Increase Health Equity Research Articles

Food Swamps Predict Obesity Rates Better Than Food Deserts in the United States.

This paper investigates the effect of food environments, characterized as food swamps, on adult obesity rates. Food swamps have been described as areas with a high-density of establishments selling high-calorie fast food and junk food, relative to healthier food options. This study examines multiple ways of categorizing food environments as food swamps and food deserts, including alternate versions of the Retail Food Environment Index. We merged food outlet, sociodemographic and obesity data from the United States Department of Agriculture (USDA) Food Environment Atlas, the American Community Survey, and a commercial street reference dataset. We employed an instrumental variables (IV) strategy to correct for the endogeneity of food environments (i.e., that individuals self-select into neighborhoods and may consider food availability in their decision). Our results suggest that the presence of a food swamp is a stronger predictor of obesity rates than the absence of full-service grocery stores. We found, even after controlling for food desert effects, food swamps have a positive, statistically significant effect on adult obesity rates. All three food swamp measures indicated the same positive association, but reflected different magnitudes of the food swamp effect on rates of adult obesity (p values ranged from 0.00 to 0.16). Our adjustment for reverse causality, using an IV approach, revealed a stronger effect of food swamps than would have been obtained by naïve ordinary least squares (OLS) estimates. The food swamp effect was stronger in counties with greater income inequality (p < 0.05) and where residents are less mobile (p < 0.01). Based on these findings, local government policies such as zoning laws simultaneously restricting access to unhealthy food outlets and incentivizing healthy food retailers to locate in underserved neighborhoods warrant consideration as strategies to increase health equity.

Announcement: Community Preventive Services Task Force Finding for Year-Round Schooling to Increase Health Equity

<i>Announcement</i>: Community Preventive Services Task Force Finding for Year-Round Schooling to Increase Health Equity

Softening Among U.S. Smokers With Psychological Distress: More Quit Attempts and Lower Consumption as Smoking Drops

It has been argued that as smoking prevalence declines, the remaining smokers represent a "hard core" who are unwilling or unable to quit, a process known as hardening. However, as recently shown, the general smoking population is softening not hardening (i.e., as prevalence falls, more quit attempts and lower consumption among continuing smokers). People with psychological distress smoke more, so they may represent hard-core smokers. Using cross-sectional time series analysis, in 2016-2017 changes in quit attempts and cigarette consumption were evaluated over 19 years among smokers with serious psychological distress (Kessler-6 score ≥13) based on the National Health Interview Survey (1997-2015), controlling for sociodemographic variables. People with psychological distress had higher smoking prevalence and consumed more cigarettes/day than people without distress. The percentage of those with at least one quit attempt was higher among those with psychological distress. The increase in quit attempts over time was similar among smokers in each of the distress levels. For every 10 years, the OR of a quit attempt increased by a factor of 1.13 (95% CI=1.02, 1.24, p<0.05). Consumption declined by 3.35 (95% CI= -3.94, -2.75, p<0.01) cigarettes/day for those with serious psychological distress. Although smoking more heavily than the general population, smokers with psychological distress, like the general population, are softening over time. To improve health outcomes and increase health equity, tobacco control policies should continue moving all subgroups of smokers down these softening curves, while simultaneously incorporating appropriately tailored quitting help into mental health settings.

Politics and Professions: Interdisciplinary Team Models and Their Implications for Health Equity in Ontario.

Ontario's efforts to reform primary care through interdisciplinary primary care teams are unprecedented in Canada. Since 2004, the provincial government has focused its reform efforts on three models: Family Health Teams (FHTs), Community Health Centres (CHCs), and Nurse Practitioner-led Clinics (NPLCs). These models vary by team structure, funding, and governance. I examine the strong preference for the FHT model by the government and medical profession, and the implications of this preference on health equity. The opportunity for teams to increase health equity in Ontario may be limited due to the preference for physician-centered FHTs over more egalitarian team models.

