health equity research collaborative literature scan · documented health equity research...

Health Equity Research Collaborative Literature Scan: Preliminary Findings DRAFT

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2016 Health Equity Collaborative Literature Scan Findings: DRAFT A report prepared by FHI 360

Table of Contents Project Overview ........................................................................................................................................ 2

Research and Funder Scan Objective ........................................................................................................ 2

Research Scan Methodology .................................................................................................................... 2

Results ........................................................................................................................................................ 3

Top Funders ............................................................................................................................................. 3

Type (Generation of Research) ............................................................................................................... 4

Heath Equity vs. Health Disparity Language ........................................................................................... 5

Socio Ecological Model: Framework for Literature Scan......................................................................... 5

Research Methodologies ......................................................................................................................... 6

Determinants of Health ........................................................................................................................... 8

Populations Represented in Search Results ......................................................................................... 10

Conclusions .............................................................................................................................................. 11

References ................................................................................................................................................ 12

Appendix A ............................................................................................................................................... 13

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PROJECT OVERVIEW

Addressing health equity is an essential part of building a Culture of Health throughout America. The

goals of advancing health and health equity are woven into each of the four Action Areas of the Robert

Wood Johnson Foundation’s Culture of Health Action Framework. But achieving action in a meaningful

way requires an understanding of what will make a difference. Critical steps forward include: finding

common ground about how best to define health equity as a central goal and value in each of the action

areas; identifying the drivers of change and effects that can be accomplished; and supporting research

to fill the most important gaps in evidence to craft strategies that will achieve successes (Robert Wood

Johnson Foundation [RWJF], 2015; RWJF, 2016; Evidence for Action, 2015).

Currently, there is an opportunity among leading government and private research funders to generate

the most evidence to inform and accelerate our national progress around addressing health disparities.

Through collaboration, research funders can bring to the table varied perspectives and expertise, work

together to identify critical gaps in evidence, explore opportunities to increase knowledge, and uncover

ways to harness the unique resources of each funder. Forming a collaborative that makes strategic

investments in policy, systems, and environmental research across diverse sectors can help jump start

the field and accelerate learning and action. The aims of this one-year project, funded by the Robert

Wood Johnson Foundation (RWJF) are to: (a) critically evaluate the state of health-equity research and

research funders to identify core aims for a national health-equity research collaborative; and (b) work

with RWJF leaders to launch the collaborative to build the field of health equity research (RWJF, 2015).

RESEARCH AND FUNDER SCAN OBJECTIVE

The following Research and Funder Scan outlines the recent focus of health equity research across

various settings (Federal, Private, Academic, Foundation, and NGO affiliations), with an emphasis on

documented health equity research priorities. The scan will help gain insights regarding:

Current funders of health equity research across Federal, Private, Academic, Foundation, and

NGO Institutions.

The focus of health equity research initiatives based on the three Generations of health equity

research, as defined by the Academy of Health.

The characteristics of recent health equity research including methodology, determinants of health, and populations.

RESEARCH SCAN METHODOLOGY

The literature scan was conducted utilizing a three-step process. First, two researchers conducted a general search of the health equity literature, to (a) compile a list of health equity search terms, and Medical Subject Heading terms (MeSH terms); (b) extract key data from all included literature; (c) develop a preliminary coding strategy for data extraction. A preliminary coding strategy was then developed for data extraction. In Step Two, these lists were reviewed and revised by our stakeholder advisory board, comprised of the FHI360 Research Team, research consultants, and representatives from the Robert Wood Johnson Foundation. Finally, in Step Three, a literature scan was conducted utilizing the refined search terms, and inclusion criteria.

The following databases were included in our literature search:

• National Library of Medicine (PubMed)

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• Web of Science • HSRproj Database • EBSCO databases (including PsychInfo)

We used multiple primary search terms and combinations relevant to the topics of interest. Overall,

search terms fell within the following primary search terms include:

• “Equity” • “Health Equity” • “Health Equity Research” • “Health Disparity (ies) “

We then combined primary search terms with secondary search terms to create additional

combinations of search criteria relevant to the topics of interest. As necessary, secondary search terms

include:

• “Health Equity + Minority (ies)”

• “Health Equity + Funded Research”

• “Health Disparity + Funded Research“

We also reviewed previously conducted literature reviews on health equity topics. The search was limited to literature published between January 2016-June 2016 and focused on studies conducted in the United States. The scan focused on 5 racial/ethnic groups, using census-defined categories: 1) African American/Black; 2) Hispanic/Latino; 3) American Indian/Alaskan Native; 4) Asian/Other Pacific Islander; and 5) Other Racial/Ethnic Origin (Humes, Jones & Ramirez, 2011). Exclusion Criteria included Health Equity initiatives within a Healthcare or Hospital Setting and Health Equity sponsored Workshops, Seminars and/or Conferences. Additionally, sexual/gender minorities (e.g., LGBTQ individuals) were included as a key population given the scope of the search, however, research articles related to HIV/AIDS were excluded upon determining the articles did not fall within scope of the project.

