What is Health Equity: And How Does a Life-Course Approach Take Us Further Toward It?
Although the terms “health equity” and “health disparities” have become increasingly familiar to health professionals in the United States over the past two decades, they are rarely defined. Federal agencies have often defined “health disparities” in ways that encompass all health differences between any groups. Lack of clarity about the concepts of health disparities and health equity can have serious consequences for how resources are allocated, by removing social justice as an explicit consideration from policy agendas. This paper aims to make explicit what these concepts mean and to discuss what a life-course perspective can contribute to efforts to achieve health equity and eliminate health disparities. Equity means justice. Health equity is the principle or goal that motivates efforts to eliminate disparities in health between groups of people who are economically or socially worse-off and their better-off counterparts—such as different racial/ethnic or socioeconomic groups or groups defined by disability status, sexual orientation, or gender identity—by making special efforts to improve the health of those who are economically or socially disadvantaged. Health disparities are the metric by which we measure progress toward health equity. The basis for these definitions in ethical and human rights principles is discussed, along with the relevance of a life-course perspective for moving toward greater health equity
KeywordsHealth equity Health disparities Life course
Although the terms “health equity” and “health disparities” have become increasingly familiar to health professionals in the US over the past two decades, they are rarely defined. Lack of clarity about the concepts of health disparities and equity has led some federal agencies to use it at times to refer generically to any health differences between any groups of people, without restrictions [1, 2]. According to this literal interpretation, for example, members of a privileged group could demand that resources for health equity/disparities be used to address their needs, because they have a higher rate of a particular health problem than some other groups; while such a health difference may deserve public health action, it is not relevant to health equity or health disparities. The consequences—for example, with respect to how resources are allocated—of adopting such a broad definition of health disparities are to remove social justice as an explicit consideration from the agenda for policy and practice. This paper aims to make explicit what these concepts mean and to discuss what a life-course perspective can contribute to efforts to achieve health equity and eliminate health disparities.
What is Health Equity?
What is health equity? And what are health disparities?
Equity means justice. health equity is social justice in health
Pursuing health equity means reducing disparities in health between groups of people who are more or less advantaged economically or socially
Examples of economically or socially more or less advantaged groups include: racial, ethnic, or religious groups; socioeconomic groups (people grouped according to their income, wealth, education or occupational prestige); groups identified by sexual orientation, gender identity, or a socially stigmatized mental or physical disability; or other groups of people who have often experienced discrimination or been excluded from opportunities or marginalized from society, regardless of whether the discrimination/marginalization was intentional or unintentional
Health disparities are the metric by which we measure progress toward health equity
Health disparities are a specific subset of health differences that raise concerns about social justice
What Makes a Health Difference a Health Disparity?
Health disparities are a specific subset of health differences that raise concerns about social justice, because they adversely affect groups of people who are economically and/or socially disadvantaged [2, 3]. Health disparities are differences in health that adversely affect economically or socially disadvantaged groups, such as groups characterized by their wealth, education, or occupational standing; their racial or ethnic identification, religion, language, gender, disability status, sexual orientation, or gender identity; or other characteristics that have often been linked with discrimination, marginalization, or exclusion from economic or social opportunities in a society. Whether a group has historically been disadvantaged can be documented, for example, in data from public agencies (e.g., the Census), peer-reviewed literature, and reports from credible non-academic organizations (e.g., credible groups that monitor hate crimes). Discrimination refers not only to intentional discrimination, but to structures or processes whose effect is to systematically put a social group at an economic or social disadvantage, even when there is no intent to discriminate. Examples include persistent racial residential segregation (resulting in Black and Latino children disproportionately growing up in neighborhoods that diminish their economic opportunities and are unhealthy in multiple other ways as well) or the policies that make public schools dependent on local property taxes (resulting in schools in disadvantaged communities being generally under-resourced, particularly in relation to students’ needs).
To call a health difference a health disparity, it must be at least plausible, with respect to current science, that the difference is avoidable; we do not have to prove that it is avoidable, but it must be believable in light of current knowledge. This requirement would mean, for example, that the fact that younger adults are generally healthier than the elderly would not qualify as a health disparity. Moreover, to call a given health difference a health disparity, we do not need to prove that it was caused by unjust actions. This is important in part because it is very difficult to prove that one factor causes a particular effect and because notions of justice can vary widely. Health disparities are inequitable, even when we do not know the causes, because they put an already economically/socially disadvantaged group at further disadvantage with respect to their health. They reflect compound disadvantage and are particularly unjust because health is needed to overcome economic/social disadvantage [2, 3]. Health disparities and equity are not the only considerations that should drive a public health agenda, but they need to be among the central priorities—along with overall population impact and costs, for example.
