health equity assignment

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Project SHARE Curriculum: Introduction to Health Equity

• About the Curriculum
• About the Project

Introduction to Health Equity

• Social Determinants of Health
• Health Literacy
• Locating & Evaluating Health Information
• Cultural Competence
• Family Health History
• Preventive Health
• Providers and Doctors' Appointments
• The Importance of Food Labels
• Planning a Nutritious Meal
• Designing Effective Presentations
• Speaking with Impact
• The Elevator Speech
• In Your Own Words
• Introduction to Policy
• Introduction to Advocacy
• Designing Effective Posters to Promote a Health Campaign
• Getting Started with Outreach
• National Standards
• Engaging Stakeholders
• Icebreakers/Discussion
• Around Food
• Out of the Classroom
• Videos/Films/Games
• Project SHARE Instructor Survey
• Description & Objectives
• Lesson Plan Documents

In the Introduction to Health Equity  lesson, students learn how and why health disparities impact social and economically disadvantaged populations and understand underlying causes of health inequality through a series of individual and small group activities and class discussion.

Objectives:

• Define and explain the concept of health disparity
• Analyze how the environment and personal health are interrelated
• Analyze how specific factors (determinants) contribute to health disparities
• Identify groups that are most affected by health disparities
• Evaluate how health disparities impact people in the local community (school, town, etc.)
• Instructor computer and projector
• Blackboard or whiteboard
• Handouts – slides
• Lesson Plan - Health Equity
• Presentation- Health Equity
• Equity Defined

National Health Education Standards that Align with Introduction to Health Disparities Lesson

• 1.12.3 Analyze how environment and personal health are interrelated.
• 1.12.6 Analyze the relationship between access to health care and health status.
• 2.12.4 Evaluate how the school and community can affect personal health practice and behaviors.
• 3.12.3 Determine the accessibility of products and services that enhance health.
• 5.12.1 Examine barriers that can hinder healthy decision making.

National Strategies that Align with the SHARE Curriculum

Healthy People 2020 Objectives

AH-2      Increase the proportion of adolescents who participate in extracurricular and/or out-of-school activities.

AH-3.2   Increase the proportion of parents who attend events and activities in which their adolescents participate.

National Partnership for Action

Goal 1         Awareness - Increase awareness of the significance of health disparities, their impact on the nation, and the actions necessary to improve health outcomes for racial, ethnic, and underserved populations.

Strategy 2: Develop and support partnerships among public, nonprofit, and private entities to provide a comprehensive infrastructure to increase awareness, drive action, and ensure accountability in efforts to end health disparities and achieve health equity across the lifespan.

Goal 2:        Leadership - Strengthen and broaden leadership for addressing health disparities at all levels.

Strategy 7:  Invest in young people to prepare them to be future leaders and practitioners by actively engaging and including them in the planning and execution of health, wellness and safety initiatives.

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• Last Updated: Jul 1, 2020 3:04 PM
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Health Equity Curricular Toolkit

The Health Equity Curricular Toolkit was championed by the Health Equity Team of Family Medicine for America’s Health and inspired by the Starfield II Health Equity Summit. This toolkit provides a structured curricular tool to facilitate exploration of some of the most pressing questions around social determinants of health, vulnerable populations, and economics and policy . The toolkit also provides resources to promote skill-building to confront drivers of persistent and pervasive inequities.

This toolkit is intended for clinical and public health learners and primary care faculty who would like an opportunity to further explore this area that often was not intentionally and adequately prioritized in past medical school and residency curricula.

The Guidebook to the Health Equity Curricular Toolkit includes a description of the socio-ecologic framework; the modular design; facilitation strategies; a glossary of definitions and health equity resources; and a worksheet to promote real-time application of an equity lens. This is accompanied by 14 modules including an introductory prerequisite 2-part module . Three short videos were also developed to assist with use of the toolkit.

• A Guidebook to the Health Equity Curricular Toolkit

Introductory Prerequisite 2-part Module

• Making America Healthier for All: What Each of Us Can Do (Part 1) AND Shifting the Paradigm Toward Social Accountability (Part 2)

Health Equity Modules

Social Determinants of Health Modules

• Identifying and Addressing Patients' Social and Economic Needs in the Context of Clinical Care
• Communities Working Together to Improve Health and Reduce Disparities AND Community Health Improvement Plans and Patient-Centered Primary Care Homes as Tools to Address Health Disparities
• Improving Patient Outcomes by Enhancing Student Understanding of Social Determinants of Health AND An Action Learning Approach to Teaching the Social Determinants of Health
• Understanding Health Experiences and Values to Address Social Determinants of Health

Vulnerable Population Modules

• Climate Change Module
• Why Rural Matters
• Racism, Sexism, and Unconscious Bias
• Immigrant Populations in a Nation of Changing Policy
• Intersectionality—The Interconnectedness of Class, Gender, Race and other Types of Vulnerability
• People with Disabilities (Developmental and Intellectual)

Economics and Policy Modules

• International Efforts to Reduce Health Disparities
• How Social and Environmental Determinants Can Be Used to Pay Differently for Health Care AND ACA Opened the Door for Payment Reform and Practice Transformation to Address Social Determinants of Health, Now What?
• Community Vital Signs: Achieving Equity through Primary Care Means Checking More than Blood Pressure
• Access to Primary Care is Not Enough: A Health Equity Road Map

Supplemental Videos

• Orientation to the Health Equity Curricular Toolkit
• Facilitating Conversations about Inequity, Oppression, and Privilege
• Application of the Equity and Empowerment Lens for Facilitators and Learners

Almost 40 content experts and educators in health equity across the United States and Canada helped develop the material for this toolkit and specific author information is provided in the Guidebook of the toolkit

More information about the Health Equity Team of Family Medicine for America’s Health can be found in: Martinez-Bianchi V, Frank B, Edgoose J, Michener L, Rodriguez M, Gottlieb L, Reddick B, Kelly C, Yu K, Davis S. Carr J, Lee JW, Smith KL, New RD. Addressing Family Medicine’s Capacity to Improve Health Equity through Collaboration, Accountability and Coalition-Building. Fam Med.2019;51(2):198-203.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

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• Conversations in Equity blog
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• What is Health Equity?
• Health Equity in Action
• Events and Trainings

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• Minority Health
• Women’s Health

Communicating About Health Equity Concepts (CHEC)

What to know.

Communicating using a health equity frame means focusing on creating broader understanding of the social, structural, and systemic factors that may impact health outcomes. This resource offers public health professionals three evidence-based principles with tangible strategies to clearly and effectively communicate about health equity concepts with diverse audiences.

What we did

CDC’s Office of Health Equity (OHE) conducted message testing in 2022 to learn what diverse audiences think, understand, and feel about the concept of health equity. Findings helped to inform improved approaches for creating effective messages for specific audiences.

What we want to change

We need to reframe public health messages to communicate about health h equity instead of focusing on health disparities. Why? When you shift the focus to the systemic and structural issues, you show a pathway to address health disparities in a meaningful, non-stigmatizing, and sustainable way. This approach encourages strategies to address root causes and boosts broader systems-level changes that benefit us all.

How we move upstream

Results from OHE’s 2022 message testing helped develop three principles to improve communication about health equity concepts. The principles below help to change the conversation to addressing health equity instead of naming and quantifying health disparities.

Principle 1: Meet the audience where they are.

This means : Learn your audience's beliefs, attitudes, values, and biases towards health equity concepts.

Why it matters : Knowing how your audience understands these concepts, such as equity, equality, justice, fairness, and social determinants of health, and their potential resistance to certain words, can help tailor effective messages.

In practice:

• Take small steps with your audience. Use enabling language that promotes choices. Help the audience see concepts as their own ideas.
• Set the context . Explain how health disparities and inequities happen before mentioning which people and communities are most affected.
• Help the audience draw new conclusions. Help the audience transform or develop a different perspective to influence their actions and views.

Principle 2: Communicate health equity as a “we” issue.

This means : Build on society's shared values, interconnectedness, and empathy. Help your audience see themselves as impacted by inequities and prevent an "us versus them" mentality.

Why it matters : Messages framed in a negative way are ineffective to convey the importance of addressing health equity. These messages highlight disparities as the problem instead of showing the outcome of the problem. These messages may create fear in some audiences. Instead, write messages that lead the audience to focus on the systemic drivers (e.g., lack of transportation, etc.). This framing destigmatizes health disparities and enables audiences to see how inequities might impact them. This framing might help your audience understand how health equity efforts could potentially benefit them.

• Use gain-framed messaging. Gain-framed messaging focuses on the positive outcome, encouraging disease prevention (e.g., eating healthy foods, exercising regularly, using sunscreen). With a health equity frame, gain-framed messaging should focus on making "the best possible health" accessible to everyone.
• Make clear that achieving health equity is not a "zero sum game." Explain that when an intervention helps one group of people, it does not mean that other people or communities have to lose something in return.
• To destigmatize health disparities, share examples of how equitable approaches can benefit everyone . Examples like the curb-cut effect (i.e., the ramps on sidewalks that were initially intended to help people with mobility disabilities but proved to be beneficial for far more people).

Principle 3: Frame health equity as achievable.

This means : Health equity can be broken down into more manageable concepts when solutions are offered across multiple levels. Provide examples of how individuals and communities can advance health equity, as well as public health agencies, healthcare delivery systems, and/or state, tribal, local, and territorial governments can help people to understand different points of view.

Why it matters : Messages that frame health disparities as caused by systems and structures (e.g., systemic racism as a root cause of racial and ethnic health inequities, rather than personal behaviors, may cause some audiences to believe they have limited control to change their health outcomes or advance health equity. This can prevent a person's efficacy, or motivation, to take action.

• Use action terms. When educating audiences about situations, conditions, and policies that create inequities, show pathways to address disparities. That way, audiences can see that achieving health equity is feasible and within their control.
• Avoid language that speaks to previously defined assumptions. Fatalism, or the false belief that nothing can be done to change health outcomes prevents people from see policies and structural interventions as a way for meaningful change. Instead, include messages that help people identify social conditions as the cause of many health disparities. This makes it easier to see policies and structural interventions as a way for meaningful change.

Health Equity

CDC's Office of Health Equity strives to advance the science and practice of achieving health equity for all.

Health Equity in Healthy People 2030

As Healthy People has evolved over the decades to reflect the most current science and address the latest public health priorities, it has strengthened its focus on health equity. This focus is reflected in one of the overarching goals of Healthy People 2030: “Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all.”

Healthy People 2030’s emphasis on health equity is closely tied to its focus on health literacy and social determinants of health . Social determinants — like structural racism or systemic bias — can affect health literacy and contribute to health disparities. Taking steps to address these factors is key to achieving health equity.

In line with this focus, Healthy People 2030 provides tools for action to help individuals, organizations, and communities committed to improving health and well-being advance health equity.

Leveraging Healthy People to Advance Health Equity

Health equity 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 social determinants of health — and to eliminate disparities in health and health care. 

