How Do We Advance Health Equity?

Evelyn Sharkey, MPH, MSW
Wisconsin Population Health Service Fellow
City of Milwaukee Health Department 
Milwaukee, WI

Hester Simons, MPH
Wisconsin Population Health Service Fellow
Wisconsin Division of Public Health
Centro Hispano of Dane County 
Madison, WI


“How can professionals dedicated to improving health continue our traditional roles of promoting healthy behaviors and delivering quality health care and also balance our repertoire by adding the skills, competencies, tools, and methods to address the socioeconomic policies, systems, and environments that so strongly influence health?” (p. 218)

Dr. Geof Swain, founding director of the Wisconsin Center for Health Equity, and former Fellows Katarina Grande (2010-2012 cohort), Carly Hood (2012-2014 cohort), and Paula Tran Inzeo (2010-2012 cohort) ask this question to frame their commentary published in the December 2014 issue of the Wisconsin Medical Journal, posing a dilemma that confronts physicians and other health care professionals on a daily basis as they care for patients. 

Determinants of health, from Dahlgren & Whitehead (1991), as cited in Exworthy (2008)

Before getting into the authors’ suggestions for overcoming this dilemma, let’s get some background on the broader issues addressed in the commentary:  health and the things that make people and communities more or less healthy.  According to the World Health Organization (WHO), health is more than just not being sick; rather, it’s “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”¹  Overall health is influenced by various factors known as “health determinants,” which include not just health care, but also genetics and biology, individual behaviors, social and economic conditions, and the physical environment.^2,3  Most of these determinants are “modifiable” in the sense that it’s possible to change or control them, including health care, individual behaviors, social and economic factors, and the environment.  However, it’s not yet possible to significantly alter an individual’s genetics and biology.  It’s also important to note that many of these determinants are external to an individual, including health care, social and economic factors, and the physical environment.

The Rankings model of modifiable health 

factors that impact community health 

(County Health Rankings, 2014).

The social, economic, and physical environment conditions that affect a person’s health are known as the “social determinants of health.”⁴  You can think of these determinants as “the conditions in which people are born, grown, live, work and age.”^2,5,6 Examples of various social determinants of health from Healthy People 2020 include “the resources and supports available in our homes, neighborhoods, and communities; the quality of our schooling; the safety of our workplaces; the cleanliness of our water, food, and air; and the nature of our social interactions and relationships.”⁴

As Swain et al. point out, almost all of the health-related funding in the U.S. is geared towards improving access and quality of health care services.  While health care is undoubtedly important, there is a great deal of evidence that social and economic factors and the physical environment may actually have a stronger impact on health.  This is shown by one model of the impact of health determinants developed by the County Health Rankings & Roadmaps program.  This program is a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, which created the model to estimate the relative contribution of modifiable health determinants.⁷  Biology and genetics are not modifiable and are therefore not included.

What does the Rankings model show?  First, 50% of the modifiable factors that influence health are social determinants of health.  If you dig deeper into this 50%, you can see that the influence of social and economic factors is especially strong, accounting for 40% of the factors that impact health.  Based on this, it’s clear that people who seek to promote health should address these social and economic influences.  However, according to Swain et al., there is limited guidance as to how physicians and other health care professionals and health systems can actually go about doing this.  This may be why more than 80% of U.S. physicians think unmet social needs negatively affect health but do not feel capable of addressing the social needs of their patients.⁸ 

Through exploring two social determinants of health that have been studied extensively—income/employment and education—Swain et al. review evidence-based examples of both clinical and policy-level actions that health care professionals can take to address social determinants.  They conclude their commentary by providing concrete and actionable suggestions and resources for addressing income/employment, education, and other socioeconomic factors that influence individual and community health.  At the clinical level, the authors suggest health care professionals screen for socioeconomic issues like food and employment during clinical visits and coordinate their services with social workers, community health workers, and others.  At the population level, suggested strategies include advocating for social and economic policies that promote health, working collectively with peers and professional associations; and being “both patient and persistent” (p. 220).

