SOC101: Introduction to Sociology

Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health. Achieving this requires ongoing societal efforts to:

• Address historical and contemporary injustices;
• Overcome economic, social, and other obstacles to health and health care; and
• Eliminate preventable health disparities. [1,2]

To achieve health equity, we must change the systems and policies that have resulted in the generational injustices that give rise to racial and ethnic health disparities. Through its CORE strategy, the U.S. Centers for Disease Control and Prevention (CDC) is leading this effort in the work we do on behalf of the nation's health and the work we do internally as an organization.

Preventable Health Disparities

Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health experienced by populations disadvantaged by their social or economic status, geographic location, and environment.[1] Many populations experience health disparities, including people from some racial and ethnic minority groups, people with disabilities, women, people who are LGBTQI+ (lesbian, gay, bisexual, transgender, queer, intersex, or other), people with limited English proficiency, and other groups.

Across the country, people in some racial and ethnic minority groups experience higher rates of poor health and disease for a range of health conditions, including diabetes, hypertension, obesity, asthma, heart disease, cancer, and preterm birth, when compared to their White counterparts. For example, the average life expectancy among Black or African American people in the United States is four years lower than that of White people.[3] These disparities sometimes persist even when accounting for other demographic and socioeconomic factors like age or income.

Communities can prevent health disparities when community- and faith-based organizations, employers, healthcare systems and providers, public health agencies, and policymakers work together to develop policies, programs, and systems based on a health equity framework and community needs.

Factors Affecting Health Equity (Social Determinants of Health)

Social determinants of health are the conditions in the places where people live, learn, work, play, and worship that affect a wide range of health risks and outcomes. Long-standing inequities in six key areas of social determinants of health are interrelated and influence a wide range of health and quality-of-life risks and outcomes. Examining these layered health and social inequities can help us better understand how to promote health equity and improve health outcomes.

Social and Community Context (including Discrimination and Racism)

A person's social and community context includes their interactions with the places they live, work, learn, play, and worship and their relationships with family, friends, co-workers, community members, and institutions.[4] 

Interventions are critical to protecting the health and well-being of people who do not get the level of support they need to thrive in their social and community context. For example, children of incarcerated or detained parents may gain from their parents' participation in reentry programs that assist with job placement or offer parenting support,[5] and lesbian, gay, or bi-sexual high school students who are bullied would benefit from school-based programs to reduce violence and prevent bullying.[6]

Social and community context also includes discrimination – or the unfair treatment of people or groups based on characteristics such as race, gender, age, or sexual orientation. Discrimination exists in many systems in society, including those meant to protect well-being or health, such as health care, housing, education, criminal justice, and finance.[7] Discrimination often has a negative effect on the people and groups who experience it, and some people who belong to groups that historically have experienced discrimination, such as people with disabilities, people experiencing homelessness, and people who are incarcerated or detained. As a result, people who have experienced discrimination may be affected by layered health and social inequities.

A growing body of research shows that racism has occurred for centuries at many levels in society in the United States and has had a negative impact on communities of color.[8] Racism is a system, supported and maintained through institutional structures and policies, cultural norms and values, and individual behaviors.[9] There are various forms of racism that – for more than 400 years – have defined and created most of the inequitable structures that exist in our society and lead to health inequities today.

The three types of racism include:

• Structural, Institutional, or Systemic Racism: Differential access to the goods, services, and opportunities of society by race
  
  
• Personally-mediated or Interpersonal Racism: Prejudice (differential assumptions) and discrimination (differential actions) by individuals towards others
  
  
• Internalized Racism: Acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth[10]

Racism determines opportunity based on how people look or their skin color. It also shapes social and economic factors that put some people from racial and ethnic minority groups at increased risk for negative mental health outcomes, health-related behaviors, and chronic and toxic stress or inflammation.[11],[12] Racism prevents millions of people from attaining their highest level of health and, consequently, affects our nation's health.

