6/25/2013
ADDRESSING HEALTH INEQUITIES –
THE ROLE OF LOCAL HEALTH
DEPARTMENTS IN MINNESOTA
Melanie Peterson-Hickey, PhD
Kim Edelman, MPH
Minnesota Center for Health Statistics
Minnesota Department of Health
Agenda
• Demonstrate the differences between health disparities,
social determinants of health (SDOH) and health inequity
(HI).
• Discuss how public health can move from “downstream”
to an “upstream” approach.
• Present results from our RWJF funded health equity
project with LHDs.
• Highlight the challenges and barriers to initiating and
sustaining health equity efforts at the local level.
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HEALTH DISPARITIES
Definition
Health Disparity
of disease and other
health status
indicators between
different population
groups (e.g. race,
age, gender).
8.0
Rate per 1,000 births
• Differences in burden
Infant Mortality Rate by Group
10.0
8.9
6.0
5.0
4.0
2.0
0.0
Group A
Group B
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Health Disparity
of disease and other
health status
indicators between
different population
groups (e.g. race,
age, gender).
8.0
Rate per 1,000 births
• Differences in burden
Infant Mortality Rate by Group
10.0
8.9
Disparity
6.0
5.0
4.0
2.0
0.0
Group A
Group B
DETERMINANTS OF
HEALTH
Definition
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Determinants of Health
Source: Dalhgren & Whitehead, 1991
Social Determinants of Health
External
environments and
conditions that
contribute to health
or lack of health.
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Examples of Social Determinants of Health
SDOH Category
Example
Socio/Cultural/Environmental
Income
Living/Working Conditions
Employment
Social/Community Networks
Family
Structure
Health Status
(e.g. infant
mortality)
HEALTH INEQUITY
Definition
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Health Inequity
• A health inequity is a health disparity that is the result of
social determinants of health that are systemic and
avoidable – and thus unjust and unfair (Unnatural
Causes).
Health
Disparity
Health
Inequity
SDOH
Health Inequity:
Diabetes by Income Level, Minnesota 2010
Have you ever been told by a doctor that you
have diabetes?
25
Percent
20
19.1
15
9.4
10
8.2
6.7
5
4.4
0
Less than
$15,000
$15,00024,999
$25,000$35,00034,999
49,999
Income Category
$50,000+
Source: CDC Behavioral Risk Factor Surveillance System
Percentages are weighted to population characteristics.
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HEALTH EQUITY
Definition
Health Equity
• A health equity is achieved when every person has the
opportunity to "attain his or her full health potential" and
no one is "disadvantaged from achieving this potential
because of social position or other socially determined
circumstances."
Inequity
Equity
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Health Equity: Equal Health regardless of SDOH
Have you ever been told by a doctor that you
have diabetes?
25
Percent
20
15
10
5
4.4
4.4
Less than
$15,000
$15,00024,999
4.4
4.4
4.4
0
$25,000$35,00034,999
49,999
Income Category
$50,000+
Health Equity: Improve SDOH to
Improve Health
Percentage of incoming ninth graders who
graduate in four years from a high school with a
regular degree
100 Percent
100
80
60
40
20
0
2005
2010
2015
2020
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HEALTH EQUITY –
UPSTREAM EFFORTS
Definition
Framework
Emerging PH Practice
Current PH Practice
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Examples of Upstream Efforts
• Partner with county, community-based agencies and
religious and neighborhood improvement organizations to
build community capacity in low-income neighborhoods
that will result in high career expectations of youth
• Engage in a living wage campaign through coalition
building and outreach
• Promote policies based on the science of early childhood
development by building a policy agenda, organizing
support at the community level and monitoring policy
changes and childhood outcomes
Key Components of Health Equity Work
• Clearly defined and commonly understood definitions
• Prioritizing health equity (HE) through organizational
•
•
•
•
statements (e.g. vision, mission, statements of values)
Using data as a basis for HE work (e.g. conducting
assessment, linking SDOH and disparities)
Building community and partnerships (e.g. engagement,
mobilization, support)
Policy emphasis (e.g. legislative efforts, advocating for
policy)
Providing resources (e.g. allocation of funds, building staff
capacity)
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HEALTH EQUITY PROJECT
Project
• Examined the extent to which local health departments in
Minnesota engage in activities to reduce health inequities
and their capacity to do so.
• Our goals:
• To increase the understanding of capacity and current efforts of
Minnesota Local Health Departments to address health inequities.
• To introduce new health inequity measures into Minnesota’s annual
local public health reporting system.
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Methods
• Document Review
• Key Informant Interviews
• Health Inequity Survey
Key Informant Interviews
• Purpose
• Determine general understanding of terms health disparities, health
inequities and social determinants of health and help shape survey
questions
• Interviews
• Eight interviews conducted: four local public health directors, two
former local public health directors, one state agency staff and one
group of local public health staff.
• Geography and governance and structure type were used to select
interview candidates.
• Interviews took place in person and over the phone and were about
30 minutes in length.
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Health Inequity Survey
• Developed using key informant interview
findings and existing health equity surveys
and materials.
• Piloted with MN Research to Action
Network and local public health
representatives.
• Survey administered late 2012 and early
2013.