Economic Crises, Inequity and Health Systems: The Importance of Mitigating the Impact on the Population

In this article the proposition that health systems are an essential tool in order to mitigate the impact which the economic crises have on the population will be analysed and explained. These play a relevant role in the increase of preventable deaths, years of potential life lost, cardiovascular diseases, neoplasias and suicides. In these hard times, the focus should be in the correction of unhealthy lifestyles, such as smoking, alcoholism or lack of physical activity, in the early detection of hypertension and tumours, and the treatment of diseases which were historically mortal, and have reappeared because of the socioeconomic changes. The state should be responsible for planning, regulating and acting needed in order to diminish health inequalities. At present, there are privileges, social and legal pressures, and no policy prioritisation. Therefore, we are not directing our efforts towards those actions which increase health equity.

The Department of Health and Human Services Action Plan to Reduce Racial and Ethnic Health Disparities: A Commentary on Data Needs to Monitor Progress Toward Health Equity

The 2011 Department of Health and Human Services (HHS) Action Plan to Reduce Racial and Ethnic Health Disparities (the Action Plan) signified an unprecedented federal commitment to eliminating racial and ethnic disparities in health and health care. HHS monitored the Action Plan so that stakeholders could understand whether it had been carried out as expected and was having its intended impact on disparities. This commentary (1) describes the key facilitators of HHS’s process to monitor Action Plan implementation and (2) presents strategies to support data needs of others—such as HHS agencies and state and local governments—who monitor and evaluate similar strategic plans to increase health equity. The strategies include: (1) incorporating monitoring from the outset of strategic planning, (2) defining the purposes of monitoring, (3) including outcome targets, (4) developing logic models and identifying indicators, (5) assessing available data sources, (6) building capacity for data collection and reporting, and (7) collecting and reporting data on race and ethnicity.

The old age health security in rural China: where to go?

IntroductionThe huge number of rural elders and the deepening health problems (e.g. growing threats of infectious diseases and chronic diseases etc.) place enormous pressure on old age health security in rural China. This study aims to provide information for policy-makers to develop effective measures for promoting rural elders’ health care service access by examining the current developments and challenges confronted by the old age health security in rural China.MethodsSearch resources are electronic databases, web pages of the National Bureau of Statistics of China and the National Health and Family Planning Commission of China on the internet, China Population and Employment Statistics Yearbook, China Civil Affairs’ Statistical Yearbook and China Health Statistics Yearbooks etc. Articles were identified from Elsevier, Wiley, EBSCO, EMBASE, PubMed, SCI Expanded, ProQuest, and National Knowledge Infrastructure of China (CNKI) which is the most informative database in Chinese. Search terms were “rural”, “China”, “health security”, “cooperative medical scheme”, “social medical assistance”, “medical insurance” or “community based medical insurance”, “old”, or “elder”, “elderly”, or “aged”, “aging”. Google scholar was searched with the same combination of keywords.ResultsThe results showed that old age health security in rural China had expanded to all rural elders and substantially improved health care service utilization among rural elders. Increasing chronic disease prevalence rates, pressing public health issues, inefficient rural health care service provision system and lack of sufficient financing challenged the old age health security in rural China.ConclusionsIncreasing funds from the central and regional governments for old age health security in rural China will contribute to reducing urban–rural disparities in provision of old age health security and increasing health equity among rural elders between different regions. Meanwhile, initiating provider payment reform may contribute to improving the efficiency of rural health care service provision system and promoting health care service access among rural elders.

What all students in healthcare training programs should learn to increase health equity: perspectives on postcolonialism and the health of Aboriginal Peoples in Canada.

BackgroundThe ongoing role of colonialism in producing health inequities is well-known. Postcolonialism is a theoretical approach that enables healthcare providers to better understand and address health inequities in society. While the importance of postcolonialism and health (PCH) in the education of clinicians has been recognized, the literature lacks guidance on how to incorporate PCH into healthcare training programs. This study explores the perspectives of key informants regarding content related to PCH that should be included in Canadian healthcare training programs, and how this content should be delivered.MethodsThis qualitative study involved in-depth, semi-structured interviews with nineteen individuals with insight into PCH in Canada. Data were analyzed collaboratively to identify, code and translate key emergent themes according to the six phases of the DEPICT method.ResultsThree themes emerged related to incorporating PCH into Canadian healthcare training programs: (1) content related to PCH that should be taught; (2) how this content should be delivered, including teaching strategies, who should teach this content and when content should be taught, and; (3) why this content should be taught. For the Canadian context, participants advised that PCH content should include a foundational history of colonization of Aboriginal Peoples in Canada, how structures rooted in colonialism continue to produce health inequities, and how Canadian clinicians’ own experiences of privilege and oppression affect their practice. Participants also advised that this content should be integrated longitudinally through a variety of interactive teaching strategies and developed in collaboration with Aboriginal partners to address health inequities.ConclusionsThese findings reinforce that clinicians and educators must understand health and healthcare as situated in social, political and historical contexts rooted in colonialism. Postcolonialism enables learners to understand and respond to how colonialism creates and sustains health inequities. This empirical study provides educators with guidance regarding PCH content and delivery strategies for healthcare training programs. More broadly, this study joins the chorus of voices calling for critical reflection on the limits and harms of an exclusively Western worldview, and the need for action to name and correct past wrongs in the spirit of reconciliation and justice for all.