The Fields of Ethics and Human Rights Provide a Basis for the Concepts of Health Equity and Health Disparities
The concepts of health equity and health disparities are grounded in widely accepted social values. Ethicists have noted that because health is essential to normal functioning in every sphere of life, it is not a commodity like a luxury car or designer clothing; consequently, resources needed for health should be distributed according to need, not privilege [4, 5]. As discussed later in this paper, resources needed for health include not only medical care but the social factors, such as education and living and working conditions, which can profoundly influence health [4, 6, 7]. Nobel Laureate economist Amartya Sen has written about the ethical obligation of a society to support the attainment by everyone of basic human capabilities, such as health and education .
Human rights principles provide a firm conceptual basis for defining health equity and disparities
Human rights agreements obligate governments to progressively remove barriers in the way of all people achieving all of their rights, giving particular attention to those people who face more barriers
Human rights agreements prohibit policies or social structures with either the intent or the effect of discrimination
Human rights agreements and principles indicate the groups that are of greatest concern from a disparities/equity perspective—that is, groups that have systematically experienced discrimination or social exclusion (see Table 1)
In addition to civil and political rights, such as freedom of speech and assembly and freedom from torture or arbitrary imprisonment, there also are economic, social and cultural rights; furthermore, all human rights are considered inter-related and indivisible. Economic and social rights include, for example, the right to a standard of living adequate for health and the right to a level of education necessary to participate fully in society as well as the right to health. The right to health is defined as the right to attain the highest attainable standard of health. This can be interpreted as the right to achieve the health status experienced by the most economically and socially advantaged group in a society—as indicated, for example, by those in the top quintile of wealth, income, or education—because that level of health should be biologically attainable by everyone in a society [3, 9]. The indivisibility of all human rights, codified in human rights agreements, supports approaches to health that address economic and social determinants, rather than only medical care .
The human rights principles of non-discrimination and equality also provide a crucial foundation for the concepts of health equity and disparities by making explicit that everyone has equal rights and that human rights are violated by policies or social structures with either the intent or the effect of discrimination. Human rights agreements discussing non-discrimination and equality make another important contribution to defining health equity by specifying a number of groups who deserve special protection from discrimination [10, 11], implicitly acknowledging that these groups have experienced discriminatory treatment on a systematic (rather than exceptional) basis. This provides a solid foundation for identifying the groups considered to be economically/socially disadvantaged and hence the groups of concern from an equity/disparities perspective, as listed above in Table 1 .
Health Equity, Health Disparities, and the Life-Course Perspective
What is a Life-Course Perspective?
How are health equity and the life-course perspective linked? Like “health disparities,” the term “life course” means far more than its literal translation. A life-course approach considers how health later in life is shaped by earlier experiences. It is not, however, simply taking a longitudinal view. A life-course approach means not only considering the roots of adult health and illness in an individual’s health during previous stages of the life course, but also systematically considering the economic and social (along with biomedical and other relevant) factors across the life course that influence health. Other papers in this issue define a life-course approach in detail and document the evidence base supporting it.
How does a life-course perspective help us move toward greater health equity?
A life-course perspective systematically considers the economic and social factors across the entire life-course that influence health
A life-course approach is profoundly relevant to health equity because it is essential forunderstanding how health disparities are created, exacerbated or mitigated, and potentially transmitted across generations
Social factors are powerful determinants of health disparities, not only because they influence exposure to healthy and unhealthy living and working conditions, but also because they shape vulnerability—or resilience—to the health effects of adverse exposures
A life-course lens directs our gaze upstream—to fundamental causes now and earlier in life
An Example: A Life-Course Approach to Understanding Racial Disparities in Birth Outcomes
For example, a life-course perspective suggests important lines of inquiry into the large and persistent disparities in birth outcomes (low birth weight and preterm birth) between African American (Black) and European American (White) women; these disparities have not been explained by differences in prenatal care, smoking or other health-related behaviors, obesity, levels of income and education around the time of pregnancy, or stressful life events during pregnancy [12, 13, 14].
