Social Determinants of Health and Reducing Health Inequity in Behavioral Health

We are now in a time in history that is more medically and technologically advanced than ever before. Despite this fact, however, vast sectors of the population in the US and abroad aren’t reaping the benefits of all that modern healthcare has to offer. This is most often a result of health inequity.

The CDC defines health equity as when everyone has the opportunity to be as healthy as possible. Health inequity, by contrast, represents systemic issues concerning healthcare access and the distribution of resources. The causes of health inequity are most often unjust and simultaneously avoidable. Health inequity not only affects an individual’s overall quality of life, but has a society-wide and even global impact.

Those working to further improve health equity and narrow the health gap must take a look at complex and overlapping data from a variety of sources in order to have a fuller view of this vast issue. This need for intersectionality when addressing healthcare concerns is why prominent healthcare organizations push for what is called Health in all Policies, or HiaP. Countries, states and cities that have enacted policies using the principles of HiaP have seen improved health and quality of life in their communities as a result of their efforts. Health equity is possible and we have the power to level the playing field with a concerted effort and the right data to inform actionable plans.

Health Inequity Around the World

When it comes to global health issues, the statistical information available is immensely sobering. While countless private organizations and governmental agencies are working hard to combat issues related to health inequity globally, there is still a long way to go, and countries facing issues of economic struggle, malnutrition and poor healthcare services are hit the hardest. Let’s examine just one specific issue in-depth to learn more. 

According to the World Health Organization, 15,000 children under the age of five die every day globally on average. The number of such deaths decreased from 12.6 million in 1990 to 5.3 million in 2018. This, of course, is cause for hope, but the grim statistics illustrate how the various intersection factors affecting health equity disproportionately affect those in populations struggling from multiple sides.

When it comes to this particular set of statistics, children from Sub-Saharan Africa and Central and Southern Asia are at high risk, accounting for 80 percent of the under-five deaths in 2018. Many of these deaths can be attributed to preventable and/or treatable ailments, such as pneumonia, diarrhea and malaria. In these populations, however,  where malnutrition, unsafe drinking water and other unsafe conditions are common, ailments that are not as severe of an issue to children in places with more resources, become extremely deadly.

WHO’s response to this issue is as follows: “Moving from ‘business as usual’ to innovative, multiple, and tailored approaches to increase access, coverage, and quality of child health services will require strategic direction and an optimal mix of community and facility-based care. Health sector and multisectoral efforts are also needed to overcome the inequalities and the social determinants of health.” 

According to WHO, other major indicators of health inequity include:

  • Maternal mortality– 99 percent of yearly maternal deaths occur in the developing world
  • Tuberculosis– 95 percent of TB deaths occur in the developing world
  • Shorter life expectancy– low-income countries can have an average life expectancy up to 34 years lower than high-income countries
  • Premature deaths due to noncommunicable diseases– families from low and middle income countries are unable to keep up with the healthcare costs associated with NCDs, accounting for 87 percent of these deaths

The principles of HiaP would dictate solving problems such as these from multiple angles, such as increasing access to clean drinking water, providing adequate sources of nutrition and increasing access to educational and occupational opportunities.

Not all helpful solutions, however, come from such large-scale interventions. Even the spreading of information can have a huge impact on long-term outcomes for those in high-risk communities. In Bangladesh, for example, where cholera is a common health concern, a study was conducted whereby households were taught how to use four layers of old sari material to filter water. This was a simple and free way for residents to have safer water and is effective in removing 99 percent of cholera bacteria from the water. Upon follow-up, cholera incidents went down by half in these households when compared to the control group.

Health inequities not only lead to higher mortality rates and reduced quality of life on an individual level, but their societal-wide impact also slows economic growth, productivity and overall development. It is in everyone’s best interest, from the small scale to the large, to invest time, energy and effort into improving global health equity. 

Health Inequity in the U.S.

While the U.S. is far from a developing country, it still struggles with an abundance of issues concerning health inequity. In the U.S., there are large disparities in healthcare access and outcomes across the board when looking at all of the various intersectional factors at play. The most common indicators of these disparities are often race/ethnicity and socioeconomic status.

The Centers for Disease Control and Prevention is working towards gaining a better understanding of these factors and how to improve them. In 2013, the CDC released its second Health Disparities & Inequalities Report addressing such concerns. The introduction to the report states in part:

“Data from the REACH U.S. Risk Factor Survey of approximately 30 communities in the United States indicate that residents in mostly minority communities continue to have lower socioeconomic status, greater barriers to health-care access, and greater risks for, and burden of, disease compared with the general population living in the same county or state.”

Some examples of the major issues in health equity faced by those in the US include:

  • Access to healthier food retailers– estimates say between 30-40 percent of Americans do not have easy access to retailers that offer fresh fruits and vegetables, with those in rural areas being most affected.
  • HIV– According to the WHO African Americans make up half of all new HIV infections, despite comprising just 13 percent of the US population
  • Diabetes– Diabetes incidence rates have been on the rise since the 1990s and are affected by race, ethnicity, and socioeconomic status
  • Obesity– On the rise since the 1960s, large disparities in obesity rates exist across various demographics

How Health in all Policies Can Improve Health Equity

Health in all Policies, as defined by the CDC, is a collaborative approach to policymaking which recognizes that healthcare consists of the integration of a multitude of factors that extend beyond what is traditionally thought of as healthcare. In simple terms, an overall healthy community will mean better overall health equity and therefore better healthcare outcomes. 

According to the CDC’s HiaP Guide, a healthy community provides:

  • Basic needs–  this includes transportation, housing, clean water and access to fitness and enrichment activities such as art and music
  • Healthy environment– a sustainable living environment that is clean, quiet, has access to affordable energy, green spaces and is aesthetically pleasing 
  • Economic and social development– factors include a living wage, healthy economy, job opportunities and access to high-quality education
  • Supportive social relationships-social and civic engagement, safe and supportive communities free of violence

The opportunities to improve healthcare through a HiaP lens are virtually limitless and can be used by organizations and governments across a broad spectrum of industries and specialties. 

Successful use of HiaP: A Case Study

The California Health in all Policies Task Force was established in 2010, by way of the governor’s executive order, and brought together 22 different governmental offices to analyze and better understand how to make healthcare more equitable. 

Here are just some of the departments involved in the Task Force:

  • The Department of Parks and Recreation
  • The Department of Transportation
  • The Department of Education
  • The Office of the Attorney General
  • The Labor and Workforce Development Agency
  • The Department of Housing and Community Development

The Task Force works to generate problem-solving ideas and engage and educate members of the community in and outside of governmental roles. They also develop and implement plans of action based on those ideas. 

Now, ten years after its inception, the Task Force is still active and updating its accomplishments via California’s Strategic Growth Council website. The majority of the work of the Task Force centers around bringing together collaborative groups and spreading HiaP education.

Some successes from 2019-2020 include:

  • Inspiring similar HiaP Task Forces in the US and around the world
  • The creation of Capitol Collaborative on Race & Equity (CCORE), which is now launching a new cohort program to help empower leaders to improve racial equity
  • Presenting HiaP principles to UC Berkley students to educate future generations of policymakers
  • Evaluating and improving equity in various state grants

Conclusions

Health equity is an achievable goal, but it will take a collaborative effort. Whether you are a CEO with the power to implement policies for the benefit of your company’s employees and customers, a government official who can push for and enact changes on a governmental level, or are simply acting as a citizen working to improve conditions in your own backyard, health equity is a cause all of us can contribute to. Now, more than ever, is the time to start making changes to improve health equity for all. 

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