Identify priorities by browsing Leading Health Indicators and other objectives

Compare population-level progress to national targets

Use Healthy People data  to track health disparities and inform program and policy development

Find inspiration by consulting evidence-based resources to use in your community

Review Healthy People in Action stories to learn how others are addressing health equity

Use the Healthy People 2030 framework as a model for program planning

Use the social determinants of health framework to build partnerships across sectors and communicate root causes of health disparities

Definitions

Use the definitions of health equity and health disparities to promote a shared understanding and identify areas for collaborative action to improve health for all

Download the graphic

Leveraging Healthy People to Advance Health Equity [JPG — 591.48 KB]

How Does Healthy People Define Health Equity and Health Disparities?

Defining health equity and health disparities promotes a shared understanding of these concepts and helps individuals, organizations, and communities nationwide align their resources and efforts — and identify areas for collaboration.

Similar to Healthy People 2020, Healthy People 2030 defines health equity as “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.”

Healthy People 2030 defines a health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”

How Does Healthy People 2030 Address Health Disparities?

Measuring health disparities is essential to advancing health equity. That’s why Healthy People 2030 monitors differences across population groups as it tracks progress toward meeting objectives . Healthy People data tools summarize and display these health disparities to help identify priority populations.

Healthy People 2030 also features evidence-based resources focused on strategies that are proven to improve health. These resources include interventions to address public health issues among specific population groups and improve the health of all people.

In addition, Healthy People 2030 collects Healthy People in Action stories that highlight how states, communities, and organizations address health disparities, advance health equity, and improve health by:

• Using evidence-based interventions and strategies
• Evaluating interventions
• Forming multisector collaborations

Learn more about health equity and health disparities definitions and frameworks

The Health Equity and Health Disparities Environmental Scan explored how health equity and health disparities are defined and communicated within the field of public health.

Download the report [PDF – 3.53 MB]

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See You Now: Focus on Health Equity (Free)

Health equity is a topic that you need to understand and address as a professional nurse. You may feel overwhelmed by the problem when discussing it with your colleagues. How can you start to be part of the solution(s) that will result in better health outcomes for more patients? Sometimes all you need is a little inspiration.

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Course Details

Listen to and reflect on this set of SEE YOU NOW podcasts to learn how nurses like you are innovating how they address specific health equity gaps in their communities. These empowering stories include:

• Reading the Signs : Nurses are often the first point of clinical contact for victims and play a key role in identifying and providing resources to them. You will meet Danielle Bastien, RN, DNP, FNP-BC, a nurse practitioner at Henry Ford Hospital in Detroit, Michigan who researched and explored human trafficking and how health systems, and nurses specifically, can identify and protect victims, help them find a way out, and a safer, more secure path forward.
• Black Midwives & Mamas Matter: Hear from three healthcare innovators who personally and professionally—as Black women and advisors to the Black Mamas Matter Alliance—work tirelessly to advance policy grounded in human rights and reproductive justice to improve Black maternal health and lives. You will learn from Jennie Joseph, LM, CPM, RM, Founder and Executive Director of Commonsense Childbirth and Founder of the National Perinatal Task Force; Joia Crear-Perry, MD, Founder and President of the National Birth Equity Collaborative; and Monica McLemore, PhD, MPH, RN, FAAN, Tenured Associate Professor at the University of California, San Francisco and member of the Bixby Center of Global Reproductive Health.
• Virtual Screening for Safer Shelter(s) : Nurse Disrupted—a pandemic response start-up in Madison, WI—was launched in record time to build fast, simple, virtual health screenings for homeless shelters and communities. Bre Loughlin, MS, RN, and Tracy Zvenyach, PhD, APRN-NP, co-founders of Nurse Disrupted discuss how their different, yet complementary backgrounds of technology and policy are part of the strength of their partnership. You will also learn how in solving one problem, they simultaneously solve several more.
• Counting on Faith : Clergy and faith-based organizations are pivotal and trusted players in their communities providing service, leadership, connection, communication, distribution of services, and increasingly, innovation. UK Healthcare’s Chief Diversity Officer Tukea Talbert, DNP, RN, CDP explores how partnerships with our communities’ faith leaders and congregations can build trust, break systemic barriers to access, and move toward health equity.

After listening to this set of podcasts, you will benefit from:

• Expanded knowledge of health equity issues in multiple care settings
• Broadened understanding of the gaps and impacts on health care caused by disparities
• Inspiration and empowerment from new and proven approaches to increase equitable access to care

The free CNE contact hours for this content was developed with the support of Johnson and Johnson.

Key Learning Outcomes

• Describe innovative and human-centered solutions addressing today’s most challenging healthcare problems

Location Details

Use of these or any other course(s)/material(s) does not imply eligibility for certification or successful performance on any certification exam, nor is it a requirement to qualify for individual certification.

American Nurses Credentialing Center (ANCC) does not endorse any products or services.

Accreditation Statements

The American Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation.

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Fact Sheet: Advancing Health Equity Across HHS

This National Minority Health Month, the U.S. Department of Health and Human Services (HHS) is proud to highlight some of its efforts to advance health equity for all, including people of color and others who have been historically underserved, under-resourced, marginalized, and adversely affected by persistent poverty and inequality.

Advancing health equity and addressing health disparities is a top priority of President Biden and Secretary Becerra. Across HHS, achieving equity is a department-wide effort. Some of HHS’s most significant health equity accomplishments are highlighted below. HHS commits to building on this progress and continuing to address and close health disparities for all Americans.

Lowering Health Care Costs

Thanks to President Biden’s signature of the lower cost prescription drug law — the bipartisan Inflation Reduction Act —Americans enrolled in Medicare are saving money on their prescription drugs.

• Capping the Cost of Insulin to $35 for a Month’s Supply and Making Recommended Vaccines Free: The Inflation Reduction Act signed by President Biden is already saving Medicare enrollees money by capping out-of-pocket spending at $35 per month’s supply of each insulin product covered under Medicare. The Inflation Reduction Act also eliminated out-of-pocket costs for vaccines covered under Medicare Part D that are recommended by the Advisory Committee on Immunization Practices (ACIP). These benefits extend to all Medicare participants enrolled in the Part D program, including the estimated 5.8 million Black , 5.3 million Hispanic/Latino , and 2.1 million Asian Americans enrolled.  
• Negotiating the Price of Prescription Drugs : For the first time in history, Medicare is now able to directly negotiate the price of some of the costliest prescription drugs covered under Medicare. HHS, through the Centers for Medicare & Medicaid Services (CMS), last year announced the first 10 drugs covered under Medicare Part D selected for negotiation. The negotiations with the drug companies of these 10 selected drugs are underway, and any negotiated Maximum Fair Prices will become effective beginning in 2026. Some of these drugs treat serious conditions such as blood clots, diabetes, cardiovascular diseases, heart failure, autoimmune conditions, and chronic kidney disease, many conditions which disproportionately impact Black, Hispanic/Latino, American Indian, and Alaska Native communities.
• Removing Barriers to Vaccination : The Administration for Community Living (ACL) awarded two grants totaling $125 million to rapidly increase the number of older adults and people with disabilities who have received the updated COVID-19 vaccine and annual flu vaccine. These programs host community vaccine clinics, provide in-home vaccinations, provide transportation to vaccination sites, conduct outreach and education to older adults as well as people with disabilities, and more.
• Providing Access to COVID-19 Treatment : The HHS Administration for Strategic Preparedness and Response (ASPR) is providing Paxlovid at no cost to patients with public insurance through 2024, and to uninsured patients through 2028 or until the U.S. government supply is depleted. These actions help address the disparate impact of COVID-19 in American Indian, Alaska Native, and Black American communities as well as other racial and ethnic minorities.

Record Expansion of Health Care Coverage

A historic 21.3 million Americans have selected an Affordable Care Act Insurance Marketplace plan during the 2024 Open Enrollment period.

• Quality Affordable Health Care : HHS has continued its commitment to making health insurance available and affordable to everyone. Thanks to the Inflation Reduction Act and the American Rescue Plan, 4 out of 5 people on the Marketplace can find coverage for $10/month or less after financial subsidies.
• Reaching All Americans : For this past enrollment cycle, the Administration issued almost $100 million in Navigator Awards, allowing organizations to hire staff who are trained to help consumers find affordable, comprehensive health coverage. Navigators, as they are known, have been key to reaching consumers where they are, and helping them enroll in quality health insurance plans in every Marketplace state. While data disaggregated by race for the 2024 Open Enrollment period will be available in the coming weeks, we know, based on the historic number of enrollees and the work Navigators have done at the community and neighborhood level, that many of the Americans who have enrolled are American Indian and Alaska Native, racial/ethnic minorities and/or come from rural communities.
• Increasing Health Coverage in Rural Communities : Medicaid expansion has played a key role in expanding health coverage in rural communities. Rural communities rely on the Marketplace, Medicaid, and Medicare;  1 in 3 rural adults are enrolled in Medicare, 1 in 6 are enrolled in state Medicaid programs, and 1 in 10 are covered by Marketplace coverage . In 2019, rural uninsured rates were  nearly twice as high  in non-expansion states as expansion states.

Improving Health Outcomes

HHS is committed to addressing health disparities and advancing health equity by expanding access to care, improving health care quality, and supporting health care providers who serve populations who are at increased risk for poor health outcomes.