The life-course lens directs us to consider experiences that occurred in a woman’s life before she became pregnant, that plausibly could have affected her subsequent birth outcomes, based on current scientific knowledge. There is limited understanding of the pathways and biological mechanisms leading to adverse birth outcomes, but enough is known to conclude that it is biologically plausible that stress experienced earlier in a woman’s life could play a role in her later birth outcomes [12, 14, 15, 16, 17, 18]. Did she grow up in an impoverished household, with the stressful circumstances that often accompany poverty? Was she exposed at critical periods in her development and/or during sustained periods of her childhood, adolescence, or young adulthood, to food insecurity or outright hunger, or to housing insecurity or homelessness? Did she live in a crime-infested neighborhood where it was unsafe to play outdoors and she and her family constantly feared gang violence? Were her parents or guardians so overwhelmed by struggling to cope with serious challenges in the face of inadequate resources that there was often family conflict and perhaps disruption? Did she directly or vicariously experience racial discrimination—a potential stressor independent of economic circumstances—during her childhood or adolescence, key periods of time in the formation of identity, self-esteem, and a sense of being able to influence the circumstances of one’s life? Did she experience stress chronically or in multiple aspects of her life, and did the damages to her health accumulate over time?
Chronic or severe stress during childhood could influence a woman’s risk of an adverse birth outcome through mechanisms involving neuroendocrine, immune/inflammatory, and/or vascular phenomena [12, 14, 15, 17, 19, 20, 21]. Chronic stress appears to be more damaging to health than acute stress [22, 23], and facing multiple stressors at the same time may exact a particularly high toll [24, 25, 26]. Many studies have linked early childhood economic deprivation or psychosocial trauma with chronic disease that does not manifest until middle or later adulthood, and/or with premature aging or mortality [23, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38]. It has been hypothesized that chronic stress in childhood could potentially cause neuroendocrine or immune dysregulation that could lead to wear and tear on multiple organs, even if later childhood and/or adulthood were less stressful [14, 39].
Looking through a life-course lens would lead one to investigate systematically circumstances earlier in life, and particularly during childhood, not only around the time a woman gives birth. Because of the historic legacy of racial discrimination and segregation, African American women are more likely than European American women of similar current education or income to have experienced economic adversity during their childhood. For example, using educational level of her parents/guardians as a rough marker of socioeconomic circumstances during a woman’s childhood, among women at least 25 years old who gave birth in California during 2003–2004 and were college graduates when they gave birth, only 34 % of African American college graduates had been raised by a college-graduate parent/guardian, compared with 58 % of European American college graduates . This suggests that many Black and White women of similar current income or educational levels around the time of pregnancy have had substantially different experiences in childhood, with Black women far more likely to have experienced socioeconomic adversity as children, and therefore the adverse consequences, including greater stress, often associated with economic hardship. Failure to consider childhood economic and social circumstances may lead to erroneous conclusions, e.g., assuming a genetic basis, about the causes of observed racial disparities in birth outcomes and/or adult health.
Compared with European American women, African American women are not only more likely to have experienced poverty/low income and its adverse correlates within their own households during childhood, but also, because of long-standing racial residential segregation, to have lived in areas with concentrated poverty [40, 41]. Neighborhoods with concentrated poverty are generally more likely to be characterized by exposure to physical hazards (e.g., air pollution, other contaminants, crime, lack of safe places to exercise) and social hazards (e.g., unhealthy norms and role models, lack of nearby sources of healthy foods) [41, 42, 43]. They often have low-performing schools and may have limited access to employment, especially if they lack good public transportation. This could have major consequences for the health of Black and White women before they become pregnant, in ways that may affect their birth outcomes and yet may not otherwise manifest until much later in their lives. The effects on a woman’s birth outcomes of the social and physical environments she experienced during childhood—which are largely determined by the economic and social advantages of her parents and in turn of her parents’ parents—illustrate how economic and social advantage and disadvantage—and health consequences—can be transmitted across generations [27, 44].
A Life-Course Perspective Means Systematically Considering Economic and Social Factors at Each Life Stage
Looking at different time periods in an individual’s life is only part of a life-course perspective; a fundamental element of the life-course approach is considering systematically how economic and social factors at each life stage can affect health at that life stage and subsequent stages. The need to consider health effects of social factors is based on a large body of scientific knowledge. Psychosocial and biomedical knowledge has accumulated, particularly over the past two decades, indicating how diverse economic and social factors experienced early in life—such as the quality of child care in the first years of life, the quantity and quality of schooling, and the consequences of economic hardship and psychosocial trauma—are strongly linked with premature mortality and the development of cardiovascular disease and diabetes [27, 34]. A critical mass of scientific knowledge shows that living and working conditions are powerful influences on health-related behaviors. Furthermore, harmful physical exposures that often accompany economic deprivation can affect health directly without involving behaviors. While much is unknown, plausible explanations are provided by current knowledge of diverse biological mechanisms triggered by pathways beginning in social circumstances. Considerable knowledge reveals that differences in living and working conditions are shaped by differences in the basic economic and social opportunities and resources that different groups of people have in virtue of their income, wealth, education, and racial identification, for example [6, 45].
