Health Equity CLC presentation and vetting

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The CDC Health Equity Workgroup (HEWG) From
Definitions to Actions for Equity in a Healthier
America Hazel D. Dean, ScD, MPH Camara Jones,
MD, MPH, PhD Jamila Rashid, PhD, MPH Marian
McDonald, DrPH Marilyn Metzler, RN Lorine
Spencer, RN, BSN, MBA and the CDC HEWG The
findings and conclusions in this presentation are
those of the authors and do not necessarily
represent the views of the Centers for Disease
Control and Prevention (CDC).
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Overview of Presentation

• Equity in CDCs identity themes
• History of health equity focus at CDC
• Why the sense of urgency now?
• Health Equity Work Group (HEWG) activities
• Pre-existing definitions of health equity
• Working definition of health equity chosen by
  CDC/ELB
• Vetting of ELB working definition of health
  equity
• Feedback and recommendations from vetting
  conversations
• Next steps

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Equity in CDCs Identity Themes

• Vision - Healthy People in a Healthy
  WorldThrough Prevention
• Mission - To promote health equity and quality
  of life by preventing and controlling disease,
  injury, and disability
• Core Values
• Accountability
• Respect for individual cultural diversity
• Integrity

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History of Health Equity Focus at CDC

• CDC policy decisions
• CDCs Office of Minority Health (1988-)
• CDC/ATSDR Minority Initiatives Coordinating
  Committee (1998-)
• Futures Initiative (2003-)
• CDCs Office of Minority Health and Health
  Disparities was renamed and re-positioned (2004-)
• Health Equity Work group (2007-)
• Science-related workgroups started by employees
• Social Determinants of Health Workgroup (2000-)
• Racism and Health Workgroup (2001-)

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Why Sense of Urgency Now?

• Percentage of US population with social
  disadvantage is growing fueled by declining
  income, increased drop out rate, more women and
  children living in poverty, and immigration from
  less developed countries
• Without effective action, health inequities
  linked to social disadvantage will increase, thus
  reducing the health of the entire nation
• Other nations are doing more to improve health
  equity (e.g., UK, Sweden, Canada)
• States and counties are doing more to improve
  health equity
• See http//www.kingcounty.gov/exec/equity.aspx
• CDC intends to continue leading on this issue

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Health Equity Work Group (HEWG)

• Formed at the request of CDC Director, Dr. Julie
  L. Gerberding (Summer, 2007)
• CDC Directors view
• CDC has a two-part mission - health protection
  and health equity and CDC should be striving
  toward both in our goal action plans and in our
  efforts to contribute to health system
  transformation.
• Charged with developing a working definition of
  health equity for CDC

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HEWG Research Deliberations

• Reviewed existing definitions and literature
• Conducted 10 facilitated meetings of HEWG
• Started with theoretical (conceptual) definitions
• Assessed candidate definitions using objective
  criteria (clear, concise, easily operationalized,
  retains spirit of existing definitions)
• Defined key terms in candidate definitions

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HEWG Research Deliberations Contd

• Used web-based application (FacilitatePro) to
  elicit feedback on candidate definitions from CDC
  staff and contractors both in the field and at
  head quarters Ranked and voted on candidate
  definitions
• Presented 3 alternative definitions to CDC
  Executive Leadership Board (ELB)
• Vetted ELB working definition inside CDC

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Pre-existing Definitions
1. The working definition Margaret Whitehead used
in her paper entitled The concepts and
principles of equity and health, 1985 was equal
access to available care for equal need, equal
utilization for equal need, and equal quality of
care for all. 2. P. Braveman and S. Guskin in
their article Defining equity in health
concluded that equity in health is the absence
of systematic disparities in health (or in the
major social determinants of health) between
groups with different levels of underlying social
advantage/disadvantagethat is, wealth, power,
or prestige 3. Definition provided to the
leadership in 2004 in discussions of the name for
the current OMHHD. Health Equity embraces the
concepts of -Absence of modifiable health
disparities among the most vulnerable groups
-Absence of avoidable and unfair differences in
the determinants and manifestations of
good health and longevity Operational
definition of Health Equity is striving to
eliminate disparities in health between more
and less-advantaged groups (i.e. groups that
occupy different positions in a social
hierarchy.)
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Why Consider Other Definitions?

• Health equity does not have a universally
  accepted meaning
• CDC and its partners need a commonly understood
  definition of health equity to guide our work
• Pre-existing definitions cannot readily be
  applied in CDCs work without modification
• Discussions about the limitations of existing
  definitions inevitably led to consideration of
  more alternatives

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Working Definition Chosen by ELBOctober 2007
Health equity is the fair distribution of health
determinants, outcomes, and resources within and
between segments of the population, regardless of
social standing
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Vetting of ELB Working Definition of Health
Equity

• Internal Blog (n 101)
• Leadership and staff of CDC operating divisions
• Seminars and informal discussions (n 133)
• Leadership and staff of CDC operating divisions
• 5 seminar presentations
• 5 informal discussions (brown bags)

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Questions for Vetting ELB Definition

• QUESTION 1
• Would this definition contribute to or limit the
  work you do now?
• QUESTION 2
• How might we revise the working definition to
  make it more useful to CDC?
• QUESTION 3
• What can you or your unit (Team, Branch,
  Division, Center) do now to support work on
  health equity?

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Feedback From Vetting Conversations

• Key terms in the ELB definition should be
  defined
• fair, distribution, determinants, and resources
• Key concept of fair is too vague and hard to
  measure
• Key concept health disparities should be part
  of definition because it is important for
  measurement
• Alternatives to the ELB definition should be
  considered
• Definition is not as important as actions to
  achieve health equity aims through CDCs ongoing
  work

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Recommendations from Vetting Conversations

• Include standard language in funding opportunity
  announcements (FOAs)
• Include equity-related actions in CDC Goal Action
  Plans
• Develop workshops and courses on health equity
• Centralize health equity work in a CDC
  organizational unit
• Promote health equity as a CDC priority
• Integrate health equity concerns into CDC
  partnerships to achieve Healthiest Nation
  objectives

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Next Steps in Pursuing Health Equity

• Moving from conceptual to operational definition
  with variables contained in health monitoring
  systems
• Healthy People 2010 objectives and data systems
• Health people 2020 objectives and data systems
• CDC goals, objectives, and health action plans
• Promoting health equity as a CDC priority
• Healthiest Nation initiatives
• Health system transformation
• Engaging CDCs external partnerships

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Moving from Concepts to Measures

• Fair ness
• In proportion to need, merit, ability to pay,
  etc?
• Income, assets, other means tests
• Distribution
• Frequency distribution of attributes
• Percentile, quartile, etc.
• Between population segments
• Men versus women, black versus white, etc
• Within population segments
• Among men, among black persons, etc.
• Defined by social standing
• Sex, race, ethnicity, social class, geography,
  disability, income, sexual orientation, etc.

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Moving from Concepts to Measures

• Determinants of health
• Social and physical environments, health care,
  behavior
• Social status, racism, sexism, chronic stress
• Outcomes
• Markers of exposure, dysfunction, disease,
  disability, death
• Smoking, lung cancer incidence, deaths from heart
  attacks and stroke, etc.
• Resources
• Money, people, information, programs, services
• Grants, budgets, field assignees, data, etc.

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Health Equity Workgroup