Katana VentraIP

Health equity

Health equity arises from access to the social determinants of health, specifically from wealth, power and prestige.[1] Individuals who have consistently been deprived of these three determinants are significantly disadvantaged from health inequities, and face worse health outcomes than those who are able to access certain resources.[2][1] It is not equity to simply provide every individual with the same resources; that would be equality. In order to achieve health equity, resources must be allocated based on an individual need-based principle.[1]

According to the World Health Organization, "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".[3] The quality of health and how health is distributed among economic and social status in a society can provide insight into the level of development within that society.[4] Health is a basic human right and human need, and all human rights are interconnected. Thus, health must be discussed along with all other basic human rights.[1]


Health equity is defined by the CDC as "the state in which everyone has a fair and just opportunity to attain their highest level of health".[5] It is closely associated with the social justice movement, with good health considered a fundamental human right. These inequities may include differences in the "presence of disease, health outcomes, or access to health care"[6]: 3  between populations with a different race, ethnicity, gender, sexual orientation, disability, or socioeconomic status.[7][8]


Health inequity differs from health inequality in that the latter term is used in a number of countries to refer to those instances whereby the health of two demographic groups (not necessarily ethnic or racial groups) differs despite similar access to health care services. It can be further described as differences in health that are avoidable, unfair, and unjust, and cannot be explained by natural causes, such as biology, or differences in choice.[9] Thus, if one population dies younger than another because of genetic differences, which is a non-remediable/controllable factor, the situation would be classified as a health inequality. Conversely, if a population has a lower life expectancy due to lack of access to medications, the situation would be classified as a health inequity.[10] These inequities may include differences in the "presence of disease, health outcomes, or access to health care". Although, it is important to recognize the difference in health equity and equality, as having equality in health is essential to begin achieving health equity.[1] The importance of equitable access to healthcare has been cited as crucial to achieving many of the Millennium Development Goals.[11]

Health inequality and environmental influence[edit]

Minority populations have increased exposure to environmental hazards that include lack of neighborhood resources, structural and community factors as well as residential segregation that result in a cycle of disease and stress.[130] The environment that surrounds us can influence individual behaviors and lead to poor health choices and therefore outcomes.[131] Minority neighborhoods have been continuously noted to have more fast food chains and fewer grocery stores than predominantly white neighborhoods.[131] These food deserts affect a family's ability to have easy access to nutritious food for their children. This lack of nutritious food extends beyond the household into the schools that have a variety of vending machines and deliver over processed foods.[131] These environmental condition have social ramifications and in the first time in US history is it projected that the current generation will live shorter lives than their predecessors will.[131]


In addition, minority neighborhoods have various health hazards that result from living close to highways and toxic waste factories or general dilapidated structures and streets.[131] These environmental conditions create varying degrees of health risk from noise pollution, to carcinogenic toxic exposures from asbestos and radon that result in increase chronic disease, morbidity, and mortality.[132] The quality of residential environment such as damaged housing has been shown to increase the risk of adverse birth outcomes, which is reflective of a communities health. This occurs through exposure to lead in paint and lead contaminated soil as well as indoor air pollutants such as second-hand smoke and fine particulate matter.[133][134] Housing conditions can create varying degrees of health risk that lead to complications of birth and long-term consequences in the aging population.[134] In addition, occupational hazards can add to the detrimental effects of poor housing conditions. It has been reported that a greater number of minorities work in jobs that have higher rates of exposure to toxic chemical, dust and fumes.[135] One example of this is the environmental hazards that poor Latino farmworkers face in the United States. This group is exposed to high levels of particulate matter and pesticides on the job, which have contributed to increased cancer rates, lung conditions, and birth defects in their communities.[136]


