What Does Health Equity Really Mean? UR Nursing Experts Break It Down

 

“….to ensure we are moving in the same direction together, the pathogens of divisiveness and bigotry need to be treated as the deadly, life-shortening contagions they truly are. This is how we begin to transform the concept of resilience from an individual trait to one that describes a community — and society — that cares for everyone. Rather than hoping a child is tough enough to endure the insurmountable, we must build resilient places — healthier, safer, more nurturing and just — where all children can thrive. This is where prevention and healing begin.”

Dr. Mona Hanna-Attisha, pediatrician and professor at Michigan State University College of Human Medicine, in the New York Times. 

 

Having a foundational understanding of health equity and its impact is important for all health care professionals, health care organizations, and communities. 

To assist in providing this understanding, I interviewed two experts at the School of Nursing—Drs. Theresa Green, PhD, MBA, and Maria Quiñones-Cordero, PhD.

Dr. Green is an associate professor of public health sciences, who holds a joint appointment at the School of Nursing where she teaches the Population Health course in the Leadership in Health Care master’s program. Additionally, she has an appointment at the Center for Community Health and Prevention, and leads the Health Equity Task Force. Dr. Quiñones is an assistant professor of clinical nursing and faculty diversity officer at the School of Nursing. She leads the Hispanic/Latino Core at the Roybal Center for Social Ties & Aging, and is the associate director at the Elaine Hubbard Center for Nursing Research on Aging.

Throughout our conversation, Drs. Green and Quiñones define health equity, community-engaged research, population health, and social determinants of health in their own words, and describe how those concepts are translated in their work. The following highlights some excerpts of our conversation. The full conversation can be watched here.

Community-Engaged Research

The World Health Organization defines community engagement as “a process of developing relationships that enable stakeholders to work together to address health-related issues and promote well-being to achieve positive health impact and outcomes.” Dr. Quiñones relates this goal to the way she approaches her research to fully incorporate members from the community as critical actors within the research process.

As she outlines, community engagement can occur at different levels, from community members merely informing the research to them leading the entire research process. Community involvement at any of these levels serves to shift the power dynamics of research so that community members are recognized as experts of the issue or topic being researched, rather than the researcher determining the topic or issue, or the direction of the research for the community. This power shift recognizes that researchers often hold vastly different social and socio-economic positionalities from the communities with whom they seek to collaborate. This is especially significant as those communities tend to encompass those in our society who are marginalized and historically underserved by such social systems like health care, or are underrepresented in academia.

Vanessa Watts, Paul MacPherson Chair of Indigenous Studies at McMaster University, shares that when a community, such as Indigenous communities who have been significantly harmed by academic research, is recognized for their expertise rather than utilized as research subjects, this generates a paradigm shift that mitigates research being conducted as a manner of extraction, where researchers take knowledge from the community to benefit their prestige and advancement. Additionally, this paradigm shifts changes the perception that communities are a problem to be fixed, or to be saved by the institution.

For Dr. Quiñones, this paradigm emerges in her work within the Hispanic/Latino community, when they identify the interventions that they want to address to impact the health of older Latinos. They then determine if it is an intervention that needs to be developed, deconstructed, or culturally adapted so that the intervention may better serve that community’s specific needs.

One such project entails working with a Community Advisory Board (CAB) that includes a Spanish-speaking neurologist, a community service provider, and individuals who are caring for an older adult with dementia. With Dr. Quiñones’ assistance, the CAB examines ways to reduce barriers that interfere with Latino caregivers seeking the support they need, such as increasing access to dementia services.

Within their discussion, the CAB examined the specific social determinants of health that encompass the issue, especially that of language and literacy. By addressing this concern, the CAB determined that providing information about available resources would not only need to be available in Spanish, but they need to be constructed with consideration of the various levels of literacy within the Latino community.

As outlined in Healthy People 2023, literacy includes multiple components of language communication and comprehension, including listening and speaking skills, writing and reading skills, and cultural and conceptual knowledge. While literacy is related to educational attainment, for those whose primary language is other than English, literacy requires the need to grasp broader cultural contexts in order to fully comprehend information.

When these factors aren’t taken into consideration, language and literacy can generate barriers for an individual to effectively engage with their health care providers and fully comprehend health information.

Health Equity

While the goals of community-engaged research helps to advance the Centers for Disease Control and Prevention’s (CDC) definition of health equity, “in which everyone has a fair and just opportunity to attain their highest level of health,” Dr. Green emphasized that it is only one tool that coincides with community-engaged learning and intervention. However, all of these approaches encompass the need for addressing social determinants of health and health disparities.

“Community-engaged learning offers current and future health care providers essential education to, as Green states, “bridge the cultural divide by learning about the communities served.”

This outcome aligns to the Carnegie Classification of community engagement, which is defined “as a collaboration between institutions and their larger communities.” As Dr. Green underscores, the efforts of community engagement is not about the institution giving to the community or saving the community, rather it encompasses a mutual exchange of knowledge between the institution and the community.

