Addressing Health Equity in Public Health Practice: Frameworks, Promising Strategies, and Measurement Considerations.

This review describes the context of health equity and options for integrating equity into public health practice. We first discuss how the conceptualization of health equity and how equity considerations in US public health practice have been shaped by multidisciplinary engagements. We then discuss specific ways to address equity in core public health functions, provide examples of relevant frameworks and promising strategies, and discuss conceptual and measurement issues relevant to assessing progress in moving toward health equity. Challenges and opportunities and their implications for future directions are identified.

Racial/Ethnic Disparities in Mortality: Contributions and Variations by Rurality in the United States, 2012⁻2015.

The value of disaggregating non-metropolitan and metropolitan area deaths in illustrating place-based health effects is evident. However, how place interacts with characteristics such as race/ethnicity has been less firmly established. This study compared socioeconomic characteristics and age-adjusted mortality rates by race/ethnicity in six rurality designations and assessed the contributions of mortality rate disparities between non-Hispanic blacks (NHBs) and non-Hispanic whites (NHWs) in each designation to national disparities. Compared to NHWs, age-adjusted mortality rates for: (1) NHBs were higher for all causes (combined), heart disease, malignant neoplasms, and cerebrovascular disease; (2) American Indian and Alaska Natives were significantly higher for all causes in rural areas; (3) Asian Pacific islanders and Hispanics were either lower or not significantly different in all areas for all causes combined and all leading causes of death examined. The largest contribution to the U.S. disparity in mortality rates between NHBs and NHWs originated from large central metropolitan areas. Place-based variations in mortality rates and disparities may reflect resource, and access inequities that are often greater and have greater health consequences for some racial/ethnic populations than others. Tailored, systems level actions may help eliminate mortality disparities existing at intersections between race/ethnicity and place.

Public Health Agency Responses and Opportunities to Protect Against Health Impacts of Climate Change Among US Populations with Multiple Vulnerabilities.

During the past several decades, unprecedented global changes in climate have given rise to an increase in extreme weather and other climate events and their consequences such as heavy rainfall, hurricanes, flooding, heat waves, wildfires, and air pollution. These climate effects have direct impacts on human health such as premature death, injuries, exacerbation of health conditions, disruption of mental well-being, as well as indirect impacts through food- and water-related infections and illnesses. While all populations are at risk for these adverse health outcomes, some populations are at greater risk because of multiple vulnerabilities resulting from increased exposure to risk-prone areas, increased sensitivity due to underlying health conditions, and limited adaptive capacity primarily because of a lack of economic resources to respond adequately. We discuss current governmental public health responses and their future opportunities to improve resilience of special populations at greatest risk for adverse health outcomes. Vulnerability assessment, adaptation plans, public health emergency response, and public health agency accreditation are all current governmental public health actions. Governmental public health opportunities include integration of these current responses with health equity initiatives and programs in communities.

Racial/Ethnic Health Disparities Among Rural Adults-United States, 2012-2015: MMWR Surveillance Summaries / November 17, 2017 / 66(23);1-9.

PROBLEM/CONDITION: Rural communities often have worse health outcomes, have less access to care, and are less diverse than urban communities. Much of the research on rural health disparities examines disparities between rural and urban communities, with fewer studies on disparities within rural communities. This report provides an overview of racial/ethnic health disparities for selected indicators in rural areas of the United States. REPORTING PERIOD: 2012-2015. DESCRIPTION OF SYSTEM: Self-reported data from the 2012-2015 Behavioral Risk Factor Surveillance System were pooled to evaluate racial/ethnic disparities in health, access to care, and health-related behaviors among rural residents in all 50 states and the District of Columbia. Using the National Center for Health Statistics 2013 Urban-Rural Classification Scheme for Counties to assess rurality, this analysis focused on adults living in noncore (rural) counties. RESULTS: Racial/ethnic minorities who lived in rural areas were younger (more often in the youngest age group) than non-Hispanic whites. Except for Asians and Native Hawaiians and other Pacific Islanders (combined in the analysis), more racial/ethnic minorities (compared with non-Hispanic whites) reported their health as fair or poor, that they had obesity, and that they were unable to see a physician in the past 12 months because of cost. All racial/ethnic minority populations were less likely than non-Hispanic whites to report having a personal health care provider. Non-Hispanic whites had the highest estimated prevalence of binge drinking in the past 30 days. INTERPRETATION: Although persons in rural communities often have worse health outcomes and less access to health care than those in urban communities, rural racial/ethnic minority populations have substantial health, access to care, and lifestyle challenges that can be overlooked when considering aggregated population data. This study revealed difficulties among non-Hispanic whites as well, primarily related to health-related risk behaviors. Across each population, the challenges vary. PUBLIC HEALTH ACTION: Stratifying data by different demographics, using community health needs assessments, and adopting and implementing the National Culturally and Linguistically Appropriate Services Standards can help rural communities identify disparities and develop effective initiatives to eliminate them, which aligns with a Healthy People 2020 overarching goal: achieving health equity.