RESULTS

Top Funders

The 86 articles that were included in this scan were funded by over 40 different funding agencies.

Additionally, some articles were unfunded and others did not have funding information.

The top 5 funders of these articles were:

National Institute on Minority Health and Health Disparities

National Institute of Mental Health

National Cancer Institute

National Institute of Nursing Research

National Heart, Lung, Blood Institute

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Non-government funders included:

Robert Wood Johnson Foundation

American Cancer Society

Center for Economic Opportunity

Amgen Foundation

Northwest Health Foundation

Oregon Clinical and Translational Research Institute

Susan G. Komen for the Cure

Wichita State Office of Research

W. K. Kellogg Foundation

Mayo Clinic

The Queen’s Health System

Indiana University School of Nursing & the Jonas Center for Nursing Excellence

Hogg Foundation for Mental Health

Baptist State Convention of North Carolina

The Kate B. Reynolds Charitable Trust

The Duke Endowment

Additional funding unrestricted research grant from The Coca-Cola Company

Type (Generation of Research)

According to a 2014 Academy Health report, health equity research can be grouped into three types or

generations of research. These generations, first conceptualized by Kilbourne and colleagues (2006),

include:

1. First generation research: documenting disparities that exist among populations and sectors

2. Second generation research: understanding the drivers that contribute to the disparity

3. Third generation research: reducing disparities through solutions oriented research

The review of the 2016 literature yielded 86 total articles with roughly 18% of articles focused on

generation one research (documenting disparities), 45% of articles categorized as generation two

research (understanding drivers) and 37% of articles fit in generation three research (solutions

oriented).

Table 1. Breakdown of studies by generation of research (n=86)

Generation Percentage (%) Count

Generation 1 18% 16

Generation 2 45% 39

Generation 3 37% 32

Total 86

Examples of generation one research topics

Health status of Delta counties versus non-Delta counties

The prevalence of obesity among Hispanic/Latino youth compared to their non-Hispanic peers

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Examples of generation two research topics

Whether Infant Mortality Rates (IMR) vary by zip code in the greater Newark region

Regional variations of rates of CVD morbidity and mortality

Examples of generation three research topics

A community-based participatory research (CBPR) approach to reduce disparities in childhood

immunizations

A multi-community intervention successfully increased the prevalence of actions to control

hypertension among Hispanics

Health Equity vs. Health Disparity Language

Approximately 96% percent of articles (n=77) mentioned health disparities versus health equity (n=17),

although some articles used both terms.

Socio Ecological Model: Framework for Literature Scan

The Social Ecological Model (SEM) is a theoretical framework that visually shows the

interconnectedness of factors that influence health. Originally proposed by Brofenbrenner (1977), the

Centers for Disease Control and Prevention’s (CDC) Health Equity Toolkit (2013) includes SEM to help

users understand how health equity is influenced at different levels. For the existing scan, FHI360 and

RWJF adapted the framework to include 6 levels.

Six levels of focus were identified in the 2016 literature, including: community, environment, individual,

institution, policy, and system. A community level of focus is defined as interventions that create

change on a specific sub-set of populations of geographical area and/or proximity affiliation (CDC,

2013). The environmental level of focus includes interventions that involve physical or material changes

to the economic, social, or physical environment, i.e., incorporating sidewalks, paths, and recreation

areas into community design (CDC, 2013). An individual level of focus is defined as interventions that

create change at the individual level, whereas an institution level of focus is defined as interventions

that create change for populations of specific organizational settings.

A policy level of focus includes articles that work to create or amend laws, ordinances, resolutions,

mandates, regulations, or rules and a system focus characterizes interventions that impact specific

elements of an organization, or institution, such as improving school systems (CDC, 2013). These six

categories were not exclusive of each other and many articles reviewed were categorized in two or

more categories.

A community focus was identified in about half of the articles reviewed (55%), followed by a focus on

the individual in 37% of articles. An environment level focus and a systems level focus were identified

in 15% and 14% of the articles, respectively. A policy lens followed by an institution lens were the least

common, 8% and 1%, respectively.

