Apply a Health Equity Lens

Introductory Paragraph

This is the first in a pair of related articles on health equity and disparities as it pertains to the field of substance use. This particular article focuses on defining health equity and introduces general resources associated with building health equity. The second article, “Addressing SUD Disparities,” focuses on various populations who more frequently encounter health inequity and avenues to increase health outcomes across these disparate populations.

Health equity is a broad term that describes the ability of everyone to have a fair and just opportunity to attain their highest level of health. The first step in understanding health equity is to recognize that the opportunity to be healthy is not equally available everywhere or for everyone in the community. This leads to a more personal understanding of the importance of increasing health equity and paves the way to addressing the root causes of health inequity. Many factors impact our ability to achieve health equity, such as our race, ethnicity, sex, gender identity, sexual orientation, disability/disease type, language, religious, socioeconomic status, health care coverage, access to healthy food, transportation, and geographic location among others. Since all of these factors are different for each of us as individuals, we all have a different opportunity to obtain health. When we are impacted by health inequity, it contributes to our quality of life, disease type, disability status, and even death.

It has been well-documented that there are differences in health outcomes for different groups of people. Populations that are more likely to experience health inequity include people of color, Native Americans, LGBTQI+ individuals, individuals with disabilities, and those with low socio-economic status. The lack of health equity and inequity has become amplified in social issues involving substance use disorder. Recently, the term has become more highly politicized; however, there is exhaustive historical research and data demonstrating clear disparities in health. It is typical for this work to become politicized because policy and funding decisions are usually intermixed with issues that impact health equity, like access to housing, environment, education for example.

Key Information

Health equity requires an active commitment to identify groups in your community that are more negatively impacted by substance use and remove obstacles that keep them from being able to achieve their greatest potential for health. This includes increasing opportunities to access care, reducing active, problematic substance use, and increasing outcomes across disparate populations.

There are two strategies embedded within health equity work. One approach is to increase access to substance use services and to increase positive health outcomes. The complementary approach is to remove barriers that cause health disparities. This requires going deeper into the root causes of intergenerational patterns and understanding the differences in values that underlie cultural behaviors. Likewise, reversing disparities that exist as a result of policy decisions that systematically disadvantage some populations over others will create new avenues for advocacy.

Key Terms

One way to understand the objectives for advancing health equity is to look at the language of this work. We can decouple the term health equity from related, but distinctly different terms, such as cultural competency, cultural humility, and the social determinants of health. Cultural competency can be understood as the foundational level. It typically involves methods for decreasing cultural offense. In communities, an example of this would be increasing the offering of materials and services in multiple languages. In contrast, cultural humility requires a higher order of understanding. It moves from an awareness of what the differences are to why the differences have caused inequity. Addressing the social determinants of health is a systems approach that provides a complex set of solutions.

Working across the continuum of care takes a systems approach. This positions our communities to take on more complex systems work, such as that associated with social determinants of health. It is difficult to work for long in the behavioral health field without bumping into multiple interrelated systems, creating a foundation to advance in the territory of social determinants of health. It is useful to realize the potential difficulties and to adjust expectations of outcome accordingly. This creates the foundation for advancing cultural competency and cultural humility in the territory of social determinants of health.

• Cultural Competence is central to each of the five phases of the Strategic Prevention Framework (SPF). See three SAFE Solutions articles titled “Collect and Share Data,” “Build Capacity,” and “Plan, Implement, and Evaluate.” Cultural Competence is defined as the ability of providers and organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of patients. A culturally competent healthcare organization seeks to understand the culture of the population served, recognizes the impact of cultural differences, fosters internal learning opportunities to improve cultural knowledge among care teams, and modifies patient care to meet the patient’s unique needs. There continues to be an increase in training in cultural competency. However, since addressing the substance use disorder epidemic is a complex problem requiring a complex and coordinated set of solutions, much of the implementation of learned skills remains superficial.

• Cultural Humility. Health equity requires more than being culturally competent. It requires an examination of our personal biases. While cultural competence can be seen as operational at the community scale, cultural humility is grounded in personal relationships. It transcends one-way communication by moving into a two-way communication, which involves suspension of judgment and active listening. For example, the commonly used term, “target population,” carries a subtle message that leads to talking at people, rather than working with them. Cultural humility shifts the focus of communication from content to engagement. An example from youth engagement can be drawn from the work of Roger Hart (1992). His “youth participation ladder” has five phases which move beyond the non-participation of tokenism:
  • Assigned, but informed
  • Consulted and informed
  • Adult-initiated with shared decision-making
  • Youth initiated and directed
  • Youth-initiated with shared adult decision-making

Building cultural humility is a very layered process and is never finished. The main point is to be aware of the different values, behaviors, and institutions of various populations and to address those respectfully and purposefully.

• Social Determinants of Health (SDOH). The CDC defines SDOH as “the nonmedical factors that influence health outcomes — the conditions in which people are born, grow, work, live, worship, and age.” Five key areas in which this work is advanced include:
  • healthcare access and quality
  • education access and quality
  • social and community context,
  • economic stability, and
  • neighborhood and built environment

Building Capacity for Health Equity

It is useful to keep in mind a common phrase in the recovery community: “Nothing about us, without us.” This speaks to the fact that there are unique needs for various populations and that the people being served should have a central voice in the planning and delivery of your coalition’s initiatives. Such a systems-change intention taps our leadership and communication skills because it requires coalitions to build meaningful partnerships, establish trust with each other and within the community, and allow for the time and space to identify shared priorities and evaluate outcomes for continuous improvement. Overall, health equity requires a focused intention to cultivate new partnerships with people from different backgrounds. A challenging task within the health equity domain is understanding the readiness of the coalition members to recognize the systemic nature of health inequity within the substance use crisis and increasing the ability of the coalition to generate the level of systemic community change that is required to address the social determinants of health. There is usually a readiness to close disparity gaps, but the ability may not be there yet. Coalitions should work towards building a plan that focuses specifically on achieving greater health equity in their community as it relates to behavioral health. A culturally competent organization seeks to understand the culture of the population served, recognizes the impact of cultural differences, fosters internal learning opportunities to improve cultural knowledge among care teams, and modifies patient care to meet the patient’s unique needs.

