1. Developing a Public Health Equity Lens
Nashville Public Health Learning Collaborative
December 5, 2014

2. Disclosures
The following educational planners, speakers, moderators and/or panelists of this CME activity have no relevant financial relationships with commercial interests to disclose:
Leah Alexander, Ph.D., M.P.H.
Marie Griffin, M.D., M.P.H.
Mohamed Kanu, Ph.D., M.P.H.

3. Learner Objectives
At the end of the session, participants will be able to:
Define health equity and discuss the factors that give rise to health inequities
Articulate specific health disparities and the populations they affect in Davidson county
Utilize a health equity assessment tool as a framework to understand & address health inequities
Explain the process of health policy development based on health disparities data

4. Health Equity
“Achieving the highest level of health for all people. It entails focused societal efforts to address avoidable inequalities by equalizing the conditions for health for all groups, especially for those who have experienced socioeconomic disadvantage or historical injustices.”
Healthy People 2020
So we know that in Alameda County for many disease areas, there are differences between groups of people.
Health disparities are the differences in rates of illness, disease, or conditions among different populations.
We can think of it as the difference in health outcomes.
Full sources: The University of Washington School of Public Health and Community Medicine/Robert Wood Johnson Foundation/National Association of County and City Health Officials
Turning Point: Collaborating for a New Century in Public Health, The University of Washington School of Public Health and Community Medicine/Robert Wood Johnson Foundation/National Association of County and City Health Officials

5. Health Equity
“Achieved when every person has the opportunity to achieve his or her full health potential. No one is disadvantaged from achieving this potential because of social position or other socially determined circumstances.”
Centers for Disease Control & Prevention/World Health Organization
Health disparities are the differences in rates of illness, disease, or conditions among different populations.
We can think of it as the difference in health outcomes.
Full sources: The University of Washington School of Public Health and Community Medicine/Robert Wood Johnson Foundation/National Association of County and City Health Officials
Turning Point: Collaborating for a New Century in Public Health, The University of Washington School of Public Health and Community Medicine/Robert Wood Johnson Foundation/National Association of County and City Health Officials

6. Health Inequities
“Differences in health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust.”
–Margaret Whitehead
Department of Public Health
University of Liverpool
So there are differences in health outcomes, or health disparities, that we see by place, race, and income. All of those 11 areas we had in the social inequity slide contribute to this. When you start adding all the slides together, you start to see a pattern. You might not even need the slides because you see this in the communities you work with.
When we talk about inequities, we are talking about what’s causing those health disparities. It’s a small difference in language but an important concept. Inequities can be thought of as differences in opportunities and exposures that cause different health outcomes. So one group may be exposed to a more toxic environment while another has more opportunities for education, physical activity, and other things.
When we talk about health inequities, we are talking about the systemic patterns. Things that happen over and over again. We are talking about the things in the community and society that might be causing these disparities, like the factors we put into the outer ring.
We are also talking about power. Disparities might just happen—the difference in breast cancer rates between men and women for example. That doesn’t represent a difference in power. But if we think back to how power is distributed in the US and ALCO, and who has the power to make decisions about housing, transportation, education, and other areas, we see that health inequities are a product of power inequities.
A lot of government publications at the national level talk about eliminating health disparities. But they never mention addressing racism or class exploitation. If we can see such a clear link between these things, as in the previous slides, how realistic is a plan to address health disparities that fails to focus on health inequities, or what’s at the root of the problem—social inequities?

7. Health Inequity Several definitions for the concept
Essential elements across all definitions….
Health inequities are unjust, unnatural, and avoidable differences in health status, distribution of disease, and mortality rates across population groups
The are beyond control of the individuals, meaning they are systemic problems. While individual choices influence health, these patterns across populations are not a result of an individual’s choices alone
They are sustained over time and generations.

8. Behavior is Shaped by Context

9. What does Health Inequity look like in our community
What does Health Inequity look like in our community? Think of some examples….

10. Factors that Affect Health
Socioeconomic Factors
Changing the Context
to make individuals’ default
decisions healthy
Long-lasting
Protective Interventions
Clinical
Interventions
Counseling
& Education
Examples
Eat healthy, be physically active
Largest
Impact
Smallest
Rx for high blood pressure, high cholesterol, diabetes
Immunizations, brief intervention, cessation treatment, colonoscopy
Fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax
Poverty, education, housing, inequality

11. Sources
Health Equity:
U.S. Department of Health and Human Services, Office of Minority Health. National Partnership for Action to End Health Disparities. The National Plan for Action Draft as of February 17, Chapter 1: Introduction. Available at: 
Health Disparity:
U.S. Department of Health and Human Services. The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for Phase I report: Recommendations for the framework and format of Healthy People Section IV. Advisory Committee findings and recommendations. Available at:  Accessed 1/6/10.

12. Push to Achieve Health Equity
Driven by values of social justice (the equitable distribution of resources)
Focuses on outcomes (achieving equity) rather that problems (ending disparities)
Focuses on structural and institutional changes to address the conditions that produce illness and disease
-DRA Project 2009

13. Principles of Health Equity
Health equity is a cross-cutting issue associated with fundamental social values and well-being
Health equity is connected to all aspects of public health work and the most basic influences on the health of populations
Working to achieve health equity requires multidisciplinary approaches and a more holistic, comprehensive view of health and coordinated strategies (Troutman, 2009)

14. Public Policies
Public policies are “authoritative decisions made in the legislative, judicial, or executive branches of government.”
(Longest, 1998)

15. Policy Development
Policies develop after the confluence of three factors
Existence of a problem
Potential solution to the problem
Political circumstances

16. Agenda Setters or Policy Actors?
The government
The media
Interest groups
Individuals
Lobbyists
Public agencies
Elected officials

17. Government Criteria for Agenda Issues
Who says issue is a problem, and why?
Is it a legitimate problem for govt.?
Any possible agreement on issue?
Is the issue timely?
Is the issue framed at the appropriate level?

18. A Framework for Viewing Health Equity

19. Health Equity Assessment Tool*
Understanding health inequities
What inequities exist in relation to the health issue to the health issue under consideration?
In this situation, who is most advantaged and how?
How did the inequities occur? What are the mechanisms by which the inequities were created, maintained or increased?
Intervening in inequities
How will you improve the health outcomes and reduce the health inequities experienced by the population at risk? (hint think about the causal chain and pathways)
How could this intervention affect health inequities?
Responsiveness to vulnerable populations
How will you improve the health outcomes and reduce health inequities experienced by the population at risk?
Is there an evidence-based standard or practice that would reduce the burden of this problem? If so, is it being employed to reduce or eliminate the inequity?
Reviewing and Refining your Intervention
How could this intervention affect inequities?
What might be the unintended consequences?
What will you do to make sure the intervention does reduce inequities?
How will you know if inequities have been reduced?
*Based on tool used by New Zealand Ministry of Health

21. Davidson County Motor Vehicle Collision Fatality Rates

22. TAKING PUBLIC TRANSPORTATION TO WORK

23. TEEN SMOKERS