• Medicaid and the Children’s Health Insurance Program (CHIP) finance more than 4 in 10 births in the U.S. and are an important source of maternal health care. HHS has encouraged states to take up a new option to extend postpartum coverage under Medicaid and CHIP from 60 days to 12 months. Thus far, 45 states plus Washington, D.C. and the U.S. Virgin Islands have expanded postpartum coverage.
• President Biden signed legislation that increased funding for the Tribal Maternal, Infant, and Early Childhood Home Visiting Program from $12 million in 2022 to $30 million in 2023. This major expansion brings evidence-based home visiting services to more tribal communities.
• In September 2023, the Health Resources and Services Administration (HRSA) announced nearly $90 million in awards to increase access to care in maternity care deserts, address maternal depression, and grow the maternal health workforce.
• In 2023, HHS reached a milestone of more than 1,900 birthing facilities participating in the Alliance for Innovation on Maternal Health , a program under which hospitals and other facilities adopt proven strategies to increase safe births and reduce negative birth outcomes.
• HHS has invested in and made HHS’s new maternity care quality data easily accessible through the Care Compare “Birthing-Friendly” designation, a consumer-friendly icon noting that a hospital or health system has demonstrated a commitment to improving maternity care quality.
• In 2023, HHS reached a milestone of supporting 36 Perinatal Quality Collaboratives (PQCs) . PQCs are state or multi-state networks of multidisciplinary teams working to improve population-level maternal and infant healthcare and outcomes statewide. PQCs advance evidence-based clinical practices and processes using quality improvement principles and convene and collaborate with diverse representatives (clinical teams, experts, partners, patients, families) to rapidly improve perinatal healthcare and outcomes statewide and reduce disparities in healthcare and outcomes between subpopulations within a state.
• The Housing and Services Partnership Accelerator , launched in collaboration  with the U.S. Department of Housing and Urban Development (HUD), supports eight states and the District of Columbia, to develop or expand housing-related supports and services for people who are Medicaid-eligible, including people with disabilities, and older adults who are experiencing or are at risk of experiencing homelessness.
• Under the Medicare inpatient hospital payment system, CMS has recognized the higher costs that hospitals incur for treating people who are experiencing homelessness, when hospitals report social determinants of health codes on claims.  CMS also finalized new Medicare care navigation codes, which describe services intended for people who have an unmet social need (which can include homelessness) that affects the diagnosis and treatment of medical problems, in the Calendar Year 2024 Medicare Physician Fee Schedule.
• Through the HRSA Ryan White HIV/AIDS Program (RWHAP), nearly 9 out 10 of people with HIV who receive RWHAP medical services reached viral suppression in 2022.  This means that they cannot transmit HIV to their partners and these individuals can live longer, healthier lives. The percentage of Black/African American clients, Hispanic/Latino clients, and youth and young adult clients aged 13-24 who received care through the RWHAP and reached viral suppression all far exceeded overall national viral suppression rates.
• Due, in part, to the efforts of multiple HHS agencies to expand pre-exposure prophylaxis (PrEP) awareness, availability, and provider capacity, preliminary data indicate that in 2022, 36% of the 1.2 million people who could benefit from PrEP were prescribed it, compared to 23% in 2019, the year that the Ending the HIV Epidemic in the U.S. (EHE) Initiative was announced.
• Centers for Disease Control and Prevention’s (CDC's) EHE-funded programs have provided more than 44,000 PrEP prescriptions and connected with over 260 Syringe Services Programs (SSPs), 60% of which provide mobile services.
• In 2020 and 2021, HRSA’s RWHAP served nearly 38,000 clients new to care or re-engaged in care in support of the EHE. In the first 2 years of EHE, more than 20% of people in EHE jurisdictions who were undiagnosed or not previously in care were served by HRSA-funded EHE providers.
• The Substance Abuse and Mental Health Services Administration (SAMHSA) funded three Minority HIV/AIDS Fund: Integrated Behavioral Health and HIV Care for Unsheltered Populations Pilot Project grants in fiscal year 2023 for a total of $1,997,536. The program provides comprehensive healthcare and addresses disparities facing medically underserved people experiencing unsheltered homelessness through the delivery of portable clinical care delivered outside that is focused on the integration of behavioral health and HIV treatment and prevention services.
• From data collection and research to the approval of new therapies, HHS is answering the call, and supporting programs critical for helping people with SCD live healthier lives. Ongoing efforts include expanding the Sickle Cell Data Collection program ; releasing a Sickle Cell Disease Action Plan ; continuing research on treatment including through the Cure Sickle Cell Initiative ; supporting programs that span across the SCD system of care, such as newborn screening, diagnosis, access to treatments; and considering testing approaches to improve access to innovative treatments and reduce program expenditures starting with SCD under the Cell and Gene Therapy Access model recently announced by the CMS Innovation Center.

Bolstering Rural Health Care Providers

HHS is taking actions to improve health outcomes in rural communities by focusing on access to care.

• Grants to Rural Hospitals and Communities to Provide Health Care Services : HHS has several grant opportunities to support rural communities, including $28 million to provide direct health services and expand infrastructure and $16 million to provide technical assistance to rural hospitals facing financial distress. In 2023, 60 rural hospitals received technical assistance to maintain financial viability and ensure continued access to care. The HHS Office of Climate Change and Health Equity is also helping rural facilities access funding made available in the Inflation Reduction Act for energy efficiency, renewable energy, and resilience .
• Increase Resident Training Opportunities in Hospitals Serving Underserved Communities: CMS is allocating 1,000 new Medicare-funded physician residency training slots to qualifying hospitals authorized by the Consolidated Appropriations Act, 2021, phasing in 200 slots per year over five years and prioritizing hospitals with training programs in geographic areas demonstrating the greatest need for additional providers. CMS is also working to implement the allocation of an additional 200 slots for Fiscal Year 2026, which includes at least 100 slots specifically for psychiatry and psychiatry subspecialty residencies, as enacted in the Consolidated Appropriations Act, 2023. HHS expects to provide additional outreach and technical assistance to rural hospitals to encourage them to apply for these new residency positions. HHS, through HRSA, also awarded over $11 million through the Rural Residency Planning and Development Program (RRPD) to help establish new rural residency programs. Accredited RRPD-funded programs are already training over 300 resident physicians in family medicine, internal medicine, psychiatry, and general surgery.
• In March 2024, HHS announced the launch of nearly $50 million for HRSA’s Rural Opioid Treatment and Recovery Initiative and released the initiative’s funding application. Funding will support establishing and expanding comprehensive substance use disorder treatment and recovery services in rural areas, including by increasing access to medications for opioid use disorder, such as buprenorphine. Opioid use disorder is particularly concerning in rural communities and accessing treatment can be challenging due to geographic isolation, transportation barriers, and limited substance use disorder providers.
• SAMHSA has also updated the 42 CFR part 8 federal regulations that set the standard for opioid treatment program (OTP) accreditation, certification and treatment to expand access to care by reducing barriers to entry, allowing for the use of telehealth among OTPs, and by codifying mobile treatment units. This helps to overcome geographic disparities in access to care, particularly among rural populations.
• The National Institutes of Health (NIH) Helping to End Addiction Long-term (HEAL) initiative received a total of $636 million in Congressionally appropriated funds in Fiscal Year 2023 in part to provide awards to advance research to mitigate disparities in health care for pain and associated mental health impact. The program aims to develop and implement evidence-based, non-opioid interventions that enhance access to pain care by addressing stigma, bias, and discrimination at the levels of individuals, providers, communities, and systems.
• To address this issue, CMS released guidance clarifying that Medicaid and CHIP coverage and payment of interprofessional consultation is permissible, even when the beneficiary is not present, as long as the consultation is for the direct benefit of the beneficiary.
• SAMHSA’s Rural Emergency Medical Services (EMS) Training grant program offers the opportunities for rural EMS organization to recruit and train EMS personnel in rural areas with a particular focus on addressing substance use disorders and co-occurring disorders substance use and mental disorders.

Bolstering Tribal Health Care Providers

HHS is taking actions to improve health outcomes in Tribal communities and help Tribal health care providers stay open.

• Improving Tribal Water and Sanitation Systems: Thanks to $3.5 billion from President Biden’s Bipartisan Infrastructure Law (BIL), from 2022 through 2026, the Indian Health Service (IHS) will provide 71,000 American Indian and Alaska Native homes with critical services like water wells, onsite wastewater disposal systems, and connections to community water supply and wastewater disposal systems. By December 31, 2023, the IHS had exceeded its original goal by completing the Construction Document Phase for 124 projects.
• Expanding Access to Telehealth Services : IHS Telebehavioral Health Center of Excellence (TBHCE) has expanded telebehavioral health services markedly since the pandemic. In partnership with Tribes, counseling and prescribing services are now available to thousands of patients for whom lack of transportation may have been a barrier to care. Over 8,000 patients have received child, adult, and addiction psychiatry and counseling. According to early estimates, the availability of telehealth behavioral health services has resulted in over $1 million in avoided travel costs and over 25,000 hours of work or school not missed.
• Supplemental Payments for Indian Health Service and Tribal Hospitals : This supplemental payment from CMS supports stability in uncompensated care payments and mitigates long-term financial disruption for these hospitals.
• Strengthening Public Health Systems and Services in Indian Country: As of October 2023, CDC has awarded nearly $26 million to 26 federally recognized American Indian and Alaska Native Tribes and regional Tribally designated organizations to improve Tribal public health infrastructure and services to Tribal communities through a new 5-year cooperative agreement.  This program will strengthen the quality, performance, and infrastructure of tribal public health systems, including workforce, data and information systems, and programs and services. This funding will help improve public health outcomes and lessen health inequities in Indian Country.

Advancing Civil Rights and Nondiscrimination in Health Care

HHS enforces federal civil rights laws that protect the rights of individuals and entities from unlawful discrimination on the basis of race, color, national origin, disability, age, or sex in covered health and human services.

• CMS has reinstated requirements that Medicare Advantage (MA) and Part D plans include a multi-language insert to inform beneficiaries of the availability of free language and translation services and that MA plan provider directories include a provider’s cultural and linguistic capabilities.
• SAMHSA’s 988 Suicide & Crisis Lifeline has expanded to include Spanish text and chat services in addition to existing phone capabilities. 988 also now includes American Sign Language (ASL) and videophone services for people who are deaf or hard of hearing.
• The SAMHSA Disaster Distress Helpline (DDH) is the first national hotline dedicated to providing year-round disaster crisis counseling. This toll-free, multilingual, crisis support service is available 24/7 to through call, text, and ASL videophone to all residents in the U.S. and its territories who are experiencing emotional distress related to natural or human-caused disasters through call, text, videophone.
• The National Institutes of Health-funded Qungasvik Toolbox study, developed through a collaboration with Yup’ik communities and researchers at the University of Alaska, examined how tapping into a community’s culture can reduce youth substance misuse and suicidal ideation and behavior(s). Findings showed that the Qungasvik intervention was effective in reducing co-occurring youth alcohol misuse and suicide risk, and ultimately, alcohol use disorder and death by suicide.
• The HHS Office for Civil Rights (OCR) proposed to update and clarify critical provisions that help persons with disabilities access health and human services and prohibit discrimination on the basis of disability under Section 504 of the Rehabilitation Act. The rule updates Section 504 to align with other disability nondiscrimination laws and adds specifics in new areas to prevent and respond to discrimination on the basis of disability in covered programs.
• The Administration for Community Living (ACL) updated its regulations implementing the Older Americans Act (OAA) for the first time in more than 30 years to better reflect the needs of today’s older adults. The OAA requires the aging services network, which provides the services funded by ACL under the OAA, to focus on older adults, elders, and family caregivers who have the greatest economic and social need, with particular attention to people with lower incomes and older adults from minority populations, older adults living in rural communities, with limited English proficiency, or at risk of institutional care. Consistent with the OAA statutory language, the updated OAA regulations align the definition of greatest social need with Executive Order 13985.
• OCR proposed to amend Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy regulations to prohibit the use or disclosure of protected health information to investigate or prosecute patients, providers, and others involved in the provision of lawful reproductive health care.
• In 2023, Title X clinics provided family planning services to 2.6 million clients, almost 1 million more clients than in the previous year. The Title X program remains a critical safety net for people in all 50 states, Washington, D.C., and eight U.S. Territories and Freely Associated States. Title X clinics provide services for free or on a reduced scale for clients, 31% of whom are uninsured and 84% of whom have family incomes below 250% of the Federal Poverty Level. Clients can receive a wide range of voluntary, client-centered family planning and related preventive services through a network of over 4,000 Title X clinics.
• OCR has proposed to update the regulations implementing Section 1557 of the Affordable Care Act (ACA) to restore and strengthen nondiscrimination protections for LGBTQI+ people seeking care in Federally funded health programs and activities. The proposed rule affirms protections against discrimination on the basis of sex, including sexual orientation, gender identity, and pregnancy status in the provision of health services.
• OCR has also released a proposed update to the HHS Grants Rule that protects LGBTQI+ people from discrimination in certain covered human services programs by clarifying the prohibition on discrimination on the basis of sex includes discrimination on the basis of sexual orientation and gender identity. The proposed HHS Grants Rule would confirm nondiscrimination protections in covered HHS programs as well as services and grants that provide aid. 
• SAMHSA’s 988 Suicide & Crisis Lifeline has expanded to include specialized call, text, and chat services for LGBTQI+ youth and young adults wanting to connect with counselors specifically focused on meeting their needs.
• In 2024, SAMHSA announced four awards totaling $5.1 million for Family Counseling and Support for Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex+ Youth and their Families. These grants are in addition to $1.7 million in grant funding previously awarded in 2023 to four other recipients. All eight awardees will be engaging LGBTQI+ youth and their families to prevent risk of health conditions, including behavioral health conditions and promote well-being for LGBTQI+ youth by establishing family counseling and support programs and training providers on family counseling and support interventions tailored for LGBTQI+ families.
• The NIH National Institute on Minority Health and Health Disparities (NIMHD) has recently awarded grants to six institutions through the John Lewis NIMHD Research Endowment Program . Totaling $60 million, these esteemed grants will create institutional endowments that propel the development and expansion of research capacity at recipient institutions and support research education for students from diverse backgrounds, including  those from underrepresented groups.
• Since 2011, the Centers for Disease Control and Prevention (CDC) has been partnering with institutions to offer fellowships that introduce undergraduate and graduate students to public health topics including minority health and health equity, supporting their career development, and preparing the future public health workforce through the John R. Lewis Undergraduate Public Health Scholars (Lewis Scholars) Program and the James A Ferguson Emerging Infectious Diseases (Ferguson) Graduate Fellowship .

