Implementation Epidemiology Part II: Built on Equity

In KROUN’s last article “Implementation Epidemiology Part I: Building a Framework”, I began the journey of walking you through my background and why I have arrived at positioning myself as an implementation epidemiologist and health equity innovator/champion. I wrote briefly about epidemiology, its many applications, and the necessary marriage of implementation science with the field. It’s time, now, to provide you with a deeper understanding of health equity, why it matters, how I use its language fluently, and how I use several frameworks related to it to guide the development, execution, and evaluation of public health programs. 

Health equity in and of itself is not a new concept. It has always been known that minoritized and historically excluded individuals have suffered poorer disease outcomes unnecessarily and unjustly at the hands of a healthcare system specifically designed to uphold white supremacy by ensuring the highest quality of health for its white consumers. Thus, equity is always discussed but never actually realized. It’s seen as some prize in the far distance of the healthcare (the system) and the health care (those delivering care) reality (Kuang, 2020). Hence, it is vitally important that we move from a place of admiration and aspiration to activation and results. 

Before diving too deep into health equity, let’s take a moment to define a few terms mentioned in Part I and some that have yet to be mentioned but are relevant to the work. I have stated that there are barriers to optimal health that drive disparities and perpetuate inequities. But, what does that mean? Barriers to optimal health in populations usually stem from the social, political, and systemic determinants of health. The social determinants of health, where people live, learn, work, eat, play, and pray, or the conditions within which individuals are born, greatly impact health in complex ways (Catalyst, 2017). Things like socioeconomic status (SES) or economic instability, food insecurity, built environments, racism, transportation, educational opportunities, and the healthcare system in which patients must navigate all affect the morbidity, mortality, life expectancy, health care expenses, health status, and any functional limitations thereof of individuals (Orgera et al., 2021). Furthermore, according to Daniel Dawes, all social determinants of health are preceded by policies that favor the inclusion of the majority (Dawes, 2020). Precisely, Dawes notes that “every social determinant of health is preceded by a political action, inaction, or impetus. Political determinants of health create the social drivers—including poor environmental conditions, inadequate transportation, unsafe neighborhoods, and lack of healthy food options—that affect all other dynamics of health” (Dawes, 2020). I tend to take these frameworks a step further in understanding that the political determinants that precede social determinants feed into structures and systems that consequently create their own policies that perpetuate inequities. Accordingly, the systemic determinants of health have as much to do with the persistent and pervasive inequities that exist as the other two determinants. 

These determinants create, what we call in the public health field, gaps in health outcomes between social groups, or disparities. Basically, if one health outcome is of greater or lesser degree among social constructs and stratifications such as race, ethnicity, age, disability, SES, biological sex, sexual identity, gender identity, or geographic location, then that such outcome is considered a disparity (Healthy People 2020, 2021). Simply put, disparities depict gaps in data of the health outcomes between population groups. Inequities, then, are the unnecessary and often unjust differences in health outcomes arising from structural inequities and imbalances of power amongst and within social groups (Weinstein et al., 2017). These unjust outcomes are often perpetuated by systems of oppression, such as racism, sexism, homophobia, transphobia, and the like. Naming these injustices and speaking truth to power is quite equally important. All too often we hear the words “implicit” or “explicit” bias when referencing these isms and phobias. While bias is certainly a part of the equation, it does not constitute the entire ism. These isms only exist because one social group has historically been disenfranchised and disempowered. Therefore, a power structure exists that creates these isms. Subsequently, the party in the ism equation that has no power cannot perpetuate the ism itself. They can certainly have biases, as we all do. They can make discriminatory decisions based on their frame of reference. But those without power cannot be racist or sexist, for example. The very definition precludes this. Which is why I am often adamant about calling a thing a thing and speaking truth to power. It makes most people uncomfortable. However, there is no real chance of eliminating or even addressing inequities without naming these isms and phobias for what they are. 

With that, it’s important to remember that inequities are both “unjust” and “unnecessary”. Meaning, we can purposely and actively avoid inequities. We should, then, purposely and actively strive toward equity. Therefore, advancing and/or achieving health equity means we create systems that allow everyone the opportunity to live with their individualized version of optimal health. It does not mean giving everyone the same access to the same healthcare and health care, which would be health equality. Rather, health equity means you and I get the pair of shoes (healthcare and health care) that fits us in size, color, occasion, needs, etc. 

Now that you’re well-versed in several definitions, let’s talk about taking these things a step further. There are several public health theories and frameworks that drive my everyday application of the above concepts. We’ve already discussed the social, political, and systemic determinants of health, which are the first three. A fourth is understanding public health in terms of what is called a social ecological model (SEM). Social ecological models are slightly complex, vary in their applications, as they can be tweaked per intervention. However, the basic tenants of any SEM are structured around reciprocal causation at multiple levels (McLeroy et al., 1988). Essentially, there are several levels (individual, interpersonal, organizational, community, and policy/systems) at which behavior shapes and is shaped by certain influences and at which interventions may occur (McLeroy et al., 1988). 

Thomas, Ashli. (2016). FIGURE: Social Ecological Model.