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Table 2. Search findings denoting level of focus on research (n=82)*

Levels Percentage (%) Count

Community 55% 45

Individual 37% 31

Environment 15% 18

Systems 14% 17

Policy 8% 7

Institution 1% 1

Total 82 *All categories do not sum to 100%; studies may have more than one level of focus

Examples of a community focus

To address cardiovascular health in at-risk populations in Washington, D.C., researchers joined

community leaders to establish a community advisory board, which performed a needs

assessment to evaluate cardiovascular health, social determinants of health, and physical

activity-monitoring technologies.

A community-based coalition partnered with Latino youth throughout the research process to

address health disparities in unintended teen pregnancy rates in a local community.

Examples of an individual focus

Neighborhood socioeconomic deprivation and neighborhood-level social support affected

individual-level perceived social support indirectly through individual-level predictors.

Individual women experienced unwanted pregnancies.

Examples of environmental focus

Individual academic achievement is a well-known predictor of adult health, and addressing

education inequities may be critical to reducing health disparities.

Policy Systems Environment (PSE) change approaches address “upstream” factors that impact

health disparities and also promote community and environmental changes regarding food

security and access to healthy foods.

Example of a systems focus

High school quality may predict adult health outcomes after controlling for baseline health,

socio-demographics, and individual academic achievement.

Example of a policy focus

Focused on PSE change approaches that addressed “upstream” factors that impact health

disparities. The coalitions assessed disparities in health care access and outcomes and

advocated for equitable health care access, service delivery, and quality

Research Methodologies

Seven research methodologies were identified in the 2016 literature scan: 1) case study; 2) modeling;

3) experimental; 4) quasi-experimental; 5) qualitative methods; 6) program evaluation; and 7) literature

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reviews. As defined by Guest & Namey (2015), methodologies were identified as follows, to ensure

consistency between reviewers:

1. Case studies: in-depth investigations of a single person, group, event, or community, which

may continue for an extended period of time (Guest & Namey, 2015)

2. Modeling methodology: defined set of assumption about a set of data

3. Experimental design: a research design that removes all factors that could influence the

outcome except for the variable being studied (Guest & Namey, 2015)

4. Quasi-experimental designs: research experiments defined by their lack of random assignment

5. Qualitative methods: ethnographic and non-experimental methods such as naturalistic

observations, in-depth interviews, and/or focus groups (Guest & Namey, 2015)

6. Program evaluation methodology: assessing the value and impact of a specific program or

initiative

7. Literature reviews: synthesized research findings of previously published scientific literature

The highest percentage of articles reviewed used a modeling method (30%). Program evaluation was

the next highest method at 22%, followed by case study methodology at 20%. Seventeen percent of

articles included by the research team were literature reviews. The three least common methodologies

were qualitative methods, quasi-experimental design, and experimental design at 10%, 10%, and 7%,

respectively.

Table 3. Breakdown of research methodologies in included studies (n=81)*

Research Methodology Percentage (%) Count

Modeling 30% 24

Case Study 20% 16

Program Evaluation 22% 18

Literature Reviews 17% 14

Quasi-Experimental Design 10% 8

Qualitative Methods 10% 8

Experimental Design 7% 6

Total 81 *All categories do not sum to 100%

Example of modeling methodology

Nationally representative data from the U.S. Consumer Expenditure Survey was merged with

census-track data from the 2010 United States Census to model racial/ethnic disparities in

spending on fresh and processed fruit and vegetables as a function of residential racial/ethnic

segregation, income, household size and structure, educational attainment, marital status, age

and sex.

Example of a Case Study

Minnesota’s efforts were examined and the new Council on Institutional Collaboration

initiative—partnering large research universities with state health departments in addressing

the social determinants of health—was discussed.

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Example of Program Evaluation

A community-based participatory research (CBPR) approach was used to intervene and reduce

disparities in childhood immunizations. Behavior change models, education, social marketing

campaign, and theory of planned behavior interventions all contributed to the elimination of

immunization disparities in children.

Determinants of Health

In February 2016, the Prevention Institute released a report funded by the Robert Wood Johnson

Foundation Achieving Health Equity Team. The report defined 8 Determinants of Health that produce

health inequity, which include: socio-cultural environment, built/physical environment, housing, public

safety, education, employment, income and wealth, and access to quality health care systems

(Prevention Institute, 2016). These determinants of health were utilized to classify research articles.

Many articles represented multiple determinants of health and were thus categorized.