Healthcare Access and Use

People with disabilities and people from some racial and ethnic minority groups, rural areas, and White populations with lower incomes are more likely to face multiple barriers to accessing health care.[13][14] For example, structural barriers related to socioeconomic status, such as lack of insurance,[15] transportation, childcare, or the ability to take time off work, can make it hard to go to the doctor. Cultural differences between patients and providers and language barriers affect patient-provider interactions and health care quality.[16] Inequities in treatment[17] and historical events, like the Tuskegee Study of Untreated Syphilis in the African American Male and sterilization of American Indian women without their permission, might also explain why some people from racial and ethnic minority groups do not trust healthcare systems and the government's health-related guidance.[18],[19],[20],[21]

Neighborhood and Physical Environment

People from racial and ethnic minority groups are disproportionately affected by difficulties finding affordable and quality housing. The practice of redlining or denying mortgages among people of color – and, as a result, access to public transportation, supermarkets, and health care – has contributed to the segregation of cities in the United States.  Although the U.S. Federal Government has enacted legislation since the 1970s to reduce the segregation of cities,[22] this historical discriminatory practice has limited housing options among racial and ethnic minority groups to neighborhoods and residences that have school districts with inadequate funding, higher crime rates, and poorly resourced infrastructure. These conditions may make illnesses, diseases, and injuries more common and more severe among these groups. In addition, these groups may have limited access to nutritious, affordable foods and experience more environmental pollution within their neighborhoods.[23],24]

Workplace Conditions

Not all workers have the same risk of experiencing a work-related health problem, even when they have the same job. Occupational health inequities are avoidable differences in work-related disease incidence, mental illness, or morbidity and mortality that are closely linked with social, economic, and/or environmental disadvantage, such as temporary work arrangements, socio-demographic characteristics (e.g., age, sex, gender identity, race, or class), and organizational factors (e.g., lack of worker safety measures, limited or no health insurance benefits).

Education

People who have been historically marginalized, such as people from racial and ethnic minority groups, people with disabilities, and people with lower incomes, are disproportionately affected by inequities in access to high-quality education. [13][14] Policies that link public school funding to the tax base of a neighborhood limit the resources available in schools of lower-income neighborhoods. This results in lower-quality education for lower-income residents, leading to lower literacy and numeracy levels, lower high school completion rates, and barriers to college entrance. In addition to educational barriers, limited access to quality job training or programs tailored to the language needs of some racial and ethnic minority groups may limit future job options and lead to lower-paying or less stable jobs.

Income and Wealth Gaps

People from some racial and ethnic minority groups and other historically marginalized groups also face greater challenges in getting higher-paying jobs with good benefits due to less access to high-quality education,[25] geographic location, language differences, discrimination, and transportation barriers. People with limited job options often have lower incomes, experience barriers to wealth accumulation, and carry greater debt. The historical practice of redlining and denying mortgages to people of color has also created a lack of opportunity for home ownership and, thus, wealth accumulation due to the inability to pass down property and build wealth. Such financial challenges may make managing expenses, paying medical bills, and accessing affordable quality housing, education, nutritious food, and reliable childcare difficult.

OHE's Role in CDC's CORE Commitment to Health Equity

The CDC is transforming its public health research, surveillance, and implementation science efforts to expand beyond listing the markers of health inequities to identifying and addressing the drivers of these disparities. Through the CORE strategy, CDC is integrating health equity as a foundational element across our work – from science and research to programs, partnerships, and workforce. As part of the initiative, CDC's Office of Health Equity (OHE) has adopted four CORE goals.

1. Cultivate Comprehensive Health Equity Science

CDC's Office of Health Equity (OHE) will facilitate and accelerate health equity principles' adoption across CDC programs, policies, data systems, and funding structures.

OHE is working to:

• Standardize health equity language and principles.
• Establish standards in health equity data collection.
• Provide guidance on analyzing and using data to assess health equity and manage public health programs.
• Incorporate health equity principles and data collection standards into Notice of Funding Opportunities that support research and non-research public health programs at the state and local levels.

Potential Impact: National, state, local, tribal, and territorial public health staff will have a better understanding of health equity, the increased capacity to use data to integrate health equity into public health systems and interventions, and ultimately eliminate health disparities in the communities they serve.

Goal in Action: CDC's CORE Commitment to Health Equity Science and Intervention Strategy

2. Optimize Interventions

CDC's Office of Health Equity (OHE)/Office of Women's Health will collaborate with partners to address and reduce the impact of gender discrimination and gendered racism in the workplace.