Marijuana Use and Its Association with Participation, Navigation, and Enrollment in Health Research among African Americans

This analysis examined the association between marijuana (Mj) use, willingness to participate, navigation and enrollment in health research among African Americans. Data from HealthStreet, a community-engagement model implemented in North Central Florida that reduces health disparities by engaging and linking community members to medical and social services and health research opportunities, were analyzed to determine willingness of African American Mj users to participate, be navigated to and enroll in health research studies. Among 1,496 African American community members, 8.0% were current Mj users, 30.3% were past Mj users and 61.7% reported never using Mj. Current and past Mj users were more willing to volunteer for a research study that only involved the use of medical records, required an overnight stay in a hospital or clinic, or might require use of medical equipment compared to those who never used Mj. Current Mj users were significantly less likely to be navigated (95% CI: 0.21–0.58) to health research studies while past Mj users (95% CI: 1.05–2.64) were significantly more likely to be enrolled in health research studies. Navigating and enrolling Mj users into health research studies could help decrease health disparities and increase health equity for the entire community since study findings would undoubtedly be more representative of the entire community rather than a select few.

Seven key investments for health equity across the lifecourse: Scotland versus the rest of the UK

While widespread lip service is given in the UK to the social determinants of health (SDoH), there are few published comparisons of how the UK's devolved jurisdictions ‘stack up’, in terms of implementing SDoH-based policies and programmes, to improve health equity over the life-course. Based on recent SDoH publications, seven key societal-level investments are suggested, across the life-course, for increasing health equity by socioeconomic position (SEP). We present hard-to-find comparable analyses of routinely collected data to gauge the relative extent to which these investments have been pursued and achieved expected goals in Scotland, as compared with England and Wales, in recent decades. Despite Scotland's longstanding explicit goal of reducing health inequalities, it has recently been doing slightly better than England and Wales on only one broad indicator of health-equity-related investments: childhood poverty. However, on the following indicators of other ‘best investments for health equity’, Scotland has not achieved demonstrably more equitable outcomes by SEP than the rest of the UK: infant mortality and teenage pregnancy rates; early childhood education implementation; standardised educational attainment after primary/secondary school; health care system access and performance; protection of the population from potentially hazardous patterns of food, drink and gambling use; unemployment. Although Scotland did not choose independence on September 18th, 2014, it could still (under the planned increased devolution of powers from Westminster) choose to increase investments in the underperforming categories of interventions for health equity listed above. However, such discussion is largely absent from the current post-referendum debate. Without further significant investments in such policies and programmes, Scotland is unlikely to achieve the ‘healthier, fairer society’ referred to in the current Scottish Government's official aspirations for the nation.

