurance coverage may not be linear with income; the wealthy may opt not to have health insurance, and benefit recipients may have state-provided coverage. Policy-related changes leading to changes in insurance patterns for different social groups over time complicate longitudinal analyses. The relationship between coverage and health for working poor is likely to be highly variable and associated at the micro level with heterogeneous contextual factors such as size of employer and family composition. In England, benefit recipients (and those with long-term chronic conditions) are exempt from prescription charges, so in this context it may be the working poor paying for prescriptions who suffer the highest financial burden of ill health. Examining and characterising the group most at risk by considering the context of the population setting is a crucial step in measuring inequalities. Quadratic terms can be added to regression models to allow for non-linear relationships. 15

Accurate ascertainment of the population in need of health care may be hampered by several factors. First, incidence and prevalence from health-care data are likely to be inaccurate if there are a high number of undiagnosed cases of the condition in the community. Diagnosis (and diagnostic delays) are influenced by help-seeking behaviour, which is itself socially patterned. Second, disease presentation can also vary by social group. For example, women with ischaemic heart disease may present with symptoms that differ from the typical chest pain presentation by men. 16 This could lead to underascertainment in women if these differences are not reflected in study diagnosis criteria. Third, there may be a lack of consensus about the definition of need for intervention, for example in total hip replacement. Where the clinical rationale for intervention is not clear-cut, investigation and treatment may be influenced as much by the availability of doctors and diagnostic equipment, or by financial factors (such as a fee-for-service system), as by clinical need. 17 This highlights the problem of inequity owing to the overuse of medical interventions, which puts patients at risk of complications unnecessarily and drives up the cost of health care. Finally, health-care systems which are not universal are limited by their access to medical record databases which relate only to the insured population, excluding those without coverage, and there may be also unknown missing data bias for out-of-area medical visits.

• Examining whether or not inequalities matter

We have already described why it is necessary to examine whether or not health-care inequalities matter in terms of their impact on outcomes. For example, in a study of the effect of secondary prevention in 30-day stroke survivors it was found that people aged 80–89 years were only half as likely to receive a lipid-lowering drug as those aged 50–59 years. 18 This treatment inequality was important because the receipt of secondary drug prevention was associated with a halving of the mortality risk. Crucially, there was little evidence that the effect of treatment differed by age. Therefore, the undertreatment of older people cannot be justified, unless it is explained by informed patient choice. If patient preferences explain some of the differences observed, then it is important to unravel their origin. This is a theme that we discuss later, in Social variations in the clinical encounter .

• The gap versus the gradient

Policy-makers distinguish between the gap (the relative difference between advantaged and disadvantaged groups) in service provision, and the gradient (the continuum along which increasingly worse health is associated with a unit drop in the social factor of interest). An example of an approach to target the most disadvantaged subgroups only is the Nurse Family Partnership in the USA, 19 named the Family Nurse Partnership (FNP) in the UK 20 and VoorZorg in the Netherlands, 21 which provides intensive support to multiply disadvantaged first-time mothers. Three evaluations of these programmes in the USA report positive results for mothers and their babies, including improvements in birth outcomes, children’s cognitive development and uptake of preventative health care. 19 , 22 , 23 A trial of the intervention in the Netherlands reported lower smoking rates in nurse-visited pregnant women and increased breastfeeding duration. However, in England, where FNP was added to the usually provided health and social care, no additional benefits were achieved in the primary outcomes, which included smoking in pregnancy, birthweight, rates of second pregnancies and emergency hospital visits for the child. 24 There were important differences in both the trial design and the health-care context between the US and English studies: the English trial was a large, pragmatic, independently led evaluation, in contrast to the US evaluations, which were single centre and led by the intervention developers with a greater emphasis on efficacy. Women in England have access to more statutory public health, health care and social services than US women. The lack of any additional benefit from the English FNP suggests that macroeconomic policies and structural changes are required to complement intensive support services when tackling complex, multifactorial and enduring problems.