This is a helpful article for anyone interested in promoting the health and well-being of both individuals and communities, and it was excellent foundational reading for the fellowship’s February monthly meeting on health equity.  Fellows were joined at this meeting by students from the TRIUMPH program.  TRIUMPH, which stands for Training in Urban Medicine and Public Health, is a program for 3^rd and 4^th year medical students at UW Madison’s School of Medicine and Public Health.  The program integrates clinical medicine with community and public health and aims to provide medical students with the knowledge and skills needed to promote health equity and reduce disparities.

During the meeting, attendees learned about The National Equity Atlas, a new policy and data tool that can be used to make the economic case for equity.  The Atlas includes data from all 50 states, Washington D.C., and the largest 150 metropolitan statistical areas in the U.S. (including the Madison and Milwaukee metropolitan areas).

A picture depicting the difference between
“equality” and “equity,” featured in the February meeting
presentation by Angela Russell and Jordan Bingham.  
Source:  City of Portland Office of Equity and Human Rights

In the afternoon, fellows and TRIUMPH students participated in an in-depth conversation on health equity strategies for public health and medical professionals led by Dr. Geof Swain. They wrestled with the difference between equality and equity and discussed frameworks for thinking about how the social determinants of health lead to health disparities. The day ended with an engaging presentation by Angela Russell and Jordan Bingham, Health Equity Coordinators from Public Health Madison Dane County, on how to talk to policy makers about health equity. 

Sources:
¹WHO Definition of Health. World Health Organization Website.  http://www.who.int/about/definition/en/print.html. Accessed February 11, 2015.
²McGovern L, Miller G, Hughes-Cromwick P. Health Policy Brief:  The Relative Contribution of Multiple Determinants to Health Outcomes.  Health Affairs. August 21, 2014. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=123. Accessed February 11, 2015.
³The Determinants of Health. World Health Organization Web Site. http://www.who.int/hia/evidence/doh/en/. Accessed February 11, 2015.
⁴ Healthy People 2020. Social Determinants of Health. http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health. Accessed March 6, 2015.
⁵Braveman P, Egerter S, Williams DR.  The Social Determinants of Health:  Coming of Age.  Annu Rev Public Health.  2011;32:381-98. doi:  10.1146/annurev-publhealth-031210-101218. http://www.ncbi.nlm.nih.gov/pubmed/21091195. Accessed February 11, 2015.
⁶Social Determinants of Health. World Health Organization Web Site. http://www.who.int/social_determinants/en/. Accessed February 11, 2015.
⁷About the Program. County Health Rankings & Roadmaps Web Site. http://www.countyhealthrankings.org/about-project. Accessed February 11, 2015.
⁸Goldstein D, Holmes J. 2011 Physicians’ Daily Life Report. Harris Interactive.  Prepared for the Robert Wood Johnson Foundation. November 15, 2011. http://www.rwjf.org/content/dam/web-assets/2011/11/2011-physicians--daily-life-report. Accessed February 11, 2015.

Public Health: Moving Forward

Colleen Moran, MPH MS
Wisconsin Population Health Service Fellow
Wisconsin Division of Public Health
Madison, WI




Public Health is cool, right? Well, I suppose it depends upon whom you ask. This became a topic of discussion the other day - how do we "rebrand" public health? How do we communicate what it is and how cool it is? Most of the time when I tell people I work in public health, they ask me something regarding primary care, something clinical. I have to gently let them know that I'm not in, "that kind of health," that, "I work in prevention - I try to change the environments we live, work, learn and play in, and incorporate health into policies, to make the healthy choice the easy choice, so that fewer people have to visit the clinic," I'm usually met with a blank stare and the inevitable followup question: "so what is it exactly that you do?"


That question, a good one I might add, is what I dedicate my blog post to today. I'd like to answer that question of "what is it that I do" and in the process, try to explain just how amazingly cool public health really is. So in recognition of National Public Health Week, this blog post is dedicated to celebrating the great successes public health has accomplished so far, while also focusing on where the future lies for the world of public health. And hopefully along the way I'll answer that nagging question.

How Far We've Come . . .

First, let's take a moment to remember how far we've come. Back in the early days of public health, contaminated water was causing disease outbreaks such as cholera (remember Dr. Jon Snow and the Broad St. pump?), overcrowding was leading to transmission of infectious diseases, workplaces were unsafe, and family planning was unheard of. Just a few generations ago mothers and father worried about their children contracting polio, measles and mumps, and many did with devastating effects. 