Racial segregation is another environmental factor that occurs through the discriminatory action of those organizations and working individuals within the real estate industry, whether in the housing markets or rentals. Even though residential segregation is noted in all minority groups, Black people tend to be segregated regardless of income level when compared to Latinos and Asians.[137] Thus, segregation results in minorities clustering in poor neighborhoods that have limited employment, medical care, and educational resources, which is associated with high rates of criminal behavior.[138][139] In addition, segregation affects the health of individual residents because the environment is not conducive to physical exercise due to unsafe neighborhoods that lack recreational facilities and have nonexistent park space.[138] Racial and ethnic discrimination adds an additional element to the environment that individuals have to interact with daily.[140] Individuals that reported discrimination have been shown to have an increase risk of hypertension in addition to other physiological stress related affects.[141] The high magnitude of environmental, structural, socioeconomic stressors leads to further compromise on the psychological and physical being, which leads to poor health and disease.[130]


Individuals living in rural areas, especially poor rural areas, have access to fewer health care resources. Although 20 percent of the U.S. population lives in rural areas, only 9 percent of physicians practice in rural settings. Individuals in rural areas typically must travel longer distances for care, experience long waiting times at clinics, or are unable to obtain the necessary health care they need in a timely manner. Rural areas characterized by a largely Hispanic population average 5.3 physicians per 10,000 residents compared with 8.7 physicians per 10,000 residents in nonrural areas. Financial barriers to access, including lack of health insurance, are also common among the urban poor.[142]

Lack of a regular source of care. Without access to a regular source of care, patients have greater difficulty obtaining care, fewer doctor visits, and more difficulty obtaining prescription drugs. Compared to whites, minority groups in the United States are less likely to have a doctor they go to on a regular basis and are more likely to use and clinics as their regular source of care.[143] In the United Kingdom, which is much more racially harmonious, this issue arises for a different reason; since 2004, NHS GPs have not been responsible for care out of normal GP surgery opening hours, leading to significantly higher attendances in A+E

emergency rooms

Lack of financial resources. Although the lack of financial resources is a barrier to health care access for many Americans, the impact on access appears to be greater for minority populations.

[144]

barriers. Access to medical care by low-income immigrant minorities can be hindered by legal barriers to public insurance programs. For example, in the United States federal law bars states from providing Medicaid coverage to immigrants who have been in the country fewer than five years.[6]: 10  Another example could be when a non-English speaking person attends a clinic where the receptionist does not speak the person's language. This is mostly seen in people who have limited English proficiency, or LEP.

Legal

Structural barriers. These barriers include poor transportation, an inability to schedule appointments quickly or during convenient hours, and excessive time spent in the waiting room, all of which affect a person's ability and willingness to obtain needed care.

[145]

Scarcity of providers. In inner cities, rural areas, and communities with high concentrations of minority populations, access to medical care can be limited due to the scarcity of primary care practitioners, specialists, and diagnostic facilities. This scarcity can also extend to the personnel in the medical laboratory with some geographical regions having significantly diminished access to advanced diagnostic methods and pathology care.[147] In the UK, Monitor (a quango) has a legal obligation to ensure that sufficient provision exists in all parts of the nation.

[146]

The health care financing system. The in the United States says fragmentation of the U.S. health care delivery and financing system is a barrier to accessing care. Racial and ethnic minorities are more likely to be enrolled in health insurance plans which place limits on covered services and offer a limited number of health care providers.[6]: 10 

Institute of Medicine

Linguistic barriers. Language differences restrict access to medical care for minorities in the United States who have .[148]

limited English proficiency

Health . This is where patients have problems obtaining, processing, and understanding basic health information. For example, patients with a poor understanding of good health may not know when it is necessary to seek care for certain symptoms. While problems with health literacy are not limited to minority groups, the problem can be more pronounced in these groups than in whites due to socioeconomic and educational factors.[146] A study conducted in Mdantsane, South Africa depicts the correlation of maternal education and the antenatal visits for pregnancy. As patients have a greater education, they tend to use maternal health care services more than those with a lesser maternal education background.[149]

