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Health Equity 101An Introduction to Health EquityJune 26, 2013

Thank you for attending this presentation entitled Health Equity 101, hosted by the Minnesota Department of Health. This power point will be co-presented by me, Angela Pope, Policy Coordinator for the Office of Statewide Health Improvement Initiatives and Susan Bishop, Worksite Wellness Coordinator, who is also in the Office of Statewide Health Improvement Initiatives.

Todays presentation is an overview of health equity. The aim of this presentation is to not only introduce you to health equity as a critical issue to improving health for all Minnesotans but also serve as a refresher for some of you already engaged in achieving health equity.1MDH and Health Equity: Why Health Equity Matters?Minnesota rates as one of the healthiest states in the U.S. yet has significant health disparities among certain populations.

Aligns with Healthy Minnesota Vision: All people in Minnesota enjoy healthy lives and healthy communities.

Broadens the focus of public health in addressing key upstream health determinants that shape where people live, play, work, and learn.

Health equity is a matter of public health, justice, and a cornerstone of healthy communities. Our goal at MDH is to make Minnesota the healthiest state possible, but what is keeping us from attaining that goal is the persistence of health disparities.

In Minnesota, the populations experiencing the greatest disparities in health status are also the populations experiencing the greatest inequities in the opportunity for health, in education, income, health care, and living environments. According to The Health of Minnesota: Statewide Health Assessment, American Indian and African-American populations in Minnesota experience consistently higher rates of poverty, especially among children. Poverty is closely linked to both education and health, as poverty limits access to safe places to live, work, play, and buy healthy food. And the data show that, indeed, these populations do also experience substantially higher mortality rates at earlier ages, have lower rates of on-time high school graduation and have lower rates of employment.

The significance of this is that only when these disparities are reduced can we improve the health of all people in Minnesota. Studies consistently show that eliminating health disparities would result in decrease medical care expenditures and reduce premature death and disability.

However, to address disparities we cannot rely solely on programs and interventions that promote individual healthy behaviors or health care access. Policies, systems and environmental improvements in social, economic, and other conditions also are vital.

2ObjectivesDefine health equity and related terms

Explain the importance of health equity as a key public health issue

Illustrate health disparities and inequities in Minnesota

Explain what is a health equity lens and how it can be useful to your work

The objective for todays presentation are:First, define health equity and related terms;Second, explain the importance of health equity as a key public health issue;Our third objective is to illustrate health disparities and inequities in Minnesota; andFourth, explain what is a health equity lens and how it can be useful to your work.

3Health Equity: DefinitionsHealth Equity - Attainment of the highest level of health possible for all people. Achieving health equity requires valuing everyone with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health disparities and health care disparities. Health Inequity- Differences in health status between more and less socially and economically advantaged groups, caused by systematic differences in social conditions and processes that effectively determine health. Health inequities are avoidable, unjust, and therefore actionable.

I would like to take this time to define some key health equity terms that are frequently used and have recently been adopted by the Minnesota Department of Health.

Health Equity is the attainment of the highest level of health possible for all people. Achieving health equity requires valuing everyone with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health disparities and health care disparities. Health Inequity are differences in health status between more and less socially and economically advantaged groups, caused by systematic differences in social conditions and processes that effectively determine health. Health inequities are avoidable, unjust, and therefore actionable.

4Health Equity: DefinitionsHealth Disparities - Differences in the incidence, prevalence, mortality, and burden of disease and other adverse health conditions that exist between specific population groups.

Social Determinants of Health - Conditions found in the physical, cultural, social, economic and political environments that influence individual and population health. The inequities in the distribution of these conditions lead to differences in health outcomes (health disparities).

Health Disparities are differences in the incidence, prevalence, mortality, and burden of disease and other adverse health conditions that exist between specific population groups.

Social Determinants of Health are conditions found in the physical, cultural, social, economic and political environments that influence individual and population health. The inequities in the distribution of these conditions lead to differences in health outcomes (health disparities).

Examples of social determinants of health include: poverty, socio-economic status, stress, education and care in early life, social exclusion, employment and job security, social support, and food security.

5Health Equity LensA health equity lens is a way of adjusting how we look at and consider individual and population health. It looks beyond a populations overall health status and compares how different groups are doing and takes into consideration the unique concerns of those in disadvantaged groups.

