Progress on Major Public Health Challenges: The Importance of Equity

“Injustice anywhere is a threat to justice everywhere.” —Dr Martin Luther King, Jr (Letter from Birmingham Jail, April 16, 1963)

Health disparities are “avoidable inequalities in health between groups of people within countries and between countries.” ¹ In the United States, these differences among population groups in the attainment of full health potential are reflected in shorter life expectancy and higher rates of heart disease, stroke, diabetes, cancer, trauma and violence, substance use, infant mortality, and low birth weight among socially disadvantaged groups compared with socially advantaged groups. Disparities exist across many dimensions, including race, ethnicity, gender, sexual orientation, disability status, socioeconomic status, refugee or migrant status, and geographic location—even between neighborhoods in close proximity to one another. Health disparities reflect social injustice because these differences in health across groups are unnecessary, avoidable, and unfair. ² Health equity is “when every person has the opportunity to ‘attain his or her full health potential’ and no one is ‘disadvantaged from achieving this potential because of social position or other socially determined circumstances.’” ³ Achieving equity in health requires a societal willingness to address challenges associated with the social determinants of health, including racism and bigotry, poverty, residential segregation, substandard housing, low-quality education, limited employment opportunities, lack of public safety, unequal access to and quality of health care, and the lack of neighborhood amenities and resources that enable people to maintain and improve their health. ^3,4

During the past 30 years, dramatic improvements in health status and reductions in infant and premature mortality have been achieved in the United States. However, differences in life expectancy among educational and income groups have increased. ^3,5,6 Rates of morbidity and mortality among some minority groups, including African American, American Indian/Alaska Native, and low-income white people, are comparable with rates of people living in low- and middle-income countries. ⁷

In this commentary, we consider the importance of equity in addressing major public health challenges in the United States, such as cardiovascular disease, cancer, obesity, infant mortality, and mental illness. We argue that without addressing the fundamental drivers of health disparities, policies and interventions aimed at combating public health challenges will fail to achieve major improvements in overall population health and, even worse, may exacerbate disparities.

Despite decades of efforts to address health disparities, only modest improvements in reducing disparities have been achieved at the national level. ⁸ Thus, public health research and policy must name health equity as an explicit priority in addressing these challenges. Cumulative exposure to disadvantage has lifelong implications for health and has implications for people in every phase of their lives. ⁹ Failure to address upstream factors (eg, poverty, limited opportunities, and discrimination) that perpetuate inequities will limit the effectiveness of public health interventions among groups affected by health disparities. A paradigm shift—broadening the lens of interventions to include more upstream determinants—is critically important for solving complex public health problems and ensuring that all populations in the United States achieve optimal health. Advancing health equity can be a win-win proposition in which not only population health overall improves, but the health of disadvantaged populations also improves at a pace that exceeds improvements for the overall population.

Priority areas for future work include research to address fundamental evidence and translation gaps. ¹⁰ Some of these gaps include the development of multilevel, practical, and targeted interventions. These interventions should incorporate knowledge about how to mitigate the effect of upstream drivers of inequities and use rigorous evaluation methods. These interventions should also be guided by broad stakeholder engagement and multidisciplinary and cross-sector collaborations, ¹¹ which are, in turn, informed by relationship-centered principles (eg, openness to examination of participants’ own biases and prejudices, respect for diverse perspectives, clear communication, individual and institutional trustworthiness and accountability, and partnership in decision-making). ¹² Such efforts will enhance the innovation, relevance, and effectiveness of interventions and optimize their translation and dissemination into sustainable programs and policies to address key public health challenges.

We discuss how cross-sectoral work; collaborations among practitioners, researchers, and educators; leadership development; education and training; and policy translation can improve public health efforts to achieve equity. We also provide examples of evidence-based strategies, best practices, and recommendations for future efforts.