literacy

Lack of in the health care workforce. A major reason for disparities in access to care are the cultural differences between predominantly white health care providers and minority patients. Only 4% of physicians in the United States are African American, and Hispanics represent just 5%, even though these percentages are much less than their groups' proportion of the United States population.[6]: 13 

diversity

Age. Age can also be a factor in health disparities for a number of reasons. As many older Americans exist on fixed incomes which may make paying for health care expenses difficult. Additionally, they may face other barriers such as impaired mobility or lack of transportation which make accessing health care services challenging for them physically. Also, they may not have the opportunity to access health information via the internet as less than 15% of Americans over the age of 65 have access to the internet. This could put older individuals at a disadvantage in terms of accessing valuable information about their health and how to protect it. On the other hand, older individuals in the US (65 or above) are provided with medical care via Medicare.

[150]

Criminalization and lack of research of ,[151] and mental health treatments.[152] Mental illness accounts for about one-third of adult disability globally.[153] Conventional drug treatments have dominated psychiatry for decades, without a breakthrough in mental healthcare. Access to psychedelic-assisted therapy, and the decriminalization of Psilocybin and other entheogens are questions of health justice.[154]

traditional medicine

Advocacy. Advocacy for health equity has been identified as a key means of promoting favourable policy change. EuroHealthNet carried out a systematic review of the academic and grey literature. It found, amongst other things, that certain kinds of evidence may be more persuasive in advocacy efforts, that practices associated with knowledge transfer and translation can increase the uptake of knowledge, that there are many different potential advocates and targets of advocacy and that advocacy efforts need to be tailored according to context and target.[185] As a result of its work, it produced an online advocacy for health equity toolkit.[186]

[184]

Provider based incentives to improve healthcare for ethnic populations. One source of health inequity stems from unequal treatment of non-white patients in comparison with white patients. Creating provider based incentives to create greater parity between treatment of white and non-white patients is one proposed solution to eliminate provider bias. These incentives typically are monetary because of its effectiveness in influencing physician behavior.

[187]

Using Evidence Based Medicine (EBM). Evidence Based Medicine (EBM) shows promise in reducing healthcare provider bias in turn promoting health equity. In theory EBM can reduce disparities however other research suggests that it might exacerbate them instead. Some cited shortcomings include EBM's injection of clinical inflexibility in decision making and its origins as a purely cost driven measure.[189]

[188]

Increasing awareness. The most cited measure to improving health equity relates to increasing public awareness. A lack of public awareness is a key reason why there has not been significant gains in reducing health disparities in ethnic and minority populations. Increased public awareness would lead to increased congressional awareness, greater availability of disparity data, and further research into the issue of health disparities.

The Gradient Evaluation Framework. The evidence base defining which policies and interventions are most effective in reducing health inequalities is extremely weak. It is important therefore that policies and interventions which seek to influence health inequity be more adequately evaluated. Gradient Evaluation Framework (GEF) is an action-oriented policy tool that can be applied to assess whether policies will contribute to greater health equity amongst children and their families.

[190]

The AIM framework. In a pilot study, researchers examined the role of AIM—ability, incentives, and management feedback—in reducing care disparity in pressure-ulcer detection between African American and Caucasian residents. The results showed that while the program was implemented, the provision of (1) training to enhance ability, (2) monetary incentives to enhance motivation, and (3) management feedback to enhance accountability led to successful reduction in pressure ulcers. Specifically, the detection gap between the two groups decreased. The researchers suggested additional replications with longer duration to assess the effectiveness of the AIM framework.

Monitoring actions on the social determinants of health. In 2017, citing the need for accountability for the pledges made by countries in the Rio Political Declaration on Social Determinants of Health, the World Health Organization and United Nations Children's Fund called for the monitoring of intersectoral interventions on the social determinants of health that improve health equity.