We've come a very long way. Listed below are 10 of the greatest public health achievements of the 20th century. To many, the achievements listed below are so basic that they virtually go unnoticed. However, I think it's time to pause and recognize how far we've come, thanks to public health.

Ten Great Public Health Achievements in the 20th Century

1. Immunizations*
2. Motor-Vehicle Safety
3. Workplace Safety
4. Control of Infectious Diseases
5. Declines in Deaths from Heart Disease and Stroke
6. Safer and Healthier Foods
7. Healthier Mothers and Babies
8. Family Planning*
9. Fluoridation of Drinking Water*
10. Tobacco as a Health Hazard

While  most of us take these advances for granted, there a few of the achievements on the list that create controversy and I would feel remiss if I did not make note of that (the * above denote these controversial public health practices). However, I do not want to spend time refuting the arguments people make against these public health achievements. Rather, I would like to use this blog post to acknowledge the fact that we've largely moved from the focus of the 20th century on infectious diseases and injury prevention to a 21st century focus on chronic diseases and the environments, systems and policies that must be changed to create a healthier world. There is so much more to be done in public health. It's time to move forward. 

So What IS Public Health . . . ?

So what do we mean when we say "environmental, systems and policy level changes"? Well, think about your daily routine: 

• How do you get to work? 
• How do your kids get to school and are they safe and happy there?
• Where do you purchase your groceries? 
• Where do your kids play outside?  
  

http://healthsciences.curtin.edu.au/teaching/soph_whatis.cfm

If you said you drive to work, is this because there is no public transportation? The research demonstrates that if you use public transportation you get more exercise simply getting to and from the transit stop than if you drove yourself, thereby helping you reach your recommended levels of physical activity. Not to mention the environmental benefits of using public transit which lead to improved respiratory health outcomes from cleaner air. We must change your environment so that you can access public transit but this must be done at a systems and policy level. This is public health. 

https://www.safeschoolscoalition.org/
RG-posters.html

If you said, "I drive my kids to school because it's too far for them to walk," or, "I don't feel safe letting my kids take the bus," that is public health. If you said, "my child is bullied at school," or,"the lunch they are fed is not healthful" - that too is public health. Where we site our schools, if our kids can incorporate physical activity into their daily routine by walking to and from school, if you feel that the neighborhood is safe enough for your children to walk in - this is your environment and changes to the systems and policies that create this environment must be made. This is public health. 

https://www.flickr.com/photos/35586421@N03/
3331755112/in/pool-683857@N21

If you said, "I drive 30 minutes to the nearest full service grocery store to purchase my groceries," this is a public health issue. What about the folks that don't have access to a grocery store because they don't have a car, can't drive, and/or there is no public transportation? How do we feed ourselves healthy foods if we can't access them, can't afford them, or have to spend hours per week simply in transport to retrieve them? What type of zoning we create, where we site our grocery stores, and what types of foods we sell in them create our environment and at the systems and policy level, we must make changes. This is public health. 




http://www1.ochca.com/ochealthinfo.com/docs/newsletters/whatsup/2013/13-04.htm

If you said, "my kids don't play outside," why is this? Is there no park in your neighborhood? Are there no sidewalks for your children to walk, bike or play on? Is there a  park but you don't feel safe sending your children there? Do the cars drive too fast to allow you to feel safe letting your kids walk anywhere? This is your environment and we can make systems and policy level changes to make it healthier. We can change the zoning regulations to allow for urban agriculture in empty lots and front yards, we can create "road diets" to slow down traffic, we can increase the pedestrian and biking infrastructure, plant shade trees, and create community centers. This is public health. 

So Where Do We Go From Here?

The new face of public health focuses on these upstream social determinants of health. Where you live, work, learn and play are the biggest factors in your health and well being. An example of such public health work in action is an op ed recently posted by my friend and fellow Fellow, Carly Hood, on How to improve the health of Wisconsin families.


County Health Rankings Model
University of Wisconsin Population Health Institute
County Health Rankings and Roadmaps 2014. www.countyhealthrankings.org

"In short, when people don't have access to education, healthy food options, safe and active living environments or transportation to and from a decent-paying job, their health suffers."


