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5. What are the social determinants of health?

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Social determinants of health are “the structural determinants and conditions in which people are born, grow, live, work and age”

(Citation: Overview, #9). They include factors like income, education, environment, employment, and social support, and access to health care.

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4. What is health equity?

Health equity is defined as “attainment of the highest level of health for all people” (Citation: Overview, #4). Health Equity ensures that all people have full and equal access to opportunities that enable them to lead healthy lives. Health inequities are described as differences in health that are avoidable, unfair, and unjust. Health inequities are affected by social, economic, and environmental conditions (or social determinants). Health disparities are the differences in health outcomes among groups of people. 

“Where systematic differences in health are judged to be avoidable by reasonable action they are quite simply, unfair. It is this that we label health inequity."

—Dr. Margaret Cho, Director General, WHO

(Citation: Overview, #8)

Examples of health inequity:

  • Of the hundreds of elementary schools in the Denver Metro Area, two are situated within 500 feet of a major highway. Eighty-eight and 75 percent of the students at these two schools are Hispanic/Latino, even though Hispanic/Latinos comprise only 28 percent of elementary students statewide.These children are at an increased risk for asthma (Citation: Overview, #7).

  • Sixty-four percent of people living in Colorado communities where drinking water exceeds the standard for radium and uranium are Hispanic/Latino. Hispanic/Latinos are more than twice as likely to drink bottled or vended water compared to Whites (30 percent versus 12 percent), yet are the group least able to afford it. Bottled water is not fluoridated and does not provide protection against dental decay (Citation: Overview, #7).

  • African Americans represent 13% of U.S. population, but account for more than half of all new HIV infections. There are no biological or genetic reasons for this difference (Citation: Overview, #4).

  • Babies born to African American women in the U.S. are more likely to die in their first year of life than babies born to Caucasian women. Many scientists have shown links between the stress from racism and negative health outcomes and less educational attainment among African American mothers and negative health outcomes (Citation: Overview, #4),

Sources and types of evidence for making evidence-based decisions may include quantitative (numbers) and qualitative (stories, narrative and descriptive) input and data from many fields, including public health, epidemiology, health care, social sciences, and education (Citation: Overview, #3).

 

There are many kinds of evidence, ranging from subjective to objective.  It is important to know what kind of evidence, or what combination of evidence, is most effective to help people make decisions in public health.  For example, a combination of personal stories backed up by data, may be an effective way to help people understand causes of health inequities and point towards strategies to improve health.

3. What are sources and types of evidence for public health decision making?
2. Why is evidence-based decision making important in public health?
Resources

For foundational training in evidence-based decision-making use the following resources:

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1. What is evidence-based public health and evidence-based decision-making?

Evidence-based public health is the development, implementation, and evaluation of effective programs and policies in public health through application of principles of scientific reasoning.  The process involves integrating science-based interventions with community preferences to improve the health of populations. Underneath the umbrella of an evidence-based framework is making program and policy decisions based on the best scientific evidence. This process is referred to as evidence-based decision-making (EBDM) (Citation: Overview, #2). This tool is based on the framework developed by Dr Ross Brownson and colleagues at the Prevention Research Center in St. Louis (Citation: Overview, #2).

Evidence-based decision-making in public health involves:

  • Engaging the community in assessment and decision making;

  • Using data and information systems systematically;

  • Applying program planning frameworks;

  • Using best available evidence

  • Conducting sound evaluation; and

  • Disseminating findings to partners and community

(Citation: Overview, #2)

“Health inequities result from a complex web of factors that span multiple sectors and disciplines.”

-- Health Equity Guide for Public Health Practitioners and Partners,

   Delaware Division of Public Health (Citation: Overview, #1)

Examples of health equity:

  • The Colorado Department of Transportation (CDOT) has worked with local communities to reconstruct a structurally deficient 50-year-old viaduct, which did not meet environmental standards. The viaduct crosses through the Elyria and Swansea Neighborhoods of Denver, communities that are composed of many racial and ethnic minorities and low-income households. This effort brings improvements to the neighborhood, ensures environmental justice principles are maintained, and reduces the health impacts of the highway which include increased asthma incidence and air and soil pollutants among neighborhoods close to a highway. Based on CDOT’s consultation with local communities, CDOT will remove the viaduct and replace it with a below-ground highway as well as and reduce air quality impacts among children in schools near the construction by providing new doors, new windows, and a new heating, ventilation, and air conditioning (HVAC) system (Citation: Overview, #5).

