Defining Health Equity

In May 2017, the Robert Wood Johnson Foundation released a report titled “What is Health Equity? And What Difference Does a Definition Make?” with the purpose “stimulate discussion and promote greater consensus about the meaning of health equity and the implications for action within the Culture of Health Action Framework.” In doing so, the authors identify crucial elements to guide effective action. The way we define health equity is important as it reveals the values and beliefs that are used to make decisions, justify actions, and promote policies.

The document provides a general definition of health equity:

Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.

In pointing out the importance of measurement for accountability, the authors added the following:

For the purposes of measurement, health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.

With those definitions as a starting point the report offers :

  • Series of definitions for different audiences
  • Explanation of key concepts
  • Criteria for defining health equity
  • Discussion of steps to advancing health equity
  • Guiding principles
  • Glossary of terms often arising in health equity discussions

See a summary of the report.

Download the report, Braveman P, Arkin E, Orleans T, Proctor D, and Plough A. What Is Health Equity? And What Difference Does a Definition Make? Princeton, NJ: Robert Wood Johnson Foundation, 2017.

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Attitudes for Designing Population Health Interventions

In this video from AJMC.com,  Dr. Moon S. Chen, Jr., professor of hematology and oncology at UC Davis Comprehensive Cancer Center and principal investigator of The National Center for Reducing Asian American Cancer Health Disparities, responds to the question , “What are some important considerations in designing health interventions for minority populations?” As a part of his answer, Dr. Chen discusses the attitude of humility and the need to work with the community instead of on the community.

‘Connectivity’ as the Key to Healthy Communities

The following excerpt originally appeared in in an article by Shannon Firth in MedPage Today  on May 11, 2017 summarizing a panel discussion that had taken place on May 9, 2017.


Keeping people connected to resources necessary to maintain good health — not least of which is other people — is a vital but often neglected factor in modern healthcare, policy experts and scholars said here Tuesday.

Transportation is an “underappreciated” health problem, said Dayna Bowen Matthew, JD, a nonresident senior fellow at the Brookings Center for Health Policy, at a panel discussion hosted by the Brookings Institution on Tuesday.

She noted that interstate highways aren’t always a means of connecting people to each other and to resources: in cities, they create barriers as well.

A grid of superhighways can mean a person living in a city’s southeast quadrant must take two buses and time off from work to reach a well-intentioned “food solution” in the northwest quadrant.

“That community’s not connected,” said Bowen Matthew, who is also a professor at University of Colorado Law School and the Colorado School of Public Health, and author of Just Medicine: A Cure for Racial Inequality in American Health Care.

Those families across town from farmers’ markets and other fresh food resources will rely on the more accessible options instead, which may be fast food.

Tuesday’s discussion focused heavily on the social determinants of health — nonmedical factors that greatly influence a population’s health such as transportation, housing, access to food — but one thing unites these influences: connectivity.

Social Networks are Key

The National Health Service in England has a “district nurse,” an individual responsible for keeping watch over certain neighborhoods, explained, Stuart Butler, PhD, a senior fellow in economics for the Brookings Institution.

Growing up in England, Butler’s mother ran a post office, which was a key source of “intel” for the district nurse on the community residents’ well-being. If Butler’s mother hadn’t seen someone for a few days, the nurse would learn of this and ride her bicycle to the person’s home.

Decades later and an ocean away, Matt Brown, RN, a geriatric nurse navigator at Sibley Memorial Hospital in Washington, learned quickly about the importance of follow-up phone calls to ensure smooth transitions back to the community.

During his first such call as part of a senior-focused transition project, he spoke to a patient who had just returned home after being hospitalized for pneumonia.

In the course of the phone call, the patient reluctantly admitted he had fallen and couldn’t get up off the floor of his home. Brown convinced him to call 911, rather than wait for the patient’s wife to come home. When the ambulance arrived, Brown spoke with the emergency medical technicians to confirm his patient was okay.

To further reduce the risk of injuries, the Sibley Innovation Hub has offered a short training course focused on transitions after certain surgeries, which they are now supplementing with animated patient education videos.

Read the full article.

Turning research into action

The following excerpt originally appeared in a blog article by Jillian West and Stephanie Chernitskiy on the Policies for Action Blog on May 16,. 2017.


Multivariate analysis. Face validity. Sampling bias. For researchers, these are everyday terms. For policymakers, advocates, and other stakeholders, they might as well be ancient Sumerian.