• Health Inequity Survey included 21
questions – 9 opened ended questions.
Health Equity Themes and Survey Focus
Areas
• Clear and consistent understanding of terms
(Health Disparity, SDOH, Health Equity).
• Prioritization of health disparities and health
inequities with LHDs.
• Understanding and use of data to document
HD, SDOH, and HE.
• Authentic community partnerships.
• Efforts to move health inequity policy at local,
state national levels.
• Commitment of resources to HE work.
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Health Inequity Survey Respondents
• 77 surveys sent out, 62 responded
• The response rate was 80 percent.
• The respondents were evenly dispersed through Minnesota.
• Most respondents work in public health agencies with only a few
working within a human service agency or a health and human
service agency.
• About 70 percent of the respondents were either directors or administrators of their agencies. Map of Respondents
Participating
Counties
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RESULTS
Defining Health Equity
• Respondents had a better understanding of the terms health
disparities and social determinants of health and less of an
understanding of health inequities.
• Respondents were more likely to use the terms health
disparities and SDOH in their local health department (LHD)
than health inequities.
• Respondents indicated that racial/ethnic groups, low income,
and elderly were their most common disparate populations.
• Income, housing, employment and access to care were the
most common SDOH mentioned by respondents.
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Examples of Health Inequities
• Employment and Education
• Higher rates of respiratory disease linked to some of the housing
for lower income people.
• Access to dental care – less for lower income populations.
• Not enough jobs that pay a living wage with health insurance benefits. • Racism and Stress
• Higher rates of overweight and obesity in low income areas due to
increased stress – less access to affordable high quality food and
less opportunities for safe physical activity
Prioritizing Health Equity
• Between 22 and 34 percent of the respondents indicated
that health disparities, SDOH and HE were in their local
health department’s organizational statements.
• LHDs were more likely to place very high or high priorities
on planning and assessment activities.
• Allocating departmental funds, training and technical
assistance for staff and applying for or receiving grants
were less of a priority for LHDs.
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Using Data to Assess Health Equity
• Over 50 percent of respondents used data to document
health inequities in their communities.
• LHDs are actively involved in using data to describe and
link health outcomes and social determinants of health,
compile data on health resources/threats, and identify
subgroups affected by SES and environmental factors.
• LHDs were less likely to identify and assess
environmental health threats (e.g. air or water quality)
Building Partnerships and Community
• Community knowledge, strengths and resources for HE
work were strongly recognized among respondents.
• Respondents indicated that they were familiar with the
needs values, concerns and resources of communities.
• LHDs were less likely to
• Promote community’s analysis and advocacy of HE policies
• Have strategies in place to mobilize community groups and support
the work of community groups.
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Building Partnerships and Community
• LHDs were more likely to partner or take the lead in
partnering with local government, schools, hospitals,
community organizations and state government.
• They were less like to partner with environmental and
conservation organizations, tribal organizations and
community health centers.
Policy Involvement
• Respondents were more likely to be involved in the
following HE policy activities:
• Assessment
• Education of elected officials and local board of health
• Advocating for SDOH
• They were less likely to:
• Develop HE plans
• Prepare issue briefs
• Take public policy position (e.g. testify at the legislature)
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Summary of Findings
• There is not a shared or common understanding of health equity
terminology and programming.
• The majority of HI activities were focused on individuals and less
on upstream prevention
• LHDs encounter challenges to addressing health disparities and
health inequities including funding, staffing, political support and
lack of data at the local level.
• There are ranges of type and intensity of health equity activities
among LHDs in Minnesota.
Next Steps
• Develop a common understanding of health equity
terminology and programming.
• Provide better data for documenting health inequities at
the local level.
• Provide support to LHDs to successfully implement
health equity activities (e.g. examples of health equity
activities).
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Next Steps
• Technical assistance and support is needed for:
• Prioritizing health equity in LHDs
• Placing data at the center of a health equity activity
• Building authentic partnerships
• Organizing and mobilizing communities
• Realigning resources to support health equity activity
Last Thoughts
• The opportunity for health begins before the need for
medical care, in our homes, families, communities, work
and environments.
• Equal opportunity for health means equal opportunity in
education, employment, housing, access to health care,
living free from stress and racism and the opportunity for
building cultural and community resilience.
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“Interventions to improve access to medical care
and reduce behavioral risk have only limited
potential for success if the larger societal and
economic context in which people live is not
improved.”
Institute of Medicine
QUESTIONS
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Acknowledgements
• Robert Wood Johnson Foundation
• Practice Based Research Network in Public Health: 2011 Research
Acceleration and Expansion Supplement Series Administrative
Supplement-Diversity and Methodology
• The Public Health Practice‐Based Research Networks
National Coordinating Center at the University of
Kentucky College of Public Health
• The Minnesota Public Health Research to Action Network
• The Minnesota Department of Health, Office of
Performance Improvement
Contact Information
• Melanie Peterson-Hickey, PhD
• Senior Research Scientist
• Minnesota Center for Health Statistics, MDH
• 651-201-5949
• [email protected]
• Kim Edelman, MPH
• Senior Epidemiologist
• Minnesota Center for Health Statistics, MDH
• 651-201-5944
• [email protected]
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