Creating a Continuum for Latino-Focused Nutrition Education

ObjectiveA pipeline for nutrition education (NE) ideally flows from the university to the local community creating an environment for improved health awareness, nutrition knowledge, and eating/physical activity behavior. Three objectives of a five-year, transdisciplinary grant are to develop and institutionalize a ‘Graduate Certificate in Latino Health and Nutrition Studies’ for students to gain knowledge, skills and confidence in their future profession from courses and service-learning activities, for local community programs to partner as training sites, and for a high-risk Latino community to receive culturally-relevant NE to increase health equity, potentially reducing obesity among families.Target AudienceAll graduate students at CSULB, CBOs, and Latino families with children (ages 2-8).Theory, Prior Research, RationalePrinciples of Community Based Participatory Research (CBPR) were used to integrate university activities with community education.DescriptionSix 3-unit courses were developed, 4 community partners identified, and 8-topic charla developed and implemented at partners’ sites.EvaluationThe ‘Graduate Certificate’ was institutionalized, 86.8% follow-up rate achieved at three-month assessment; significant increases in knowledge, psychosocial and behavioral variables were observed.Conclusions and ImplicationsBy developing Latino health-focused, college-level courses enriched with experiential learning, culturally-competent students and faculty in nutrition and health science disciplines create a sustainable pipeline for NE. CBPR can facilitate increases in positive behavior change to reduce health disparities among the growing U.S. Latino population.FundingUSDA Grant #2011-67002-30152. ObjectiveA pipeline for nutrition education (NE) ideally flows from the university to the local community creating an environment for improved health awareness, nutrition knowledge, and eating/physical activity behavior. Three objectives of a five-year, transdisciplinary grant are to develop and institutionalize a ‘Graduate Certificate in Latino Health and Nutrition Studies’ for students to gain knowledge, skills and confidence in their future profession from courses and service-learning activities, for local community programs to partner as training sites, and for a high-risk Latino community to receive culturally-relevant NE to increase health equity, potentially reducing obesity among families. A pipeline for nutrition education (NE) ideally flows from the university to the local community creating an environment for improved health awareness, nutrition knowledge, and eating/physical activity behavior. Three objectives of a five-year, transdisciplinary grant are to develop and institutionalize a ‘Graduate Certificate in Latino Health and Nutrition Studies’ for students to gain knowledge, skills and confidence in their future profession from courses and service-learning activities, for local community programs to partner as training sites, and for a high-risk Latino community to receive culturally-relevant NE to increase health equity, potentially reducing obesity among families. Target AudienceAll graduate students at CSULB, CBOs, and Latino families with children (ages 2-8). All graduate students at CSULB, CBOs, and Latino families with children (ages 2-8). Theory, Prior Research, RationalePrinciples of Community Based Participatory Research (CBPR) were used to integrate university activities with community education. Principles of Community Based Participatory Research (CBPR) were used to integrate university activities with community education. DescriptionSix 3-unit courses were developed, 4 community partners identified, and 8-topic charla developed and implemented at partners’ sites. Six 3-unit courses were developed, 4 community partners identified, and 8-topic charla developed and implemented at partners’ sites. EvaluationThe ‘Graduate Certificate’ was institutionalized, 86.8% follow-up rate achieved at three-month assessment; significant increases in knowledge, psychosocial and behavioral variables were observed. The ‘Graduate Certificate’ was institutionalized, 86.8% follow-up rate achieved at three-month assessment; significant increases in knowledge, psychosocial and behavioral variables were observed. Conclusions and ImplicationsBy developing Latino health-focused, college-level courses enriched with experiential learning, culturally-competent students and faculty in nutrition and health science disciplines create a sustainable pipeline for NE. CBPR can facilitate increases in positive behavior change to reduce health disparities among the growing U.S. Latino population. By developing Latino health-focused, college-level courses enriched with experiential learning, culturally-competent students and faculty in nutrition and health science disciplines create a sustainable pipeline for NE. CBPR can facilitate increases in positive behavior change to reduce health disparities among the growing U.S. Latino population.

Achievements in health equity: nesting an NIMHD center of excellence within a CTSA.

The Clinical and Translational Science Awards (CTSA) program of the National Center for Advancing Translational Sciences (NCATS) aims to speed the process of transforming new discoveries into improvements in human health. Critical to achieving this outcome of improving human health is the engagement of community, broadly defined, across the research spectrum. Moreover, including community members who do not traditionally participate in research nor benefit from research findings, must occur. Indeed, the Institute of Medicine highlighted the importance of engagement and collaboration in its recent review of the CTSA program (IOM, 2013). Translational science is a team-based endeavor; the more diverse the team, the greater the likelihood new discoveries will benefit more people. Unique populations (age, ethnicity, gender, place, race) experience disparities in health outcomes that translational science must address. The challenge becomes one of how to minimize these disparities by harnessing the promise of translational science through the CTSA program, while bringing voices of all constituencies to the table. In the latest strategic plan to combat health disparities (HD), the NIH listed four major goals: promoting HD research; fostering innovative collaborations and partnerships; training a diverse workforce; and translating and disseminating new discoveries. It is evident that both the CTSA program and the NIH strategic HD plan emphasize the necessity to engage community. Likewise, a CTSA Advisory Work Group identified three additional strategic goals that align with the HD plan: workforce development, integration, and development of novel methods. Thus, a rather unique opportunity exists to improve human health and reduce disparities, while achieving these established goals. At the University of Wisconsin Madison (UW), we integrated a P60 Center of Excellence funded by the National Institutes for Minority Health and Health Disparities (NIMHD) within our CTSA program to create the partnership required to effectively conduct community engaged HD research. Institutional commitment, along with shared personnel, resources, and complementary expertise, are transforming the academic culture to value engagement along the entire translational research spectrum. In time, we believe “nesting” of the P60 within the CTSA will improve the health of Wisconsin citizens and increase health equity.