Advancing Data Equity

Health equity data can help care teams identify and address health disparities, which leads to improved health outcomes at an individual and population level. Data can make it possible to streamline social care referrals and improve care delivery, person-centered decision-making, research, population health improvement, and public health. The privacy interests of American Indian and Alaska Native populations should be respected when working with Tribal communities.

• Standardizing Social Determinant of Health and Sexual Orientation and Gender Identity (SOGI) Data: The Office of the National Coordinator for Health Information Technology (ONC) U.S. Core Data for Interoperability (USCDI) is a standardized set of health data elements for nationwide, interoperable health information exchange. Starting in 2026, many certified health information technology (IT) products will need to support new data elements that promote health equity including SOGI data and Social Determinant of Health assessment data, for instance, assessments of housing and food insecurity risk.
• As part of the SOGI Data Action plan, CDC added SOGI data to HIV , Sexually Transmitted Infections (STI) , and mpox surveillance and added a question about experiences with LGBTQI+ discrimination to the Youth Risk Behavior Survey .
• CDC’s National Center for Health Statistics added sexual orientation questions to the National Health Interview Survey in 2013, and gender identity questions in 2022. Additionally, the National Health and Nutrition Examination Survey, as well as the National Survey of Family Growth, include measures related to sexual orientation.
• IHS has published a circular adding SOGI to their patient records.
• CMS added SOGI questions to all HealthCare.gov Marketplace applications and proposed adding SOGI to the Medicare Part C and Part D enrollment forms. CMS also issued an Information Bulletin to states allowing them to add SOGI questions to state Medicaid and Children’s Health Insurance Program (CHIP) applications.
• The Administration for Children and Families Office on Trafficking in Persons has embedded SOGI measures in all victim assistance and training information requests.
• SAMHSA added SOGI questions in its National Survey on Drug Use and Health.
• ACL has begun to add SOGI questions to its Information Collection Requests for its aging and disability programs.
• Collecting Information that Strengthens Our Understanding of the Drivers of Inequities in Maternal Mortality : CDC’s Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) program supports standardized data collection across Maternal Morality Review Committees (MMRCs) active in states and territories, to understand the circumstances surrounding all pregnancy-related deaths and strategies for prevention. In addition to adding fields to specifically capture discrimination and racism in the Maternal Mortality Review Information Application (MMRIA), CDC worked with the HHS Office of Minority Health and other partners to develop and implement a web portal for MMRCs to view “Community Vital Signs” dashboards that provide increased community details and context (e.g., obstetricians or nurse midwives per capita, unmet need for drug treatment, poverty rate, community levels of education, violent crime rates) to MMRCs during their review of each death.
• Transparent Use of Equity-Related Health Information : Since ONC launched the Health IT Certification Program in 2010, almost all U.S. hospitals and close to 80 percent of office-based physicians use certified electronic health records. ONC recently established first of its kind transparency requirements for artificial intelligence and other predictive algorithms that are part of certified health IT certified to the decision support intervention certification criterion. HHS’s leading-edge regulatory approach promotes the safe development and use of artificial intelligence, machine learning and predictive clinical decision support by promoting health equity, fairness, and identifying issues of bias.
• Efforts to Examine Bias in Healthcare Algorithms: The Agency for Healthcare Research and Quality (AHRQ) and the National Institute on Minority Health and Health Disparities (NIMHD) convened a diverse panel of experts, who developed a conceptual framework to apply guiding principles across an algorithm’s life cycle, centering health and health care equity for patients and communities.
• Intellectual and Developmental Disabilities (I/DD) Counts: I/DD Counts is a cross-agency initiative, led by ACL, to establish and maintain accurate data on the prevalence of intellectual and developmental disabilities (I/DD) in the United States and its territories, and improve the collection, analysis, and interpretation of the health-related data of people with I/DD. The goal of the initiative is to increase our collective understanding about factors that affect the health and well-being of people with I/DD, which will in turn support development of effective policies and programs to support them and their families. Partners are currently working with stakeholders developing a 10-year plan to guide the development of the health surveillance system for people with I/DD.
• Health Equity Science Principles: CDC published Health Equity Science Principles which introduces health equity science as a conceptual framework to advance health equity and describes six principles to guide the development, implementation, dissemination, and use of effective health equity science. Leaders are able to apply these equity principles in public health surveillance, research, and evaluation.

We invite you to learn more by reading each division’s factsheet:

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• Publications /

Healthy, prosperous lives for all: the European Health Equity Status Report

The adoption of the 2030 Agenda for Sustainable Development and the Sustainable Development Goals have provided a framework within which to strengthen actions to improve health and well-being for all and ensure no one is left behind. Despite overall improvements in health and well-being in the WHO European Region, inequities within countries persist. This report identifies five essential conditions needed to create and sustain a healthy life for all:

• good quality and accessible health services;
• income security and social protection;
• decent living conditions;
• social and human capital and decent work; and
• employment conditions.

Policy actions are needed to address all five conditions. The Health Equity Status Report also considers the drivers of health equity, namely the factors fundamental to creating more equitable societies: policy coherence, accountability, social participation and empowerment. The report provides evidence of the indicators driving health inequities in each of the 53 Member States of the Region as well as the solutions to reducing these inequities.

• Open access
• Published: 13 July 2021

Health disparities in Russia at the regional and global scales

• Natalia Shartova   ORCID: orcid.org/0000-0003-2758-9612 1 ,
• Vladimir Tikunov 1 &
• Olga Chereshnya 1  

International Journal for Equity in Health volume  20 , Article number:  163 ( 2021 ) Cite this article

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The capacity for health comparisons, including the accurate comparison of indicators, is necessary for a comprehensive evaluation of well-being in places where people live. An important issue is the assessment of within-country heterogeneity for geographically extensive countries. The aim of this study was to assess the spatial and temporal changes in health status in Russia and to compare these regional changes with global trends.

The index, which considers the infant mortality rate and the male and female life expectancy at birth, was used for this purpose. Homogeneous territorial groups were identified using principal component analysis and multivariate ranking procedures. Trend analysis of individual indicators included in the index was also performed to assess the changes over the past 20 years (1990–2017).

The study indicated a trend towards convergence in health indicators worldwide, which is largely due to changes in infant mortality. It also revealed that the trend of increasing life expectancy in many regions of Russia is not statistically significant. Significant interregional heterogeneity of health status in Russia was identified according to the application of typological ranking. The regions were characterized by similar index values until the mid-1990s.

Conclusions

The strong spatial inequality in health of population was found in Russia. While many regions of Russia were comparable to the countries in the high-income group in terms of GDP, the progress in health was less pronounced. Perhaps this can be explained by intraregional inequality, expressed by significant fluctuations in income levels.

Data sources

We used an integral index to measure the health of populations which integrates objective indicators of population health: infant mortality rate and life expectancy at birth for men and women. We called it Public Health Index (PHI) due to life expectancy and infant mortality are basic statistics that indicate public health achievements and social development, including the health system, infrastructure, and vital statistics [ 40 ].

The use of these simple indicators offers several important advantages: relevant data are available for almost all countries, expert assessment is not required, and the indicators are reliable [ 41 ].

The data sources for the infant mortality rate and life expectancy were the World Bank database [ 42 ] for countries worldwide and the Federal State Statistics Service “Rosstat” [ 43 ] for the regions (85 federal units) of Russia. The data covered the period from 1990 to 2017. Additionally, data on GDP values were used as the driver of health to compare the health status to the income level. The information was taken from the World Bank database [ 44 ] and “Rosstat” [ 43 ].

Several problems of data quality in Russian statistics are given in the introduction. This should be considered while interpreting the results. Nevertheless, a unified methodology of Rosstat for collecting and aggregating data allows them to be used for cross-country analysis and international comparing. World Bank relay on professional standards in the collection and compilation of data to ensure the data consistency and accuracy. Developing countries receive support to improve the capacity and efficiency of national statistical systems. Thus, this data is widely used in population health assessment and human development studies [ 45 , 46 , 47 , 48 ].

Index calculation and typological ranking

For calculation of the PHI, an evaluative algorithm was developed by one of the authors [ 49 ]. The normalization of initial indicators is achieved by the following formula:

where \( \overset{\circ }{x} \) is the worst value (for each indicator), in terms of the impact on the population health in the regions of Russia (the maximum infant mortality rate, lowest life expectancy);

max/min x is the most different from the \( \overset{\circ }{x} \) values of n countries and regions.

m is the number of indicators used for the calculations (3).

The ranking is carried out by comparing all territorial units on a conditional basis, characterized by values of \( \overset{\circ }{x} \) . If there are reasonable weights for the indicators, they can also be included in the formula of normalization, but in our calculations, the weights were the same due to the contribution of infant mortality and life expectancy in health loss can vary over time and countries may also be at different phase of the epidemiological transition.

When the normalized values \( {\hat{x}}_{ij} \) are reduced to comparable forms, they can be simply summarized to obtain the PHI.

Received values \( \hat{\ \mathrm{S}\ } \) characterize the estimated position of the countries and regions of Russia. The algorithm can be very parsimonious. The ranking is carried out by comparing all territorial units on a conditional basis, characterized by values of \( \overset{\circ }{x} \) . This is done using the Euclidean distance as a measure of the proximity of all territorial units to a conditional basis (a worst-case value \( \overset{\circ }{x} \) throughout a range of indicators). We believe that improvement experiences should start with the worst regions / countries, thus, we focused on the worst regions in order to highlight “hotspots” for further improvement of the situation.

