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Equity and Practicality in Health Disparities Research John R. Stone, MD, PhD Center for Health Policy and Ethics Creighton University School of Medicine Learning Objectives • Explain meanings of “health equity” and “healthcare equity.” • Understand links to equality, justice, and respect. • Explain practical implications for health disparities research. Health Disparities Clarity & Practicality Clear Definitions Braveman et al. (2011) AJPH Clear Indications • Healthcare • Social policy Respect • Everyone has equal and substantial moral worth and their equal worth is recognized, honored, and ensured. Health Disparities • “Health differences that adversely affect socially disadvantaged groups.” – “plausibly avoidable” – Assoc w/ “discrimination or marginalization” • “Disparities in health and its determinants are the metric for assessing health equity.” Braveman et al. (2011) AJPH Equity & Disparities Health Equity • Core value Eliminate Disparities Braveman et al. (2011) AJPH Soc Justice Health Health Rights Equity Disparities Braveman et al. (2011) AJPH Equity & Practicality • In health disparities research – The concept of health equity is practically important. • Yes/No (Example) – The concept of healthcare equity is practically important. • Yes/No (Example) Ethical Actions Possible Actions Practical = Possible Ethical Actions Practical = Possible & = “Plausible” = = Reasonably Possible? or =Should do, all moral factors considered Equity & Practicality • Is the concept “health equity” practically helpful in health disparities research? – Gives helpful ethical guidance and/or – Provides helpful new guidance and/or – Facilitates what should be done Health Disparities Research • Is the concept of health equity of practical significance? Is it practically helpful? • If so, how or why? Justice Equity Equality Equity, Rights, Health, Healthcare • Ethical Right to health/healthcare: 1o or 2o (R1/R2) • Equitable H/Hcare – Fair honoring of R1/R2 – Not overridden by other Rs & additional ethical factors as determined through a fair deliberative process Equity (& Equality) • Feature of justice • Justice as Fairness – Likes are treated alike (equality) – To each (grp, individ) what is due (e.g. equal opportunity) – Priority to the worse off, especially worst off – Outcomes of a decision procedure that employs appropriate ethical guidelines, including fair equality of opportunity for participation. Equity in Health/Healthcare • Fair opportunity for a sufficient level of health* – Just distribution of social determinants – Genuine access to needed healthcare – Needed healthcare • Remediation of deficiencies, given no overriding ethical considerations *Powers, M., & Faden, R. (2006) Practicality & Disparities Research • Healthcare Equity – Fair & substantial equal opportunity for access • Sort by challenges: poverty, language, education, etc. • Structural barriers: agencies, policies • System facilitators – Equality after system entry • Quality improvement outcomes • System “treatment” (policies, procedures, personnel) Causality & Practicality • “It must be plausible, but not necessarily proven, that policies could reduce the disparities, including not only policies affecting medical care but also social policies addressing important nonmedical determinants of health and health disparities, Braveman et al. (2011) AJPH Health Equity, Social Disadvantage Health Sciences Centers • Does health equity, a form of social justice, require that health sciences centers work to eliminate unfair inequalities in social determinants that contribute to health disparities? • Why/why not? • If so, how? Equity: Health & Healthcare • Does health equity require that healthcare institutions/systems assess outcomes by race/ethnicity, gender, sexual orientation, language, socioecon status, geographic location, etc.? • Why/why not? • If so, how? References • Braveman, P. A., Kumanyika, S., Fielding, J., Laveist, T., Borrell, L. N., Manderscheid, R., & Troutman, A. (2011). Health disparities and health equity: The issue is justice. American Journal of Public Health, 101 Suppl 1, S149-55. • Powers, M., & Faden, R. (2006). Social justice: The moral foundations of public health and health policy. New York: Oxford Univ. Press.