In short, EVERYTHING is public health. As public health professionals today, we work to create healthier environments in which to live, work, learn and play tomorrow.

Moving Beyond #72

Moving Beyond #72:  Improving Health in Menominee County

Lauren Lamers, MPH
Wisconsin Population Health Service Fellow
Menominee Tribal Clinic
Shawano-Menominee Counties Health Department
Keshena, WI 

On March 26, the Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute released the 2014 County Health Rankings.  Within each state in the U.S., the Rankings rank counties from most to least healthy based on heath outcomes as well as the environmental, clinical, social, and behavioral factors that influence health.  For many counties, the release of the Rankings is an opportunity to see how their community’s health measures up to other counties in their state, identify successes in improving community health, and hone in on areas that still need improvement.  For Menominee County, however, the Rankings tend to be all too predictable. 

County Health Rankings Model
University of Wisconsin Population Health Institute. 
County Health Rankings and Roadmaps 2014.  www.countyhealthrankings.org

Every year since the Rankings have been released nationally, Menominee County has ranked 72^nd of Wisconsin’s 72 counties for both health outcomes and the factors that influence health.  Perusing the data behind Menominee County’s ranking, several factors driving the low ranking quickly become apparent: unemployment and child poverty rates more than double the state average, high rates of teen pregnancy, and a high prevalence of health risks such as smoking and obesity just to name a few.  Furthermore, considering the wide disparities in health outcomes and health determinants between Menominee County and other counties in Wisconsin, the #72 ranking is unlikely to change any time soon.

Although consistently being ranked last in the Health Rankings can paint a rather grim and defeating picture, when I began my fellowship with the Menominee Tribal Clinic I quickly realized how much the Health Rankings, while not necessarily inaccurate, do not capture.  In many ways, it is the factors that the Rankings cannot directly measure that tell a much richer and more inspiring story about the health of this community.

First, there are a host of historical factors not directly captured in the County Health Rankings that nonetheless underlie the Rankings’ measures of heath outcomes and health determinants.  As a predominantly Native American community, the historical trauma experienced by the Menominee Tribe, including forced relocation to the present reservation, boarding school educational policies intended to destroy Menominee culture, and termination of the Menominees’ status as a federally recognized tribe in the mid-twentieth century, continues to dramatically affect the health of the community.  Many of the indicators captured in the Rankings, such as high rates of poverty, substance abuse, and premature death, are direct reflections of this legacy of historical trauma.

Many efforts are currently underway, however, to address and move beyond this trauma and improve the physical, social, emotional, and spiritual wellbeing of the Menominee people.  Through Fostering Futures, an initiative to promote trauma-informed care across tribal and county agencies, community leaders have joined together to discuss the impact of historical and intergenerational trauma and discuss how to build resilience among families and children.  Additionally, in response to the county’s health ranking, a Community Engagement Workgroup of stakeholders across a variety of sectors has been meeting for several years to implement initiatives aimed at reducing youth obesity and teen pregnancy and improving school readiness.  Other local coalitions and programs are actively addressing issues such as substance abuse and are promoting healthy youth development through the teaching of the Menominee language and traditional cultural practices.  Through this work, community members have identified how a variety of social, environmental, and behavioral factors interact to influence health, and their collaboration has enabled them to take a multifaceted approach to improving community wellbeing.

While the engagement, collaboration, and resilience of the Menominee community are not necessarily quantifiable factors that can be incorporated to a Health Rankings model, they are crucial for eventually making changes to improve community health.  It will take years for small improvements in health to be manifest in the overall health ranking, but there are already some indicators of the fantastic work that this community is doing.  For instance, in the 2010 Rankings, the percentage of Menominee County ninth grade students who graduated in four years was 68% – the lowest in Wisconsin.  In the 2014 Rankings, that number has increased to 93% - above state average.  Violent crime has decreased, and Menominee County is currently ranked 45^th for clinical care and 15^th for environmental factors. 

