Communities in Action Pathways to Health Equity (2017) / Chapter Skim
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1 Draft manuscript from Melanie C Dreher, Rush University Medical Center, provided to staff on February 19, 2016, for the Committee on Community-Based Solutions to Promote Health Equity in the United States.
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B. Health is a product of multiple determinants. Social, economic, environ mental, and structural factors and their unequal distribution matter more than health care in shaping health disparities.
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Shifts in economic mobility, income inequality, and persisting legacies of social problems such as structural racism are hampering the attainment of health equity, causing economic loss, and, most overwhelmingly, the loss of human lives and potential. Although moral arguments to promote health equity exist,2 promoting health equity could afford considerable economic, national security, and other benefits.
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, income inequality, drug use, suicide, and the relative deprivations of rural life have all emerged as key themes. Report Conceptual Model As part of its statement of task, the committee was asked to review the state of health disparities in the United States and to explore the
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. Figure S-1 is a conceptual model that grounds the report of the Committee on Community-Based Solutions to Promote Health Equity in the FIGURE S-1 A conceptual model for community-based solutions to promote health equity.
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The figure 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. Unlike a logic model, which is linear and progresses neatly from inputs to outputs and outcomes, the model in Figure S-1 is circular to reflect the topic's complexity, with inputs shown in the outer circle and background -- depicting the context of structural inequities, socioeconomic and political drivers, and determinants of health in which health inequities and community-driven solutions exist.
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. It is becoming clearer that health insurance coverage alone will not address health disparities, including those across race, ethnicity, socioeconomic status (SES)
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These structures, policies, and norms -- such as segregation, redlining and foreclosure, and implicit bias -- play out on the terrain of the social, economic, environmental, and cultural determinants of health. COMMUNITY AGENCY TO PROMOTE HEALTH EQUITY A community is the place where one lives, works, and plays.
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The committee was asked to identify and examine six or more examples of community-based solutions that address health inequities, drawing from deliberate and indirect interventions or activities that promote equal opportunity for health. The nine examples in Chapter 5 span health and non-health sectors and take into account the range of factors that contribute to health inequity in the United States, such as systems of employment, public safety, housing, transportation, education, and others.
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People United for A nonprofit organization that Housing Sustainable Housing mobilizes residents to secure quality, Buffalo, NY affordable housing and advance economic justice. WE ACT for A nonprofit organization that Physical environment Environmental Justice engages in community organizing, Harlem, NY community-based participatory research, and advocacy to confront environmental injustice.
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• Studies examining the ways in which a single structural factor may influence multiple health outcomes. • Increased funding opportunities dedicated to developing and testing relevant theories, measures, and scientific methods, with the goal of enhancing the rigor with which investigators examine structural inequities such as structural racism and health disparities.
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health disparities that exam ines the multiple effects of structural racism (e.g., segregation) and implicit and explicit bias across different categories of mar ginalized status on health and health care delivery; and (b)
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The CHI Navigator is intended for individuals and groups who lead or participate in CHI work "within hospitals and health systems, public health agencies, and other community organizations. It is a one-stop shop that offers community stakeholders expert-vetted tools and resources for: depicting visually the who, what, where, and how of improving community health; making the case for collaborative approaches to community health improvement; establishing and maintaining effective collaborations; and finding interventions that work for the greatest impact on health and well-being for all" (CDC, 2015)
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, with implications for expanding health inequity; and increasing disparities. Recent events involving race and law enforcement relations have offered a disturbing illustration of systematically unequal treatment that is causing fear, mistrust, anger, and divisiveness.
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Recommendation 6-1: All government agencies that support or conduct planning related to land use, housing, transportation, and other areas that affect populations at high risk of health inequity should: • Add specific requirements to outreach processes to ensure robust and authentic community participation in policy development. • Collaborate with public health agencies and others to ensure a broad consideration of unintended conse quences for health and well-being, including whether the benefits and burdens will be equitably distributed.9 • Highlight the co-benefits of -- or shared "wins" that could be achieved by -- considering health equity in the devel opment of comprehensive plans10 (e.g., improving public transit in transit-poor areas supports physical activity, promotes health equity, and creates more sustainable communities)
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This guidance should outline a process by which schools can identify model needs assessments, including those with a focus on student health and wellness. Recommendation 6-3: To support schools in collecting data on student and community health, tax-exempt hospitals and health systems and state and local public health agencies should: • Make schools aware of existing health needs assess ments to help them leverage current data collection and analyses.11 • Assist schools and school districts in identifying and accessing data on key health indicators that should inform school needs assessments and any related school improvement plans.
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As one strategy to support a focus on health disparities, the Centers for Medicare & Medicaid Services could undertake research on payment reforms that could spur accounting for social risk fac tors in the value-based payment programs it oversees. The National Academies' Committee on Accounting for Socioeconomic Status in Medicare Payment Programs has shown in its reports (NASEM, 2016a,b,c,e)
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Continuing this work is needed to overcome dis crimination and the structural barriers that affect health. Conclusion 6-2: The committee concludes that using civil rights approaches in devising and implementing community solutions to promote health equity can guard against unjustified and unnecessary discriminatory impacts, as well as against intentional discrimination in programs that affect health.
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. To inform community-based efforts to promote health equity, novel research is needed, but to make that possible, changes to the dominant research paradigm are needed.
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and others (Martin et al., 2005; Miller and Rivera, n.d.; O'Mara, 2012) have highlighted the complex, sometimes contentious relationships and history between anchor institutions and their communities (e.g., community perception that they receive no benefit and may even be harmed by the local anchor institution)
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make expanding opportunities to promote health equity in their community a strategic priority. This should be done by: • Deploying specific strategies to address the multiple determinants of health on which anchors can have a direct impact or through multi-sector collaboration; and • Assessing the negative and positive impacts of anchor institutions in their communities and how negative impacts may be mitigated.16 Policy makers include a wide variety of actors (e.g., city council members, mayors, school board members, state legislators, etc.)
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Recommendation 7-5: The committee recommends that pub lic health agencies and other health sector organizations build internal capacity to effectively engage community development partners and to coordinate activities that address the social and economic determinants of health. They should also play a con vening or supporting role with local community coalitions to advance health equity.
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The current state of health disparities has severe consequences for the nation, and it is a call to action to stem the high human and economic cost of health inequity. Clearly, considerable support for addressing health equity has been established in the U.S.
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They are provided in Box S-2, along with the three key elements found in all nine examples of community-based solutions to promote health equity highlighted in Chapter 5. Chapter 8 provides a range of tools for facilitating multi-sector collaboration, making health equity a shared vision and value, and building capacity to shape outcomes in the community.
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It will take considerable time to address these root causes, and it will require system-level changes to reduce poverty, eliminate structural racism, improve income equality, increase educational opportunity, and fix the laws and policies that perpetuate structural inequities. All actors in the community -- businesses, state and local governments, anchor institutions, and other community residents -- have the power to change the narrative and help promote health equity.
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2010. Health disparities across the lifespan: Meaning, methods, and mechanisms.
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https://www2. ed.gov/admins/lead/safety/healthy-students/toolkit.pdf (accessed October 17, 2016)
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. http://www.innovation.cc/volumes-issues/martin-u-partner4final.pdf (accessed October 20, 2016)
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2011. Community researchers conducting health disparities research: Ethical and other insights from fieldwork journaling.
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2009. Estimating the cost of racial and ethnic health disparities.
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