Health inequity is a pervasive problem in American life and one that disproportionately impacts communities of color. A report from the National Academy of Medicine (NAM) found that “racial and ethnic minorities receive lower-quality health care than white people—even when insurance status, income, age, and severity of conditions are comparable.”
Addressing health inequity will require health and human services agencies, including both public sector and community-based organizations (CBOs), to work collaboratively to overcome the chasm between health care delivery and health outcomes. Key to this effort is the need to address the social determinants of health (SDoH)—the conditions in which people live, work, and play.
CBOs have an important role in this collaboration and the systems change that is needed to truly achieve health justice. To better understand the complex issues at work that impact health outcomes, CBOs are working in communities using place-based approaches, harnessing data on risk and protective factors, as well as listening to the voices of those with lived experience. Based on this knowledge, they are co-creating approaches to address these issues in a way that shifts toward greater positive outcomes, bringing both cultural relevance and scientific rigor to bear in the transformation of health delivery systems.
Disparities in Healthcare Spending and Human Services Spending
America’s healthcare spending—which currently totals more than $10,000 per person per year—is higher than that of any other developed nation. In fact, according to a recent report from the Commonwealth Fund, America spends twice as much as any other developed nation.
Despite this level of investment and our nation’s access to life-saving technologies, our health outcomes have not kept pace. In fact, just the opposite is true. The United States ranks near last among developed nations in key health outcomes such as life expectancy, infant and maternal mortality, and deaths from preventable diseases.
What could account for this disparity? A growing body of research points to the fact that only 20 percent of health outcomes are attributable to actual healthcare; while 80 percent are attributable to environment, behavior, and socioeconomic factors, often known as the social determinants of health (SDoH).
Another factor lies in our nation’s investment in human services, which is among the lowest in developed nations. Increasingly, researchers are making a direct connection between investments in human services and health outcomes, noting that “states with higher ratios of social to health spending had better health outcomes one and two years later.” And conversely, we can also correlate health inequities in a community with other inequities such as higher rates of poverty, unequal access to jobs, safe and affordable housing, nutrition, behavioral health services, and more.
Community-based social and human services organizations offer a broad range of services and supports that address social determinants. They connect individuals and families to place-based resources that enhance health and well-being, economic and educational opportunity, and safety and security.
In a 2018 report that highlights the impact of community-based human service organizations, authors note: “CBOs are more than just service providers. Human services CBOs contribute to the development of policies to improve the human capital of our nation. They create innovative approaches to better outcomes, and they produce significant economic return in their local economies as employers and purchasers of goods and services.”
Defining Health Inequity
The World Health Organization (WHO) defines health inequity as “differences in health status or in the distribution of health resources between different population groups, arising from the social conditions in which people are born, grow, live, work, and age.”
Health inequity results when systems and the people who run them devalue individuals due to race, sex, class, country of origin, or ability; this can occur at both an institutional and interpersonal level, including overt and implicit bias. It is important to note that health inequity negatively impacts everyone, leading to worsening outcomes for not just those directly affected but for the broader community.
Health inequity forces millions of people into poverty, costs our nation billions of dollars each year, and raises the cost of healthcare for everyone. Health inequity can also make it more challenging to contain infectious diseases like COVID-19.
Global Pandemic Illuminates Mistrust Among Communities of Color
There is no question that the COVID-19 pandemic shed a harsh light on the inequities in health that communities of color face. African Americans and Latinxs are four to nine times more likely to contract COVID than their white counterparts and have the highest death rate. These outcomes are not due to genetics. They are due to a combination of factors related to SDoH: more densely populated neighborhoods, fewer health care services, and jobs that don’t afford the luxury of working from home.
And, for communities of color, mistrust has also played an outsized role.
From the syphilis studies conducted on Tuskegee Airmen to the non-consensual use of Henrietta Lacks cancer cells for decades, medical abuses targeting Black Americans have resulted in a troubling historical lack of trust among Black communities toward health professionals. That lack of trust has spilled over into vaccine hesitancy among Black Americans toward the COVID-19 vaccine. In fact, an NAACP survey from November 2020 found that only 14 percent of Black respondents trusted the vaccine and only 18 percent noted they would get the vaccine.
Rebuilding Trust Among Communities of Color with a Place-Based Approach
Human services CBOs pioneered the concept of place-based approaches with the launch of the settlement movement in 1886. Spearheaded by middle and upper-class white Americans, the propagators of the settlement movement were more than dispensers of charity; they embraced the poor immigrant communities they served and chose to live within them. Settlement houses became community hubs, providing sustenance, learning, social, and recreational activities, as well as a sense of community for thousands.
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By focusing on the social and physical environment of a community and the services that would improve conditions in life, a place-based approach is aimed at addressing SDoH, such as safe housing and access to economic and educational opportunities. By using a community engagement approach to address complex problems, CBOs can build trust among families and communities, creating important connections, establishing credibility within neighborhoods, and helping people be more engaged, empowered, and resilient.
An essential element of that approach is shifting the power dynamics in a community. By lifting up the voices of those who live in a community and access services, providers can have greater insight into the real needs of the community and the supports and services that would be most effective. This applies to healthcare systems as well. By balancing power among all stakeholders in healthcare systems, resources are able to be directed where they are most needed and have the potential to achieve more positive health outcomes.