The ranking was performed by comparing all indicator values attributed to territorial units with conditional \( \overset{o}{x} \) values. Euclidean distances ( d° ) were used for the ranking procedure. ( d° ) is the measure of the closeness of all territorial unit values to the worst values of conditional ( \( \overset{o}{x} \) ) regarding the whole set of indicators.

The algorithm required the preliminary processing of the data array using the method of principal component analysis to orthogonalize and convolute the system of indicators. The received data of the column vector d° presenting assessment characteristics were additionally normalized for convenience using the following formula:

d° varies from zero to one. Zero corresponds to the worst integrated assessment, and one corresponds to the best.

The algorithm also enabled the detection of homogeneous territorial groups in the assessment. This was done via a partition of the corresponding ranked values of Euclidean distances into homogenous groups. The allocation procedure for these groups was multivariant and enabled them to receive a spectrum number of homogenous groups of territorial allocation variants. Allocation quality was assessed using canonical correlation coefficients as well as absolute ( A k ) and relative ( O k ) coefficients of heterogeneity:

where k is the number of identified groups, p is the number of orthogonalized coefficients to calculate distances, t max , t min are the maximal and minimal number of groups, and I jk is a binary indicator pointing to the presence (1) or absence (0) of the territorial unit in group k .

A sharp increase in the absolute or relative coefficients of heterogeneity with a decrease in the number of identifiable clusters indicates an increase in heterogeneity within the identified clusters, while a smooth increase in the coefficients is a sign of a uniform increase. The threshold followed by a sharp increase in heterogeneity can be optimally taken as the final number of clusters. The algorithm was originally described in [ 49 ] and has been tested in previous studies [ 30 , 40 , 50 ]. In this study, the dynamics of health status in Russia and in the world for 1990–2017 were revealed according to the calculation of the PHI.

Trend analysis

The observed changes in health status index components were analysed. The Mann-Kendall nonparametric statistical test was used to assess the significance level of trends, and the Sen slope coefficient was used to assess the rate of change [ 51 ]. These statistical methods can be applied even if the time series does not follow a normal distribution [ 51 , 52 ]. The statistical significance of changes was obtained for each territorial unit (countries at the global level and regions of the Russian Federation) and each parameter. Results with a p -value < 0.05 were considered statistically significant. The specific value of Sen slope coefficient depends on the values of estimated variables. A positive value indicated an upward trend and a negative value indicated a downward trend in the time series for each territorial unit.

Index calculation and typological ranking was made by algorithm, elaborated by one of the authors [ 49 ]. Trend analysis was performed by R software (package ‘trend’). All results were displayed using QGIS software. The gradations for each parameter are based on natural intervals (Jenks natural breaks) with further manual adjustments [ 53 ].

Health status dynamics

Globally, there is a trend of an increase in PHI values over the past 20 years (Fig.  1 ). During this time, the lowest rate was in Sierra Leone (0.14 in 1990 and 0.44 in 2017). In 2017, the same low value (0.44) was noted in Central African Republic. Countries with high PHI values were generally stable over time. The maximum value of the index remained unchanged – approximately 0.9 in Japan. For several European countries (Iceland, Sweden, the Netherlands, Spain, Italy and France), there was a slight decrease in the index in 2017 compared to 2015.

Changes in population health identified by PHI in the regions of Russia and the world during 1990–2017; a) 1990; b) 1995; c) 2000; d) 2005; e) 2010; f) 2015; g) 2017

The regions of Russia were homogeneous for a long time, with the index values within the country ranging from 0.6–0.8. In 1990 the worst value of the index was in Tuva (0.64), which is comparable to Uzbekistan, the Philippines, Vanuatu and Cape Verde. The value of the index in Moscow (0.75) was close to Tonga and Albania. The highest values (0.78) were in Dagestan and Karachay-Cherkessia that corresponded to United Arab Emirates, Kuwait and Czech Republic. After 2015, the index values changed to 0.8–0.9 in some regions: the largest cities of Russia (Moscow and St. Petersburg), the republics of the North Caucasus, several regions in the south of the European part of Russia (Belgorod, Voronezh, Krasnodar, etc.) and two Siberian oil and gas producing regions, the Khanty-Mansiysk and the Yamalo-Nenets autonomous regions. The maximum value of the index in 2017 in Ingushetia (0.90) was the same as in Cyprus, Denmark, or Germany.

Observed trends in health indicators

Since life expectancy and infant mortality determine the PHI, their spatiotemporal trends were analysed. The most obvious trends towards a decrease in infant mortality were found in African (the most intensive decline was observed in Sub-Saharan Africa with Sen’s slope coefficient below 4.0), Asian, and some South American countries (Fig.  2 ). The decline in infant mortality in regions of Russia was within a small range of Sen’s slope coefficient, from 0.3 to 0.9. The maximum rates of decline (0.98–0.70) were observed primarily in Siberian regions (Tyva, Altai, Khakassia and the Trans-Baikal Region), as well as in some republics of the North Caucasus (Ingushetia and Chechnya). At the same time, the coefficient values in Tuva corresponded to Ecuador, in Altai and Ingushetia – to Mexico and Lebanon, and in Khakassia and Trans-Baikal Region – to Romania, Guyana, Somalia. The minimum rates (0.35–0.40) were predominantly found in the European territories of Russia but were also observed in Kamchatka (Far East) and Karachay-Cherkessia (North Caucasus). It is comparable to Hungary, Lithuania, South Africa and Qatar. The changes in infant mortality in Russia were more noticeable than those in European countries but less noticeable than those in countries of Asia and South America. A sharp increase in infant mortality in Russia in 1993 and 2012 should be mentioned, it is associated with the transition to new criteria for live birth according to the WHO recommendations [ 54 ].

Decline in infant mortality according to the spatial distribution of Sen’s slope coefficients of trends in the regions Russia and in the world during 1990–2017

The trends were statistically significant ( p -value < 0.05) for all countries except several in Sub-Saharan Africa (Zimbabwe, Lesotho, Swaziland, South Africa) and island countries (Fiji, Saint Vincent, and the Grenadines). In Russia, this trend was not significant for Chukotka (in the northern part of the Far East), which can be explained by the small population in the region.

As expected, trends towards an increase in male and female life expectancy were observed overall worldwide. The trend of increasing male life expectancy was most remarkable in Sub-Saharan Africa with Sen’s slope coefficient > 0.8 (Fig.  3 ). The variations in Sen’s slope coefficient for the regions of Russia were also small, ranging from 0.07 to 0.6. The most pronounced increase in life expectancy was recorded in three completely different regions – Ingushetia (North Caucasus), Moscow (the capital and largest city in the country) and the Khanty-Mansiysk autonomous region (an oil-producing region). The absence of changes was also identified in spatially dispersed regions – Mari El (Volga region), and the Amur region and Chukotka (Far East).

Increase in male life expectancy according to the spatial distribution of Sen’s slope coefficients of trends in the regions Russia and in the world during 1990–2017

The trends were not statistically significant at the p -value < 0.05 in 13 analysed territorial units. These are some regions of the European part of Russia, and the Amur region and Chukotka in the Far East as well as Sub-Saharan African countries (Lesotho, Namibia, South Africa, and Swaziland), Syria and Belize. The number of such territories increased to 60 when statistical significance was set to a p-value< 0.001. They include 46 regions of Russia and Ukraine and Belarus.

The trends of female life expectancy were similar to the trends for male life expectancy. The Sen’s slope coefficient for the regions of Russia varies even less (from 0.06 to 0.4), although the range of values is from 0.18 to 1.61 at the global level (Fig.  4 ). The maximum increase in female life expectancy was identified in the same regions where the increase in male life expectancy was observed. There were no changes in female life expectancy in Chukotka, the Jewish Autonomous Region (Far East) or Chechnya (North Caucasus).

Changes in female life expectancy according to the spatial distribution of Sen’s slope coefficients of trends in the regions Russia and in the world during 1990–2017

In addition, the trends of female life expectancy were more statistically significant than those of male life expectancy. There was no statistical significance at the p -value < 0.05 in 10 territorial units (Chukotka and Chechnya in Russia, as well as Sub-Saharan Africa, Belize in Central America). In total, 36 territorial units, including 22 spatially dispersed regions of Russia, Montenegro and Iraq had nonsignificant trends at a p-value < 0.001.

Health and income level

The PHI varied from 0.05 (Sierra Leone) to 0.98 (Japan), on average, during 1990–2017. Most territorial units were valued from 0.6 to 0.8 (Fig.  5 ). The PHI values were the most homogeneous in the Europe & Central Asia group Footnote 2 and the least homogeneous in Sub-Saharan Africa. The regions of Russia were quite compact in the distribution of the PHI values (Fig.  6 ). The index values varied from 0.5 to 0.8. Moreover, the maximum PHI values in Ingushetia and Dagestan (North Caucasus) and the lowest PHI values in Tyva, the Jewish Autonomous Region and Chukotka (Siberia and the Far East) were defined as outliers.

Spatial distribution of average PHI in the regions of Russia and in the world during 1990–2017

Distribution of PHI in regions of Russia and in countries according to the World Bank geographic regions

After excluding outliers, the highest PHI values were recorded in Moscow and St. Petersburg and in the republics of the North Caucasus. The regions with high PHI are located in the south of the European part of Russia and in areas of oil and gas production in Western Siberia. The Far Eastern regions, Eastern Siberia, and the northern European part of Russia were identified as having the lowest PHI.

The regions of Russia were close to the regions of Latin America & the Caribbean and the Middle East & North Africa in terms of PHI values, although many of the regions of Russia had lower values. The PHI was predominantly higher in the European and Central Asian regions.

The countries belonging to the high-income group Footnote 3 were the most homogeneous in terms of the PHI (Fig.  7 ). A wide range of PHI values was observed in the low-income group and a slightly smaller range in the lower-middle-income group. The upper-middle-income group included the outliers.

Distribution of PHI in countries according to the World Bank income groups of regions

The average PHI values corresponded with income level; however, there was a slightly lower PHI in regions of Russia (0.7) compared to other countries with upper middle income (0.73) (Table  1 ).

The distribution of the PHI depending on GDP per capita was analysed similarly. The GDP data for 2018 and the values of the PHI for 2017 were used. There was a general trend of an increase in the PHI with an increase in GDP. However, while many regions of Russia were comparable to the countries in the high-income group in terms of GDP per capita, they had a lower PHI (Fig. 8 ). Moreover, the regions of Russia had PHI values lower than those in many countries in Europe & Central Asia and the Middle East & North Africa, although they had comparable GDP per capita.

Distribution of PHI in regions of Russia and in countries in accordance with GDP (a) and World Bank geographic regions (b)

Typological classification

Five homogeneous groups of countries and regions of Russia were identified according to the PHI in 1990–2017 (Fig.  9 ).