A life-course perspective challenges us to consider a person’s experiences not only as an individual and a member of a household, but in a social context. For example, a number of studies have shown that a range of economic and social characteristics of neighborhoods have been linked with birth outcomes (as well as other health outcomes), even after control for individual/household factors .
Social Factors Affect Health Not Only by Determining Exposures But Also by Shaping Vulnerability, Resilience, and the Social Consequences of Illness
When social factors are considered as potential influences on health and health disparities, we usually think of their role in influencing who is exposed to healthy and unhealthy living and working conditions. They also can create and exacerbate health disparities, however, by influencing vulnerability—or resilience—to the health effects of adverse exposures. For example, a child growing up in an impoverished household is more likely to be exposed to physical hazards such as air pollution, lead, dust, mites, mold, poor nutrition and violence, and psychosocial hazards such as unhealthy role models and norms, family conflict, or intensive, targeted advertising of tobacco and alcohol. At the same time, s/he is more likely to lack resources and opportunities that can promote resilience to the adverse effects of these exposures, such as the presence of a supportive adult, because poverty produces stressors that often put adult caregivers under constant strain and often causes family disruption. Insofar as poverty is transmitted across generations, s/he is less likely to have a role model of someone she knows who has achieved economic success.
Furthermore, social factors can exacerbate and perpetuate health disparities by shaping the social consequences of illness. For example, someone with limited schooling who works as a hotel maid and who becomes physically disabled is far more likely to become unemployable than someone else with the same disability but who is a university professor and could continue working after an initial recovery period. This in turn results in more social stratification—widening inequality—over the lifetime of an individual and across generations as the children of adults who are disadvantaged economically and socially and by ill health, grow up in adversity.
A life-course perspective considers the social (as well as biomedical and physical) factors that result in health-damaging (or lack of health-promoting) effects with respect to exposure, vulnerability/resilience, and consequences of ill health, and how adverse (or favorable) factors can accumulate across the life-course. Finn Diderichsen of the University of Copenhagen has developed a useful framework that calls attention not only to the need to consider how social factors influence exposures, vulnerability and consequences, but also to consider potential points of intervention to address each aspect [27, 47].
A Life-Course Lens Directs Our Gaze Upstream: To Fundamental Causes [48, 49] Now and Earlier in Life
Many of us who try to understand and address health disparities have been drawn to consider a life-course approach as we confront gaps in the knowledge gained from research focused on exposures occurring relatively close in time to health outcomes. As noted earlier, the persistent two- to threefold disparity in low birth weight and preterm birth between Black and White newborns, for example, is not explained by the known risk factors for adverse birth outcomes, which are typically measured around the time of pregnancy or not long before . The roles of economic and social factors—such as stressful experiences resulting from low income and/or racial discrimination—in racial disparities in birth outcomes have not been conclusively established. A number of studies have, however, revealed a larger racial disparity in birth outcomes among college-educated or high-income women than among poor women, and relatively good birth outcomes of Black immigrants from the Caribbean or Africa [50, 51, 52, 53]. This and other evidence strongly suggest that economic and social factors are involved.
The essence of a life-course perspective is to examine how economic and other social factors influence health across the life span. Both elements—considering experiences during previous life stages, and specifically considering the economic and social factors that shaped experiences at each life stage—are vital. The life-course perspective does not mean confining ourselves to those considerations; it means ensuring that they are considered, along with medical care, the physical environment, genetic and other biomedical factors that may affect past as well as current health. A large and rapidly accumulating scientific literature indicates that this perspective is crucial to understanding health in general. The life-course lens is particularly useful, however, for understanding how health disparities are produced, exacerbated or mitigated, and perpetuated across lifetimes and generations; and this understanding is essential for developing effective strategies to reduce and ultimately eliminate the disparities—that is, to move toward greater health equity.
We need to be more explicit and clear about health equity, health disparities, and the life-course approach. It should be more widely understood that the concepts of health equity and health disparities are not value-neutral, but specifically address social justice in the realm of health. It should, furthermore, be clear that the life-course perspective looks not only over time across life stages, but at how economic and social factors at each life stage shape health at later stages of an individual’s life course and in subsequent generations. If we are not clear, valuable, limited resources for research and intervention intended to address health equity may—perhaps unwittingly—be diverted to efforts of little relevance to that goal.
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