Drivers of differential views of health equity in the U.S.: is the U.S. ready to make progress? Results from the 2018 National Survey of Health Attitudes.

OBJECTIVES: The public health sector has long recognized the role of the social determinants of health in health disparities and the importance of achieving health equity. We now appear to be at an inflection point, as we hear increasing demands to dismantle structures that have perpetuated inequalities. Assessing prevailing mindsets about what causes health inequalities and the value of health equity is critical to addressing larger issues of inequity, including racial inequity and other dimensions. Using data from a nationally representative sample of adults in the United States, we examined the factors that Americans think drive health outcomes and their beliefs about the importance of health equity. METHODS: Using data from the 2018 National Survey of Health Attitudes, we conducted factor analyses of 21 survey items and identified three factors from items relating to health drivers-traditional health influencers (THI), social determinants of health (SDoH), and sense of community health (SoC). Health equity beliefs were measured with three questions about opportunities to be healthy. Latent class analysis identified four groups with similar patterns of response. Factor mixture modeling combined factor structure and latent class analysis into one model. We conducted three logistic regressions using latent classes and demographics as predictors and the three equity beliefs as dependent variables. RESULTS: Nearly 90% of respondents comprised one class that was characterized by high endorsement (i.e., rating the driver as having strong effect on health) of THI, but lower endorsement of SDoH and SoC. Logistic regressions showed that respondents endorsing (i.e., rated it as a top priority) all three health equity beliefs tended to be female, older, Black or Hispanic, more educated, and have lower incomes. The class of respondents that endorsed SDoH the most was more likely to endorse all three equity beliefs. CONCLUSIONS: Results suggested that people historically impacted by inequity, e.g., people of color and people with low incomes, had the most comprehensive understanding of the drivers of health and the value of equity. However, dominant beliefs about SDoH and health equity are still generally not aligned with scientific consensus and the prevailing narrative in the public health community.

Views of Rural US Adults About Health and Economic Concerns.

Importance: The 2016 US presidential election brought national visibility to prominent economic issues affecting rural America, yet little has been done to examine serious health or economic problems in rural communities from the perspectives of rural US adults themselves. Objective: To examine views on the most serious health and economic concerns and potential solutions in rural communities. Design, Setting, and Participants: This survey study used 2 cross-sectional probability-based telephone (cellular and landline) surveys of adults living in the rural United States. The first survey was conducted June 6 to August 4, 2018, and the second survey was conducted January 31 to March 2, 2019. All results were weighted to be nationally representative of rural US adults. Data analysis was conducted in April 2019. Main Outcomes and Measures: The primary study outcomes were the prevalence of rural adults reporting their biggest community problems, problems with health care access and costs, ratings of the local economy, views on opioid addiction, and views on solving major community issues. Results: The 2018 survey included 1300 respondents (response rate, 12%; completion rate, 70%), and the 2019 survey included 1405 respondents (response rate, 8%; completion rate, 76%). Rural adults primarily identified as non-Hispanic white (78%), and more than half of respondents were 50 years or older (survey 1: 55%, survey 2: 53%). Rural adults identified opioid or other drug addiction or abuse (25%; 95% CI, 22%-28%) and economic concerns (21%; 95% CI, 19%-24%) as the most serious problems facing their local communities. Opioid or other drug addiction or abuse was reported as a serious problem in their local community by 57% (95% CI, 53%-60%) of rural adults, while 49% (95% CI, 46%-53%) of rural adults said they personally know someone who has had opioid addiction. Problems paying medical bills were reported by 32% (95% CI, 29%-36%) of rural adults, and recent issues with accessing health care were reported by 26% (95% CI, 23%-30%) of rural adults. Regarding financial and economic issues, 55% (95% CI, 52%-59%) of rural adults rated their local economy as only fair or poor, and 49% (95% CI, 44%-54%) of rural adults said they would have difficulty paying off an unexpected $1000 expense. On solving major community problems, 58% (95% CI, 54%-62%) of rural adults saw a need for outside help to solve major community problems, and among those who reported needing outside help, 61% (95% CI, 57%-66%) identified a major role for government. Conclusions and Relevance: These findings suggest that in today's economically stretched rural United States, opioid or other drug addiction or abuse has emerged as an equal problem with economic concerns. One in 3 rural adults still have problems paying their medical bills even after the passage and implementation of the Patient Protection and Affordable Care Act. Although rural communities have traditionally been self-reliant, more than half of rural adults are open to outside help to solve serious problems facing their communities, including major help from government.

Drivers Of Health As A Shared Value: Mindset, Expectations, Sense Of Community, And Civic Engagement.

Making health a shared value is central to building a culture of health, a new action framework intended to spur faster progress toward equitable health outcomes in the United States. Unlike in other US social movements, such as the environmental and civil rights movements, the necessary understanding of shared values has not yet been achieved for health. Discussions about values regarding health have primarily focused on health care instead of health or well-being. These discussions have not progressed to a clear focus on prioritizing values on health instead of simply health care. The evidence base for understanding health as a shared value is only now emerging. Making health a shared value is the first of four Action Areas in the Robert Wood Johnson Foundation's Culture of Health Action Framework. We assert that the achievement of this shared understanding of health as a cultural value will be enhanced through action in specific drivers: mindset and expectations, sense of community, and civic engagement. Building on a literature review and stakeholder engagement, this article examines the evidence base for these drivers and identifies where policy and research actions are needed to advance positive change on population health and well-being outcomes.

Strengthening Integration Of Health Services And Systems.

New care delivery models that hold providers more accountable for coordinated, high-quality care and the overall health of their patients have appeared in the US health care system, spurred by recent legislation such as the Affordable Care Act. These models support the integration of health care systems, but maximizing health and well-being for all individuals will require a broader conceptualization of health and more explicit connections between diverse partners. Integration of health services and systems constitutes the fourth Action Area in the Robert Wood Johnson Foundation's Culture of Health Action Framework, which is the subject of this article. This Action Area conceives of a strengthened health care system as one in which medical care, public health, and social services interact to produce a more effective, equitable, higher-value whole that maximizes the production of health and well-being for all individuals. Three critical drivers help define and advance this Action Area and identify gaps and needs that must be addressed to move forward. These drivers are access, balance and integration, and consumer experience and quality. This article discusses each driver and summarizes practice gaps that, if addressed, will help move the nation toward a stronger and more integrated health system.

The Perspectives of Six Latino Heritage Groups About Their Health Care.

The Latino population in the US is projected to grow substantially in the years ahead. Although often referred to as a single group, Latinos are not homogeneous. This article, based mainly on a national telephone survey of 1,478 Latino adults, examines the perspectives of six Latino heritage groups on the health care issues they face. The six groups differ in their reported health care experiences in: the types facilities they use in getting medical care, their ratings of the quality of care they receive, their experiences with discrimination in getting quality care, the level of confidence they have in being able to pay for a major illness. One thing the heritage groups agree on is that diabetes is the biggest health problem facing their families. Community health leaders, particularly at the state level, need to focus on the specific Latino groups in their state or area and their unique situations.