Typological grouping of regions of Russia and countries based on PHI

The first group (low rate, upward trend) included 23 countries exclusively on the African continent. This group was characterized by the lowest values of the index (0.42) with a pronounced increase over time.

The second group (average rate, less pronounced upward trend) was characterized by slightly higher PHI values (0.58) than the previous group but with a less pronounced upward trend. This group included 36 countries located mainly in Africa and Asia and some Pacific island states. Additionally, this group included one state of the post-Soviet space – Turkmenistan – and two regions of Russia – Tyva and Chukotka.

The third group (average rate, heterogeneous trend) was distinguished by the most heterogeneous dynamics of the PHI over time. With an average value of 0.74, it fluctuated in selected years. There was a decline from 1990 to 1994, growth around 1998, another decline around 2005, and subsequent growth. This group included post-Soviet countries (Azerbaijan, Kazakhstan, Kyrgyzstan, Tajikistan, Uzbekistan, and Moldova), as well as 44 Russian regions (mainly in Siberia and the Far East).

The fourth group (high rate, heterogeneous trend) had an average index value of 0.81. There was also a noticeable tendency for a decrease by 1995 and subsequent stabilization over time. This was the largest group, with 108 territorial units, including countries of Central and South America, Southeast Asia (Malaysia, Vietnam, Thailand), the Arabian Peninsula (Bahrain, Brunei, Kuwait, Oman, Qatar, Saudi Arabia, the United Arab Emirates), and South Korea, China, Iran, and the United States. The same group included the former socialist European countries, some of the post-Soviet countries, Belarus, Ukraine, Armenia, Latvia, Lithuania, Estonia, and 36 regions of Russia (mainly the southern part of European Russia, as well as oil-producing regions in Western Siberia).

The fifth group (high stability rate) was characterized by the highest PHI values (0.92) and was stable over time. It included 24 countries, mainly Western European countries, Canada, Australia, New Zealand, Singapore and Japan.

The study showed a trend towards convergence in the health status in the world. Over the almost 30 years, the level of health of population has increased significantly, as evidenced by the reduction in the spread of the index values (the range of index values was from 0 to 1 in 1990 to 0.4–1 in 2017). This is largely due to the ongoing convergence of infant mortality since 1950 [ 55 ]. Our study shows that the trend towards a decrease in infant mortality is statistically significant almost everywhere, except in some African countries and island states. There was a relatively rapid decline in infant mortality in regions of Russia. In the opinion of Andreev (2020) values of infant mortality are still higher than in European countries with reliable statistics due to conditions arising in the perinatal period as well as congenital disorders [ 54 ]. This may be a consequence of both factors – a lower level of medical care for pregnant women and newborns in comparison with developed European countries, and unequal access to health care.

Life expectancy has a less stable trend towards convergence between countries due to the sensitive response of mortality, which determines life expectancy, to various crises and social shocks [ 56 ]. Worthy of note is the lack of statistical significance of the trend of increasing life expectancy in many regions of Russia, which is more pronounced for male life expectancy than for female life expectancy. The trend towards an increase in male life expectancy is nonsignificant in almost half of the regions of Russia by p -value< 0.001. This indicates periodic fluctuations in life expectancy over the past 30 years, which, in turn, may indicate the absence of a stable economic and social situation in the country.

The greatest decline in the health level was noted in the early 1990s, when a sharp decrease in life expectancy due to an increase in mortality from heart disease and violent causes was observed in Russia and other post-Soviet countries (Fig.  10 ). The decline in the health level continued until 1994. Within the global experience of industrialized countries, this sharp decline in life expectancy represents a unique case [ 22 ], with rather strong regional differences [ 57 ]. In addition, the changes in health observed in those years cannot be explained solely by economic deprivation. The greatest causes were linked to the social environment, including an increase in reported crime and excessive alcohol consumption, as well as psychological stress and the deterioration of the health system [ 22 , 57 , 58 ].

Changes in PHI in average in Russia and in regions in 1990–2017. Regions with the highest and lowest values are marked by colour

After 1994 and until 1998, the health level began to rise again. However, in 1999–2005, there was a slight decrease and stagnation of the index, apparently associated with the recovery from the economic crisis of 1998. Only in 2007 did the health level in Russia return to the level of 1990 and begin to exceed it due to constant growth. It should be noted that the economic crises of 2008–2009 and 2014–2015 [ 59 ] are not visually reflected in the dynamics of the PHI.

Until the mid-1990s, the Russian regions were characterized by closer index values than those observed in the present. Strong fluctuations were typical for peripheral regions, such as Tyva, Chukotka and the Jewish Autonomous Region, and for Ingushetia, the North Caucasus region with the leading PHI.

The significant interregional heterogeneity in Russia is clearly evident in the types of PHI dynamics, and the regions can be classified into three of the five groups observed worldwide. The European, Siberian, and Far Eastern regions display a clear division. Thus, most of the regions in southern Russia are similar to the European countries of the post-Soviet space, where the PHI stabilized after 1995, while the Siberian and Far Eastern regions present a tendency similar to that of the post-Soviet countries of Central Asia, with large fluctuations in the index values. Tyva and Chukotka are comparable to poor African countries in terms of PHI.

Thus, strong spatial inequality in health of population was found in Russia. Similar patterns were found for the city of Natal in Brazil, where the difference in life expectancy between districts reached 25 years, and the districts with the worst indicators were comparable to countries in Africa [ 60 ]. In Russia, such inequality can be explained by the country’s economic geography, combined with a population decline, an ageing workforce, and a constant need to adapt to a series of economic crises [ 61 ]. Changes in the sectoral structure, including a boom in the oil industry, led to the rapid development of certain regions, while the development of many other regions slowed down.

A specific change in the health level was observed in Khanty-Mansiysk, one of the oil-producing regions with severe climatic conditions. The PHI was below the national average and the average of many other regions in the 1990s (Fig.  11 ). After 1998, the situation changed dramatically, and the health level rapidly increased. During the same period, Sakhalin and Primorsky Krai in the Far East had health levels comparable to that of Khanty-Mansiysk in the 1990s, but until the present, their PHI values are still below the national average. Thus, the economic focus on the oil and gas sector and investment inflow could lead to a rapid improvement in the health of population in oil-producing regions, including those with severe climatic conditions.

Changes in PHI in various regions of Russia – oil producing and Far East regions (a), main cities Moscow, St. Petersburg, and Ingushetia, region with the highest PHI values during 1990–2017 (b)

There is also a difference between the two largest cities in the country, Moscow and St. Petersburg, and a significant gap vis-à-vis the surrounding regions, the Moscow and Leningrad regions (Fig.  11 ). Again, this difference was more noticeable in the 2000s than in the 1990s. Against this background, the positive dynamics of the PHI in Ingushetia in the North Caucasus look rather foreign.

Population health and GDP are closely interrelated indicators. The issue is that it is not just an increase in GDP can result in a health improvement [ 62 , 63 ], but progress in national health can also lead to economic growth [ 64 , 65 , 66 ]. We found the discrepancy between the PHI and GDP per capita in Russia that are in line with other studies [ 45 , 67 ]. Shkolnikov et al. (2019), identified the gaps between the observed and the Preston-expected life expectancy values (so called Preston-curve) for both Russia and Moscow [ 67 ]. Compared to countries with a similar income level, the main cause of this gap was due to mortality for external causes in the working-age population and cardiovascular disease at older ages [ 68 ]. Thus, mortality trends that have been identified in Russia for a long time, continue to be relevant even despite the progress in healthcare. The health status in Russia may be significantly higher according to GDP values. At the same time, rates of progress can be only partially reflected by GDP, without considering inequalities in income, education, and other social determinants [ 69 , 70 ]. An unequal access to health care can be significant. Disparities should be eliminated not only between regions, but also within those regions. The discrepancy between economic indicators and health status is commonly observed in the regions of Russia [ 67 ]. Thus, Sakhalin is comparable to Singapore and Ingushetia to Honduras in terms of GRP per capita [ 61 ], and vice versa in terms of the PHI. The reason for this discrepancy may be linked to intraregional inequality. Spatial inequalities in health have also been confirmed by previous studies [ 67 , 68 , 71 , 72 ]. There is no doubt that for countries as geographically expansive as Russia, inequality is determined not only by economic factors or healthcare costs, but also by climatic, ethnic and sociocultural diversity [ 73 ]. Determining the contribution of possible factors to the health status in Russia is a goal for future research.

Thus, a way out of the crisis of the 1990s in Russia can be observed only at the end of the 2000s. Bridging the gap with developed countries is still a challenge for the future despite the improvement in health status. In 2015, only six regions, with the exceptions of Moscow and St. Petersburg, approached comparable values of the index. In 2017, their number increased significantly with the addition of the regions of southern European Russia, the Volga region, and western Siberia. The consequences of the 2020 crisis have yet to be assessed, but it can be assumed that the trend towards an increase in the level of health of population in Russia will again slow down.

The main limitation of the study is the possibility of using regional data for international comparison. Such data, especially regarding socioeconomic characteristics, are very limited in Russia. Another limitation is the lack of high-quality municipal statistical data for intraregional research on a national scale. Main problems of data quality in Russian statistics are described in the introduction.

The prolonged crisis of the 1990s caused the health status in Russia to be unsatisfactory for almost 20 years. Until the present, there has been a long-term tendency of a more favourable situation in the southeastern European part of the country and in the largest cities, Moscow and St. Petersburg, and a disadvantaged situation in the northern European part and a worsening of the situation in the east. In general, the regions in the European part are quite different from the Asian part of the country in terms of the level and dynamics of health. They are more similar to the European countries of the post-Soviet space, while the Siberian and Far Eastern regions present a tendency similar to that of the post-Soviet countries of Central Asia. In most of regions in Russia, the rate of change in population health has remained significantly slower. We found the discrepancy between population health and GDP per capita in Russia. While many regions of Russia were comparable to the countries in the high-income group in terms of GDP, the progress in health was less pronounced. Perhaps this can be explained by intraregional inequality, expressed by significant fluctuations in income levels, as well as unequal access to health care within the region. Further progress is impossible without focusing on the problem of intraregional inequality.

Availability of data and materials

All documents and publications in Russian are available at the Lomonosov Moscow State University, Moscow, Russian Federation.

Crimea and Sevastopol were excluded from the study due to the lack of statistical data for most of the period.

classification of countries by world regions according to the World Bank

World Bank classification

Acknowledgements

This research was performed according to the Development program of the Interdisciplinary Scientific and Educational School of M.V.Lomonosov Moscow State University “Future Planet and Global Environmental Change”.

This research was funded by the Russian Science Foundation (Grant 17–77-20070 “Assessment and Forecast of the Bioclimatic Comfort of Russian Cities under Climate Change in the 21st Century”).

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NS and VT conceptualized the paper and had overall responsibility for the study. VT provided an algorithm of index calculations, carried out typological classification. All authors took part in the preparation of the final draft of the paper. All authors read and approved the final manuscript.

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Shartova, N., Tikunov, V. & Chereshnya, O. Health disparities in Russia at the regional and global scales. Int J Equity Health 20 , 163 (2021). https://doi.org/10.1186/s12939-021-01502-6

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• v.57(Suppl 1); 2022 Jun

Translating research into policy and action

Amy m. kilbourne.