Community health workers as an integral strategy in the REACH U.S. program to eliminate health inequities.

Mounting evidence indicates that community health workers (CHWs) contribute to improved behavioral and health outcomes and reductions in health disparities. We provide an overview (based on grantee reports and community action plans) that describe CHW contributions to 22 Racial and Ethnic Approaches to Community Health (REACH) programs funded by the Centers for Disease Control and Prevention from 2007 to 2012, offering additional evidence of their contributions to the effectiveness of community public health programs. We then highlight how CHWs helped deliver REACH U.S. community interventions to meet differing needs across communities to bridge the gap between health care services and community members, build community and individual capacity to plan and implement interventions addressing multiple chronic health conditions, and meet community needs in a culturally appropriate manner. The experience, skills, and success gained by CHWs participating in the REACH U.S. program have fostered important individual community-level changes geared to increase health equity. Finally, we underscore the importance of CHWs being embedded within these communities and the flexibility they offer to intervention strategies, both of which are characteristics critical to meeting needs of communities experiencing health disparities. CHWs served a vital role in facilitating and leading changes and will continue to do so.

Increasing health equity and access to skilled birth delivery services for the poor through community-based health-care interventions: evidence from northern Nigeria

Background The Partnership for Transforming Health Systems Phase 2 (PATHS2) project introduced and supports community based interventions such as safe motherhood initiative demand side (SMID) and an emergency transport scheme within northern Nigeria. This study evaluates the effect of PATHS2’s community based interventions in addressing transportation as a barrier to accessing skilled birth delivery services in health facilities.

Developing a good practice model to evaluate the effectiveness of comprehensive primary health care in local communities.

BackgroundThis paper describes the development of a model of Comprehensive Primary Health Care (CPHC) applicable to the Australian context. CPHC holds promise as an effective model of health system organization able to improve population health and increase health equity. However, there is little literature that describes and evaluates CPHC as a whole, with most evaluation focusing on specific programs. The lack of a consensus on what constitutes CPHC, and the complex and context-sensitive nature of CPHC are all barriers to evaluation.MethodsThe research was undertaken in partnership with six Australian primary health care services: four state government funded and managed services, one sexual health non-government organization, and one Aboriginal community controlled health service. A draft model was crafted combining program logic and theory-based approaches, drawing on relevant literature, 68 interviews with primary health care service staff, and researcher experience. The model was then refined through an iterative process involving two to three workshops at each of the six participating primary health care services, engaging health service staff, regional health executives and central health department staff.ResultsThe resultant Southgate Model of CPHC in Australia model articulates the theory of change of how and why CPHC service components and activities, based on the theory, evidence and values which underpin a CPHC approach, are likely to lead to individual and population health outcomes and increased health equity. The model captures the importance of context, the mechanisms of CPHC, and the space for action services have to work within. The process of development engendered and supported collaborative relationships between researchers and stakeholders and the product provided a description of CPHC as a whole and a framework for evaluation. The model was endorsed at a research symposium involving investigators, service staff, and key stakeholders.ConclusionsThe development of a theory-based program logic model provided a framework for evaluation that allows the tracking of progress towards desired outcomes and exploration of the particular aspects of context and mechanisms that produce outcomes. This is important because there are no existing models which enable the evaluation of CPHC services in their entirety.