The costs of inequalities are borne not only by those at the bottom of the socioeconomic hierarchy, but by those at every level. Policies that target the most disadvantaged subgroups only, or which aim to narrow the gap between the most and least disadvantaged, underestimate the pervasive effect across the socioeconomic hierarchy and exclude those in need in the intermediate socioeconomic groups. Even for targeted interventions which are found to be effective, the population-level impact maybe smaller for these than for universal interventions. Such arguments augur in favour of tackling the gradient to address inequalities. Although it is rarely done, the gradient can be measured to examine the effect of universal interventions which are expected to reach the whole population, for example in Wardle et al. 25 Where gradients are measured, the time frame over which effects are evaluated should be carefully chosen. This is because universal interventions can increase health inequalities in the short term, as the more advantaged are usually the first to take up new services, but this effect can level over time as the advantaged groups plateau in terms of their ability to benefit. 26

Calculating the sample size needed for gradient analyses can present challenges. One strategy was developed for a universal screening programme intervention in which uptake needed to increase more in disadvantaged groups than in advantaged groups. 25 Here, the solution was to use the weighted averages of the association between the deprivation quintile and the previously observed response to screening instead of the usual proportions in the formula, with the response rate held a constant across quintiles. 27 Efficiency can be optimised by post-stratification, where treatment groups are stratified with a pre-treatment variable, treatment effects within the strata are estimated, and the weighted average of these estimates is used to calculate the overall average treatment effect estimate. 28 In studies that aim to estimate average effects, reporting by disadvantaged subgroup, even with insufficient within-study power, increases the pool of health inequality studies available for potential synthesis. There are also additional approaches that can be taken alongside subgroup analyses to estimate within-study differential effects. One method is to conduct a latent class analysis across the whole sample where key response patterns are identified across different social groups of participants. 29 This method has the advantage of not being sample size dependent, although very small samples with many multicategory variables may run into estimation problems.

• Identifying the sources of inequitable provision of care

Most research undertaken in this area examines sociodemographic variations in health-care use for a defined intervention (or package of interventions) at one point in the management pathway. Inequalities have been demonstrated at each stage of the pathway: in participation in population-based screening programmes in the community, in the management of health problems in primary care, in the access to and use of diagnostic and therapeutic procedures within secondary care, and in rehabilitation and end-of-life care.

For example, the UK breast, cervical and bowel cancer screening programmes are run by the NHS without financial cost to participants. Nonetheless, the uptake of all programmes shows a gradient by SEC. 30 , 31 The strongest gradient is for bowel cancer screening. This involves offering a guaiac faecal occult blood testing kit for use at home. In the first 2.6 million invitations in 2006–9, uptake was 61% in the least deprived quintile of residential areas and only 35% in the most deprived quintile. 32 Bowel cancer screening is currently being extended to include one-off flexible sigmoidoscopy of the lower bowel to identify polyps that may develop into bowel cancer. Overall uptake in the first six pilot centres was 33% in the most deprived areas, rising to 53% in the most affluent areas. 33

Within primary care, Lyratzopoulos et al. 34 demonstrated that, in England, younger patients, ethnic minorities and women are more likely to have visited their GP a minimum of three times prior to referral to hospital for cancer diagnosis, suggesting potential avoidable delay in their management.

