Second Opinion: The Equity Equation

April 24, 2017
Written by

Deena J. Chisolm, PhD, director of the Center for Population Health and Equity Research at Nationwide Children's Hospital, applies a health equity approach to improving infant mortality outcomes.

Health care quality and outcomes differ by race, ethnicity, wealth and place of residence. In fact, we know that health outcomes such as life expectancy, health-related quality of life and infant mortality are more defined by a person’s zip code than by their genetic code.

The field of health disparities research was developed to unite clinicians, health services researchers, epidemiologists, social scientists and others in the pursuit of understanding what differences exist, why they exist and what we can do about them. Yet even given a number of notable health disparity reductions in the past decade, many large gaps still exist.

Why? In part, because we’ve been looking at the gaps without focusing on the world in which those gaps exist. This realization has spawned a movement to change our focus from health disparities to health equity.

A health equity approach starts with the belief that everyone should have a fair opportunity to live a long, healthy life that is not compromised because of their race, ethnicity, gender, income, sexual orientation, neighborhood or any other social condition. Health equity research is designed to study how we achieve that vision. It changes our “lens” from the difference to the solution. Health equity research uses diverse data sources to identify health inequities and tests interventions to learn which approaches work best in which populations to reduce those inequities. Ultimately, this research informs health care and health policy designed to maximize health across all populations.

In 2016, The Research Institute at Nationwide Children’s formalized its commitment to research and advocacy in the area of health equity with the establishment of the Center for Population Health and Equity Research. As an epidemiologist and health services researcher, I combine clinical data and community input to learn what works and what doesn’t to maximize health across all populations.

As part of my work, I apply the health equity lens to one of Ohio’s greatest public health challenges, infant mortality. Infant mortality (IM) is defined as death of an infant in its first year of life. In Ohio, nearly half of these deaths are associated with premature birth (46.3 percent). Other leading causes included sleep related deaths (16.0 percent) and birth defects (14.8 percent).

According to the Ohio Department of Health’s most recent infant mortality report, the state’s 2015 infant mortality rate was 7.2 mortalities for each 1,000 live births, ranking 45th in the nation, and the IM rate in black births was 2.7 times higher than that in white births (5.5 per 1,000 vs. 15.1 per 1,000). Over the past two decades, the state has done a commendable job reducing the overall rate, which was as high as 9.8 in 1990, but the black-white difference has remained frustratingly consistent.

This is why:

Different populations have different infant mortality rates because they face different health and social factors that influence infant mortality risks. This means that “one size fits all” can help improve overall performance in populations but may not close the gaps.

For example, an intervention that reduces infant mortality by 10 percent for both black and white populations, will yield decreases to 13.6 and 5.0, respectively. This is a great improvement but a notable gap remains. Closing the gap requires implementing interventions that have the greatest impact in the populations that have the greatest opportunity for improvement. To reach a goal of 5 per 1,000 IM in both black and white births, we would need to implement interventions that generate a 10 percent improvement for white births and a 67 percent improvement for black births. This is a daunting challenge that some would argue is unreasonable, but the health equity lens provides us with a framework for meeting the challenge head on.

The health equity lens moves us from doing the same thing for everyone to doing the right thing for everyone. It leads us to think bigger about what that right thing is and to customize our approaches to the needs of our diverse communities.

For infant mortality, we can think about intervening at three levels: (1) we can continue to improve the quality of health care provided to premature infants and babies with congenital anomalies or traumatic injury; (2) we can continue to improve the care of expecting mothers by enhancing access to high quality prenatal care, education and support; and (3) we can improve the communities in which our future moms and dads live by improving the economic, educational and employment environments so that parents have the best potential for better birth outcomes before pregnancies happen.

In collaboration with state and local governmental and community partners, we are addressing each of these levels with a combination of innovative approaches to neonatal and infant care as well as engaged approaches to improving social determinants of health. Importantly, we are also conducting research to measure the success of our strategies. Through intervention, research and review, we can reach our goal of best outcomes for all babies.


Photo credit: Nationwide Children’s