1 Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs, Washington District of Columbia, USA

2 Department of Learning Health Sciences, University of Michigan, Ann Arbor Michigan, USA

Melissa M. Garrido

3 Partnered Evidence‐based Policy Resource Center, VA Boston Healthcare System, Boston Massachusetts, USA

4 Department of Health Law, Policy and Management, Boston University School of Public Health, Boston Massachusetts, USA

Arleen F. Brown

5 Division of General Internal Medicine and Health Services Research, UCLA School of Medicine, Los Angeles California, USA

6 Division of General Internal Medicine and Health Services Research, Olive View‐UCLA Medical Center, Los Angeles California, USA

1. INTRODUCTION

Financial and social returns on scientific investments have not been realized in the general population and especially among communities that have been economically and/or socially marginalized. 1 Science fails to make a real‐world impact on health without adequate investment in implementation science and community‐engaged research. Implementation science, or the study of strategies that promote uptake of research into the real world, 2 must be coupled with an active and ongoing partnership with communities affected by the studied issues, so that scientific results are meaningful and used by the broader population. 3

Health care organizations, payers, policy makers, communities, and research funders need to embrace both implementation science and community‐engaged research methods to identify, evaluate, and sustain the most impactful programs and policies that improve population health and reduce disparities rapidly and effectively. The passage of the Foundations for Evidence‐Based Policymaking Act (Evidence Act; US PL 115‐435) 4 provides an ideal opportunity to ensure programs and policies work for communities, by integrating implementation science and community‐engaged research methods into evidence‐building and evaluation initiatives.

2. EVIDENCE‐BASED POLICY MAKING: CLOSING THE GAP BETWEEN SCIENCE AND IMPACT

Implementation science and community‐engaged research represent important scientific directions that are needed to promote the Federal Government's priorities around evidence‐based policy. Mandated by the Evidence Act and emphasized in a recent Presidential Memorandum, evidence‐based policy is the use of “the best available science and data” to guide policy, budget, and programmatic decisions. 5 Effective programs and policies need to be responsive to the lived experiences of the people, communities, and organizations 6 that are served, while also giving attention to multi‐level factors at the service level that impact outcomes including quality, safety, equity, and efficiency.

Consistent with the recent Executive Order on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, 7 several agencies, notably the US Department of Veterans Affairs and the General Services Administration's Office of Evaluation Sciences, are leading efforts to curate, deploy, and sustain a process for embedding evidence‐based policy making as part of their routine decision making and to foster a learning organization. In brief, learning organizations, sometimes referred to as learning health systems when applied to clinical care settings, continuously, rigorously, and systematically curate data at multiple levels to optimize and inform operations. 8

To this end, rigorous evaluations to inform evidence‐based health care policy in learning organizations can greatly benefit from both implementation science and community‐engaged research methods. Both scientific fields strive for active participation and empowerment of policy and program end‐users in all aspects of a study—from defining priorities to disseminating and applying study results. In this commentary, we highlight current examples of research that use implementation science and/or community‐engaged research methods to inform evidence‐based health care policy, and we suggest resources and strategies for evidence‐based policy to reach its full potential.

3. CUTTING‐EDGE RESEARCH INFORMING EVIDENCE‐BASED POLICY MAKING

This special issue features novel and cutting‐edge research, focused on the intersection of evidence‐based policy evaluation, implementation science, and community engagement, that can ultimately inform evidence‐based practice, maximize policy impacts of research, and improve population outcomes. Our goal was to highlight emerging scientific work that utilizes these fields of research to bridge the gap between evidence generation and policy action, notably through greater community engagement and implementation science to inform policy and lead to meaningful change.

Reger et al. 9 and Bokhour et al. 10 in this issue present findings from a unique funding mechanism that establishes national partnered evaluation initiatives within the VA health care system. In these VA studies, investigators apply both implementation science and community engagement methods to work closely with clinical operations partners to deploy rigorous, peer‐reviewed evaluations of the impacts of programs and policies on outcomes related to suicide prevention and person‐centered care (“Whole Health”) in veteran patient populations.

Purtle and Colleagues 11 in this issue apply emerging systems science, implementation, and policy analysis methods to inform uptake of programs and policies at the population level. Zivin et al. 12 in this issue present novel policy research focused on the health care workforce, especially when faced with potential provider burnout and labor shortages.

Studies by Alegria and Colleagues, 13 Chinchilla et al., 14 and Albright et al. 15 in this issue present novel ways to engage community partners and at‐risk populations in informing policies to enhance the full range of human services including employment and health care. Similarly, Pearson et al. 16 and Leykum et al. 17 in this issue actively involved interested communities and partners to inform policies that improve Veteran access to care and long‐term care outcomes. Ngo and Colleagues 18 and Stadnick et al. 19 in this issue also present novel research directions that focus on community‐informed evidence‐based policy making and health equity research.

Finally, Braganza et al., 20 as well as Daumit et al. 21 (all in this issue), present novel funding mechanisms from the VA Quality Enhancement Research Initiative (QUERI) and NIH Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Risk (DECIPHeR) programs that focus on using community input and the lived experiences of individuals to inform priorities for evidence generation and development of implementation methods to promote health equity and policy impact.

4. IMPROVING TRANSLATIONAL SCIENCE THROUGH IMPLEMENTATION AND COMMUNITY ENGAGEMENT

Implementation and translation of research findings into real‐world impact through evidence‐based policy can be done more effectively if the needs of affected communities are considered. Hence, greater investments in both implementation science and community‐engaged research can further support translation into sound policy and make scientific investments more impactful in the real world. Greater investments in these novel and impactful research areas may also mitigate disparities in funding, especially among Black and other under‐represented scientists. 22

The National Institutes of Health (NIH), VA, and other federal funding agencies have increasingly recognized the need to promote the science of implementation and community engagement and have proposed enterprise‐wide investments in translational science initiatives that more directly call out these scientific areas. Notably, the NIH Common Fund's proposed Community Partnerships to Advance Science for Society initiative is one example of a national effort to align community‐driven priority goals with cross‐disciplinary research teams to build research capacity and assess and implement disease‐agnostic structural interventions (e.g., policies, population‐based programs) with the goal of advancing health equity. VA (e.g., QUERI) is also rapidly expanding its capacity to conduct evidence‐based policy evaluations using rigorous implementation science and community‐partnered research methods. The Patient‐centered Outcomes Research Initiative also launched new funding opportunities focused on implementation and dissemination of evidence‐based practices in close partnerships with health systems, clinicians, patients/consumers, and other interested parties.

5. EVIDENCE‐BASED POLICY MAKING AS TRANSLATIONAL SCIENCE: FUTURE DIRECTIONS

An evidence‐based policy‐focused translational research agenda requires openness to mixed‐methods approaches, broader data collection efforts, rapid but rigorous methods, and expanded funding resources. First, there needs to be a comprehensive effort to frame research evaluation questions that involve curation of data at all levels and contexts of the program or policy wherever possible. The origins of evidence‐based policy making as we know it in the United States today stem from the growth of the social science fields that were recruited to evaluate the rapid expansion of US federal social programs in the 1960s and 1970s. 23 , 24 Many of these evaluations relied on quantitative data that may or may not have captured the lived experiences of end‐users in addition to quantitative outcomes. Mixed‐methods approaches that combine quantitative with qualitative data are especially valued when the intervention's “evidence” may have been derived from more select populations that were not representative by those most affected by the problem.

Second, effective evidence‐based policy making will require improved capacity to capture meaningful data on socio‐economic and environmental impacts. 25 , 26 In many cases, policy studies may not elucidate the more nuanced everyday experiences of individuals 25 that impact health, such as changes in employment opportunities, safety, or social networks. 26 Organizations and systems may also act unpredictably and there needs to be more nuanced data on the impacts of programs and policies on organizational change, which in turn can influence provider and patient experience. 27 , 28 Improved data availability across different population, organizational, and end‐user experiences can increase the value of research efforts among communities and are invaluable for understanding why a policy did or did not have its intended effect. Data access would also need to be balanced with provisions for privacy protection, especially for marginalized populations. 23

Third, evidence‐based policy often requires rapid generation and translation of evidence. Many communities and organizations cannot wait for the evidence to address a policy need. In these situations, hybrid effectiveness implementation designs can shorten the translation timeline without sacrificing rigor or generalizability. 29 Several US and international initiatives, notably in HIV, have leveraged different scientific methods including implementation, community engagement, and systems science to inform actionable decisions on programs and policies when the evidence is incomplete. 6 , 30

Fourth, an evidence‐based policy‐focused translational research agenda would benefit from additional sources of funding. Philanthropists (foundations) have flexibility in topic selection and funding decisions, which makes them well‐suited to leverage cross‐disciplinary expertise to conduct broad population‐based policy evaluations. These evaluations are especially needed given that health outcomes are influenced by social and economic trends that are rarely captured from clinical data alone. 31 For example, the Arnold Foundation has adopted the use of randomized designs to inform programs and policies related to health, criminal justice, and other social issues. 32

Ultimately, for evidence‐based policy making to realize its potential, we need methods such as implementation science and community engagement that consider the complex and nuanced role of individuals, populations, and systems, as well as data infrastructure and resources to support these methods. Incorporating these approaches can help researchers better understand the impact of programs or policies—not only whether they work, but how they work and for whom, and what will it take to sustain them in the real world. Implementation science and community engagement research in turn can also help ensure programs and policies work at the local level, benefitting those who need them the most.

Kilbourne AM, Garrido MM, Brown AF. Translating research into policy and action . Health Serv Res . 2022; 57 (Suppl. 1):5‐8. doi: 10.1111/1475-6773.13980 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Funding information US Department of Veterans Affairs; Veterans Health Administration; Health Services Research & Development Service

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How to Evaluate Benefits to Ensure Health Equity for All Members

Employers and health insurers need to evaluate their plans’ benefit designs for health equity to ensure that members are getting equal actuarial value..

• Kelsey Waddill, Senior Editor and Multimedia Manager

Although the healthcare system has made great strides in health equity awareness and promotion, women pay more and get less out of their employer-sponsored health benefits than men do.

Employed women are more likely to hit their out-of-pocket maximums than men and are less likely to receive adequate coverage for their healthcare needs, a Deloitte study uncovered. As a result, women pay an estimated $15.4 billion more in out-of-pocket healthcare costs annually than their male counterparts.

In a system that is striving for value-based care, this data represents a significant gap that payers have to address.

In a conversation with Healthcare Strategies , two of the study’s authors—Andy Davis, principal at Deloitte, national leader of Deloitte's health actuarial practice, and one of the leaders of Deloitte's Future of Health, and Marielle Farina, senior manager at Deloitte Consulting and a health actuary who works exclusively with health insurers on benefit and network optimization—explained the study’s findings and what employers can do about them.

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Challenges of achieving equity in health benefits

Employers are uniquely positioned to address equity in benefits, an issue brief from the American Academy of Actuaries found. However, many avoid taking on this role for a variety of reasons.