Racial/Ethnic Health Disparities Among Rural Adults - United States, 2012-2015.

PROBLEM/CONDITION: Rural communities often have worse health outcomes, have less access to care, and are less diverse than urban communities. Much of the research on rural health disparities examines disparities between rural and urban communities, with fewer studies on disparities within rural communities. This report provides an overview of racial/ethnic health disparities for selected indicators in rural areas of the United States. REPORTING PERIOD: 2012-2015. DESCRIPTION OF SYSTEM: Self-reported data from the 2012-2015 Behavioral Risk Factor Surveillance System were pooled to evaluate racial/ethnic disparities in health, access to care, and health-related behaviors among rural residents in all 50 states and the District of Columbia. Using the National Center for Health Statistics 2013 Urban-Rural Classification Scheme for Counties to assess rurality, this analysis focused on adults living in noncore (rural) counties. RESULTS: Racial/ethnic minorities who lived in rural areas were younger (more often in the youngest age group) than non-Hispanic whites. Except for Asians and Native Hawaiians and other Pacific Islanders (combined in the analysis), more racial/ethnic minorities (compared with non-Hispanic whites) reported their health as fair or poor, that they had obesity, and that they were unable to see a physician in the past 12 months because of cost. All racial/ethnic minority populations were less likely than non-Hispanic whites to report having a personal health care provider. Non-Hispanic whites had the highest estimated prevalence of binge drinking in the past 30 days. INTERPRETATION: Although persons in rural communities often have worse health outcomes and less access to health care than those in urban communities, rural racial/ethnic minority populations have substantial health, access to care, and lifestyle challenges that can be overlooked when considering aggregated population data. This study revealed difficulties among non-Hispanic whites as well, primarily related to health-related risk behaviors. Across each population, the challenges vary. PUBLIC HEALTH ACTION: Stratifying data by different demographics, using community health needs assessments, and adopting and implementing the National Culturally and Linguistically Appropriate Services Standards can help rural communities identify disparities and develop effective initiatives to eliminate them, which aligns with a Healthy People 2020 overarching goal: achieving health equity.

Background and Rationale.

In 2011, CDC published the first CDC Health Disparities and Inequalities Report (CHDIR). This report examined health disparities in the United States associated with various characteristics, including race/ethnicity, sex, income, education, disability status, and geography. Health disparities were defined as "differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental, and geographic attributes". Among other recommendations, the 2011 CHDIR emphasized the need to address health disparities with a dual intervention strategy focused on populations at greatest need and on improving the health of the U.S. population by making interventions available to everyone. The 2013 CHDIR updated the 2011 CHDIR and included additional reports on social and environmental determinants of health; the supplement emphasized the importance of multisectoral collaboration, highlighting the need for a comprehensive, community-driven approach to reducing health disparities in the United States. A follow-up report described five interventions that were shown to be effective or demonstrated promise for reducing health disparities. These publications have focused attention on the need to address health disparities in the United States, as well as on programs and interventions that address them. This supplement describes additional interventions that address particular disparities observed by race and ethnicity, socioeconomic status, geographic location, disability, and/or sexual orientation across a range of conditions, including asthma, infection with HIV and hepatitis A, use of colorectal cancer screening, youth violence, food security, and health-related quality of life.

Epilogue.