A health equity lens is a way of adjusting how we look at and consider individual and population health. It looks beyond a populations overall health status and compares how different groups are doing and takes into consideration the unique concerns of those in disadvantaged groups.

Applying a health equity lens also means having to reshape the way we think about the causes and solutions to improving health.

It also means assessing the implications and impacts decisions have on populations including populations of color, low-income populations, aging populations, immigrants populations, and rural populations.

6Ways an equity lens can be applied to health improvementInvolve community membersUnderstand the root causes and level of health inequitiesUse health (equity) impact assessments Integrate equity goals, approaches and indicators into policies, plans and development agendasTarget resources and efforts to reach populations experiencing health disparities

According to the United States Agency for International Development, achieving equity requires a targeted focus on power and structural dynamics that determine policy and underlying social determinants of health.

When using a health equity lens you should consider involving community members. Community engagement is important to building trust, social cohesion, and valuable partnerships. Meaningful community engagement means the community is part of the solution. In addition, representatives from the communities facing health disparities should be involved in decision-making processes including committees and advisory groups or teams.

It is important to note that when engaging the community and building authentic partnerships, issues like physical activity, healthy eating and tobacco use and exposure cannot be treated in isolation from other community concerns. That also includes having to understand the root causes and level of health inequities in the communities or populations facing health disparities.

Using health equity impact assessments are a useful tool in applying a health equity lens. In general, a health impact assessment is a process that helps evaluate the potential effects of a plan, project or policy before it is built or implemented. A health equity impact assessment can help to:Analyze whether a proposed policy or program change could have a different or inequitable impact on health within the community;It can identify what groups or neighborhoods would be adversely and inequitably affected, and how; and It sets out what can be done to mitigate and avoid these adverse and inequitable effects on population health.

The fourth point is integrate equity goals, approaches and indicators into policies, plans and development agendas. A health equity impact assessment can also help with integrating health equity into your work.

And last: target resources and efforts to reach populations experiencing health disparities. This should be done in a deliberate and transparent way that will ensure sustainability and build the capacity of the community to take control of their own health promotion efforts.

7Economic Status

So now Ill let Susan Bishop present some statistics on health disparities and social determinants of health in Minnesota.

Lets look at some of the data related to health disparities in Minnesota; we enjoy a median income over $6,000 a year higher than the national average $50, 502. 8Income by Race/Ethnicity

In this chart you see the median household income of Minnesotans by race from 2007 2009. The highest median income group is Asian/other, followed by Asian/SE represented by the green bars near the top and whites represented by the red bar. The bottom bar shows the median income for all Minnesotans is only slightly less than whites.

Blacks, both foreign born and US born, have the lowest median income rate (purple bars) followed by American Indians represented by the blue bar at the top of the chart.

This illustrates the income disparity and suggests the lack of racial diversity in MN.9K 12 Lunch Support by Race

Looking at free or reduced price lunch (which is an indicator of family income) in the student population, the highest percentage of participation is among the African American, Hispanic and American Indian populations. This follows a similar pattern to that represented in the previous slide.

10Education Attainment

Education attainment is also correlated with income level. Looking at educational attainment data, Minnesota has a well educated population with over 32% of adults over 25 attaining a bachelors degree or higher; about 4% higher than the national levels. 11Trends: Education by Poverty Status

People living below the poverty level are more than 20% less likely to have a college education than those living above the poverty level.

The education attainment of all Minnesotans is slightly lower educational attainment than those living above the poverty level, which indicates that most of Minnesotans with a college degree live above the poverty level.

12Education by Race and Ethnicity

Breaking it down by race and ethnicity, the populations least likely to attain a bachelors degree are among the American Indian, African American and Hispanic populations as well as those identifying as other. The population attaining the highest percentage of college degrees is Asians (other).

13High School Graduation Rates

Taking a look at high school graduation rates in the 7 county metro area, there is a nearly 20% increase in graduation rate by income status.14High School Graduation Rates

High school graduation rates vary by race: American Indian African American and Hispanic are least likely to graduate on time, while white and Asian students are most likely to graduate on time. 15Health disparities in relation to obesityObesity rates in Minnesota:11.1% of Minnesota children are obese25.7% of Minnesota adults are obese

Illness and death due to chronic diseases are more prevalent among racial and ethnic groups. Obesity is a major risk factor for many chronic health conditions including diabetes, heart disease, hypertension, and obesity-related cancer.