According to the Robert Wood Johnson Foundation and UW Population Health Institute, the County Health Rankings are intended to “serve as a call to action for communities to understand the health problems in their community, get more people involved in improving the health of communities, and recognize that factors outside medical care influence health.”¹  The community members in Menominee County have certainly embraced this call to action wholeheartedly.  While it may not be reflected in the #72 health ranking, their fantastic work to improve health and wellbeing is an exemplary model for other communities to follow.

 

1.  County Health Rankings and Roadmaps.  Frequently Asked Questions.  http://www.countyhealthrankings.org/faq-page#t82n12072       

A Major Achievement: The Healthiest Wisconsin 2020 Baseline and Health Disparities Report

                                     

 
  e.shor, MPH and Christina R. Hanna, MPH
  Population Health Service Fellows
  HIV/AIDS Program, Division of Public Health
  Madison, Wisconsin

Over the past few years, many Fellows and staff at the Wisconsin Department of Health Services (DHS) have been working to put together the Healthiest Wisconsin 2020 Baseline and Health Disparities Report. The report serves both as a baseline report for Healthiest Wisconsin (HW) 2020, Wisconsin's state health plan, and as a report on health disparities in Wisconsin. Users can orient themselves to this large report by reviewing the text on the web page and the Executive Summary.

The report is organized into health focus areas, an infrastructure focus area focusing on access to high-quality health services, and data summaries by population. The health focus areas include:

• Alcohol and other drug use
• Chronic disease prevention and management
• Communicable disease prevention and control
• Environmental and occupational health
• Healthy growth and development
• Injury and violence
• Mental health
• Nutrition
• Oral health
• Physical activity
• Reproductive and sexual health
• Tobacco use and exposure

The data summaries by population highlight demographic and socioeconomic data for each population and emphasizes health risk behaviors and outcomes where that population experiences disparities compared to other groups. The populations highlighted in this report include:

• Blacks/African Americans
• American Indians
• Asians
• Hispanics/Latinos
• Lower socioeconomic status populations
• People with disabilities
• Lesbian, gay, bisexual, transgender populations
• Geography (rural, suburban, urban)

Fellows worked on many pieces of the report including writing SAS codes, running data, analyzing data, putting together the PowerPoint, and writing some of the chapters, editing, and evaluation. It was truly a team effort with over 60 contributors. The current and former Fellows that have contributed to this important report include Akbar Husain, Anneke Mohr, Erica LeCounte, Christina Hanna, Carly Hood, Lindsay Menard, Melissa Olson, Kelli Stader, and e.shor.

This report is unique is that it brings together a rich set of data on a diverse range of populations. Within the Wisconsin Division of Public Health, program areas have epidemiologists that collect, analyze, and present data specific to that area. For example, the HIV Program has staff members who collect and compile data and publish reports on HIV in Wisconsin. There is no one epidemiologist that is charged to compile data about racial and ethnic populations, LGBT people, and other marginalized communities and the health disparities that these communities face. A large number of people stepped out of their usual responsibilities to help put this report together. Another unique aspect of this report is that it highlights communities that are often left behind and do not get enough attention, especially given the extreme health disparities in Wisconsin. All of these factors make it incredibly important to get this report out to people working on these issues and working in these communities. If you think of someone who could benefit from the information in this report please send them the link and do your part in getting the word out!

Do Our Built Environment Redesigns Consider Health AND Equity?

Carly Hood, MPA, MPH

Population Health Service Fellow

Wisconsin Center for Health Equity

Health First Wisconsin

Wisconsin Division of Public Health

Madison, Wisconsin

Monday I attended the Population Health Sciences seminar “Retrofitting Suburbia: Urban Design for Public Health” given by Ellen Dunham-Jones who is a Professor of Architecture and Urban Design at the Georgia Tech School of Architecture. It was a great lecture with a wealth of insights on areas around the country that have undergone various methods of design to recover and invigorate the empty lots and strip malls blighting our nation. Such methods include everything from reinhabitation (repurposing of old buildings) and redevelopment (building new structures on old properties), to “regreening “or simply tearing things down to put in more space for trees, gardens and space to be active. (Archive coming soon!)

Somewhat counterintuitive and disturbing, I was surprised to learn that we have seen a dynamic shift in where poverty in our country exists, and today there are more poor people living in the suburbs than the cities (reinforced by this infographic).

