The document discusses health equity and the social determinants of health. It defines health as physical, social and mental well-being, not just the absence of disease. Public health is defined as what society collectively does to create conditions for people to be healthy. Health is determined by factors like income, education, housing, environment and social justice. Achieving health equity requires addressing inequalities and injustices to improve health for all.

1. Health Equity
March 21, 2016

2. What is health?
“Health is a state of complete
physical, social and mental well-
being, and not merely the absence
of disease or infirmity.”
World Health Organization 1948

3. Public Health
“Public health is what we, as a
society, do collectively to assure the
conditions in which (all) people can
be healthy.”
Institute of Medicine (1988), Future of Public Health

4. Factors that determine health
Tarlov AR. Public policy frameworks for improving population health.
Ann N Y Acad Sci 1999; 896: 281-93.

5. Necessary conditions for
health
• Peace
• Shelter
• Education
• Food
• Income
• Stable eco-system
• Sustainable resources
• Social justice and equity
World Health Organization. Ottawa charter for health promotion. International Conference on Health
Promotion: The Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, 1986.
Accessed July 12, 2002 at <http://www.who.int/hpr/archive/docs/ottawa.html>.

6. Social Determinants of Health
External
environments and
conditions that
contribute to health
or lack of health.

7. Health 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

8. Health Equity: Diabetes by Income
Level, Minnesota 2010
4.4 4.4 4.4 4.4 4.4
0
5
10
15
20
25
Less than
$15,000
$15,000-
24,999
$25,000-
34,999
$35,000-
49,999
$50,000+
Percent
Income Category
Have you ever been told by a doctor that you have
diabetes?

9. Health Inequity
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.

10. Health Equity: Diabetes by Income
Level, Minnesota 2010
19.1
9.4 8.2
6.7
4.4
0
5
10
15
20
25
Less than
$15,000
$15,000-
24,999
$25,000-
34,999
$35,000-
49,999
$50,000+
Percent
Income Category
Have you ever been told by a doctor that you have
diabetes?
Source: CDC Behavioral Risk Factor Surveillance System
Percentages are weighted to population characteristics.

11. Structural inequities
• Structures or systems of society — such as finance, housing,
transportation, education, social opportunities, etc. — that are
structured in such a way that they benefit one population
unfairly (whether intended or not).

12. Who’s affected by structural
inequities in Minnesota?
• American Indians
• African Americans
• Children
• Persons with mental health
challenges
• LGBTQ
• Immigrants
• Refugees
• Asian-Pacific Islanders
• Hispanics/Latinos
• Rural Minnesotans
• Women
• Older Minnesotans
• Persons with disabilities
• And more…

13. Health equity and structural
racism:
• Structural racism is the normalization of an array of dynamics
— historical, cultural, institutional and interpersonal — that
routinely advantage white people while producing cumulative
and chronic adverse outcomes for people of color and
American Indians.

14. Health inequities in Minnesota are
significant and persistent, especially
by race:
In Minnesota, an African American or
Native American infant has more than
twice the chance of dying in the first
year of life as a white baby.

15. Appendix D: Redlining and Infant
Mortality in Minneapolis, MN

16. Infant mortality rates in Minneapolis by
neighborhood, 2001-2010

17. Comparison: Redlining and
Infant Mortality in Minneapolis
“Color-coded maps indicated which
neighborhoods were considered lesser
(green=best; blue=still desirable) or greater
(yellow=declining; and red=hazardous),
investment risks,…”

18. Low Birth Weight (singletons)by Race,2011
Bloomington,Richfield
3%
5%
10%
12%
-1%
1%
3%
5%
7%
9%
11%
13%
15%
Bloomington Richfield
7%
7%
Minnesota Department of Health Vital Records, 2010
White
Black/African
American
White
Black/African
American

19. PretermBirths (singletons) by Race,2011
Edina
5%
11%
-1%
1%
3%
5%
7%
9%
11%
13%
15%
White Person of Color
6%
Minnesota Department of Health Vital Records, 2010

20. What is Structural Inequity?
• Systematic or Structural elements of society that benefit one
population unfairly.
• Finance
• Housing
• Transportation
• Education
• Social Opportunities
• ETC…
From Minnesota Department of Health Office of Health Statistics, Advancing Health Equity in Minnesota, 2014

21. Who graduates on time?

22. Structural Inequity
Employment
Financial
Security
Ability to
pay high
property tax
Access to
Quality
School
System
Education

23. Structural Inequity
Employment
Financial
Security
Ability to
pay high
property tax
Access to
Quality
School
System
Lower
Education

24. Structural Inequity
Unemployment
Financial
Security
Ability to
pay high
property tax
Access to
Quality
School
System
Lower
Education

25. Structural Inequity
Unemployment
Financial
Insecurity
Ability to
pay high
property tax
Access to
Quality
School
System
Lower
Education

26. Structural Inequity
Unemployment
Financial
Insecurity
Inability to
pay high
property tax
Access to
Quality
School
System
Lower
Education

27. Structural Inequity
Unemployment
Financial
Insecurity
Inability to
pay high
property tax
Lack of
Access to
Quality
School
System
Lower
Education

28. Structural Inequity
Unemployment
Financial
Insecurity
Inability to
pay high
property tax
Lack of
Access to
Quality
School
System
Lower
Education
Is this
Systematic?

