Communities in Action Pathways to Health Equity (2017) / Chapter Skim
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3 The Root Causes of Health Inequity
3 The Root Causes of Health Inequity
Pages 99-184
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Box 3-1 includes the definitions of structural inequities and the social determinants of health. The factors that make up the root causes of health inequity are diverse, complex, evolving, and interdependent in nature.
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HOW STRUCTURAL INEQUITIES, SOCIAL DETERMINANTS OF HEALTH, AND HEALTH EQUITY CONNECT Health inequities are systematic differences in the opportunities groups have to achieve optimal health, leading to unfair and avoidable differences in health outcomes (Braveman, 2006; WHO, 2011)
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. The impact of structural inequities follows individuals "from womb to tomb." For example, African American women are more likely to give birth to low-birthweight infants, and their newborns experience higher infant death rates that are not associated with any biological differences, even after accounting for socioeconomic factors (Braveman, 2008; Hamilton et al., 2016; Mathews et al., 2015)
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In Figure 3-1, Education Transportation Employment Social Making health Increasing Health Systems Environment equity a community & Services shared Healthier, capacity vision more equitable to shape and communities in which outcomes value individuals and families Public live, learn, work, Housing Safety and play Fostering multi-sector collaboration Physical Income & Environment Wealth FIGURE 3-1 Report conceptual model for community solutions to promote health equity. NOTE: Structural inequities are highlighted to convey the focus of this section.
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These inequities produce systematic disadvantages, which lead to inequitable experiences of the social determinants of health (the next circle in the report model, which is discussed in detail later in this chapter) and ultimately shape health outcomes.
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A recent survey revealed that 70 percent of African Americans, compared with 36 percent of whites, believe that racial discrimination is a major reason that African Americans have a harder time getting ahead than whites (Pew Research Center, 2016)
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. Racial profiling often operates at the institutional level, as with the well-documented institutionalization of stop-and-frisk practices on Hispanic and African American individuals by the New York City Police Department (Gelman et al., 2007)
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For the intrapersonal level, these mechanisms are individual knowledge, attitudes/beliefs, and skills. At the interpersonal level, they are families, friends, and social networks.
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Generally, findings show that members of all groups, including whites, report experiencing racial discrimination, with levels typically, though not always, higher among African Americans and, to a lesser degree, Hispanics than among whites. Gender differences in some perceptions about and responses to racism have also been observed (Otiniano Verissimo et al., 2014)
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Hate crimes motivated by race or ethnicity bias disproportionately affect Hispanics and African Americans (UCR, 2015) (see the public safety section in this chapter for more on hate crimes)
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Based on psychology lab experiments, functional magnetic resonance imaging (fMRI) pictures of the brain, and other tools, researchers find that white providers hold implicit biases against African Americans and that, to a lesser degree, some minority providers may also hold these biases (Hall et al., 2015)
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. Providers appear to evaluate African American patients more negatively than they do similar white patients; seem to perceive them as more likely to participate in risky health behaviors; and may be less willing to prescribe them pain medications and narcotics medications (van Ryn and Fu, 2003)
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; it constrains opportunities to engage in recommended health behaviors such as walking; it may be associated with greater density of alcohol outlets, tobacco advertisements, and fast food outlets in African American and other minority neighborhoods (Berke et al., 2010; Hackbarth et al., 1995; Kwate, 2008; LaVeist and Wallace, 2000) ; it increases the risk for exposure to environmental hazards (Brulle and Pellow, 2006)
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The organization's com prehensive strategy for change includes policy advocacy, local organizing, strategic communications, and community research. 3 For more information, see http://www.thepraxisproject.org (accessed October 20, 2016)
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Youth Perceptions About Police. Facilitated by the coordinator of the Everett Community Health Partnership's Substance Abuse Coalition, about 50 teens from the Everett Teen Center and Teens in Everett Against Substance Abuse interacted with 7 police officers including the police chief.