[191]

Changing the distribution of health services. Health services play a major role in health equity. Health inequities stem from lack of access to care due to poor economic status and an interaction among other . The majority of high quality health services are distributed among the wealthy people in society, leaving those who are poor with limited options. In order to change this fact and move towards achieving health equity, it is essential that health care increases in areas or neighborhoods consisting of low socioeconomic families and individuals.[33]

social determinants of health

Prioritize treatment among the poor. Because of the challenges that arise from accessing health care with low economic status, many illnesses and injuries go untreated or are not given sufficient treatment. Promoting treatment as a priority among the poor will give them the resources they need in order to achieve good health, because health is a basic human right.[33]

[1]

Implementing medical pluralism. Extreme differences that underlie urban and approaches emphasize the need for a system that represents the duality of the populations it intends to serve. Urban medicine generally believes that technological advancement is the best way to help treat illness as it allows for a more "sophisticated" mode of care; alternative medicine is more traditional in relying solely on herbal and natural remedies believing that the elaborate institutions of urban care are not best suited for serving individual needs. Medical pluralism, hence, is an adaptive tactic most effective for communities that include Indigenous people, and mixed rural-urban populations.[192] Medical pluralism acknowledges the needs of a variety of people and is a step closer to health equity. Medical pluralism "avoids the extremes'' of most current healthcare delivery approaches and provides a middle-ground perspective on tackling health issues that are not solved by urban or rural health alone.[193] By practicing integrative medicine, chronic and unresolved health issues are better treated, borrowing from the technological and philosophical approaches of both models of care. Aimed at embracing both medical techniques, medical pluralism is currently being considered in nations with diverse communities; it is manifested in the practice of integrative medicine which is a deliberate execution of that approach. There are currently ongoing efforts to implement this dual model of healthcare delivery regionally in nations composed of very diverse communities, and such is the case in many Latin American countries such as Ecuador that have a large indigenous population. The process of successfully implementing an integrative healthcare system is discussed as having six main steps that pose different challenges. Guito et al.'s guidelines for each steps describes the first as being 'imperceptible integration" to the sixth being "total integration".[194]

alternative medicine

(AI) can be helpful in identifying and improving issues of health disparities. A recent scoping review of the literature found that it is important to engage with various communities while AI health applications are being developed and also reviewed based on various biases that are later identified through this work.[195]

Artificial Intelligence

Pandemic Treaty. The WHO's member states made health equity the central principle of the convention or other international instrument under negotiation.

[196]

Health inequalities[edit]

Health inequality is the term used in a number of countries to refer to those instances whereby the health of two demographic groups (not necessarily ethnic or racial groups) differs despite comparative access to health care services. Such examples include higher rates of morbidity and mortality for those in lower occupational classes than those in higher occupational classes, and the increased likelihood of those from ethnic minorities being diagnosed with a mental health disorder. In Canada, the issue was brought to public attention by the LaLonde report.


In UK, the Black Report was produced in 1980 to highlight inequalities. On 11 February 2010, Sir Michael Marmot, an epidemiologist at University College London, published the Fair Society, Healthy Lives report on the relationship between health and poverty. Marmot described his findings as illustrating a "social gradient in health": the life expectancy for the poorest is seven years shorter than for the most wealthy, and the poor are more likely to have a disability. In its report on this study, The Economist argued that the material causes of this contextual health inequality include unhealthful lifestyles – smoking remains more common, and obesity is increasing fastest, amongst the poor in Britain.[201]


In June 2018, the European Commission launched the Joint Action Health Equity in Europe.[202] Forty-nine participants from 25 European Union Member States will work together to address health inequalities and the underlying social determinants of health across Europe. Under the coordination of the Italian Institute of Public Health, the Joint Action aims to achieve greater equity in health in Europe across all social groups while reducing the inter-country heterogeneity in tackling health inequalities.