29. Bloomington Unemployment
6.70%
15.60%
26.80%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
Unemployment rate Less than high school
graduate
Below poverty level
Bloomington Unemployment Rate by Education and Poverty Level
American Community Survey: 2010-2014 (5-year estimates) Employment Status

30. Edina Unemployment
5.10%
8.80%
28.40%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
Unemployment rate Less than high school
graduate
Below poverty level
Edina Unemployment Rate by Education and Poverty Level
American Community Survey: 2010-2014 (5-year estimates) Employment Status

31. Richfield Unemployment
7.70% 7.70%
27.70%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
Unemployment rate Less than high school
graduate
Below poverty level
Richfield Unemployment Rate by Education and Poverty Level
American Community Survey: 2010-2014 (5-year estimates) Employment Status

32. How could education affect
health?
Braveman P, Gottlieb L. Public Health Rep. 2014 Jan-Feb;129 Suppl 2:19-31. The social determinants of health: it's time to consider the
causes of the causes.

33. Lets look at obesity and health
equity

34. Overweight and Obesity
Leads to…
• Coronary Heart Disease
• High Blood Pressure
• Stroke
• Type 2 Diabetes
• Abnormal Body Fats
• Metabolic Syndrome
• Hold on there’s more…

35. Overweight and Obesity
Leads to…
• Cancer
• Osteoarthritis
• Sleep Apnea
• Obesity Hypoventilation Syndrome
• Reproductive problems
• Gallstones
• Overweight and Obese children are more likely to be so as adults

36. Ok, who’s obese in Bloomington,
Edina and Richfield?

37. Bloomington
Overweightby Race/Ethnicity
18.3%
18.2%
25.8%
17.4%
36.5%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
White African American Asian Hispanic or Latino
Overweight or Obese by race/ethnicity
8th, 9th and 11th grades 2013
Minnesota Student Survey, 2013 Dark bars differ significantly from White (p<0.05)

38. Edina
Overweightby Race/Ethnicity
23.6%
10.5%
34.1%
13.1% 12.5%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
White African American Asian Hispanic or Latino
Overweight or Obese by race/ethnicity
8th, 9th and 11th grades 2013
Minnesota Student Survey, 2013 Dark bars differ significantly from White (p<0.05)

39. Richfield
Overweightby Race/Ethnicity
17.5%
18.2%
30.60%
35.7%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
White African American Hispanic or Latino
Overweight or Obese by race/ethnicity
8th, 9th and 11th grades 2013
Minnesota Student Survey, 2013 Dark bars differ significantly from White (p<0.05)

40. Chronic Diseaseby Income Adults
Bloomington,Edina, Richfield and Eden
Prairie
12.4%
6.5%
38.1%
5.9%
2.8%
26.2%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
Diabetes Heart Attack Hypertension diagnosis
Adults - Ever told by a doctor you had…
<200% poverty 200%+ poverty 11.9%
Hennepin County Adult SHAPE, 2010 Dark bars and light bars differ significantly from each other (p<0.05)
3.7%
6.5%

41. Interconnectedness
If we are not all healthy together,
none of us is as healthy as we
could be.

42. Public Health
“Public health is what we, as a
society, do collectively to assure
the conditions in which (all) people
can be healthy.”
Institute of Medicine (1988), Future of Public Health

43. A community effort
•Health – and health equity - are
created in the community by people
working together to create just
economic, social and environmental
conditions that promote health.

44. Everyone needs:
• Access to economic and educational opportunities
(high school graduation, access to jobs,
transportation, etc.)…
• The capacity to make decisions and effect change for
ourselves, our families and our communities
(empowerment of women, community self-
governance, opportunities for civic participation,
etc.)…

45. Everyone needs (cont’d)…
• Social and environmental safety in the
places we live, learn, work, worship and play
(housing conditions, crime rates, school
climate, social norms and attitudes, etc.) and
• Culturally-competent and appropriate
services when the need arises (access to
health care, mental health care, financial
assistance, etc.)

46. What needs to be done
• Achieving health equity and eliminating health
disparities requires valuing everyone and
making intentional, consistent efforts to
address avoidable systematic inequalities,
historical and contemporary injustices.

47. To create change
• Public understanding – of what creates health
• Public agenda – create expectation that we
can and will address these conditions
• Public/political will – to make tough choices-
accountability for policies, programs

48. Our Approach
• Continue to support BER’s work to factor in health in all policies
• Building the capacity of our staff to understand and address health
equity
• Management team taking the Intercultural Development Inventory
• Breaking down silos and asking questions
• Thinking creatively on funding
• Health equity work does not fit the traditional public health funding model
• Collaborating
• Expanding our collaborative work within BER to address health equity
• Developing new relationship in the community
• Strengthening existing relationships
• Sharing data on health equity
• Acknowledging solution will be collaboratively developed and
implemented
• Being patient
Source: Advancing health equity: Case studies of health equity practice in four award-winning California health departments.

49. Questions