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. According to the National Initiative for Building Community Trust and Justice, implicit bias can shape the outcomes of interactions between police and residents, which in turn result in pervasive practices that focus suspicion on specific populations (National Initiative for Building Community Trust and Justice, 2015)
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There have been promising developments in the search for interventions to address implicit bias, but more research is needed, and engaging community members in this and other aspects of research on health disparities is important for ethical and practical reasons (Minkler et al., 2010; Mosavel et al., 2011; Salway et al., 2015)
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, and the social determinants of health are the "terrain" on which the effects play out. Traditionally, the most well-known and cited of the factors that shape health outcomes are the individual-level behavioral factors (e.g., smoking, physical activity, nutrition habits, and alcohol and drug use)
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For the purposes of this report, the committee has identified nine social determinants of health (see report conceptual model, Figure 3-3) that the literature shows fundamentally influence health outcomes at the community level.
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Health The access or lack of access to effective, affordable, culturally and Systems and linguistically appropriate, and respectful preventative care, chronic Services disease management, emergency services, mental health services, and dental care and the promotion of better community services and community conditions that promote health over the lifespan, including population health outcomes. It also refers to a paradigm shift that reflects health care over sick care and that promotes prevention.
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Access or lack of access to quality transportation at the community level affects opportunity for employment and vital services such as health care, education, and social services. Active transportation -- the promotion of walking and cycling for transportation, complemented by public transportation or any other active mode -- is a form of transportation that reduces environmental barriers to physical activity and promotes positive health outcomes.
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This adds an additional layer of complexity to the factors that shape health disparities. The following sections describe each of these nine determinants and how they shape health outcomes, as well as the disparities within these social determinants of health that contribute to health inequity.
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For the 2013–2014 academic year, the high school graduation rate for white students was 87.2 percent as compared with 76.3 percent among Hispanics, 72.5 percent among African Americans, and 70 percent among Native
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. Students living in community conditions that contribute to hunger, chronic stress, or lack of attention to visual or hearing needs are likely to have problems concentrating in class (Evans and Schamberg, 2009)
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. Furthermore, there has been little to no progress in closing the gap of achievement between whites and African Americans (Ryan and Bauman, 2016)
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A keen understanding of the mechanisms could help to inform the most cost-effective and targeted policies or solutions that seek to improve health and, ultimately, promote health equity (Picker, 2007)
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, which can secure safer working environments and benefits such as health insurance and sick leave. • Education affects social and psychological factors that influ ence health (e.g., self-efficacy, social status, and social networks)
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Reagan's student population is close to 80 percent Latino and about 18 percent African American. Eighty percent are identified by the state's indicator of poverty, and 30 percent are English language learners.
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Noteworthy aspects of Reagan's approach include • The community school coordinator works with both academic and non academic leadership teams to ensure alignment between students' needs and the services and programs provided • The school engages with the legal system (local civil courts) to better ad dress student discipline, and a student-led youth court was established in partnership with The University of Texas at Austin Law School • On-site daycare and clinic services are offered for student mothers and their babies • The school has partnered with the local community college to provide cost free higher education Based on 2013–2014 data, Reagan is graduating 87 percent of its students, enrollment has more than doubled, and a new Early College High School program has allowed many of Reagan's students to earn their associate's degree from a nearby community college during their time as Reagan students.
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. Concentrated poverty disproportionately affects racial and ethnic minorities across all of the social determinants of health.
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The burden faced by lowincome people suggests that efforts to advance health equity through income and wealth will need to take into consideration rising income inequality as well as significant geographic variation. Chetty and colleagues published the largest study of its kind, using 1.4 billion income tax and Social Security records to report the association between income level and life expectancy from 1999 through 2014 (Chetty et al., 2016)
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Woolf et al. suggest that among others, these mechanisms include more income providing the opportunity to afford health care services and health insurance; greater resources affording a healthy lifestyle and access to place-based benefits known as the social determinants of health; and economic disadvantage and hardship leading to stress and harmful physiological effects on the body (Woolf et al., 2015)
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. The existing literature on the social determinants of health makes it clear that there is a positive correlation between SES and health (Adler and Stewart, 2010a; Braveman et al., 2005; Conti et al., 2010; Dow and Rehkopf, 2010; Pampel et al., 2010; Williams et al., 2010)
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132 COMMUNITIES IN ACTION BOX 3-5 Family Independence Initiative: The Power of Information and Investment in Families Who Take Initiative The Family Independence Initiative (FII) envisions a future in which each per son and family recognizes their self-determination and has access to the resources and community that they need to thrive.