Some employers fear that they will come across as too paternalistic or that it will seem like they are favoring certain populations of employees. Additionally, they may have trouble acquiring the data to track results or assess population-level needs.

Systemic discrimination, better benefits for higher-paid individuals, underlying assumptions of homogeneity, and in-group biases are also major barriers to change and instigators of health benefits inequities, according to a study published in the American Journal of Health Promotion.

One of the biggest barriers to achieving equity in health benefits that was highlighted by both the American Academy of Actuaries and the authors of the American Journal of Health Promotion article is a cost-centered mindset.

“Employers’ perception [of] benefits as a cost to be managed, rather than an opportunity for strategic investment in workforce human capital, has resulted in cost-shifting to employees,” the authors of the American Journal of Health Promotion article stated. “For low-wage employees, this cost as a percentage of wages is disproportionately greater relative to higher-wage employees.”

Moreover, benefits designs typically do not tie employees’ cost-sharing to wages. High-deductible health plans also prevent real change, forcing many low-wage workers to skip care. And even when employers do alter their benefit design, employees often face a lack of diversity among their in-network provider options, which can sustain inequitable outcomes.

The status of equity in health benefits

Given the starkness of these challenges, the poor status of equity in health benefits may be unsurprising.

To assess the state of employer-sponsored health benefits equity in the US, Deloitte researchers used an employer health plan data set encompassing 16 million covered lives. They assessed medical claims from 2021, applying an average annual benefit design to the data and evaluating the differences in out-of-pocket costs as well as the actuarial value of benefits.

The evidence showed that, on average, women pay more out-of-pocket than men at every age. In total, from ages 19 to 64, employed women spent as much as $15.4 billion more in out-of-pocket healthcare costs per year than men under an average benefits design.

Additionally, the actuarial value of an employed woman’s benefits—excluding maternal healthcare costs—is lower than her male counterpart’s because the benefits do not sufficiently cover her healthcare needs. The actuarial value of benefits for women is $1.3 billion less than for men.

“It would be like [if] I bought a car…and I bought 60 months of coverage for a thousand dollars, so it covers all the problems of the car. Yet Marielle walks in—same car, same coverage, same premium, same thousand dollars—and yet, they give her 48 months of coverage,” Davis explained.

“Our healthcare system really just isn't working in the same way for men as it is for women.”

Maternity care costs do not drive the imbalance in coverage

Many might assume that women have higher healthcare costs and worse health benefits actuarial value due to maternity costs. The assumption is not without merit: maternal care from pregnancy through postpartum costs on average $18,865 in total and $2,854 in average out-of-pocket costs. Farina noted that she and her colleagues shared this hypothesis.

But the results did not concur. Farina and the Deloitte team uncovered that women pay 20 percent more than men in average out-of-pocket healthcare costs and that maternity care contributes only two percent of this. In other words, excluding maternity care, women still paid 18 percent more than men.

Mental healthcare utilization was a key cost driver. Women are more likely to seek out mental health support and, when they do, they use it more regularly than men.

Additionally, diagnostic tests and screenings that are more prevalent for women tend to push the costs higher and receive less coverage. Lab work for certain conditions that are common among women are less likely to receive zero-dollar preventive care coverage. Lastly, emergency department costs are higher for women due to higher utilization.

In a healthcare environment that is increasingly chasing high-value, low-cost care in the value-based care paradigm, these results reveal a serious gap.

Policy efforts to create greater balance

The Affordable Care Act (ACA) was a milestone in the journey to more equitable coverage.

ACA sought to reduce uninsurance, a key factor in high out-of-pocket spending. Individuals who are uninsured for a full year pay more than 40 percent of their out-of-pocket costs and are more likely to forego care and experience medical debt. The law’s efforts to expand access to coverage led to greater affordability.

The policy also established good baseline coverage, Davis noted. ACA laid out essential health benefits that plans had to cover. Moreover, it standardized the metallic tiers so that consumers had more accurate expectations of their financial responsibility.

However, even this monumental effort was unable to address the issue of benefits equity because the data was still unknown.

Now that the gaps are clear, potential areas for policy improvements include coverage for diagnostic work. For example, Farina pointed out that ACA plans must cover mammograms for free under the ACA, but coverage for diagnostic or additional mammograms is not required. These services primarily affect women.

Around 16 percent of commercially insured women who had a mammogram screening required additional breast imaging services. The price of these services can vary, but separate studies have identified that the costs of additional breast imaging can present barriers for women.

Farina acknowledged both the progress that has been made in women’s coverage due to the ACA and the gaps that remain regarding lowering out-of-pocket costs.

Steps payers can take to improve health benefits equity

Despite the staggering statistics that Deloitte’s work uncovered, Davis expressed that change is within reach.

For employers, bridging the gap in health benefits’ actuarial value could cost as little as $12 per employee each year. But before employers can realize these results, they must recognize that they have as much responsibility for health benefit equity as health insurers do.

Having shouldered this responsibility, employers should familiarize themselves with the disparities in their current benefit designs.

“We really urge both the employers and the health insurers to first and foremost take a look at their employee population, take a look at their historical claims data, the benefits designs that they have in place, and figure out where are their big pockets of disparities for women in what they have today,” Farina emphasized.

Each employer’s workforce will experience different categories of inequity, so once those gaps have been identified the process will become more individualized. To outline a path forward, employers might ask themselves:

• Where are women paying significantly more out-of-pocket?
• What are the benefits that we need to make more equitable?
• What should we expect to invest in this change and how is that being funded?

Payers should also consider both members’ out-of-pocket expenditures and which products members select. Different populations of employees will choose different health plans for specific reasons. Employers will only be able to facilitate better health equity in benefits when they understand their workforce’s needs and motivations.

Finally, employers and insurers alike need to take on the responsibility of communicating changes clearly to their plan members. This involves not only detailing the new benefits but also why those benefits were necessary.

Both Davis and Farina emphasized that increasing equity for women and other underserved populations in health benefits is achievable and it is something that employers can start working toward today.

“Health equity—I think everybody's in agreement that it's super important,” Farina concluded.

“It's been really hard to make change, especially with the lack of data. But this is something that it's clear that it exists, hiding in plain sight like our report title, and it's something that employers, for their upcoming benefit product design, they can really make a difference this year. It's not something that we have to wait five years and see what happens. The time is now to act.”

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Assignment Russia

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Becoming a foreign correspondent in the crucible of the cold war.

A personal journey through some of the darkest moments of the cold war and the early days of television news

Marvin Kalb, the award-winning journalist who has written extensively about the world he reported on during his long career, now turns his eye on the young man who became that journalist. Chosen by legendary broadcaster Edward R. Murrow to become one of what came to be known as the Murrow Boys, Kalb in this newest volume of his memoirs takes readers back to his first days as a journalist, and what also were the first days of broadcast news.

Kalb captures the excitement of being present at the creation of a whole new way of bringing news immediately to the public. And what news. Cold War tensions were high between Eisenhower’s America and Khrushchev’s Soviet Union. Kalb is at the center, occupying a unique spot as a student of Russia tasked with explaining Moscow to Washington and the American public. He joins a cast of legendary figures along the way, from Murrow himself to Eric Severeid, Howard K. Smith, Richard Hottelet, Charles Kuralt, and Daniel Schorr among many others. He finds himself assigned as Moscow correspondent of CBS News just as the U2 incident—the downing of a US spy plane over Russian territory—is unfolding.

As readers of his first volume, The Year I Was Peter the Great , will recall, being the right person, in the right place, at the right time found Kalb face to face with Khrushchev. Assignment Russia sees Kalb once again an eyewitness to history—and a writer and analyst who has helped shape the first draft of that history.

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Assignment Russia Book Events

• April 9: Politics & Prose LIVE! Marvin Kalb—Assignment Russia: Becoming a Foreign Corresponding in the Crucible of the Cold War – with Jake Tapper
• April 13: National Press Club Virtual Book Event —Marvin Kalb, Assignment Russia
• April 15: Brookings Event —Assignment Russia: A conversation on journalism and the Cold War
• April 29: Shorenstein Center on Media, Politics, and Public Policy Event —Assignment Russia: Becoming a Foreign Correspondent in the Crucible of the Cold War
• May 25: George Washington University —Assignment Russia: Becoming a Foreign Correspondent in the Crucible of the Cold War

Praise for Assignment Russia

“It is impossible to put this engrossing book down—it illuminates so many dark corners of the Cold War. With a master correspondent’s insight, skepticism, sensitivity, and great clarity, Kalb brings vividly to life all the hopes and fears of the most consequential foe this nation has had.” —Ken Burns, filmmaker

“A fascinating memoir of Marvin Kalb’s Cold War adventures as he sought to penetrate the mysteries of Nikita Khrushchev’s Soviet Russia while building his career as one of broadcast journalism’s legends.” —Jack Matlock, U.S. ambassador to Russia (1987–1991)

“Marvin Kalb’s engaging Assignment Russia is like Hamilton’s ‘The Room Where It Happens.’ It is a delightful narrative of Kalb’s personal encounters with some of the most famous characters of the 1950s and 1960s, like CBS’s legendary Edward R. Murrow, who hired Kalb, or Soviet leader Nikita Khrushchev, who nicknamed him ‘Peter the Great.’ It is also an engrossing memoir of a foreign correspondent’s adventures in the enemy camp during the Cold War. I loved it, I learned from it, and, I dare say, had fun reading it.” —Lesley Stahl, co-anchor, CBS’s 60 Minutes

“Marvin Kalb’s great new book Assignment Russia is a rollicking and engaging memoir that takes you to the front lines of the Cold War, to a mic in the early days of broadcast news, and into the mind and career of one of ‘Murrow’s Boys.’ It’s an important book from a legend in journalism, a book you can’t put down.” —Jake Tapper, CNN anchor and chief Washington correspondent

“A nostalgic treat for older readers…a wake-up call for younger ones.” —Edward Kosner, The Wall Street Journal

“Kalb’s fond, generous memoir, which vividly delineates a bygone era of early journalism, will appeal to students of 20th-century American history as well as aspiring broadcast journalists. The author was involved in many significant Cold War moments, and he brings us directly into that world. Hopefully Kalb is back at his desk; readers will be eager for the next volume.” — Kirkus Reviews

“Readers should be forewarned that once they pick up the book, it will be hard to put it down until they reach the end.” —Naseer Ahmad, Pakistan Link

Marvin Kalb is a former senior adviser to the Pulitzer Center on Crisis Reporting, a Harvard Professor emeritus, former network news correspondent at NBC and CBS, senior fellow nonresident at the Brookings Institution, and author of 16 other books, the most recent of which is the first volume of his memoirs, The Year I Was Peter the Great (Brookings).

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An earnest young correspondent in Cold War Moscow

‘Assignment Russia’ Review: Murrow’s Man in Moscow

Book Review: Assignment Russia, Marvin Kalb’s Memoir

Assignment Russia: Becoming a Foreign Correspondent in the Crucible of the Cold War

Marvin Kalb in the World

Marvin Kalb at Home and Abroad

For Your Listening Pleasure