Intervention and Public Policy Pathways to Achieve Health Care Equity.

Health care equity reflects an equal opportunity to utilize public health and health care resources in order to maximize one's health potential. Achieving health care equity necessitates the consideration of both quantity and quality of care, as well as vertical (greater health care use by those with greater needs) and horizontal (equal health care use by those with equal needs) equity. In this paper, we summarize the approaches introduced by authors contributing to this Special Issue and how their work is captured by the National Institute of Minority Health and Health Disparities (NIMHD) framework. The paper concludes by pointing out intervention and public policy opportunities for future investigation in order to achieve health care equity.

1. Introduction

Health care equity reflects an equal opportunity to utilize public health and health care resources in order to maximize one’s health potential [1]. This potential requires equitable access to and use of preventive, diagnostic, and therapeutic services. Achieving health care equity necessitates the consideration of both quantity and quality of care, as well as vertical (greater health care use by those with greater needs) and horizontal (equal health care use by those with equal needs) equity [2]. Health care inequities may occur due to disparities in distal, transitional and proximal causes that influence health care outcomes [3]. Distal causes refer to socio-environmental factors, e.g., transportation systems, exposure to pollutions, and availability of health care providers. Transitional causes are factors that are closer to health care outcomes such as individual health behaviors. Proximal causes are the biological factors that cause disease and hinder or facilitate recovery [4,5,6]. Government officials, health care providers, community leaders, academic researchers and patients have been working on policies, interventions, and strategies to address health care inequity.

This special issue of the International Journal of Environmental Research and Public Health documents how recent or proposed policy changes and interventions affect health care equity, with emphasis on the roles of how biology, behavior, the physical/built environment, the sociocultural environment, and the health care system influence at the individual, interpersonal, community, and societal levels. Lessons learned across health care settings, geographic regions, and underserved populations are provided. The National Institute of Minority Health and Health Disparities (NIMHD) provides a research framework for understanding the multifaceted domains of influence and levels of influence within domains that facilitate changes in health care equity [7]. In this paper, we summarize the approaches introduced by authors contributing to this Special Issue (Appendix A) and how their work is captured by the NIMHD framework.

2. NIMHD Framework

The NIMHD health disparities framework (Table 1) provides a way to conceptualize the multiple ways that various categories of factors may influence health outcomes, leading to reductions or improvements in health equity [7]. It builds on the National Institute on Aging (NIA) health disparities research framework [8] by combining it with the socio-ecological model developed by Urie Brofenbrenner [9]. The NIA framework focused on the four domains that influence health disparities (biological, behavioral, environmental, and sociocultural) and NIMHD added an additional domain of health systems. Bronfenbrenner’s socioecological model conceptualized that health and human development are affected at multiple levels. These levels are individual, interpersonal (including family, school, work, social networks, churches, and health services providers), community (e.g., neighbors, social services, industry, mass media, local politics), and societal (attitudes and ideologies of the culture, policies and laws of states, regions of the country or the nation). NIMHD combined these two frameworks to form a 20-cell matrix (Table 1) where each cell describes a determinant of health equity.

Table 1

National Institute on Minority Health and Health Disparities’ Health and Health Disparities Research Framework.

		Levels of Influence *
		Individual	Interpersonal	Community	Societal
Domains of Influence (Over the Life Course)	Biological	Biological Vulnerability and Mechanisms	Caregiver–Child Interaction Family Microbiome	Community Illness Exposure Herd Immunity	Sanitation Immunization Pathogen Exposure
	Behavioral	Health Behavior Coping Strategies	Family Functioning School/Work Functioning	Community Functioning	Policies and Laws
	Physical/Built Environment	Personal Environment	Household Environment School/Work Environment	Community Environment Community Resources	Societal Structure
	Sociocultural Environment	Sociodemographics Limited English Cultural Identity Response to Discrimination	Social Networks Family/Peer Norms Interpersonal Discrimination	Community Norms Local Structural Discrimination	Social Norms Societal Structural Discrimination
	Health Care System	Insurance Coverage Health Literacy Treatment Preferences	Patient–Clinician Relationship Medical Decision-Making	Availability of Services Safety Net Services	Quality of Care Health Care Policies
Health Outcomes		Individual Health	Family/Organizational Health	Community Health	Population Health

National Institute on Minority Health and Health Disparities, 2018. * Health Disparity Populations: Race/Ethnicity, Low SES, Rural, Sexual/Gender Minority Other Fundamental Characteristics: Sex/Gender, Disability, and Geographic Region.

3. Special Issue Emphasis

Articles in this Special Issue primarily focus on two domains of influence in the NIMHD framework, i.e., sociocultural environment and the health care system. All levels of influence are considered, especially community and societal influences.

3.1. Health Equity Solutions from a Health Care Systems Approach

Considering influences at the individual level, White-Means and Osmani [10] report racial inequities in breast cancer mortality can be reduced by comprehensive health insurance coverage providing preventive care access and lower out-of-pocket costs. Wang et al. [11] also report that emphasis on increasing health insurance and patients’ knowledge about self-health would reduce inequities in patient experiences with their hospital providers.

