Sarina Schrager, MD, WMJ Associate Editor
According to Healthy People 2020: Health equity1 is the “attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.”
Health disparity2 is “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.” A person’s health is related to much more than genetics and biology. Socioeconomic influences on health are powerful, and affect both the incidence and outcomes of disease. Availability of safe housing, food, high quality education, public transportation, health insurance, clean water, and culturally sensitive clinicians is intimately related to a person’s baseline health. Improving health for people in underserved communities can expand what people are able to accomplish in the community.
Health disparities in Wisconsin are some of the worst in the country. According to the University of Wisconsin Population Health Institute’s State Health Report Card in 2016,3 Wisconsin earned a B- as a health grade (measuring length and quality of life) and a D in health disparities (measuring differences in health based on gender, geography, socioeconomic status, and race/ethnicity). The D health disparity grade has persisted since 2013. Highlighted in this report are death rates of African American babies under 1 year of age that are close to 3 times as high as those of non-Hispanic white babies.
Four papers in this issue of WMJ detail community interventions that aim to improve equity by addressing health disparities. The study by Abbs, et al4 designed a stress reduction curriculum for Latina women living in poverty in Milwaukee, Wisconsin and Lima, Peru. This mindfulness-based program improved perceived health and decreased the presence of stress while improving confidence among participants to reduce stress in the future.
In “Biking for Health,” Bernstein et al5 tested a pilot intervention among 2 minority communities in Milwaukee. A biking instructor led a 12-week bicycling intervention and the people in the intervention group had access to a bicycle, a helmet, and a lock for the 12-week study period. People in the intervention group increased their comfort with bicycling and increased bicycling activity. Zellmer and Fleming describe Wheels For All, a program that pairs underserved recipients identified by local agencies in La Crosse, Wisconsin, with dontated bicycles to help them gain access to community resources.6
The fourth study to address health equity explored the use of a church-based intervention to reduce the risk of falls among African American seniors in Milwaukee.7 This study demonstrated that using faith-based organizations for health interventions shows promise as a means to improve health within a community.
All of these studies evaluated the use of novel, community-based interventions focused on reducing health disparities and improving health equity among low income, underrepresented minority populations in Milwaukee and underscore the importance of expanding health care activities into the community. The challenge for the future will be to continue similar interventions after the study timeframe is complete. The health care community in Wisconsin can use these studies as examples to integrate health care beyond traditional offices, clinics, or hospital settings.
Another component of reducing health disparities is developing a health care workforce that is able to adjust evaluations and interventions based on the specific cultural background of each patient. Two papers in this issue explore the care of elderly Hmong patients. In the case report by Askar, et al,8 an elderly Hmong man with advancing dementia develops vivid dreams and hallucinations that recall his time as a soldier in Laos during the war in the 1970s. Understanding his unique history of trauma through the assistance of a language and cultural interpreter was essential information for his primary care provider.
The second paper, in the “As I See It” section,9 describes a case of an elderly Hmong woman who is losing her eyesight. The clinician evaluates her but finds no obvious cause for her vision loss and then listens as she tells him of her visit with a shaman who counseled her about a vision spirit who had taken away her sight. The shaman told her that there were no vision spirits in this country and that to have a chance to get her sight back, she would need to travel back to Laos, which she did not want to do.
Both of these examples demonstrate the need to understand patients of different cultures and their beliefs in order to provide excellent care, underscoring the need for an expanded approach to health care provision. To optimize our vision of health equity and decrease health disparities, clinicians need to expand care models and incorporate patients’ cultural and socioeconomic needs into daily practice. The Institute for Health Care Improvement suggests 5 focus areas for health care organizations to achieve health equity for all patients:10
- Make health equity a strategic priority.
- Develop structure and processes to support health equity work.
- Deploy specific strategies to address the multiple determinants of health on which health care organizations can have a direct impact.
- Decrease institutional racism within the organization.
- Develop partnerships with community organizations to improve health and equity.
Developing these focus areas can set the strategic course of a health care organization and give recognition to the significant effort needed to address the lack of health equity in our society.
- U.S. Department of Health and Human Services, Office of Minority Health. National Partnership for Action to End Health Disparities. The National Plan for Action Draft as of February 17, 2010 [Internet]. Chapter 1: Introduction. http://www.minorityhealth.hhs.gov/npa/templates/browse.aspx?&lvl=2&lvlid=34. Accessed August 17, 2017.
- U.S. Department of Health and Human Services. The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Phase I report: Recommendations for the framework and format of Healthy People 2020 [Internet]. Section IV: Advisory Committee findings and recommendations [cited 2010 January 6]. http://www.healthypeople.gov/sites/default/files/PhaseI_0.pdf. Accessed August 17, 2017.
- Health of Wisconsin Report Card 2016. University of Wisconsin Population Health Institute website. https://uwphi.pophealth.wisc.edu/health-of-wisconsin-report-card-2016-2/. Accessed August 17, 2017.
- Abbs E, Brown M, Lemke M. Bauer L, Ohly S, Haq C. ¡Venga Y Relájese! Pilot Stress Reduction Program for Migrant Latina Women Living in Low-resource Settings From Milwaukee to Lima. WMJ. 2017;116(3):168-170.
- Bernstein R, Schneider R, Welch W, Dressel A, DeNomie M, Kusch J, Sosa M. Biking for Health: Results of a Pilot Randomized Controlled Trial Examining the Impact of a Bicycling Intervention on Lower-Income Adults. WMJ. 2017;116(3):154-160.
- Zellmer L, Fleming N. Wheels For All: Addressing Social Determinants of Health One Bicycle at a Time. WMJ. 2017;116(3)165-167.
- Briggs M, Morzinski J, Ellis J. Influences of a Church-Based Intervention on Falls Risk Among Seniors. WMJ. 2017;116(3):161-164.
- Askar W, Khan A, Borson S, Malone M. Recurring Vivid Dreams in an Older Hmong Man with Complex Trauma Experience and Cognitive Impairment. WMJ. 2017;116(3):171-172.
- Yamanuha J, Xiong XT. The Vision Spirit. WMJ. 2017;116(3):153.
- Wyatt R, Laderman M, Botwinick L, Mate K, Whittington J. Achieving Health Equity: A Guide for Health Care Organizations. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016. http://www.ihi.org/resources/Pages/IHIWhitePapers/Achieving-Health-Equity.aspx. Accessed August 17, 2017.