OHE is collaborating with internal and external partners to:

• Provide input to a national survey to assess the status and impact of gender discrimination and gendered racism in the U.S. population.
• Compile and communicate strategies, policies, and best practices intended to reduce gender discrimination and gendered racism in the workplace.
• Develop and implement strategies for strengthening organizational capacity to achieve and sustain systems changes that promote health equity in the workplace.

Potential Impact: Systems changes will occur in the workplace, including workplaces that set the standard for gender equity best practices, that decrease experiences of gender discrimination and gendered racism, and ultimately, improve mental and physical health among people of all gender identities.

Goal in Action: Evaluation of data on perceptions and experiences of gender discrimination and gendered racism in the workplace.

3. Reinforce and Expand Robust Partnerships

CDC's Office of Health Equity (OHE) will mobilize partners to develop and implement strategies addressing health disparities and long-standing inequities, including social determinants of health.

OHE is providing guidance and support to partners who respond to public health needs to:

• Develop partners' capacity to work with CDC to address health inequities, health disparities, and structural and social determinants of health in response to public health crises.
• Design new, or evaluate and refine existing, evidence-based strategies that address health equity and long-standing health disparities and inequities; and develop guidance for implementation of these strategies in diverse communities.

Potential Impact: CDC partners will be engaged and ready to respond to public health emergencies and address long-standing health inequities, health disparities, and structural and social determinants of health.

Goal in Action: National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and Ethnic Minority Populations and Rural Communities

4. Enhance Capacity and Workforce Engagement

CDC's Office of Health Equity (OHE) will transform the public health workforce to ensure diversity and health equity competencies in existing and future staff.

OHE collaborates with internal and external partners to:

• Expand access to undergraduate student internships by linking CDC Undergraduate Public Health Scholars (CUPS) grantees with state, local, and community partners interested in hosting students or establishing pipeline programs.
• Integrate competencies of health equity as well as racism and health into the CDC and public health workforce.

Potential Impact: National, state, local, tribal, and territorial public health agencies will have increased opportunities to support underserved undergraduate students and the current public health workforce by learning how to integrate health equity competencies into public health work. Ultimately, we will create a public health workforce that reflects the communities we serve and is responsive to the country's changing demographics.

Goal in Action: CDC OHE Student Programs

What You Can Do to Promote Health Equity

As a community member or member of an organization, you can join the effort to ensure that all people have equitable access to resources to maintain and manage their physical and mental health, including easy access to important information, goods and services, and affordable medical and mental health care. Community- and faith-based organizations, employers, healthcare systems and providers, public health agencies, policymakers, and others play a key part in promoting fair access to health, improving opportunity, and ensuring all communities can thrive.

Communities Can Promote Health Equity by Adopting Policies, Programs, and Practices That:

• Support equitable access to quality and affordable health and other social services (e.g., education, housing, transportation, child care) and accessibility within these services.
• Recognize, respect, and support the diversity of the community they serve.
• Partner with trusted messengers and community health workers/promotores de salud to share clear and accurate information tailored to a community's languages, literacy levels, and cultures.
• Include community engagement efforts that can help strengthen partnerships between community members and public health entities, build trust, and promote social connection.
• Engage trusted leaders known by the community and who share the same race and ethnicity, sexual orientation, and cultural or religious beliefs as the community to share information, collect input, or conduct outreach.[24]
• Use clear, easy-to-read, accurate, transparent, and consistent information from a reputable, locally and culturally relevant source in terms of language, messaging, tone, images, and format.[24] Information should be suitable for diverse audiences, including people with disabilities, limited English proficiency, low literacy, or people who face other challenges accessing health information.

Below are examples of additional actions that organizations and agencies can take to support health equity.

Community and Faith-Based Organizations Can:

• Help connect people with healthcare providers, goods (e.g., healthy foods, temporary housing), and services to meet their physical, spiritual, and mental health needs.
• Work with others to address misinformation, myths, and lack of access to appropriate resources. This might include working with trusted local media, local public health departments, or community members to share information or community insights that help connect individuals to resources and free or low-cost services.