Considering influences at the community level, Mon Kyaw Soe et al. [12] note that preventive interventions that focused on sexually transmitted infection and were administered in educational settings had a significantly positive impact on both behavioral and psychosocial outcomes; they were most effective at promoting knowledge, enhancing motivational factors, and improving behavioral skills. Yu et al. [13] report that implementing a report card program for patients undergoing total knee replacement surgery increased inequities between urban higher income and rural lower income patients because hospital selection varied based on socioeconomic status.

Considering influences at the societal level, Zhu et al. [14] use spatial analysis to posit that methods are needed to redefine equity in provider distribution, which is currently measured by equal access to providers, although some communities need greater access than others. In essence, current strategies should focus on vertical equity. In public policy planning aimed at health care equity, Wu and Tseng [15] note the importance of using geographic information system (GIS) to jointly assess geographic accessibility and equality of resource allocation, e.g., travel distance and whether travel is by public transportation or car. Population demand and supplier capacity should also be incorporated in planning. Sándor et al. [16] proposed revising human resource policy in health care systems, i.e., retirement policy, so that sufficient providers are available to forestall increases in premature mortality when provider shortages exist. Nanney et al. [17] posit that creating a climate for health system change can be based on assessing the cost of not making a change. They report that in Minnesota, if racial disparities in preventable deaths were eliminated, 475 to 812 lives would be saved each year, generating a financial savings of $1.2 billion to $2.9 billion.

3.2. Health Equity Solutions from a Sociocultural Environment Approach

Demeke et al. [18] note that sociocultural environments may influence equity in the time to and stage of treatment, as well as outcomes. They note that care must be taken in understanding differences by race and country of origin. Thus, to understand and design needed human immunodeficiency virus (HIV) prevention and control programs, one must be careful not to merge strategies developed for US-born and non-US-born blacks as though individuals in these demographic categories belong to the same group; they are not in the same group and differ in their protective characteristics. While patient–provider concordance has been a strategy for improving health outcomes, Oguz [19] found that Hispanic men have greater satisfaction with their health care when the provider is non-Hispanic. Wang et al. [20] emphasize that along with valuing clinically competent primary care health professionals, patients also value being treated respectfully and receiving clear communications from their physicians.

Considering influences at the community and societal level, Smith et al. [21] note that implementing community-based participatory research strategies, where community trust agents are engaged and community education on disease states is utilized, provide an opportunity to reach underserved populations and enhance their health outcomes. Social context is important in understanding racial disparities in physical activity [22]. The authors report that individual poverty and neighborhood poverty are associated with decreased odds of being physically active among both whites and blacks. He et al. [23] note that reducing wealth inequality among women should be a focus of national public health programs aimed at improving women’s health and well-being. However, the strategies for implementing such a policy must take into consideration existing sociocultural conditions mediating the role of household wealth status on women’s lives, such as deep-rooted gender inequality in the social value system.

3.3. Health Equity Solutions from a Physical/Built Environment Approach

Considering influences at the community level, Gaskin et al. [24] quantify the role of neighborhood disadvantage and find that the hazard of dying increased by 9.8% as neighborhood disadvantage increased by one standard deviation. Area-level poverty and mortgage delinquency were important predictors of mortality, even after controlling for individual personal income and occupational status.

3.4. Health Equity Solutions from a Behavioral Approach

Considering societal influences, Nolasco et al. [25] report geographical inequalities between provinces, both in mortality rates and avoidable mortality rates, that may be explained by inequalities in the political management of the crisis that occurred in each of the provinces. They also note that researchers must take caution in reporting possible associations between mortalities and economic crises because these factors are pro-cyclical, i.e., mortality rates are lower during economic crises and higher during economic recovery. Short-term data may not capture long-term associations.

3.5. Health Equity Solutions from a Three Component Approach that Combines the Physical/Built Environment, Sociocultural Environment, and Health Care System Approaches

Williams and Cooper [26] are unique in their approach to resolving health care inequities. In contrast to other authors, they maintain that eliminating racial inequities in health care requires a three-fold coordinated strategy. The three parts are: (1) addressing racism that incorporates place-based barriers to resources needed to enhance access, (2) health care systems that are culturally competent and emphasize prevention, and (3) knowledge, empathy and political will to eliminate racial inequities in care.

The articles in this Special Issue suggest a number of avenues to achieve health care equity. All of these avenues are very much in keeping with the NIMHD framework. Some require us to address needed change from the perspective of individual patients, while others require changes in interpersonal relations, and community and societal perspectives. Health equity is complicated. There is no single policy, program or intervention that will remedy inequities in health care. Health equity is a value that must permeate all that we do in health care and similar to access, quality and efficiency, equity must be continuously pursued. These articles suggest that the pursuit of health equity must be dynamic, multifaceted and multilayered.

4. Conclusions

Overall, this Special Issue of IJERPH identifies several strategies combining domains and levels of influence that can potentially enhance health equity. It also points out opportunities for future investigation. When NIMHD matched its 2015 awards with the NIMHD health disparities framework, it noted that several cells of the matrix were unfunded [7]. These included the biological domain as influenced by community level and societal factors. Similarly, very limited funding has been provided for research that focuses on community and societal level influences across all domains. Across domains, the least likely to receive funding by NIMHD is research that focuses on the physical/built environment. These are all areas of opportunity for providing new insights on strategies to enhance health equity.