Sociodemographic variations in the likelihood of referral by GPs into secondary care has also been found to vary depending on the presence of explicit national guidelines on referral. 35 This study used The Health Improvement Network, a widely used primary care database, to examine sociodemographic variations in referral for potentially life-threatening conditions where national guidance on referral has been published [post-menopausal bleeding (PMB) and dyspepsia in people > 55 years of age] and for symptoms where there is clinical uncertainty regarding the decision to refer (hip pain and dyspepsia in people < 55 years of age). For the three conditions examined, older patients were less likely to be referred, after adjusting for comorbidity. Women were less likely than men to be referred for hip pain [hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.84 to 0.96]. More deprived patients with hip pain and dyspepsia (if < 55 years old) were less likely to be referred. Adjusted HRs for those in the most deprived quintile compared with the least deprived were 0.72 (95% CI 0.62 to 0.82) and 0.76 (95% CI 0.68 to 0.85), respectively. There was no socioeconomic gradient in referral for PMB. These findings are important given the widespread prevalence of non-specific symptoms for which explicit referral guidance does not exist, but which could, nonetheless, be indicative of serious underlying pathology (e.g. lung, colorectal and ovarian cancers).

Access to timely secondary care has also been demonstrated to be inequitable: in England, patients from deprived areas, older people and women are more likely to be admitted to hospital as emergencies than electives for colorectal, breast and lung cancer. This was inequitable (rather than simply unequal) because people from deprived areas and older people were also less likely to receive preferred surgical procedures such as breast-conserving surgery and lung cancer resection. 36 The research was limited by the data available from routinely collected Hospital Episode Statistics. The findings suggest that social variations in both timely presentation and pathways to care need to be prospectively examined. Prospective data collection would allow the impact of potential confounders, such as tumour characteristics including stage, as well as case mix and patient preferences, to be examined.

Once in the secondary care system, women from less affluent neighbourhoods in France have lower probability of receiving ‘best practice’ treatments (Or Z, Rococo E, Bonastre J, Institute for Research and Information in Health Economics, France, 2016), and in England, patients referred from deprived practices have reduced levels of diagnostic angiography and higher waiting times. 37 There is also significant variation for women with breast cancer who live in deprived areas in England: they are more likely to be diagnosed at end stage (Stage IV) 38 and less likely to receive surgery and radiotherapy, 39 and area-based disparity in receipt of treatment may be the major driver of variation in lung cancer survival in England. 40 Inequalities in the effective provision of rehabilitation care are also evident. 41

When inequalities such as these are uncovered it is not possible to conclude whether the disparity occurs at the level of the intervention under consideration, or as a consequence of inequalities in the provision of preceding interventions, or in direct (and appropriate) response to the results of previous investigations. For example, a review of sex bias in use of cardiac care found that high-quality prospective studies reported sex differences in favour of men in the use of angiography. 12 However, there was consistent evidence of no sex difference in those patients in whom the results of previous investigations had been taken into account. This indicates that the sex inequalities identified were not inequitable , in that they were fair and made on the basis of clinical need (identified by the earlier investigation). Thus, the entire management pathway needs to be examined to establish the reasons for the differences found. The challenge is to identify data that will permit unbiased ascertainment of need and use across two or more settings (primary, secondary and community care). It is here that carefully specified individual record linkage between survey data to databanks of routinely collected data, and linking different sources of routinely collected data, is of high value.

Furthermore, while attention to the meso (organisational) level is appropriate, a comprehensive understanding of the sources of inequity also requires consideration of the impact of national policies (i.e. macro-level factors). 42 For example, although the European Union provides universal coverage, the comprehensiveness of care varies from country to country. This is in part explained by the density and position of generalist clinicians, the presence of out-of-pocket payments and the referral system (gatekeeping or not), all of which have an impact on the use of preventative, primary and specialist care. 43 In addition, in social insurance-based systems, for example in France, complex rules for reimbursement for different services appear to act as a disincentive for service use among some population groups. 44

In the UK, Cookson et al. 45 evaluated these policies by examining trends in primary care access, quality and outcomes by SEC between 2004 and 2012. They did this using routinely available whole population data including health data from four national administrative databases. The IMD (IMD 2010) 46 was used to assign socioeconomic status to neighbourhoods of approximately 1500 people each. Slope indices of inequality were measured in four indicators: patients per family doctor, primary care quality, preventable hospitalisation and amenable mortality. They found that, during this period, the NHS succeeded in substantially reducing socioeconomic inequalities in primary care access and quality but made only modest reductions in health-care outcome inequalities.