Cross-sectoral Work

The complex and intractable nature of health disparities underscores the importance of strategizing across sectors—including health care, public health, social services, neighborhood associations, community-based organizations, faith-based organizations, education, businesses, philanthropies, the media, advocacy groups, and government—to achieve health equity. These cross-sector collaborations are complex, and success is difficult to measure and attribute to specific actions. Although there is limited evidence about what makes these partnerships most effective, best practices do exist. One example is B’more for Healthy Babies (BHB), an innovative initiative in Baltimore, Maryland, to reduce infant mortality through programs that emphasize policy change, service improvements, community mobilization, and behavior change. ¹³ The Baltimore City Health Department and the Family League of Baltimore lead BHB and involve more than 100 partner agencies from the corporate, nonprofit, academic, donor, and government sectors. BHB aims to provide all families, but especially families in high-risk neighborhoods (ie, those with high rates of infant mortality and poor social and health indicators), with quality maternal and infant health services and support. The infant mortality rate per 1000 live births in Baltimore City fell by 38%—from 13.5 to 8.4—between 2009 (before BHB launched) and 2015. ¹³

Healthy Delaware is another example of cross-sector collaboration. Created in 2004 through legislation, Healthy Delaware provides universal colorectal cancer screening and treatment—including patient navigation for screening, care coordination, and case management—for all residents of Delaware. The program also provides insurance coverage for these services for uninsured and low-income residents. As a result, from 2002 to 2009, disparities in rates of screening and disease incidence were eliminated, and the percentage of African Americans with regional and distant disease at diagnosis decreased from 79% to 40%. ¹⁴

Collaborations Among Practitioners, Researchers, and Educators

To achieve equity, practitioners, researchers, and educators should engage in efforts to enhance strategic thinking, disruption to current norms, and approaches based on evidence. Several barriers and opportunities exist in these types of collaborations. For many organizations serving socially at-risk groups, meeting the requirements of payers and policy makers while also serving their clients is a challenge. In addition, resources, including staff members, space, equipment, and funding for training, are often limited. Despite these challenges, the unique circumstances often spur innovation. Together, collaborations among practitioners, researchers, and educators can identify diverse funding streams (eg, advocacy groups, foundations, business, industry) for interventions that enhance equity. Public health scholars can provide highly valued training and technical support to build capacity among practitioners and organizations and help them identify efficient ways to monitor and evaluate the fidelity and success of program implementation.

One example of a successful academic–community partnership is the Johns Hopkins Center for Health Equity Community Advisory Board. During the past 8 years, this diverse and inclusive group of stakeholders has developed several effective interventions to reduce disparities in hypertension control in a population in Baltimore, and it is now beginning to translate and disseminate these programs locally, nationally, and globally. ¹² Through this partnership, a community-based dietary intervention involving collaboration with a local grocer was developed and successfully piloted. ¹⁵ This intervention has now been translated to African Americans with hypertension and kidney disease, a population at high risk for poor clinical outcomes. ¹⁶ Several clinic-based interventions were also developed through this partnership. ^17,18 One was Project ReDCHiP (Reducing Disparities and Controlling Hypertension in Primary Care), a cost-effective care-management intervention that took place from 2012 to 2015 and achieved substantial improvements in blood pressure ¹⁹ among African American and white patients. ²⁰ Another is an ongoing, large, pragmatic clinical trial comparing the effectiveness of enhanced usual care plus audit, feedback, and education with care provided by a collaborative care team. The collaborative care intervention incorporates community health worker support and/or specialist consultation and is expected to reduce racial/ethnic disparities in hypertension control among patient participants at 30 clinics in Maryland and Pennsylvania. ²¹

Leadership Development

Many public health experts believe building leadership is an important ingredient of successful collaborations to address issues as complex as health disparities. Public health professionals can play key roles in meeting leadership challenges (eg, environmental complexities, institutional pressures, and the extent of agreement about problem definition) in cross-sector collaborations. ²² Similarly, public health leaders can strengthen collaborations among practitioners, researchers, and educators by advocating for multiple perspectives, clarifying language differences across disciplines and settings, using group decision-making techniques, fostering innovation, mentoring others, and managing compliance and problem-solving requirements. ²³ We believe cross-sector and cross-disciplinary leaders for change in health equity should include professionals with expertise in the appropriate social sectors and academic disciplines and with values and priorities consonant with social justice.

