Promoting Equity in Health and Safety:
Frameworks and Resources to
Create Common Ground
Marilyn Metzler, RN MPH
Centers for Disease Control and Prevention
National Center for Injury Prevention and Control
Division of Violence Prevention
Making it Better Conference: Creating a Healthier Community Together
Minneapolis, MN
November 15, 2011
The findings and conclusions in this presentation are those of the author and do not necessarily represent
official views of the Centers for Disease Control and Prevention (CDC).
Many thanks to
Clare Reidy, Samantha Campillo,
Jeanne Ayers, Richard Hofrichter
and many others
who contribute to my understanding of
health equity.
Assumptions

This is the beginning of a conversation that will
continue over time

There are no easy answers

But, there is much we can learn and do together to
move toward a more equitable future
Overview

Brief overview of social determinants, health
inequities

Frameworks for organizing the concepts

Examples from public health practice

Moving to action
Health Disparity
A particular type of health difference that is closely linked with
social or economic disadvantage. Health disparities adversely
affect groups of people who have systematically experienced
greater social and/or economic obstacles to health…based on
their racial or ethnic group; religion; socioeconomic status;
gender; age; mental health; cognitive, sensory, or physical
disability; sexual orientation; geographic location; or other
characteristics historically linked to discrimination or exclusion.
The National Partnership for Action to End
Health Disparities
Health Inequities
Differences in health status between most socially
advantaged and least socially advantaged groups
caused by systematic differences in the social
conditions that influence health –
differences that are unfair and avoidable.
Health Equity
Health equity is attainment of the highest level of health for
all people. Achieving health equity requires valuing
everyone equally with focused and ongoing societal efforts
to address avoidable inequalities, historical and
contemporary injustices, and the elimination of health and
healthcare disparities.
The National Partnership for Action to End
Health Disparities
Massive, and Growing, Literature on
Health Inequities…

Disease, injury, and other health outcomes
 Chronic and infectious diseases
 Violence



Infant Mortality Rate
Life expectancy
Disproportionate health burden among groups with
greater social and economic disadvantages
 Race, Ethnicity


Socioeconomic Position
Gender

Absolute and gradient effect



Poor vs. non-poor; HS and non-HS
Gradient distribution
Over the life course and across generations


Adverse Childhood experiences (ACES)
Trans-generational

Effects of place

Observed within and across countries
How Social Determinants Impact Health:
Pathways and Mechanisms

Lack of access to material resources

Stress

Limited social support

Lower social status/discrimination

Limited inclusion in society/decision-making

Over time – life course & cross-generational effects

Interactions among these – additive effects
Massive, and Growing, Interest in Social
Determinants of Health Inequities…

WHO Commission on Social Determinants of Health

Across the U.S. and in many/most countries

Healthy People 2020

State and local health departments

Community organizations
Commission on Social Determinants of Health
Overarching Recommendations
“Social justice is a matter of life and death.”

Improve daily living conditions

Tackle the inequitable distribution of
power, money, and resources

Measure and understand the
problem and assess the impact of
action
“…foster a global movement
to achieve health equity.”
WHO CSDH
2008
Socio-ecological Model
Society
Community
Relationship
Individual
Reference: Institute of Medicine. (2003). The Future of the Public’s Health in the 21st Century. Washington, D.C.: National Academies Press. Original
source: Dahlgren G, Whitehead M. 1991. Policies and Strategies to Promote Social Equity in Health. Stockholm, Sweden: Institute for Futures Studies.
World Health Organization
Social Determinants of Health Framework
STRUCTURAL DETERMINANTS OF
HEALTH INEQUITIES
World Health Organization
Social Determinants of Health Framework
SOCIOECONOMIC
POLITICAL
CONTEXT
Governance
Macroeconomic
Policies
Social Policies
Labor market,
Housing, Land
Public Policies
Education, Health,
Social protection
Culture and
Societal value
Socioeconomic
Position
Social Class
Gender
Ethnicity (racism)
Education
Material Circumstances
(Living and Working
Conditions, Food
Availability, etc.)
Behaviors and
Biological Factors
Psychosocial Factors
Social cohesion & Social capital
Occupation
Income
STRUCTURAL DETERMINANTS OF
HEALTH INEQUITIES
Health System
INTERMEDIARY DETERMINANTS
OF HEALTH
IMPACT ON
EQUITY IN
HEALTH
AND
WELL-BEING
Some limitations of the framework…

Mixed constructs

Omits some socially disadvantaged groups

Does not account for life course influence

Does not address historical context

Omits systematic influences on structural
determinants
But, several advantages…

Helps explain how inequities are created

Can be used to develop hypotheses, pathways

Can identify where you are working

Set reasonable expectations for outcomes

Fosters a growing global conversation and
actions to address health inequities

Considers human agency
Using the Framework
To Guide Action
Social Context Module
BRFSS, REACH, NISVSS

Do you own or rent your home?

How often in the past 12 months would you say you were worried or
stressed about having enough money to pay your rent/mortgage?

How often in the past 12 months would you say you were worried or
stressed about having enough money to buy nutritious foods?

At your main job or business, how are you generally paid for the work
you do?

About how many hours do you work per week at all of your jobs and
businesses combined?