Such analyses cannot assess the extent to which observed trends in preventable hospitalisation and amenable mortality are attributable to, for example, trends in multimorbidity outside the control of the NHS or in social variations in illness behaviour. However, they both provide much-needed evidence of the influence of national policies and highlight the need to address health-care inequity in every sector and setting.

Finally, synthesising equity effects of health-care interventions can be challenging. One approach that may be useful when comparing several different interventions is Qualitative Comparative Analysis (QCA), 47 which can be used in tandem with quantitative analyses to work out what works for whom and under what conditions, 48 very much under a realist perspective. 49 Blackman and Dunstan 50 illustrate QCA’s utility in health inequalities research by applying the method to survey data in order to understand the influence of place-based contextual factors related to variation in narrowing mortality gaps. Individual participant data meta-analyses (e.g. Virtanen et al. 51 ) or other synthesis techniques such as QCA (e.g. Thomas et al. 52 ) could be applied to studies in the health-care setting to explore variation in outcomes with regard to contextual effects such as the policy environment, and differential effects by disadvantage. The role of evidence synthesis in health services research is further discussed in Essay 1 of this volume.

• Social variations in the clinical encounter

A potential contributing cause of demonstrated health inequalities are social variations in individual behaviour and interactions between patients and health-care professionals. However, there are significant methodological challenges to researching the clinical encounter. Direct observation of doctors and patients offers no opportunity to control patients’ clinical and sociodemographic characteristics, and would require observation of prohibitively vast numbers of consultations to obtain the necessary numbers in specific risk or demographic categories. Use of ‘standardised’ patients (i.e. consultations with doctors by trained actors) is considered a gold-standard method because it enables more control over patient characteristics, but it is costly. The use of fictional patient profiles (vignettes) can provide a valid, generalisable and efficient approach to studying variations in decision-making by health-care professionals. Most studies, however, use text-based vignettes, and omit many features of real consultations such as real-time responses to clinicians’ questions or nuanced presentation of patient characteristics. This risks bias by offering clinicians a limited selection of response options, which primes them to consider certain actions. Many studies are small, with limited generalisability.

In one novel study, a website was constructed using interactive multimedia vignettes with actor ‘patients’ to simulate key features of consultations. GPs undertook consultations from each of six clinical profiles which varied according to the ‘patients’ sociodemographic characteristics and lung cancer risk. No GP saw the same actor twice. Within this constraint, allocation of GPs to vignettes was random. This achieved balance by sex, ethnicity and SEC, and thus GPs’ decisions to initiate lung cancer investigation could be studied in a factorial design across different combinations of clinical and sociodemographic characteristics (Sheringham J, Sequeira R, Myles J, Hamilton W, McDonnell J, Offman J, et al., University College London, 2016). This research demonstrated that, regardless of clinical risk, GPs were less likely to investigate older and black ‘patients’.

Patient vignettes can provide insight into clinical decision-making but do not contribute towards our understanding of the patient perspective or of factors influencing the interaction between patients and health-care professionals. It is often suggested that patient choice underlies inequalities in uptake of health care and public health interventions. Even if decisions to forego some aspects of care reflect ‘informed’ choice, we still need to understand the origins of and influences on these choices. Choices are influenced by individual-level factors (motivation, perceived consequences of different actions and values placed on those consequences), social networks (families, peer groups), local environments (e.g. school ethos) and the national context (taxation, regulation, advertising, subsidies). There appear to be systematic differences in expectations for good health and in perceptions of risk and benefits of treatment between advantaged and less advantaged groups. 53 Patients’ ‘choice’ for less intensive treatment may reflect inaccurate perceptions about the availability, effectiveness or risk of treatment, or be influenced by accurate observations that outcomes are worse in their community. 53 Furthermore, communication in clinical encounters is socially patterned, with clinicians providing less information and adopting a less participatory consulting style when consulting with less articulate, socially disadvantaged patients. 54 This is likely to directly impact on the decisions that patients make. 55

Innovative approaches are therefore needed to explore and explain patient ‘choice’. In-depth, observational, qualitative, longitudinal study designs are likely to be required which allow the exploration of decision-making at different points of a patient’s health-care journey. For example, interviews before and after consultations about beliefs and expectations, and how they change, together with non-participant observation of clinical encounters, could yield valuable insights.