SEM models are applied in complex ways, often across the health impact pyramid, which I won’t dive into for the sake of brevity in this piece. But, it is vitally important to note that the biggest population change occurs at the policy/systems level. This is where I attempt to operate in within my daily professional life. Focusing on the individual level to enact behavior change is the foundation of downstream public health and hasn’t seen much promise for eliminating disparities and reaching health equity. The reverse, upstream public health, focuses on the policy/systems level and what policies are created that produce the barriers that drive the disparities and perpetuate inequities. 

The fifth framework that drives my implementation epidemiology and health equity work is understanding the levels of racism as defined by Camara P. Jones, MD, MPH, PhD. Dr. Jones’ theoretic framework recognizes racism as it appears on the following levels (Jones, 2000):

• Institutionalized Racism – differential access to goods, services, and opportunities of society by race. It is normative, often legalized, and manifests as an inherited disadvantage. Institutionalized racism is structural, as has been woven into the very fabric of all our institutions.

• Personally Mediated Racism – prejudice and discrimination; differential assumptions and/or actions towards someone based on their race. 

• Internalized Racism – acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth.

Understanding the context of each of these levels as they relate to disparities helps public health practitioners design and implement more effective interventions across any of the levels of any adapted SEM. In a society within which racism is the foundation of EVERYTHING, it is of paramount importance to fluently comprehend and speak the language of Dr. Jones’ framework to make the biggest change. So, yes, I’m THAT Black woman. I am the Black woman who relates every health outcome as it intersects with and overlaps with racism. From the way our roads are constructed to the quality of healthcare and health care in our neighborhoods, racism guides every system to the favorable outcome for which it was built – the prioritization of the majority. 

The sixth framework on which I base my strategies, thoughts, actions, and assessments as a public health professional is driven by understanding public health in the context of gender-responsiveness. Being responsive to one’s gender, whether cis or trans, and understanding that the principles of health equity require us to examine every social construct as affecting the social, political, and systemic determinants of health is vital to our success in the field (Rosser et al., 2021). Thus, I take advantage of every opportunity to scrutinize health outcomes across communicable and non-communicable diseases with a gender-responsive lens. 

The seventh framework, systems building, I’ve mentioned previously. Systems thinking inspects all things as a part of being connected somehow (Peters, 2014). This is the basic principle of everything I’ve discussed in Part II. To achieve and/or advance health equity, one must critically think of the social, political, and systemic determinants of health at the intersection of racism, while accounting for gender-responsive analysis, and intervening upstream in the SEM – i.e., a SYSTEM. Because, quite frankly, the whole system is guilty as hell. 

In knowing that these things are interconnected, I’ve built an understanding of them that applies to every facet of my work. Whether it be public health program development, implementation, evaluation, clinical quality improvement, or dissemination of public health communications. All must be considered. All have shaped my knowledge and language. All guide my career. All have led me to the health equity innovator/champion portion of my self-attributed career brand/title. 

I hope this has provided a deeper context into this implementation epidemiologist. For I cannot implement epidemiologic principles without a foundation of equity on these frameworks. 

So, stay tuned for Part III. I’ll wrap it up with some practical and successful applications. 

 -Kristen Marie

 Sources:

1)    Catalyst, N. E. J. M. (2017, December 1). Social Determinants of Health (SDOH). NEJM Catalyst. https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0312. 

2)    Dawes, D. E. (2020, September 14). Managing America's crises means addressing the political determinants of health. Grantmakers In Health. https://www.gih.org/views-from-the-field/managing-americas-crises-means-addressing-the-political-determinants-of-health/. 

3)    Healthy People 2020. (2021, June 23). Disparities. Disparities | Healthy People 2020. https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities. 

4)    Jones, C. P. (2000). Levels of Racism: A Theoretic Framework and a Gardener's Tale. American Journal of Public Health, 90(8), 1212–1215. 

5)    Kuang, A. A. (2020, February 21). Health Care or Healthcare – What's the Difference? Transforming Outcomes. https://transformingoutcomes.3m.com/2019/09/30/health-care-or-healthcare/. 

6)    McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Education Quarterly. 1988; 15: 351-377 

7)    Orgera, K., Garfield, R., & Rudowitz, R. (2021, June 9). Implications of COVID-19 for Social Determinants of Health. KFF. https://www.kff.org/coronavirus-covid-19/issue-brief/implications-of-covid-19-for-social-determinants-of-health/. 

8)    Peters, D. H. (2014). The application of systems thinking in health: Why use systems thinking? Health Research Policy and Systems, 12(1), 51. https://doi.org/10.1186/1478-4505-12-51 

9)    Rosser EN, Morgan R, Tan H, Hawkins K, Ngunjiri A, Oyekunle A, Schall B, Nacif Pimenta D, Tamaki E, Rocha M and Wenham C. (2021) “How to Create a Gender-Responsive Pandemic Plan: Addressing the Secondary Effects of COVID-19.” Gender and COVID-19 Project.  genderandcovid-19.org

10) Weinstein, J. N., Geller, A., Negussie, Y., & Baciu, A. (Eds.). (2017). The Root Causes of Health Inequity. In Communities in action: Pathways to health equity (pp. 99–185). essay, The National Academies Press.