A lack of a shared language is one barrier to turning research into action, but it’s not the only one. A few weeks ago, we sat down with a group of local decision-makers to find out how we, as researchers, can more effectively ensure that our research contributes to real-world improvements in population health, well-being, and equity.

In our conversation, we weren’t surprised to hear that the budget is often the first—and largest—hurdle a policymaker must face when implementing evidence-based policy. If the funding is not there or the return on investment is unclear, the policy in question will likely fall flat.

Time constraints and limited bandwidth also get in the way. In small states, legislators are virtually on their own, with few or no staff to help track down relevant data. Additionally, online academic journals often come with paywalls and paid subscriptions, meaning that the necessary research is just out of reach.

As one decision-maker put it, “If your research is in a journal, I can’t get to it.”

Our decision-makers also spoke candidly about the framing challenges they face translating research into action.

Elected officials and other policymakers must tread carefully, balancing the needs of their constituency with the values of that constituency. No matter what, evidence doesn’t exist in a vacuum—partisanship, ideology, and belief systems matter too. One decision-maker characterized it like this:

“Most people know the evidence against smoking. But they may also harbor an ideology that government shouldn’t tell people what to do in their personal lives. There’s a significant challenge in explaining your evidence in light of these overarching lenses.”

Researchers who want to see their work bear fruit in a policy environment must understand these ideological contexts. If a policymaker has invited you to speak about your research, be sure you know what kind of environment they are navigating. Do local leaders embrace skin-in-the-game, market-driven policies, or are they looking to make a publicly funded means-tested program more effective? Or perhaps a decision-maker sees the value in a policy or practice change, but needs help making the case to other leaders in the community? Try to communicate your findings in a manner that avoids the traps of dueling ideologies. And remember, even researchers aren’t immune from ideological biases.

Read the full article.

How med student loan burdens can deepen health disparities

The following article by Caleb Zimmerschied originally appeared on AMA Wire on April 27, 2017.


The high loan burden associated with medical school can discourage students from underrepresented minority groups or lower-income families from pursuing a career as a physician. This creates a ripple effect of widening health care disparities that disproportionately affect the accessibility of primary care physicians in underserved areas.

Adjusted for inflation, the average medical student graduated in 2014 with a loan burden 3.5 times greater than a medical student in 1978. By 2014, the average loan burden was over $170,000.

Higher interest rates and unsubsidized loans for graduate students mean that they pay off more per dollar owed than undergraduate students. The Association of American Medical Colleges (AAMC) estimates that, accounting for interest under the Pay As You Earn repayment program, a student with $180,000 in loan burdens could pay almost $380,000 in total repayment. During a three-year residency, the AAMC estimates that total repayment to reach nearly $450,000. This amount increases further if a student pursues a specialty care field.

Those kinds of figures may be enough to intimidate any bright student considering a career in medicine. But students in ethnic and racial minority groups that are underrepresented in medicine, and those from lower-income families, can be particularly daunted by the prospect of six-figure loan burdens. According to the most recent AAMC report, 18.2 percent of black high-school sophomores said they aspired to apply to medical school, but only 6.7 percent actually applied. For Hispanic high-school sophomores, 24.4 percent said they wanted to go to medical school but only 6.8 percent applied.

According to 2014 AAMC data, while 13 percent of the U.S. population was black, they only made up 4.1 percent of the physician workforce. Hispanics accounted for 18 percent of Americans, but only 4.4 percent of the physician workforce. This in turn likely contributes to the lack of physicians making direct efforts to serve these communities. According to research published in JAMA, despite making up less than 30 percent of the physician workforce in 2013, physicians from underserved groups are significantly more likely to see nonwhite patients, and “nonwhite physicians cared for 53.5 percent of minority and 70.4 percent of non-English-speaking patients.”

Additionally, the cost of medical school likely deters applicants from lower-income rural communities as well. This could contribute to the fact that while 20 percent of Americans live in rural areas, only 10 percent of physicians practice where people in rural communities can access them. With a shortage of about 4,000 primary care physicians, 77 percent of rural U.S. counties are designated as health professional shortage areas.

Read full article

Segregated Living Linked To Higher Blood Pressure Among Blacks

The following article by Carmen Heredia Rodriguez originally appeared on Kaiser Health News.


For African-Americans, the isolation of living in a racially segregated neighborhood may lead to an important health issue: higher blood pressure.