Figure 1. Determinants of Health

Source: Achieving Health Equity (2016)

Socio-cultural environment can be defined as reflecting the people within a community, the interactions between them, and norms and culture, whereas the built/physical environment reflects place, including human-made physical components, design, permitted use of space and the natural environment (Prevention Institute, 2016). Housing is defined by the availability or

Achieving Health Equity

Socio-CulturalEnvironment

Built/

Physical Environment

Housing

Public Safety

Education

Employment

Income and

Wealth

Access to Quality Health

System and Services

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lack of high quality, safe, and affordable housing that is accessible for residents with mixed income levels (Prevention Institute, 2016). Public safety can be characterized by the safety and protection of the public. Education is defined as access to high quality, learning opportunities and literacy development for all ages that effectively serves all learners. Employment refers to the level of adequate participation in a job/workforce (Prevention Institute, 2016). Income and wealth refers to access of financial resources. Access to quality health systems and services is defined as access to effective, affordable, culturally and linguistically appropriate, and respectful health services that promote prevention rather than a focus on the sick (Prevention Institute, 2016). Health care quality was the most common determinant of health (37%). Physical/built environment,

socio-cultural environment, and income and wealth determinants of health appeared fairly often in the

literature at 26%, 26%, and 24%, respectively. Fifteen percent of articles were categorized as education

and 13% were related to housing. About 22% of articles were categorized as other, not fitting into the 8

sectors defined by the Prevention Institute report.

Table 4. Determinants of Health in Included Studies (n=83)*

Determinants of Health Percentage (%) Count

Health Care Quality 37% 31

Physical/Built Environment 26% 22

Social/Cultural Environment 26% 21

Income and Wealth 24% 20

Education 15% 13

Housing 13% 11

Employment 5% 4

Safety 3% 3

Other 22% 18


Examples of Health Care Quality

The coalitions assessed disparities in health care access and outcomes and advocated for

equitable health care access, service delivery, and quality.

Mothers who received no prenatal care experienced five times greater IMR than those who

had initiated prenatal care in the first trimester.

Examples of Physical/Built Environment

Patients' neighborhood socioeconomic deprivation was negatively associated with perceived

social support intercept, whereas neighborhood-level social support was positively associated

with perceived social support slope.

Poverty and neighborhood of residence, two geographically linked factors, have been tied to

CVD mortality and its risk factors, with persons living in communities that aren’t conducive to

healthy lifestyle choices being at higher risk of Cardiovascular disease.

Examples of Socio/Cultural Environment

The cultural environment influences physical activity.

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Eight studies analyzed social and community context including family structure, social cohesion,

perceptions of discrimination/equity, civic participation, or incarceration/institutionalization.

Examples of Income and Wealth

Lower Socioeconomic status was associated with a higher prevalence of each of the 5 chronic

conditions after controlling for age, sex, ethnicity, and additional pertinent risk factors.

Women of color still have a two-fold increased risk of teen pregnancy and the difference is

believed to be a main driver of limited educational advancement, career progression, poverty,

and socioeconomic disparities.

Examples of Housing

The urban poor may be exposed to elevated environmental stress as a result of overcrowding,

street violence, or the residential segregation that is experienced in many cities.

Residents may have to work with landlords, property managers, and the public housing

authority on housing code violations such as pests and mold.

Examples of other determinants in search results

Quality of Life

Household Size & Marital Structure

Populations Represented in Search Results

Health disparities and health inequity affects many populations and groups. For the current scan, the

research team focused on 5 population groups, defined by the U.S. Census Bureau, African

American/Black, Hispanic/Latino, American Indian/Alaskan Native, Asian/Other Pacific Islander, Other

Racial/Ethnic Origin, and the LGBT population. Many research articles focused on more than one

population and were therefore categorized into multiple groups.

The vast majority of articles discussed inequities facing African American/Black populations (65%) and

Hispanic/Latino population (48%). Eighteen percent of the articles reviewed focused on American

Indian/Alaskan Native populations, 12% of the research articles were on Asian/Other Pacific Islander

populations, and 1% or only one article discussed other racial ethnic groups. Four percent of the

articles reviewed addressed inequities among LGBT populations.