• Designing interventions to improve equity

Given (and in spite of) the current pre-eminence of the concept of individual choice and responsibility, these observations suggest three levels of intervention. At the level of the patient–clinician interaction it is important to understand patients’ and health professionals’ assumptions about risks and benefits of medical interventions and their accuracy. Health-care delivery preferences may be shaped by quality of service, so we need to ensure equity in the quality of services and focus on quality improvement where certain communities are poorly served. At the societal level, the observation that preferences/perceptions of opportunities are often defined by social, economic and cultural factors underscores the importance of addressing fundamental structural inequities and sociocultural norms.

One area emerging in response to the problem of complex policy and population settings is to design intervention strategies on multiple levels. A host of interventions can often be theorised; for example, simultaneous economic, organisational and behavioural interventions may be needed to tackle diabetes. The intervention framework needs consider factors at macro, meso and micro levels and their interactions, even though much of the dynamism may be focused at only one of these levels. Hawe 56 suggests ways to move towards interventions characterised not by a programme but by relationships, routines, power structures and sets of values. A number of essays in this volume take forward in a number of different ways the issue of complexity and how it can be appropriately addressed in evaluative research (see particularly Essays 1 , 6 and 7 ).

• Can austerity threaten equity?

Cutler 57 argued that consequences of governments aiming for equity by increasing coverage were increases in costs, which led to top-down policies to control costs, which, in turn, resulted in a deterioration in quality (such as long waiting times), and the interest in market-type reforms to remedy that problem. Tuohy 58 has argued that governments’ search for a system that achieves equity, controls costs with high-quality care and results in policy cycling as governments emphasise policies that tackle the most serious failure of these three objectives and implicitly neglect the other two. So, following the global financial crisis, fiscal pressures mean that governments now focus on cost control rather than on equity and quality. An obvious question is whether or not there is evidence that systems of universal coverage that are mainly free at the point of delivery, on grounds of promoting equity of access, are poorly designed to control costs. This essay has demonstrated that even with these structural characteristics, there is evidence that the inverse care law 1 still applies. Changing to partial coverage and high user charges would mean that that law would apply with even greater force. But the question is whether or not austerity would justify cycling to such policies as a way of controlling costs.

In trying to assess the impacts of government policies for the twin objectives of equity and cost control, we typically lack controlled experiments. Although there is the famous landmark study of the RAND Health Insurance Experiment, 59 which randomly allocated people to different insurance packages (with differing co-payments and co-insurance) and also included a Health Maintenance Organisation, this still falls short of assessing the macro questions of whether or not a financial system with universal coverage and services free at the point of delivery will have more serious problems of cost control than one with partial coverage and high user charges. Evans et al. 60 – 62 used the ‘natural experiment’ between the USA and Canada to investigate the impact of policies to improve equity of access to health care in terms of control of total costs. Prior to 1970, both countries were structurally similar in how health care was financed (with multiple insurers, partial coverage and high user charges) and in the delivery of care (with hospitals and physicians being independent of government and paid charges and fees for services delivered). After 1970, in Canada, only the financial system changed with the introduction of universal coverage free at the point of access for hospital care and physicians’ services. Evans 60 emphasises that an unintended outcome of policy cycling by the Canadian government was that these policies that were directed at equity were later found to be highly effective in controlling total costs of health care in Canada as compared with the USA.