A study published Monday in JAMA Internal Medicine suggested blacks living in such areas experienced higher blood pressure than those living in more diverse communities. Moving to integrated areas was associated with a decrease in blood pressure, and those who permanently stayed in localities with low segregation saw their pressure fall on average nearly 6 points.

Kiarri Kershaw, assistant professor of preventive medicine at Northwestern University in Chicago and lead author of the study, said the findings reinforce the close relationship between social policy and community health outcomes.

“It lends credence to the notion that we should bring public health practitioners and health policy officials to the table to make these decisions,” she said. Researchers used data from a long-term study that has followed 2,280 African-Americans over the course of 25 years, checking in every three to seven years to track blood pressure.

Heart disease is the leading cause of death in the United States, and African-Americans are disproportionately affected by the condition. According to the American Heart Association, 46 percent of non-Hispanic black men and nearly 48 percent of non-Hispanic black women live with a form of heart disease, while about 36 percent of non-Hispanic white men and 32 percent of non-Hispanic white women do.

Georges Benjamin, executive director of the American Public Health Association, said the burden to address such disparities falls on society at large.

“It doesn’t just hurt African-Americans or people of color. This hurts everybody,” he said. “Because everyone pays not just in terms of humanity, but in terms of dollars.”

Doctors generally record two numbers for blood pressure: the diastolic pressure — the blood’s force inside the veins when the heart is at rest — and the systolic pressure, which gauges the blood’s force when the heart beats. Blood pressure is measured in millimeters of mercury, or mmHg (using mercury’s chemical element symbol), with systolic pressure reported first, such as 115 mmHg over 75 mmHg.

Researchers found residential segregation was associated with changes in systolic blood pressure, which is tied to adverse cardiovascular events, such as a heart attack. The findings did not show any changes in diastolic blood pressure.

The scientists also collected data on a variety of other social indicators including level of education, poverty and marriage status. They ranked the level of segregation in participants’ neighborhoods as “low,” “medium” and “high” based on the number of African-Americans in the larger area.

When compared to African-Americans living in highly segregated locations, participants living in medium-segregation neighborhoods recorded blood pressure that was on average 1.33 mmHg lower. Those residing in low-segregation areas were an average 1.19 mmHg lower.

Blood pressure for black residents who permanently moved into medium segregation locations decreased on average 3.94 mmHg. African-Americans who stayed in low-segregation locales saw an average decrease of 5.71 mmHg.

Read the full article.

African American Health — The latest from the CDC

The May 2017 edition of Vital Signs released by the Centers for Disease Control and Prevention (CDC) focuses on both improvements and concerns in the health of African Americans. The report states:

  • The death rate for African Americans decreased 25% from 1999 to 2015.
  • African Americans ages 18-49 are 2 times as likely to die from heart disease than whites.
  • African Americans ages 35-64 years are 50% more likely to have high blood pressure than whites.

View the May 2017 Vital Signs online.

Download a PDF.

 

Because Social Science Is Necessary to Achieve Health Equity

The following article by Courtney Ferrell Aklin, Ph.D.(National Institute on Minority Health and Health Disparities (NIMHD) and Eliseo J. Pérez-Stable, M.D. (National Institute on Minority Health and Health Disparities (NIMHD), National Institutes of Health (NIH)) first appeared on the Why Social Science Blog? on April 25, 2017.


Living in an America in which all populations have an equal opportunity to live long, healthy, and productive lives is the vision of the National Institute on Minority Health and Health Disparities. As we bring National Minority Health Month to a close, it is important to remember that not all groups have obtained health equity. Racial and ethnic minorities, rural residents, people with disadvantaged socioeconomic resources and sexual and gender minorities carry a disproportionate burden of illness and disease. The search to determine the best way to reduce health disparities and to achieve health equity remains challenging for all of us.

The potential to live longer and healthier lives is greater than ever before with the emergence of medical and technical advances in healthcare and the adoption of healthier lifestyles. Despite these advances, health disparities continue to persist. A health disparity, defined as a health difference that adversely affects disadvantaged populations, based on one or more health outcomes, results from a series of complex and interrelated factors. To truly reduce and ultimately eliminate health disparities a framework must be applied that can address the multifaceted underlying causes of the disparity.