In Green’s experience, this mutual exchange occurs when community partners teach students and trainees while they are immersed in the community. This can include community members serving as preceptors, evaluating and providing feedback to the students. Additionally, community members advise on the overall education process and the development of the curriculum. This mutual exchange means that the community not only participates, but also has a voice, as they provide input to shape the delivery of education to future care providers.

In addition to community-engaged learning, Green leads the Health Equity Task Force, an initiative that stems from the URMC’s Office of Equity and Inclusion’s Equity and Anti-Racism plan, to build a culture of equity focused at the level of providers. She collaborates with internal partners to incorporate the following goals in their resident training programs: identifying how to provide culturally-appropriate care for patients, and how to apply quality improvement principles, skills, and tools to measure the effectiveness of the equity practices integrated within organizational systems.

Social Determinants of Health

Equity is a term that has been widely embraced in organizational mission statements, diversity statements, and commitments such as the Equity and Antiracism plan, yet as education scholar Estella Bensimon advises, it is important to remember that the roots of equity were derived from the ongoing efforts of the Civil Rights movement and other social justice movements to dismantle racism and discrimination ingrained in our social systems. The purpose of equity is to ameliorate the effects of discrimination and improve the social conditions for historically marginalized populations. This includes being cognizant of how racism and discrimination show up in an institution’s practices, policies, and interactions, in addition to how they have produced long-standing consequences of inequities for certain populations.

As defined by the CDC, social determinants of health (SDOH) focus on these consequences of inequities as they encompass the “non-medical factors that influence health outcomes, shaped by systemic and social forces” such as (but not limited to) racism, ableism, classism, homophobia, transphobia, and xenophobia. These forces limit resources, services, and support, and hinder the ability for marginalized populations to attain and maintain good health and well-being.

Concentrating on SDOH, Greene elaborates, requires health care to shift the attention from investing solely on health care delivery towards addressing the underline causes within environments that prevent people from feeling safe and healthy in their daily living, including the ability to decrease stress, and to live in safe, caring, well-resourced environments, and walkable communities with green spaces.

"It’s less about access to health care and more about building environments and support systems that keep us healthy in the first place," Green said.

One local organization that focused on this holistic view of health and community well-being is Common Ground Health, who collaborate with regional partners to conduct data analysis to address the existence of health disparities in Rochester and surrounding communities. Nationally, the Office of Disease Prevention and Health Promotion’s Healthy People 2030, outlines objectives and provides extensive resources for health organizations to actively address SDOH’s within their communities, as does the United Nation’s Sustainable Agenda on a global scale.

For Dr. Quiñones, SDOH’s guides how researchers address the root causes of issues that impact the community being engaged. Mitigating these root causes of health inequities facilitates the ability to generate systemic solutions that can ensure that people experience health care and feel seen in their humanity, where providers can establish culturally-appropriate skills in which relationships between the care receivers and caregivers are valued. Most importantly, these efforts can result in a community’s willingness to re-establish trust with a health care system that actively demonstrates its commitment to amend practices that caused historical harms. When research is engaged in the outcomes of health equity, it is mindful of how the pursuit will serve the purpose of the community and avoid doing further harm.

Dr. Green adds that health equity is relational. Its practice doesn’t require a major intervention, it can simply involve people stepping beyond their comfort zones to have difficult and honest conversations with courage and curiosity. Enacting these qualities with a sense of cultural humility enables individuals to push through what makes the conversation or topic difficult, to being open to evolving their understanding. These courageous conversations, combined with the ability to critically self-reflect, can provide some foundational tools for becoming equity-minded while building the culture of equity that institutions aspire to in their mission and values.

Doing the Work of Equity

Drs. Quiñones and Green shared examples from their work where they have been able to bear witness to the outcomes of health equity in practice.

For Dr. Quiñones, this emerged while volunteering her services at a local center for older Latino adults, by creating and facilitating educational programming in Spanish. For one of these programs, she invited a Spanish-speaking neurologist to present on dementia. This presentation opened up opportunities for participants to ask questions and have answers given in their own language. This enabled their access to information concerning culturally-appropriate resources about dementia that would better serve their needs.

Dr. Green recounted her interactions with medical students who were inspired to serve with community partners that correlated to their own lived experiences, such as one student who worked with Refugees Helping Refugees because it aligned to their own experiences being a refugee. Another returned to East High School, where they are an alum, to teach in the Health Scholars program. Green related these encounters to demonstrate how they influenced the ability for members of the community to see themselves represented amongst health care providers, which can signal a shared sense of cultural values. Additionally, the representation of shared identity provided youth within the community the ability to envision their own success as health providers.

In addition to the students' experiences, Green conveyed a sense of encouragement regarding the growing institutional commitment to advancing health equity within its infrastructure. There is a sustained momentum of change that aims to cultivate a society where our environments, systems, resources, and services support the capacity of each individual within our collective community to thrive.

This story was written by Associate Professor of Clinical Nursing and Faculty Diversity Officer Kristin Hocker, EdD and appeared in the School of Nursing Council on Diversity, Equity & Inclusion's January newsletter.