Evidence from ‘natural experiments’ is always open to challenge from potential influence from other factors and other outcomes that have not been measured. Their value is hence even more strongly dependent on developing a sound theoretical explanation, which is just what Evans 60 does in explaining what is a paradoxical outcome. Given the characteristics of health care, it is folly to regard patients as well-informed consumers making cost-conscious choices when confronted with high user charges, which are a poor way of trying to control costs when doctors typically make decisions. Indeed, Brook et al. 63 summarised the results of the RAND study as showing that ‘. . . cost sharing can be a blunt tool. It reduced both needed and unneeded health services’ (p. 4) 63 and that ‘. . . subsequent RAND work on appropriateness of care found that economic incentives by themselves do not improve appropriateness of care or lead to clinically sensible reductions in service use’ (p. 4). 63 Evans 60 goes on to argue that the key to cost control is targeting not patients but suppliers, and that is most effectively done by empowering government as the single payer with monopsony power in negotiations with physicians and hospitals. Thus, he concludes: ‘The standard theoretical analyses of health insurance, focussing on (an incomplete specification of) the incentives faced by patients, counts the peanuts but ignores the elephants’. 60

Spend on health care as a percentage of Gross Domestic Product in 2013 was 16.4% for the USA, 10.2% for Canada and 8.4% for the UK. 64 Thus, although Canada and the USA have similar delivery systems, what appears to matter in controlling costs is that Canada and the UK have similar institutional financial systems. So, although austerity strains universal systems which are largely free at the point of delivery, the evidence from North America is that dismantling that system will not only create greater inequities in access but also mean increases in total costs of health care. Such universal systems need to be developed to manage insurance to relate to differences in patients’ preferences (as revealed, e.g., through shared decision-making) but that is beyond the scope of this essay.

• Conclusions

In this essay we have highlighted strategies to address some of the methodological challenges faced when evaluating health-care equity. These include the measurement of both horizontal and vertical equity, the use of machine learning to enhance the completeness and quality of data collection and considerations on the appropriateness of gap or gradient analyses. Linkages between routinely collected data from primary, hospital and social care; disease cohort and audit data, deprivation indices, mortality registers; and judiciously chosen other sources (e.g. from education and consumer surveys) increase our ability to precisely identify sources of inequity along the patient pathway and to disentangle the influences of case mix, social and organisational context. Together with innovative methods to capture expectations and patient and health professional decision-making in real time, these strategies will inform the design and evaluation of national-, organisational- and individual-level interventions to improve health-care equity.

• Acknowledgements

The authors thank Professor David Byrne for his helpful comments.

Contributions of authors

Rosalind Raine (Professor, Applied Health Research) wrote the first draft of the essay.

Zeynep Or (Research Director, Health Economist) and Gwyn Bevan (Policy Analyst) provided additional material and along with Stephanie Prady (Research Fellow, Social Epidemiologist) commented on the draft.

• List of abbreviations

confidence interval

Family Nurse Partnership

general practitioner

hazard ratio

Index of Multiple Deprivation

post-menopausal bleeding

Qualitative Comparative Analysis

Resource Allocation Working Party

socioeconomic circumstances

Declared competing interests of authors: None

This essay should be referenced as follows: Raine R, Or Z, Prady S, Bevan G. Evaluating health-care equity. In Raine R, Fitzpatrick R, Barratt H, Bevan G, Black N, Boaden R, et al . Challenges, solutions and future directions in the evaluation of service innovations in health care and public health. Health Serv Deliv Res 2016; 4 (16). pp. 69–84.

Included under terms of UK Non-commercial Government License .

• Cite this Page Raine R, Or Z, Prady S, et al. Evaluating health-care equity. In: Raine R, Fitzpatrick R, Barratt H, et al. Challenges, solutions and future directions in the evaluation of service innovations in health care and public health. Southampton (UK): NIHR Journals Library; 2016 May. (Health Services and Delivery Research, No. 4.16.) Essay 5. doi: 10.3310/hsdr04160-69
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