Apply a Health Equity Lens

Introductory Paragraph

This is the first in a pair of related articles on health equity and disproportionality. This article focuses on defining health equity and introduces general resources associated with building health equity. The second article, “Addressing Disproportionality,” focuses on various populations who more frequently encounter health inequity and on avenues to increase health outcomes across disparate populations.

Key Information

Health equity is a broad term that describes the ability of all people to attain their highest level of health. It means that everyone has a fair and just opportunity for 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. It is a challenge to reverse long-standing social patterns and the successful coalition work to change the deep sources of our behavioral health crisis is on the leading edge of a complex set of tasks. It is imperative that coalitions grasp the scope of the required long-term effort and the necessary steps to ensure that aspirations of health equity are “front-loaded” into coalition building processes and not considered as an end-game add-on.

There are two strategies embedded within health equity work associated with substance use. One approach is to increase access to 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 historical institutional policy patterns and understanding the differences in values that underlie cultural behaviors.

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 and 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 communities to take on complex systems work associated with social determinants of health. It is difficult to work for long in our field multi-sectoral collaboration and without bumping into multiple inter-related systems. 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.” <Add links> 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. A few guideposts follow for community groups looking to improve their response to substance use and to make basic cultural competency a priority:
  • Collect race, ethnicity, and language preference (REAL) data
  • Identify and report disparities
  • Offer culturally and linguistically competent care (i.e. interpretation services)
  • Situate services in geographical areas that are easily accessible
  • Develop culturally competent management programs
  • Increase diversity and minority participation
  • Involve the community in decision-making

• Cultural Humility. Health equity requires more than being culturally competent and having multi-lingual resources. It requires an examination of our personal biases. This takes cultural humility. While cultural competence can be seen as operational at the community scale, cultural humility is grounded in personal relationship. It transcends the one-way communication typical of message delivery 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

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 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.”

• 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.