Employers Can:

• Train employees at all levels of the organization to identify and interrupt all forms of discrimination; provide them with training in implicit bias.
• Establish and maintain equitable leave policies that are fair and flexible to meet the needs of all employees.

Healthcare Delivery Systems Can:

• Deliver all health-related services in a culturally appropriate way and according to the needs of patients. This may include providing the necessary patient support (e.g., translator, patient navigators).
• Ensure providers show awareness of and respect for culture when providing care.
• Collect and report race and ethnicity data on all patients and educate staff and patients on why this information is important in ensuring populations receive equitable access to care.

Public Health Agencies Can:

• Build partnerships with different sectors (e.g., community- and faith-based organizations, racial and ethnic minority-serving organizations, tribal communities, school and transportation systems, scientific researchers, and professional organizations) and community members to share information and collaborate to advance health equity in communities.
• Address misunderstandings about why people are being asked for personal information, including race and ethnicity, and why this information is important to allocate resources and information sharing to people who need it most.

State, Tribal, Local, and Territorial Governments Can:

• Explore options to provide free or low-cost broadband Internet access so people can use telehealth and get information on health care and social services.
• Reassess policies that create barriers for healthcare providers to collect and report data on race, ethnicity, and social determinants of health.
• Partner with public health agencies to evaluate current and proposed transportation, housing, community development, and more policies for their impacts on health, using a Health in All Policies framework. Prioritize health for communities experiencing health disparities in all policy changes.
• Explore options to protect renters from evictions.
• Work to expand childcare service options.
• Increase public transportation services (e.g., free access to city bike programs).

References

1. Office of Disease Prevention and Health Promotion. (2021, August 11). Healthy People 2020: Disparities. U.S. Department of Health and Human Services. Retrieved August 13, 2021, from https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities.
   
   
2. Braveman P, Arkin E, Orleans T, Proctor D, & Plough A. (2017, May 17). What is health equity? And what difference does a definition make? Robert Wood Johnson Foundation. https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html.
   
   
3. Centers for Disease Control and Prevention. Impact of Racism on our Nation's Health. 2021 [cited 2021 Nov 12]. available from https://www.cdc.gov/healthequity/racism-disparities/impact-of-racism.html.
   
   
4. DHHS Office of Disease Prevention and Health Promotion. Healthy People 2030: Social and Community Context. Retrieved April 21, 2022 from https://health.gov/healthypeople/objectives-and-data/browse-objectives/social-and-community-context.  
   
   
5. DHHS Office of Disease Prevention and Health Promotion. Healthy People 2030: Reduce bullying of lesbian, gay, or bisexual high school students - LGBT05. Retrieved April 27, 2022 from https://health.gov/healthypeople/objectives-and-data/browse-objectives/lgbt/reduce-bullying-lesbian-gay-or-bisexual-high-school-students-lgbt-05. 
   
   
6. DHHS Office of Disease Prevention and Health Promotion. Healthy People 2030: Reduce the proportion of children with a parent or guardian who has served time in jail - SDOH05. Retrieved April 27, 2022 from https://health.gov/healthypeople/objectives-and-data/browse-objectives/social-and-community-context/reduce-proportion-children-parent-or-guardian-who-has-served-time-jail-sdoh-05. 
   
   
7. American Psychological Association (2019, October 31). Discrimination: What it is, and how to cope. Retrieved March 21, 2022 from https://www.apa.org/topics/racism-bias-discrimination/types-stress.
   
   
8. DHHS Office of Disease Prevention and Health Promotion. Discrimination | Healthy People 2020. Retrieved March 21, 2022 from https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/discrimination.
   
   
9. Center for the Study of Social Policy. (2019, September). Key equity terms and concepts: A glossary for shared understanding. Retrieved July 29, 2021, from https://cssp.org/resource/key-equity-terms-and-concepts-a-glossary-for-shared-understanding.
   
   
10. Jones CP. Levels of Racism: A Theoretic Framework and a Gardener's Tale. Am J Public Health. 2000;90: 1212-1215. https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.90.8.1212.
    