In 1985, the Report of the Secretary's Task Force on Black and Minority Health was published after the federal government convened the first group of health experts to analyze racial/ethnic health disparities among minorities. This analysis, also known as the Heckler report, revealed higher illness and death rates among minorities. The year 2015 marks the 30th anniversary of the Heckler Report and presents an opportunity to evaluate and continue to improve minority health at the national, state, tribal, territorial, and local levels.

Measurement of Health Disparities, Health Inequities, and Social Determinants of Health to Support the Advancement of Health Equity.

Reduction of health disparities and advancement of health equity in the United States require high-quality data indicative of where the nation stands vis-à-vis health equity, as well as proper analytic tools to facilitate accurate interpretation of these data. This article opens with an overview of health equity and social determinants of health. It then proposes a set of recommended practices in measurement of health disparities, health inequities, and social determinants of health at the national level to support the advancement of health equity, highlighting that (1) differences in health and its determinants that are associated with social position are important to assess; (2) social and structural determinants of health should be assessed and multiple levels of measurement should be considered; (3) the rationale for methodological choices made and measures chosen should be made explicit; (4) groups to be compared should be simultaneously classified by multiple social statuses; and (5) stakeholders and their communication needs can often be considered in the selection of analytic methods. Although much is understood about the role of social determinants of health in shaping the health of populations, researchers should continue to advance understanding of the pathways through which they operate on particular health outcomes. There is still much to learn and implement about how to measure health disparities, health inequities, and social determinants of health at the national level, and the challenges of health equity persist. We anticipate that the present discussion will contribute to the laying of a foundation for standard practice in the monitoring of national progress toward achievement of health equity.

Toward Achieving Health Equity: Emerging Evidence and Program Practice.

Health equity, in the context of public health in the United States, can be characterized as action to ensure all population groups living within a targeted jurisdiction have access to the resources that promote and protect health. There appear to be several elements in program design that enhance health equity. These design elements include consideration of sociodemographic characteristics, understanding the evidence base for reducing health disparities, leveraging multisectoral collaboration, using clustered interventions, engaging communities, and conducting rigorous planning and evaluation. This article describes selected examples of public health programs the Centers for Disease Control and Prevention (CDC) has supported related to these design elements. In addition, it describes an initiative to ensure that CDC extramural grant programs incorporate program strategies to advance health equity, and examples of national reports published by the CDC related to health disparities, health equity, and social determinants of health.

Sustaining a Focus on Health Equity at the Centers for Disease Control and Prevention Through Organizational Structures and Functions.

The public health infrastructure required for achieving health equity is multidimensional and complex. The infrastructure should be responsive to current and emerging priorities and capable of providing the foundation for developing, planning, implementing, and evaluating health initiatives. This article discusses these infrastructure requirements by examining how they are operationalized in the organizational infrastructure for promoting health equity at the Centers for Disease Control and Prevention, utilizing the nation's premier public health agency as a lens. Examples from the history of the Centers for Disease Control and Prevention's work in health equity from its centers, institute, and offices are provided to identify those structures and functions that are critical to achieving health equity. Challenges and facilitators to sustaining a health equity organizational infrastructure, as gleaned from the Centers for Disease Control and Prevention's experience, are noted. Finally, we provide additional considerations for expanding and sustaining a health equity infrastructure, which the authors hope will serve as "food for thought" for practitioners in state, tribal, or local health departments, community-based organizations, or nongovernmental organizations striving to create or maintain an impactful infrastructure to achieve health equity.

Increasing Diversity in the Health Professions: Reflections on Student Pipeline Programs.

Despite major advances and technological improvements in public health and medicine, health disparities persist by race and ethnicity, income and educational attainment, and in some cases are increasing (Jackson & Garcia, 2014). These health disparities among these populations have even worsened or remained about the same since the landmark 1985 Report of the Secretary's Task Force on Black & Minority Health released by then Secretary Margaret M. Heckler. Ensuring diverse public health and healthcare workforces to provide services to diverse populations, in combination with other strategies, can increase access to and quality of healthcare for vulnerable populations and decrease healthcare disparities. One mechanism for achieving a diverse public health and healthcare workforce is to establish, promote, and conduct student training programs in public health. The Office of Minority Health and Health Equity, Centers for Disease Control and Prevention (CDC), has partnered with institutions, colleges, universities, foundations, national organizations and associations to form and implement student training programs. This paper highlights a session "Public Health Professions Enhancement Programs" that was held during the 2015 symposium titled "National Negro Health Week to National Minority Health Month: 100 Years of Moving Public Health Forward" in Atlanta, Georgia. Presenters at the symposium consisted of interns and fellows who had participated in student programs in the Office of Minority Health and Health Equity at the CDC.