Did you vote in the 2008 presidential election?
Social Context Module Questions
Home ownership
Food insecurity
Housing insecurity
Hours worked/week
How paid
Voter participation
WHO CSDH 2008
Working Across the Silos…
Intimate Partner Violence
Women at greater risk:
 Belief in strict gender roles (e.g., male dominance and
aggression in relationships)
 Low academic achievement
 Unemployment
 Economic stress
 Poverty and associated factors (e.g., overcrowding)
HIV Among Women in the U.S.

Racial/ethnic populations disproportionately affected
by HIV/AIDS

African Americans and Hispanics make up 28% of
the U.S. population,1 yet comprise over 69% of the
cases of HIV/AIDS.2

Approximately 81% of HIV-infected women in the US
are racial/ethnic minorities.3
1.
2.
3.
US Census Bureau. USA Quick Facts 2008. Retrieved from: http://quickfacts.census.gov/qfd/states/00000.html
CDC HIV/AIDS Facts. 2009. CDC HIV/AIDS among African Americans. Retrieved from:
http://www.cdc.gov/hiv/topics/aa/resources/factsheets/pdf/aa.pdf.
CDC HIV/AIDS Fact Sheet. 2008. HIV/AIDS among women. Retrieved from:
http://www.cdc.gov/hiv/topics/women/resources/factsheets/pdf/women.pdf.
Women and HIV in the U.S.
Women at greater risk:






Intimate partner violence
Gender inequality
Low educational attainment
Economic dependency
Poverty
Residential segregation
From: Identifying and Addressing the Social Determinants of Infectious Diseases by Marian C. McDonald, DrPH, Assoc. Dir. for Minority & Women’s
Health, Division of Emerging Infections & Surveillance Services , National Center for Preparedness, Detection, and Control of Infectious Diseases, CDC.
Percent in Poverty in U.S.
by Race and Gender, 2007
30.00%
26.50%
25.00%
23.60%
22.30%
Male
Female
19.60%
20.00%
15.00%
11.60%
10.00%
10.70%
9.70%
9.40%
5.00%
0.00%
White
N=25,120
African-American
N=9,237
Hispanic
N=9,890
Asian
N=1,349
Numbers in Thousands
U.S. Census Bureau. (2007). Annual Social and Economic Supplement. Retrieved September 28, 2009, from US Census
Bureau:http://www.census.gov/hhes/www/macro/032008/pov/new01_100.htm
Female to Male Earnings Ratio and
Earnings, 1959-2008
U.S. Census Bureau. (2008). Income, Poverty, and Health Insurance Coverage in the United States, 2008.
Retrieved September 28, 2009, from http://www.census.gov/prod/2009pubs/p60-236.pdf
Metropolitan areas where African-American
females are at least twice as likely to receive highcost loans than white females
Income is No Shield, Part III. Assessing the Double Burden: Examining Racial and Gender Disparities in Mortgage Lending. National Council of
Negro Women, in partnership with the National Community Reinvestment Coalition. June 2009. Available at
http://www.ncnw.org/images/double_burden.pdf Accessed June 2, 2010.
Metropolitan areas where Hispanic females are at
least twice as likely to receive high-cost loans
than white females
Income is No Shield, Part III. Assessing the Double Burden: Examining Racial and Gender Disparities in Mortgage Lending.
National Council of Negro Women, in partnership with the National Community Reinvestment Coalition. June 2009.
Available at http://www.ncnw.org/images/double_burden.pdf Accessed June 2, 2010.
Responding to IPV and HIV
Address income, education
and occupation inequities
Shelter, food,
etc.
Healthy
relationships
Community strength to
change conditions
Provide
services,
trainings,
etc
Examples of Division of Violence
Prevention Projects to Address
Health Inequities
Emerging Activities in the
Division of Violence Prevention
Minimum
income for
healthy
living
Microfinance as primary prevention
Family
Support
Policies
Education
Funding
Building Bridges:
Community strength and PH
Roots of Health Inequities Project
Gender Inequities in Health and Safety
American Birthright project
Aligning Public Health and
Community Organizing to Achieve
Health Equity

CDC, NACCHO and Healthy Heartland/ISAIAH
partnership

Building power to change conditions for health

What each brings to the partnership

Power to Thrive meeting

Next steps
Health Equity and Public Health Leadership…
“ …the leadership
necessary for achieving
health equity must start
with a foundation for
science but ultimately will
require innovative social
strategy, abundant
political will, and supreme
interpersonal skill.”
Howard K. Koh, MD, MPH
Juleigh M. Nowinski, BS
Office of the Assistant Secretary for Health
Office of theSecretary
Department of Health and Human Services
The mission of public health is “what
we as a society do to collectively
assure the conditions in which
people can be healthy.”
Institute of Medicine.
The Future of Public Health.
Washington, DC: National
Academy Press; 1989, 2003.
“…foster a global movement
to achieve health equity.”
Thank you.
[email protected]
Resources

WHO Commission on Social Determinants of Health

Unnatural Causes: Is Inequality Making Us Sick?

National Association of City & County Health Officials

Achieving Health Equity: A Resource to Help Communities
Address the Social Determinants of Health

Healthy People 2020

APHA Spirit of 1848 caucus and list-serve

RWJ Commission to Build a Healthier America (resources)

The Spirit Level – Richard Wilkinson

Unequal Lives – Hilary Graham

Health & Social Justice – Richard Hofrichter, ed.