    
11. Paradies Y. A systematic review of empirical research on self-reported racism and health. Int J Epidemiol. 2006; 35(4):888–901. DOI: https://doi.org/10.1093/ije/dyl056.
    
    
12. Simons RL, Lei MK, Beach SRH, et al. Discrimination, segregation, and chronic inflammation: Testing the weathering explanation for the poor health of Black Americans. Dev Psychol. 2018;54(10):1993-2006. DOI: https://doi.org/10.1037/dev0000511.
    
    
13. Krahn GL, Walker DK, Correa-De-Araujo R. Persons with disabilities as an unrecognized health disparity population. Am J Public Health. 2015;105 Suppl 2(Suppl 2):S198-S206. doi:10.2105/AJPH.2014.302182
    
    
14. Baah FO, Teitelman AM, Riegel B. Marginalization: Conceptualizing patient vulnerabilities in the framework of social determinants of health-An integrative review. Nurs Inq. 2019;26(1):e12268. doi:10.1111/nin.12268
    
    
15. Berchick ER, Barnett JC, and Upton RD. Current Population Reports, P60-267(RV), Health Insurance Coverage in the United States: 2018, U.S. Government Printing Office, Washington, DC, 2019.
    
    
16. Institute of Medicine (US) Committee on the Consequences of Uninsurance. Care Without Coverage: Too Little, Too Late. Washington (DC): National Academies Press (US); 2002. DOI: https://doi.org/10.17226/10367.
    
    
17. Institute of Medicine. 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press. DOI: https://doi.org/10.17226/10260.
    
    
18. U.S. National Library of Medicine. Native Voices: Timeline: Government admits forced sterilization of Indian Women [online]. 2011 [cited 2020 Jun 24]. Available from: https://www.nlm.nih.gov/nativevoices/timeline/543.html.
    
    
19. Novak NL, Lira N, O'Connor KE, Harlow SD, Kardia SLR, Stern AM. Disproportionate Sterilization of Latinos Under California's Eugenic Sterilization Program, 1920-1945. Am J Public Health. 2018;108(5):611-613. DOI: https://dx.doi.org/10.2105%2FAJPH.2018.304369.
    
    
20. Stern AM. Sterilized in the name of public health: race, immigration, and reproductive control in modern California. Am J Public Health. 2005 Jul;95(7):1128-38.  DOI: https://dx.doi.org/10.2105%2FAJPH.2004.041608.
    
    
21. Prather C, Fuller TR, Jeffries WL 4th, et al. Racism, African American Women, and Their Sexual and Reproductive Health: A Review of Historical and Contemporary Evidence and Implications for Health Equity. Health Equity. 2018;2(1):249-259. DOI: https://dx.doi.org/10.1089%2Fheq.2017.0045.
    
    
22. Njoku, A., Joseph, M., & Felix, R. (2021). Changing the Narrative: Structural Barriers and Racial and Ethnic Inequities in COVID-19
    Vaccination. International journal of environmental research and public health, 18(18), 9904. DOI: https://doi.org/10.3390/ijerph18189904.
    
    
23. Krieger, J., & Higgins, D. L. (2002). Housing and health: time again for public health action. American journal of public health, 92(5), 758–768. DOI: https://doi.org/10.2105/ajph.92.5.758. 
    
    
24. Swope, C. B., & Hernández, D. (2019). Housing as a determinant of health equity: A conceptual model. Social science & medicine (1982), 243, 112571. DOI: https://doi.org/10.1016/j.socscimed.2019.112571.
    
    
25. The Annie E. Casey Foundation. Unequal Opportunities in Education [online]. 2006 [cited 2020 Jun 24]. Available from: https://www.aecf.org/m/resourcedoc/aecf-racemattersEDUCATION-2006.pdf.
    
    
26. Centers for Disease Control and Prevention. A Guide for Community Partners-Increasing COVID-19 Vaccine Uptake Among Racial and Ethnic Minority Communities [online]. 2021 [cited 2021 Nov 12]. Available from: https://www.cdc.gov/vaccines/covid-19/downloads/guide-community-partners.pdf. 

Source: Centers for Disease Control and Prevention, https://www.cdc.gov/healthequity/whatis/index.html
This work is in the Public Domain.