Moving to health data as it relates to the social determinants of health, obesity is a major risk factor for many chronic diseases and rates in Minnesota follow national trends. We now have over 11% of our children and over 25% of adults who are obese in Minnesota.16Education Attainment and Obesity

When we look at education and obesity, Minnesotans with higher levels of education are associated with lower levels of obesity and significantly so for those with a college degree or higher.

17Adult Obesity: Education and Income

In this slide, the bars on the right side of each cluster represent the highest level of education and the levels of income. The vertical axis represents the rate of obesity. As you can see, the highest levels of education and income seem to be most strongly correlated with lower rates of obesity.18Adolescent Overweight or ObesePercent who self report overweight or obese

Looking at adolescent overweight and obesity, we see that all races affected by obesity.The lowest rates of obesity are among white students at 20% at both grade levels.The highest obesity rates are among American Indian and Hispanic populations (represented by the red and purple bars) at over 30% in all instances.

19Obesity in Minnesota WIC ChildrenObesity rates in American Indian children ages two to five years continued to rise

Turning to data of young children participating in the WIC program, obesity rates appear to be declining slightly among most race/ethnic groups. However, rates of obesity among American Indian children ages two to five continue to rise.

In 2010, the obesity rate of American Indian children was 28%; over twice the rate of all Minnesota race/ethnicity groups obesity rate of 12.7%.

The obesity rate of Hispanic children ages two to five was 16.8%.

Some interesting information not represented on the slide: the 2010 obesity rates for White Non-Hispanic (NH) children participating in the WIC program met the 2020 Healthy People Goal of 9.6%. 20Health disparities in relation to tobacco Smoking occurs at much higher rates among Native Americans and Alaska Natives and the LGBT (Lesbian, Gay, Bisexual and Transgender) population.

Smoking also occurs more frequently among persons of lower income and lower education.

Tobacco use rates in Minnesota:21% use some form of tobacco16.1% are smokers

As with other health behavior, smoking rates are higher among some populations experiencing health disparities. Overall 21% of Minnesotans use some form of tobacco, while 16.1% of the population smoke tobacco.21Tobacco Use in Minnesota

These charts are from different data sets: on the left is BRFSS 2001-07 data and on the right, the 2012 MN Adult Tobacco Survey.

Highest tobacco use rates are among American Indians at over 45%. Other factors correlated with higher rates of tobacco use are; a high school education, low income, or a history of mental health problems..22Adolescent Tobacco Use

In the adolescent population, low income, race and ethnicity are also associated with higher rates of tobacco use among adolescents, with the highest rates among American Indian adolescents at 22% (represented by the purple bar).23Things To RememberWe need to consciously and consistently address health disparities and inequities

It takes time!

Partnerships with community members and organizations is a must

Community capacity building and community empowerment are key strategies for reducing health disparities and achieving health equity

Populations experiencing health disparities are not homogenous and data does not tell the whole picture

Before we conclude this presentation here are some things to remember:

We need to consciously and consistently address health disparities and inequities.

Remember that the root causes of health inequities are systemic, institutionalized, and many decades or even centuries in the making. At the same time, some of the countrys greatest public health achievements took a long time to achieve.

Partnerships with community members and organizations is a must. It creates awareness about public health efforts within the community but often times the community members are aware of the issues that exist before those who work in public health are. Therefore, building partnerships with communities experiencing health disparities can help public health staff better identify both the causes and solutions.

Community capacity building and community empowerment are key strategies for reducing health disparities and achieving health equity. This requires a process that will engage communities experiencing health disparities on their own terms and local public health will have to be willing to not always expect to take the lead in their own agenda but to serve in a supportive role.

And finally, populations experiencing health disparities are not homogenous and data does not tell the whole picture. Populations experiencing health disparities have diverse subgroups and while data are important it doesnt speak for themselves and we run the risk of pathologizing communities. Therefore, understanding the community through meaningful engagement and partnership as well as understanding the real lived experiences of community members will contribute to better shared knowledge and change. 24For more informationPlease refer to the SHIP Guiding documents and Health Equity Implementation Guide for more details and resources

If you have questions, please direct them to: Health.MakingitBetter@state.mn.us

For more information, please refer to the Statewide Health Improvement Program guiding documents and health equity implementation guide for details and resources, located at the MN Department of Statewide Health Improvement Program website.

If you have questions, please direct them to Health.MakingitBetter@state.mn.us.

Thank you for your participation in this presentation and have a good day.25