Bias in research[edit]

Research to identify health inequities, how they arise and what can be done to address them is essential to securing health equity. However, the same exclusionary social structures that contribute to health inequities in society also influence and are reproduced by researchers and public health institutions.[203] In other words, medicine and public health organizations have evolved to better meet the needs of some groups more than others. While there are many examples of bias in medical and public health research, some general categories of exclusionary research practices include:[204] 1) Structural invisibility – approaches to collection, analysis or publication of data which hide the potential contribution of social factors to the distribution of health risks or outcomes. For example, limitations in public health surveys in the United States to collect data on race, ethnicity, and nativity; (2) Institutionalized exclusion – codification of exclusionary social structures in research practices, instruments, and scientific models resulting in an inherent bias in favor of the normative group. For example, the definition of a human as an 80 kg man in toxicology; (3) Unexamined assumptions – cultural norms and unconscious bias that can impact all aspects of research. In other words, assuming that the researchers' perspective and understanding is objective and universally shared. For example, the lack of conceptual equivalence across multi-lingual survey instruments.[205][206]

Health disparity and genomics[edit]

Genomics applications continue to increase in clinical/medical applications. Historically, results from studies do not include underrepresented communities and races.[207] The question of who benefits from publicly funded genomics is an important public health consideration, and attention will be needed to ensure that implementation of genomic medicine does not further entrench social‐equity concerns.[208] Currently the National Human Genome Research Institute counts with a Genomics and Health Disparities Interest Group to tackle the issues of accessibility and application of genomic medicine to communities not normally represented. The Director of the Health Disparities Group, Vence L. Bonham Jr., leads a team that seeks to qualify and better understand the disparities and reduce the gap in access to genetic counseling, inclusion of minority communities in original research, and access to genetic information to improve health.[209]


There is some movement toward progress, though. Sickle cell disease, which disproportionately impacts Black people where every 1 of 365 births[210] has the condition, is treatable with gene therapy. In December 2023, the United States' Food and Drug Administration (FDA) approved two gene therapy treatments[211] that use gene editing machinery known as CRISPR/Cas9 to alleviate the sickling of the red blood cells. This will greatly improve the livelihoods of millions, but especially people of color who are much more at risk for this condition.

2014 Health Disparities Legislation

Progress in Community Health Partnerships: Research, Education, and Action (PCHP)

was created to enable dialogue and discussion of issues related to the visibility of racial and ethnic disparities in health and health care as a national problem, the development of programs and strategies to reduce disparities and the emergence of new leadership.

Institute of Medicine Roundtable on Health Disparities

European Portal for Action on Health Inequalities

Center for Managing Chronic Disease

videos presentations from expert lecturers, University of Wisconsin School of Medicine and Public Health

Cultural Diversity in Health Care Speaker Series

video presentations from expert lecturers, University of Wisconsin School of Medicine and Public Health

Cultural Diversity in Health Care Research Symposium

National Center on Minority Health and Health Disparities

Journal of Health Care for the Poor and Underserved

Understanding Health Disparities

United States government minority health initiative

Initiative to Eliminate Racial and Ethnic Disparities in Health

Health Disparities Collaborative

EuroHealthNet's European Partnership for Improving Health, Equity and Wellbeing

Massachusetts General Hospital seeks to bridge healthcare's racial gap

Diversity Health Institute Clearinghouse

Case Center for Reducing Health Disparities

FIU Health Disparity Research Group

News summary report from kaisernetwork.org

"Kaiser Health Disparities Report: A Weekly Look at Race, Ethnicity and Health"

Health inequality in New Zealand

BBC News article regarding health inequalities

EXPORT Project webpage atTuskegee University

Archived 2007-09-30 at the Wayback Machine, April 4, 2007, featuring Paula Braveman, Gregg Bloche, George Kaplan, Thomas Ricketts, Mary Lou deLeon Siantz, and David Williams

VIDEO: Health Status Disparities in the US

UK National Health Service Specialist Library for Ethnicity & Health

[1]

National Rural Health Association

The National Partnership for Action to End Health Disparities

The National Partnership for Action Toolkit for Community Action

Social Determinants of Health Task Force, Centers for Disease Control and Prevention, USA

Social Determinants of Health

The National Institute for Occupational Safety and Health (NIOSH), 2022.

Occupational Health Equity Program