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Disparities in employment between African Americans and whites persist even when level of education, a major predictor of employment, is held equal between the two groups (Buffie, 2015)
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134 COMMUNITIES IN ACTION FIGURE 3-8 Unemployment rates by race and Hispanic or Latino ethnicity, 1973– 2013 annual averages. NOTE: People whose ethnicity is identified as Hispanic or Latino may be of any race.
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For example, the health impact of a job that requires intense, laborious physical activity will be different than of a job in which the tasks are primarily sedentary. There is also emerging evidence suggesting that women working hourly jobs bear a larger burden due to hazardous conditions in the workplace than their male counterparts on outcomes such as hypertension, the risk of injury, injury severity, rates of absenteeism, and the time to return to work after illness (Clougherty et al., 2010; Hill et al., 2008)
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Program outcomes have been positive with 190 of 250 participants placed in unsubsidized employment. a For more information, see http://www.itsmycommunity.org/green-jobs.php (accessed December 5, 2016)
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The idea is to promote access to effective and affordable care that is also culturally and linguistically appropriate. Health care spans a wide range of services, including preventative care, chronic disease management, emergency services, mental health services, dental care, and, more recently, the promotion of community services and conditions that promote health over the lifespan.
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Continued work is needed to figure out how to translate increased access to care into improved health outcomes and increased health equity. In light of the ACA's emphasis on access to improving quality, health outcomes, and population health, it makes sense to look at the environments in which patients live.7 If the social determinants of health are not addressed in a multi-sectoral approach by educational systems, health systems, communities and others, the country will fall short of the triple aim.
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. However, systematic differences in access to care still exist and negatively affect poor households and racial and ethnic minority groups, including Hispanics and African Americans (NCHS, 2016)
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At the community level, it can partner with community-based organizations and explore locally based interventions (Heiman and Artiga, 2015) , creating payment models that take into account social determinants and implementing service delivery models that lend themselves to more community engagement and intervention.
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. Conditions in multiunit residential buildings, including whether indoor smoking is permitted, are another dimension of housing that can affect health outcomes.
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and for-profit developers partnered to renovate the Rolling Hills Apartment Complex and convert it into official affordable housing. In doing so, the project addressed multiple social determinants of health, including education, health and health services, housing, income and wealth, the physical environment, and the social environment, result ing in the following enhancements to the Rolling Hills Apartment Complex: • Renovated apartments designed to serve families.
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(HUD, n.d.) Homeless Populations For homeless people, a lack of stable housing contributes to disparities in the social determinants.
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Exposure to a harmful physical environment is a well-documented threat to community health. Such threats include environmental exposures such as lead, particulate matter, proximity to toxic sites, water contamination, air pollution, and more -- all of which are known to increase the incidence of respiratory diseases, various types of cancer, and negative birth outcomes and to decrease life expectancy (Wigle et al., 2007)
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. Proximity to park facilities also matters, as evidenced by a decrease in physical activity by more than half when distance between one's home and the park doubles (Giles-Corti and Donovan, 2002)
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In urban environments, a higher concentration of liquor stores is found in low-income, African American, and Hispanic communities, contributing to an elevated risk of alcohol-associated disorders in these neighborhoods (Berke et al., 2010)
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There are many co-benefits, and the policies, if implemented correctly, have the potential to significantly improve health outcomes and reduce health disparities (Rudolph et al., 2015)
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. Transportation In the social determinants of health literature, transportation is typically discussed as a feature of the physical (or built)
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, and it is also vital to accessing goods, services (including health and social services) , social networks, and employment.
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In a 2005 report from the Transportation Research Board and the Institute of Medicine, the authoring committee stated that "[r] esearch has not yet identified causal relationships to a point that would enable the committee to provide guidance about cost beneficial investments or state unequivocally that certain changes to the built environment would lead to more physical activity or be the most efficient ways of increasing such activity" (TRB and IOM, 2005, p.