The social sciences have provided the very frameworks necessary for understanding the complexity of health disparities. Health, which is at the center of health disparities, is a combination of interactions among biological pathways, individual behavior, social interactions, physical or built environment, and the intersections with the health care system. Research to date shows that the development and maintenance of disease cannot be explained solely by genes and biological mechanisms. Behavioral and social factors are just as crucial to understanding the trajectory of health disparities as those contributed by biology. Important research questions such as adherence to treatment regimens, patient and clinician racial/ethnicity or gender match and its effects on health outcomes, and the interaction of chronic stress and health behaviors in development of disease are all derived out of social science theory.

The examination of where we work, live, and play, also known as the social determinants of health (SDOH) has taken a prominent role as a contributor to differences in health outcomes for health disparity populations. SDOH sit at the intersection of where social science theory and research methodology are applied to the practice of public health. Given the public health concern that continues to arise as health disparities persist, despite a myriad of targeted interventions to address them, NIMHD is committed to ensuring that all factors contributing to the etiology of health disparities are recognized.

Read the full article.

HDRG Recap: Health Care Apartheid: Labor Markets, Race-Ethnicity, and Affordable Care

At the April 21, 2017, meeting of the Health Disparities Research Group (HDRG), Dr. Kenneth Hudson and his team presented findings from their research on the impact of the Patient Protection and Affordable Care Act (ACA) on insurance rates. This work is part of the research project The Impact of Labor Force/Labor Market  Status on Access to Health Care. The presentation focused on analysis of data from the  Current Population Survey (CPS).

Dr. Hudson began his talk by outlining the theoretical foundations of and major influences on his work. Citing the work of Dr. William Julius Wilson on race and labor markets and the work of Clayton and Byrd on the history of minority health disparities, Dr. Hudson outlined three eras in American history focusing on race and labor relations, and the provision of medical care. After the civil rights movement, institutions  such as hospitals couldn’t overtly discriminate on race, but they could, however, discriminate based on the ability to pay. Currently, the primary mechanism for covering the cost of health care in the United States is health insurance, which is usually provided by either an employer, family members, or a government program such as Medicare or Medicaid.

Within this context, Dr. Hudson relayed the findings from his team’s analysis of the health insurance data from the CPS. The findings reaffirmed what was already known; the ACA substantially reduced the rate of uninsured Americans. They also found that the expansion of Medicaid was the primary mechanism for this reduction, even though 19 states chose not to participate in the Medicaid expansion program..

Dr. Hudson and his team are currently preparing their findings for publication.

Lancet series puts spotlight on health inequity in the U.S.

From the article by Paige Minemyer on FierceHealthcare:

Societal issues in the U.S., including systemic racism, poverty and mass incarceration, contribute to health inequity, a new series of studies has found.

The Lancet released a five-part look at health inequity in the U.S., titled the “United States of Health,” and researchers found that institutional racism, the increasing income gap and high rates of incarceration are all factors that make it harder for minorities and the poor to access healthcare. And the healthcare system, as it is financially structured today, only makes this problem worse, the researchers concluded.

…Poor Americans have made limited gains in life expectancy over the past 15 years, researchers found. Since 2001, the poorest 5% have not seen their survival rates increase at all, while while middle- and high-income people have seen their life expectancy increase by two years. The richest 1% of Americans live between 10 and 15 years longer than those who are among the poorest 1%.

Economic insecurity is a key factor in some of today’s biggest public health crises, including the opioid epidemic and increasing rates of obesity, study author Jacob Bor, Sc.D., assistant professor at the Boston University School of Public Health, said in announcement. But despite their increasing health concerns, it is becoming increasingly hard for Americans in poverty to pay for healthcare, creating a “health-poverty trap,” Bor said.

Poor Americans are also the most likely to be uninsured. Though the Affordable Care Act has made strides toward decreasing the number of people without insurance, a lack of options in ACA exchanges, particularly in states that did not expand Medicaid, leaves many poorer people in the U.S. with few avenues to get health insurance, researchers found. In 2015, for instance, about a quarter of poor Americans were uninsured, compared with just 7.6% of people with middle or high incomes.

Minority groups are also hit hard by societal barriers that lead to health inequity, and research reflects poorer outcomes—for instance, infant mortality rates for black populations are twice those for white ones, according to the study. Structural racism relegates many black Americans to neighborhoods with poor housing options, high rates of crime and air pollution. These neighborhoods may also be neglected by public health officials, worsening the problems, researchers found.

Read the full article.