This is in part the result of what’s known as the “drive til you qualify” phenomenon whereby if you want a shorter and cheaper commute, you have to be able to pay for it in home price (and vice versa). This lack of regulation on housing prices and affordability, as Professor Dunham-Jones pointed out, has led to uneven and unsustainable patterns in development as we see them today.

But it was as she shared pictures of a case study (one from her incredible database of 800 locales!) from my home state of Oregon that I got to thinking…not all suburbs are created equal. She was sharing changes made to a structure in a suburb of Portland called Lake Oswego which happens to have the greatest concentration of Portland-area homes worth more than $1 million. And so it struck me: Are the people in Lake Oswego the people most in need of retrofitting for the “public’s health?” Now I recognize that this is just one of many examples of a suburb that is reusing space for new purposes; some examples are found in impoverished communities, others in more well off areas. And Professor Dunham-Jones did share stories from both ends of the spectrum. But given that lower socioeconomic status has consistently been associated with poorer health outcomes (which holds across the income gradient), if one of the goals of “retrofitting suburbia” is to improve population health, wouldn’t we be more successful at achieving this goal if our efforts were more often targeted in areas with poor health, less community cohesion, and fewer options for safe shared space?  

There’s no doubt empty strip malls, large parking lots, and poorly designed suburban neighborhoods are not only eye-sores, but are contributing to our car-dependent and chronic-disease ridden country.

But should we be looking towards those with longest commutes, fewest parks, and/or highest rates of morbidity to consider such beneficial transformations? And even before we ask those questions, I’d explore just what may be occurring inside those communities that we can’t see from the outside…Kaid Benfield, Special Counsel for Urban Solutions at Natural Resources Defense Council, highlights, “As [suburban] properties have declined, so have their rents, making them affordable to small, often entrepreneurial businesses,” businesses often owned and frequented by inner-suburb immigrant populations. Says Benfield, “The risk is that, as we reshape these old properties with new buildings and concepts, the replacement properties will be much more valuable than their predecessors; indeed, that’s why new development is appealing to investors and how it is made possible.  Overall, that’s a good thing.  But small businesses either go under, unable to afford new rents, or relocate as a result. “ In housing policy, when an area is rezoned many cities now have inclusionary zoning policies e.g: “a percentage of units in a new development or a substantial rehabilitation that expands an existing building set aside affordable units in exchange for a bonus density. The goals of the program are to create mixed income neighborhoods; produce affordable housing for a diverse labor force; seek equitable growth of new residents; and increase homeownership opportunities for low and moderate income levels.” But that policy doesn’t necessarily translate to the rezoning of small, local businesses run by lower and middle class populations.

Furthermore, the potential negative implications of redesigning run-down suburbs don’t just apply to small business owners; development and the resulting risk of gentrification can hurt the workforce and overall economy of an entire region as is the case in DC where the free market is picking winners and losers by pricing much of DC’s workforce out of the area.

This can happen in cities and in suburbs. And—as my economics side must loudly add—that’s just capitalism functioning as it’s supposed to! Without a “check and balance” of some sort, that’s the way our system is meant to function.

Alas, the challenges remain—and professor Dunham-Jones spoke eloquently to these: How do we ensure beautifying old structures isn’t pushing out the very people who are making the only use of them? How do we even determine if in fact retrofitting efforts ARE having an impact on health? And finally, I’d push us to ask: are we getting at the roots of the problem? Increasingly more and more people across the country are spending less time using services, purchasing goods and/or enjoying public space.  America’s poor paying jobs that demand long hours, multiple shifts, and/or too much time in transit are squeezing our middle class. An extreme example, but one we could do well to learn a lesson from before it’s too late, is that of China’s ghost cities, captured here on CNN.

I see the benefits of retrofitting our suburban landscape, and through Professor Dunham-Jones’ lecture, have learned of the amazing structures and spaces erected, community built, economies revitalized and local business improved through such efforts. I recognize health is not the only goal in redeveloping our suburban landscape, and equity can’t be the sole factor in determining repurposing projects. But that’s the lens I wear. And for those most sick and in most in need of a louder voice, I can’t help but ask, “How do we decide fairly which space to retrofit?”