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. McCormack and Shiell conducted a systematic review of 20 crosssectional studies and 13 quasi-experimental studies and concluded that most associations "between the built environment and physical activity were in the expected direction or null" (McCormack and Shiell, 2011)
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For the purposes of this report, the social environment can be thought of as reflecting the individuals, families, businesses, and organizations within a community; the interactions among them; and norms and culture. It can include social networks, capital, cohesion, trust, participation, and willingness to act for the common good in relation to health.
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. The social environment interacts with features of the physical environment at the neighborhood level to shape health behaviors, stress, and, ultimately, health outcomes (Diez Roux and Mair, 2010)
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. Public Safety Public safety and violence are significant, intertwined social determinants of health, but they are also each significant indicators of health and community well-being in their own right.
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Over the years, the Family Policy Council also disseminat ed research about the connections between adverse childhood experiences and associate risks for social and health problems such as academic failure, mental and physical illness, substance abuse, and violence.a One such network is the Cowlizt Community Network, which was formed in 1995 and whose mission is to bring the community together and create opportuni ties to help at-risk youth and families succeed. Its initiatives focus on improving the child maternal health system in Cowlitz County and connecting young, at-risk mothers to the resources they need to help them and their children.
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. This is because there are specific racial and ethnic groups, such as African Americans, Hispanics, and Native Americans, who are vastly overrepresented
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. African American males 15 to 19 years old are six times as likely to be homicide victims as their white peers (Prevention Institute, 2011)
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SOURCES: Cure Violence, n.d.-a,b.
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. Child abuse and neglect not only affect health directly, they also affect outcomes within the other social determinants of health, such as education, work, and social relationships (IOM and NRC, 2014)
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. Research suggests that disproportionately more Hispanics and African Americans are confined in jails and prisons than would be predicted by their arrest rates and that Hispanic and African American juveniles are more likely than white juveniles to be referred to adult court rather than juvenile court (Harris, 2009)
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CONCLUDING OBSERVATIONS The root causes of health inequity begin with historical and contemporary inequities that have been shaped by institutional and societal structures, policies, and norms in the United States. As discussed in this chapter, these deeply rooted inequities have shaped inequitable experiences of the social and other determinants of health: education, income and wealth, employment, health systems and services, housing, the physical environment, transportation, the social environment, and public safety.
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The existing approaches to prevention and health promotion are still "catching up" with what is known about the social determinants of health and population health. Kindig and Stoddart pointed out that "much of public health activity, in the United States at least, does not have such a broad mandate" (Kindig and Stoddart, 2003, p.
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An understanding of theories that articulate the complex mecha nisms of action in the social determinants of health and how place influences health.
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Chapter 5 will provide an in-depth overview of nine communities that are addressing the root causes of health inequities. REFERENCES Abercrombie, L
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2001. A definition of "social environment." American Journal of Public Health 91(3)
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2014. The social determinants of health: It's time to consider the causes of the causes.
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American Journal of Preventive Medicine 51(4)
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2008. Closing the gap in a genera tion: Health equity through action on the social determinants of health.
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American Journal of Public Health 104(2)
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Study. American Journal of Preventive Medicine 14(4)
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2002. The relative influence of individual, social and physical environment determinants of physical activity.
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2015. Beyond health care: The role of social determinants in promoting health and health equity.
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American Journal of Preventive Medicine 50(2)
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American Journal of Public Health 93(3)
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2000. Health risk and inequitable distribution of liquor stores in African American neighborhood.
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2007. Race, race-based discrimination, and health outcomes among African Americans.
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2006. Social environment and physical activity: A review of concepts and evidence.
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American Journal of Public Health 93(1)
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American Journal of Community Psychology 24(1)
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American Journal of Epidemiology 167(5)
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2012. Perceived discrimination and hypertension among African Americans in the Jackson Heart Study.
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2016. Evaluating strategies for reducing health disparities by addressing the social determinants of health.
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American Journal of Public Health 105(5)
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http://www.frbsf.org/ community-development/publications/working-papers/2015/august/gentrification displacement-role-of-public-investment (accessed October 31, 2016)
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