To have legitimacy and to be effective, these leaders need authority, vision, integrity, relational and political skills, and commitment to the collective desired outcome. They also must be empowered to participate in governance and change narratives around health equity, which have heretofore focused on individual risk behaviors to the exclusion of structural factors that play a role in perpetuating health disparities. Health equity leaders should be equipped with skills to make more explicit connections among political engagement, societal policies, and health. Health equity leaders also should be able to shift normative responses to social inequities in their respective disciplines, social sectors, and the general public through role modeling. These leaders should be trusted by people from disadvantaged communities. They should inspire people from marginalized communities to engage in, rather than withdraw from, the political process, and advocate for change in their respective communities. People with lived experiences from disadvantaged groups should be given opportunities for training to become knowledgeable and effective health equity leaders.

Education and Training

Educating and training a diverse group of public health and clinical investigators and practitioners in transdisciplinary methods is important for addressing the health equity crisis. It is particularly important that people from disadvantaged communities cultivate their talents and interests in this work because their personal experiences confer a unique expertise in the realities of developing, implementing, and evaluating health equity interventions. Although evidence of the effectiveness of training programs is limited, several best practices exist. ^{24 -27} These programs incorporate didactic and experiential opportunities in multidisciplinary areas, including social epidemiology, implementation science, health services research, behavioral science, intervention development, community-based participatory research, quality improvement, evaluation science, and health policy research. Evidence of the effectiveness of training in communication skills, cultural competency, and teamwork and leadership skills is also limited ^28,29 ; however, best practices strengthen trainees’ understanding of the ways in which social determinants of health influence the ability of individuals and families from disadvantaged communities to engage in healthy behaviors, obtain needed health care and social services, and improve their health. Many programs also provide researchers and practitioners with service-learning opportunities in community settings to develop skills in program and policy development, implementation, and evaluation.

Future educational programs targeting health equity should train researchers, practitioners, and lay members in at-risk communities alongside each other to enhance professionals’ skills in developing and delivering culturally acceptable and contextually relevant interventions. In addition, training lay members of disadvantaged communities in health topics and leadership skills may build these individuals’ capacity to support their communities through peer education and advocacy. Current and future health equity training programs should be evaluated by using rigorous methods that incorporate learner behavioral and population health outcomes and that examine program influences on reducing health disparities.

Policy Translation

The field of public health needs practitioners who understand the social determinants of health and can connect the dots from research to policy to program implementation by advocating for the incorporation of health effects into policy evaluations. Achieving health equity involves research examining how programs and policies in sectors ranging from housing to immigration produce both intended and unintended consequences for health. For example, research by Roche et al ³⁰ examined the real-time mental health effects of changes to immigration enforcement policies in the United States in recent years. Results of the study showed that these policies were associated with an increased likelihood of psychological distress among Latino parents of adolescents, which in turn may negatively affect the health and well-being of their children and families. ³⁰ Public health practitioners must advocate for such research and ensure that it informs policy development and implementation.

Cross-sector policies, such as those addressing consumption of sugar-sweetened beverages and housing mobility programs, are important for addressing major public health challenges such as obesity and cardiovascular disease. ^31,32 Yet a lack of political will and challenges to funding can hinder efforts to disseminate such approaches and expand them to scale to meet population needs. The relationship between policy translation and health equity is complex and necessitates interactive evaluation. For example, nutrition policies to improve healthful food in schools can reduce obesity risk among children, ³³ but such policies do not address the broader social context of segregation and concentrated poverty that negatively affect children’s health and economic trajectories over time. ^34,35 Efforts such as Health Impact Assessment (HIA) and program evaluation are important for policy development and long-term assessments of how policies produce unintended consequences for population health and health equity. ^{35 -37} HIA is a process by which to assess the potential health effects of non–health sector policies or programs under consideration. It is a cross-sector process. Similarly, program evaluation can be used to evaluate the health and health-related effects of various policies or programs, ranging from zoning code reform to youth empowerment programs. Addressing health equity through policy and advocacy requires both implementation of proven policy approaches to improve health and evaluation of social policies to identify health effects. In addition, augmenting the public health workforce with people who have training in social and economic policy and cross-sector expertise is important to ensure these effects are evaluated.

Conclusions

Strategies such as cross-sector partnerships; collaborations among practitioners, researchers, and educators; leadership development; equity training; and equity-informed policy translation should enable the reduction of current health disparities and achievement of better health and quality of life for all people in the United States, regardless of their socially determined circumstances.