Pillsbury United in Minnesota
When CBO Pillsbury United collaborated with Children’s Minnesota—a network of hospitals, primary and specialty care clinics, and rehabilitation sites—their goal was to engage in a process that would bring community voice to the process of conducting a community health needs assessment as mandated by the Affordable Care Act (ACA). As part of a Community Advisory Committee (CAC), Pillsbury United worked in partnership with a diverse group of community stakeholders, including local advocates and other representatives of community organizations and systems serving children and families.
The CAC developed a set of core principles for the assessment that focused on using a trauma-informed lens to influence decision-making, consideration of the impact of social determinants on the community, and centering equity in all decision-making.
The health topics considered through the assessment process included community conditions and other factors that contribute to health, such as poverty, education, and housing. The top health priorities were determined through criteria recommended by the CAC that valued quantitative and qualitative data and drew on the experience and expertise of committee members and others with lived experience.
CAC members and the Children’s Minnesota team identified six issues as being the most important for Children’s Minnesota to focus on in order to support the health and well-being of children and their families. Two fell into the category of specific health issues and included asthma and mental health. The remaining four came under the heading of SDoH and included access to resources, income and employment, education, and structural racism.
Based on these findings, Children’s Minnesota developed an implementation plan that coordinated efforts with the CAC and additional community stakeholders in identifying implementation strategies. Pillsbury United and other members of the CAC continue to stay engaged with Children’s Minnesota in sustainability efforts to engage community residents in their broader work and to foster the partnerships that formed or strengthened during this assessment process.
This example illustrates the power of leveraging the place-based expertise and community credibility of CBOs and how their knowledge can yield important insights for those within the formal healthcare infrastructure seeking to improve health outcomes.
Child Safety Forward in Hartford, Connecticut
Another example is the work being done by the Child Safety Forward team from Saint Francis Hospital, a member of Trinity Health of New England. Child Safety Forward is a demonstration initiative funded by U.S. Department of Justice to develop multidisciplinary strategies and responses to address fatalities or near-death injuries as a result of child abuse and neglect. The initiative takes place across five sites, and the Saint Francis site is primarily focused across the Hartford, Connecticut region.
The challenges the team face include socioeconomic conditions across the region such as poverty, racially segregated communities, and inadequacies in data collection and reporting that have led to limited opportunities for a proactive (prevention) approach to solving the problem of child safety. By using a population health approach, the goal is to reduce the rate of repeated child injuries and fatalities in Hartford, which is currently two times the national average.
Central to this effort is the data-driven collaborative approach that engages parents alongside grassroots neighborhood organizations, caregivers, health professionals, researchers, foundations, state agencies, and others.
The effort started with a retrospective review of child fatalities to identify the characteristics of those children most at risk. The findings illustrated a higher-than-average number of unsafe sleep deaths among infants. When this data was shared with the Parent Engagement Workgroup, the parents were shocked at the level of disparities in negative outcomes experienced by communities of color. Parents shared their lived experiences about the conditions that led to unsafe sleep practices including unstable childcare and contradictory advice from healthcare professionals (including a breast-feeding coach who told a new mother that it was okay to sleep with her baby). They expressed how much light the data shed on issues and questioned why this data and the disparities had not been shared with the community previously. Armed with the data and with parents engaged to support this work, the Child Safety Forward team in Hartford is developing culturally appropriate safe sleep messages for their communities.
Child Safety Forward is an example of what can be accomplished through a data-informed, place-based approach that engages at a community level to rebalance power and collaborate to solve a specific need in community. It reflects a growing trend in child welfare to shift from a reactive to a proactive approach and to highlight the importance of collaboration when addressing complex problems like child safety.
Tackling Complex Systems Change
Achieving greater health justice by giving voice to those with lived experience and shifting power can be challenging. Healthcare systems are among the most complex and tackling change at this level will require CBOs to collaborate and come together around a common agenda to change the status quo, which includes centering equity in all we do.
Community power is defined as “the ability of communities most impacted by structural inequity to develop, sustain and grow an organized base of people who act together through democratic structures to set agendas, shift public discourse, influence who makes decisions and cultivate ongoing relationships of mutual accountability with decision-makers that change systems and advance health equity.” Large scale systems change requires a shift in power to encompass community power.
Because so many of our systems, including healthcare, behavioral health, child welfare, education, justice, and more are interrelated, we cannot tackle systems change in silos. We must work collectively across multidisciplinary systems and agencies with a broader goal of understanding and addressing SDoH and how they impact communities.
Deep change is seldom instantaneous. Achieving the systemic change needed to bring about greater health equity will require an approach more evolutionary than revolutionary. It will take commitment, effort, and time and will need to be supported by coordinated shifts in policies, practices, and funding.
Perseverance and partnerships that capitalize on the strengths and credibility of CBOs and other partners are at the core of future solutions. Collaboration of public agencies, healthcare systems, and the social sector with an intentional focus on investment in efforts that engage and reflect the voices of those with lived experience, coupled with community data insights, have the most promise to address the social determinants of health. Let’s build on what’s working, adapt and redesign what is not, and move toward systems that are truly nested within communities to bring about greater health equity for all populations.