  • By the time children enter kindergarten, a significant achievement gap exists between low-income or minority children as compared to higher income or non-minority children. The Rural Resort Region Northeast Early Childhood Council in Colorado is an organization that invests in the early years. Bringing together stakeholders in Grand and Summit counties, the organization works to increase the quality, accessibility and equity of early childhood services. To date, the council has created an electronic app to track a child’s development, alert health care and child care providers to screening results, and suggest appropriate activities (Citation: Overview, #6).

  • Medicaid and Medicare reduce disparities in access tocare by income and consequently by race.These public health insurance programs offer access to health care to vulnerable populations by paying a substantial sum of health care costs to preventive and emergent care that these population would otherwise forgo (Citation: Overview, #4).

  • The Head Start program reduces income and racial disparities in early childhood development, which is the foundation for adult health.  Head Start is offered to young children of low-income families, providing them with important school readiness skills and connection to resources (Citation: Overview, #4). 

Resources

No two public health problems, programs, projects, or policies are the same. The decision-making process depends upon available research and evidence, as well as the skills and values held by the individuals and groups involved. Decision-makers (your agency, team, organization, or partnership) draw on their knowledge and expertise to include all the relevant factors into make a final decision, conclusion or recommendation. Evidence-based decision-making in public health offers many benefits including the adoption of effective and cost-efficient interventions; practical use of limited resources; and better health outcomes for individuals and communities.

6. What is the link between health equity, health disparities/inequalities, and social determinants?

Health equity, health disparities, health inequalities, and social determinants are linked. “Health equity means social justice in health (i.e. no one is denied the possibility to be healthy for belonging to a group that has been historically been economically, socially disadvantaged. Health disparities are the metrics we use to measure progress toward achieving health equity. A reduction in health disparities (in absolute and relative terms) is evidence that we are moving toward greater health equity” (Citation: Overview, #10).

Including a health equity lens in evidence-based decision-making is critical to reducing health disparities.  

The next module is Agency-Focused Change for Health Equity

…An equity framework draws attention to the concepts of fairness and justice in the distribution of resources. Furthermore, it highlights the idea that social inequities in health are avoidable through collective action and that inaction is unacceptable. In addition, a health equity framework provides a positive vision to work towards—it is inclusive, affirming, and empowering.

-- Karyl T. Rattay, MD, MS, Delaware Division of Public Health

(Citation: Overview, #1)

The questions below are designed to be conversation starters and thought prompts as you work with staff, colleagues, and stakeholders. Many of the questions link out to additional resources that provide examples or lend support to your program or agency.

 

Start the journey of Advancing Your Health Equity Work by answering the questions listed below.

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This module reviews the concepts of evidence-based decision-making and health equity and the relevance of doing evidence-based decision-making using a health equity lens in public health. The module provides local and national examples of public health working to address health equity.​

Identifying Inequity

  • What is the problem your group is trying to solve?  

  • Who are you intending to serve/address/help with your solution?

  • What population is most affected by the issue you are trying to address?

  • What are some examples of the absence of health equity?

  • What are examples of when public health might fail to adequately address health equity?

Understanding Inequity
Core Questions
Addressing Inequity

  • Why is health equity important to you/your group?  

  • What does health equity mean to your group’s members? Develop a statement or statements on how your group will prioritize and/or address equity.

  • Why is it important to use a systematic process like the evidence-based public health framework to address health equity?

  • How could existing approaches to this problem actually worsen health disparities?

  • How can we ensure selected strategies build on one another to form a comprehensive approach that advances the achievement of health equity in our community?

  • How is the population most affected benefiting by what you are currently doing and how do you know?

  • What are sources and types of evidence that are relevant to and important to questions of health equity?

  • What sources and types of evidence are needed to understand the relevant the social determinants of the existing health disparities and inequities the group is trying to remedy?

  • What are the social and environmental factors where inequality creates health inequity?

  • Which social determinants of health and/or root causes are leading to the disparity (e.g. transportation, housing, higher ed)?

Overview of Advancing Health Equity

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