Table 5. Breakdown of Frequency of Studied Populations in Search Results (n=66)*

Population Percentage (%) Count

African American/Black 65% 43

Hispanic/Latino 48% 32

American Indian/Alaskan Native 18% 12

Asian/Other Pacific Islander 12% 8

Other Racial/Ethnic Origin 1% 1

LGBT 4% 3


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CONCLUSIONS

Findings suggest that health equity research is largely focused on health disparities research. Much of

this work has been conducted with the minority populations of interest to the present work (e.g.,

racial/ethnic minorities, LGBT populations). We found that the majority of research funded by

government agencies was funded by the National Institutes of Health (i.e., National Institute on

Minority Health and Health Disparities, National Institute of Nursing Research). In terms of non-

governmental entities, the RWJF has funded the majority of this research. Most of the data we found

focused on second generation research, which seeks to understand drivers of health disparities

(Kilbourne et al., 2006; Table 1).

Next, informed by the Social Ecological Model (Brofenbrenner, 1977; CDC, 2013), we identified that

over half of the studies had a community level approach (some had more than one level of focus; Table

2). Studies varied widely in research methodologies; these methods included case studies,

experimental designs, and literature reviews (Table 3). Expanding upon the Socio Ecological Model, we

applied the determinants of health identified by the Prevention Institute health equity report (2016),

and found that most studies examined the following determinants: 1) Healthcare quality (37%); 2)

Physical/Built environment (26%); 3) Social/Cultural Environment (26%); and 4) Income and Wealth

(24%; Table 4).

Finally, most studies included African American and/or Hispanic/Latino populations, which is in keeping

with literature that suggests these individuals face the majority of health disparities in the United

States. Future research and health equity should examine the role of intersecting risk in health

disparities—for example, promoting health equity for African American LGBT individuals who are

uninsured.

Addressing health equity is an essential part of building a Culture of Health throughout America (RWJF,

2015; RWJF, 2016). Our findings, in keeping with the RWJF’s framework, suggest that establishing

shared health values among health equity stakeholders and supporting research to fill the most

important knowledge gaps are key steps to mitigating health disparities. Through collaboration

between governmental, non-governmental, research, advocacy, and program organizations, the field of

health equity research can strengthen and progress.

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REFERENCES

Association of American Medical Colleges (2014). The State of Health Equity Research: Closing Knowledge

Gaps to Address Inequities.

Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American

Psychologist, 32, 513–31.

Centers for Disease Control and Prevention (CDC) (2013). Framing the Issue – Social Ecological Model.

Retrieved September 30, 2016, from http://www.cdc.gov/nccdphp/dnpao/state-local-

programs/health-equity/framing-the-issue.html.

Guest, G., & Namey, E.E. (Eds). (2015). Public Health Research Methods. Thousand Oaks, CA: SAGE

Publications.

Humes K.R., Jones, N.A., & Ramirez, R.A. (2011). Overview of Race and Hispanic Origin: 2010 Census

Briefs. Retrieved September 30, 2016, from http://www.census.gov/prod/cen2010/briefs/c201

0br-02.pdf.

Evidence for Action (2015). Creating the evidence to build a Culture of Health across America.

Retrieved May 25, 2016, from http://www.evidenceforaction.org/.

Kilbourne, A.M., Switzer, G., Hyman, K., Crowley-Matoka, M., & Fine, M.J. (2006). Advancing Health

Disparities Research Within the Health Care System: A Conceptual Framework. American Journal

of Public Health, 96, 2113–21.

Prevention Institute (2016). Countering the Production of Inequities to Achieve an Equitable Culture of

Health. 2016: Prevention Institute Achieving Health Equity Team.

Robert Wood Johnson Foundation (2016). Culture of health – healthy communities. Retrieved

September 30, 2016 from, http://www.rwjf.org/en/our-focus-areas/focus-areas/healthy-

communities.html.

Robert Wood Johnson Foundation (2015). Measuring What Matters: Introducing a New Action

Framework. Retrieved September 30, 2016, from http://www.rwjf.org/en/culture-of-

health/2015/11/measuring_what_matte.html.

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APPENDIX A: CODING SCHEMA

1. Funder 2. Researcher 3. Types of research

Surveillance

Measurement

Evaluation 4. Research focus

Measurement of inequity

Causes/drivers of inequity

Solutions 5. Research Methodology

Case Study

Statistical Modeling

Experimental

Natural

Quasi-Experimental

Program Evaluation 6. Domains

Housing

Employment

Income and wealth

Education

Safety

Physical/built environment

Social/cultural environment

Quality health care/system

Other 7. Level of the Social Ecological Model

Policy

Environment/Community

System

Institution

Individual 8. Populations

African American

Latino

American Indian

Asian/Pacific Islander

Other racial/ethnic group

LGBTQ 9. Geography

Urban/Rural/Suburban

Geographical region (Northeast, Midwest, South, West)

State

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