A few guideposts follow for community groups looking to improve their response to substance use and to make health equity a priority:

• Collect demographic data including race, ethnicity, language preference, and other indicators that track trends over a period of time and allow for comparison across different populations,
• Identify and report on disparities regularly in order to maintain accountability,
• Work in partnership with other sectors (like housing, criminal justice, education, etc.) to incorporate unique perspectives and allowing for better integration of services,
• Offer culturally and linguistically competent care (i.e. interpretation services, respecting and offering diverse dietary options),
• Situate services in geographical areas that are easily accessible to people across the entire community,
• Develop culturally competent management programs,
• Increase diversity and minority participation including those with lived experienced,
• Involve the community in the decision-making process,
• Train staff on sociocultural factors and recognition of personal biases, and
• Make health equity a priority and educate others, including policymakers.

Relevant Research

• World Health Organization. A landmark work titled “Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health,” is the final report of WHO’s Commission on Social Determinants of Health. This research set the stage for the work being done on social determinants since then.

• This article delineates a more recent assessment of research directions for SDOH.

• JUSTICE SQUARED (Just Leaders for a Just Health System) provides a library of over 5000 resources including leading research on health equity.

Impactful Federal, State, and Local Policies

• In 2023, the White House published “The U.S. Playbook to to Address Social Determinants of Health.”

• The US Department of Health and Human Services hosts the Social Determinants of Health Workgroup which includes six lead federal agencies. Its work is focused upon eight “Healthy 2030” objectives, such as reducing poverty and increasing employment and housing opportunities. This is paralleled by the Healthy 2030 Substance Use Workgroup which has and 25 measurable objectives.

• SAMHSA has examined health equity in great detail. It provides many resources that discuss how to improve cultural competence in the areas of substance use and mental health.

• The National Institute for Minority Health and Health Disparities (NIMHD) provides funding for the Health Equity Action Network (HEAN), a national consortium of health researchers and community partners.

• CDC sponsors "Health Equity in Action" which highlights the work of CDC and CDC-funded projects that work to reduce health disparities and advance health equity.

• The National Academy for State Health Policy (NASHP) focused its 2024 annual conference on health equity, promoting “whole-of-government” strategies to encourage cross-agency and system-wide collaboration in establishing policies to address health disparities Their publication, “Data Strategies to Understand and Address Health Disparities” indicates that there remains variability between states regarding data collection and analysis procedures on health equity. The NASHP report highlights examples of states which are leading in implementing data strategies.

Available Tools and Resources

• The School of Medicine at the University of California, Davis. This 2-minute video provides a quick introduction to health equity by differentiating it from the term “equality.”

• Pfizer Multicultural Health Equity Collective has published "Health Equity in Action: Optimal Interventions to Systemic Drivers of Racial Health Inequities." This action guide resulted from a summit held with partner co-conveners, including The Century Foundation, the National Minority Quality Forum, the Morehouse School of Medicine, and the National Association of County and City Health Officials. The Summit brought together thought leaders from industry, research and academic institutions, healthcare settings, advocacy organizations, and others to surface key opportunities to address racism and structural inequities that contribute to racial and ethnic healthcare disparities.

• Hawai’i Department of Health. This is an example of a training which promotes cultural humility by focusing on the connections made through cultural wisdom.

• The National Association of County and City Health Officials (NACCHO) offers a free online course titled “The Roots of Health Inequity.” This is not an “101” on health equity, but rather a useful tool for agencies ready to take an “intermediate” course requiring approximately 10 hours over a few weeks, with regular office hour support provided. The 10 modules in the course unpack the root causes of health inequity, weave the histories of public health and social justice efforts, and examine power dynamics, such as structural racism.

• Recovery Village provides a guide on how to participate in World Drug Day, an international day dedicated to raising awareness about SUDs and the importance of treatment and equitable access.

Promising Practices

• The Health Equity Advisory Team (HEAT) is a national arm of the Health Care Payment Learning & Action Network (HCPLAN). It works to identify and prioritize opportunities to advance health equity through alternative payment models (APMs). HEAT’s goal is person-centered and focuses on leveraging APMs to help make needed care more accessible, drive better patient outcomes, and reduce disparities. The team comprises a diverse group of regional and national health equity implementers and subject matter experts committed to mitigating health inequities in the nation’s health care system and applying APM design principles to intentionally address factors that drive health inequities.

• Minnesota. The Minnesota Department of Human Services (DHS) met with leaders of community-based organizations working to advance racial equity in health care and published a report titled, “Building Racial Equity into the Walls of Minnesota Medicaid.”

• Nebraska. The Winnebago Tribe operates the Winnebago Comprehensive Healthcare System which centers cultural traditions and beliefs in its work. It takes a community-focused approach to health and wellness and uses the Indigenous Social Determinants of Health.