Difference in health inequity between two population groups due to a social determinant of health.

The World Health Organization defines social determinants of health as "complex, integrated, and overlapping social structures and economic systems" that are responsible for most health inequities. Similar to the individual-level risk factors such as behavioral and biological risk factors that influence disease, we consider social determinants of health such as the distribution of income, wealth, influence and power as risk factors for risk of disease. We operationally define health inequity in a disease within a population due to a risk factor that is unfair and avoidable as the difference between the disease outcome with and without the risk factor in the population. We derive expressions for difference in health inequity between two populations due to a risk factor that is unfair and avoidable for a given disease. The difference in heath inequity between two population groups due to a risk factor increases with increasing difference in relative risks and the difference in prevalence of the risk factor in the two populations. The difference in health inequity could be larger than the difference in health outcomes between the two populations in some situations. Compared to health disparities which are typically measured and monitored using absolute or relative disparities of health outcomes, the methods presented in this manuscript provide a different, yet complementary, picture because they parse out the contributions of unfair and avoidable risk factors.

Background and rationale.

In 2011, CDC published the first CDC Health Disparities and Inequalities Report (CHDIR). This report examined health disparities in the United States associated with various characteristics, including race/ethnicity, sex, income, education, disability status, and geography. Health disparities were defined as "differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental, and geographic attributes". Among other recommendations, the 2011 CHDIR emphasized the need to address health disparities with a dual intervention strategy that focuses on populations at greatest need and improves the health of the general population by making interventions available to everyone. The 2013 CHDIR included updates on most topics from the 2011 CHDIR and on new topics. Compared with the 2011 CHDIR, the 2013 CHDIR included more reports on social and environmental determinants of health and emphasizes the importance of multisector collaboration. The 2013 CHDIR highlights the need for a "comprehensive, community-driven approach" to reducing health disparities in the United States.

Epilogue.

As racial and ethnic minorities constitute ever larger percentages of the U.S. population, the overall health statistics of the nation increasingly reflect the health status of these groups. Overcoming persistent health and health-care disparities that affect racial/ethnic minorities benefits the entire society. For example, the economic well-being of a nation relies on the health of its populace. According to one report, "The nation's dependence on an increasingly minority workforce means that healthy communities of color are vital to the nation's economic fortunes". Other U.S. population groups, such as persons with disabilities or special health-care needs, persons living in certain geographic locations, and persons with certain sexual identities or sexual orientations, also have higher rates of preventable morbidity and premature death, and efforts should be directed toward improving their health outcomes and eliminating health disparities.

Potential strategies to eliminate built environment disparities for disadvantaged and vulnerable communities.

In 2006, the Federal Collaboration on Health Disparities Research (FCHDR) identified the built environment as a priority for eliminating health disparities, and charged the Built Environment Workgroup with identifying ways to eliminate health disparities and improve health outcomes. Despite extensive research and the development of a new conceptual health factors framework, gaps in knowledge exist in areas such as disproportionate environmental and community hazards, individual and cumulative risks, and other factors. The FCHDR provides the structure and opportunity to mobilize and partner with built environment stakeholders, federal partners, and interest groups to develop tools, practices, and policies for translating and disseminating the best available science to reduce health disparities.

Pandemic influenza preparedness and response among public-housing residents, single-parent families, and low-income populations.

During the early stages of an influenza pandemic, a pandemic vaccine likely will not be available. Therefore, interventions to mitigate pandemic influenza transmission in communities will be an important component of the response to a pandemic. Public-housing residents, single-parent families, and low-income populations may have difficulty complying with community-wide interventions. To enable compliance with community interventions, stakeholders recommended the following: (1) community mobilization and partnerships, (2) culturally specific emergency communications planning, (3) culturally specific education and training programs, (4) evidence-based measurement and evaluation efforts, (5) strategic planning policies, (6) inclusion of community members as partners, and (7) policy and program changes to minimize morbidity and mortality.