REAL Data Collection Essential for Care of Vulnerable Populations

With minorities projected to constitute a majority of the U.S. population by 2043 (Census Bureau, 2012)-and considering that the disparities in healthcare access and quality they face are well documented (CDC, 2011)-it's clear that improving care for this population will depend on understanding who they are and where gaps exist. The need to reduce disparities in care has become particularly pressing with the Affordable Care Act's (ACA) focus on value-based care and quality improvement and a growing recognition that a reformed, high-performing healthcare system must make eliminating disparities a fundamental goal. We can achieve this goal by providing the best care possible to society's most vulnerable.Low-income and other disadvantaged patients are a population that members of America's Essential Hospitals (formerly the National Association of Public Hospitals and Health Systems) know well and a key reason we have joined forces with our allies in the Equity of Care initiative. Essential hospitals-those that serve a safety net role in their communities-are uniquely positioned to help reduce healthcare disparities, as more than half our patients are racial and ethnic minorities and a majority are uninsured or qualify for Medicaid. Although our members represent just 2% of U.S. hospitals, they deliver nearly 20% of all uncompensated care (NAPH, 2012).So, collecting reliable race, ethnicity, and language (REAL) data-and viewing it as an essential component of quality improvement-has become a priority for us and our hospitals, as it should be for all healthcare providers.WHY REAL DATA IS IMPORTANTIt seems self-evident, but this tenet is often overlooked: To provide the best quality of care to your patient population, you need to know who your patients are. REAL data helps you understand your patients' varying needs and view treatments and outcomes through the lens of their rich ethnic and racial diversity. It drives better care and a better patient experience. It enhances prevention-risk of disease varies by ethnicity and race, making this information as important to the future as it is to the present. It supports culturally competent care that respects each patient's social and cultural background and aids communication to improve patient compliance and outcomes.While improving patient care and the patient experience is the primary reason for collecting REAL data, regulatory and other compliance issues also come into play- meeting federal requirements for meaningful use of health information technology, for example, and achieving patient-centered medical home certification. Collecting REAL data is always the right thing to do and often the required thing to do.WORK TO DATE, AND MOVING FORWARDIn 2011, the Equity of Care National Call to Action made collecting and using REAL data a key component of a three-pronged approach to reducing disparities that also seeks increased cultural competency training and leadership diversity (Equity of Care, 2011).Other national stakeholders over the past decade have joined the fight to improve equity, including through better collection of data. In 2001, the Institute of Medicine (lOM) report Crossing the Quality Chasm: A New Health System for the 21st Century named equity as one of six domains of quality that all healthcare organizations must address. Other important milestones along the way, particularly with respect to REAL data, include the 2009 American Recovery and Reinvestment Act and its meaningful use requirements; the 2010 ACA, with its requirement that federally funded programs collect data on race, ethnicity, primary language, disability status, and gender; the 2011 federal Action Plan to Reduce Health Disparities, which outlines ways to increase health equity, including upgrading collection and analysis of REAL data and other demographics consistent with the ACA; and The Joint Commission's 2012 patient-centered communication standards, which require hospitals to collect a patient's preferred language for both verbal and written communications regarding their care. …

Use of community-based participatory research in primary care to improve healthcare outcomes and disparities in care

Community-based participatory research (CBPR) has emerged to bridge the gap between research and primary-care practice through community engagement and social action to increase health equity. It is widely acknowledged that access to high-quality primary care services is important to the overall health of a community. Here, CBPR studies in a primary care setting are reviewed to assess the use of CBPR associated with common health problems seen in primary care such as access to care and disparities in chronic disease management across vulnerable populations. CBPR involves building relationships with local communities, determining areas of need and establishing priorities for health concerns. Studies showing improved access to care for a Hispanic population, reduced asthma symptoms and weight loss are highlighted.

Health Equity in Developing Countries: A Need for Effective and Responsive Public Service Delivery to Improve Access to Health Services

In developing countries, there exist health disparities, due to various social inequalities prevailing among several socially disadvantaged groups. The causes for such health disparities are multi dimensional. The paper, however, considers, 'The access to health,' as one of the major social determinants of health, and discusses the problem of accessibility among various groups of society like children, women, urban poor and tribal populations. The paper further treats the mechanism of public service delivery as a mean to improve the access to health. Later, it moves on building a meaningful relation between the public services delivery and the Health equity. While doing so, the paper discusses the changing paradigm and various models of public service delivery in the context of changing socio-economic and political scenarios, and the way it could be changed or modified to assure fair and just distribution of health services, to all sections of society, according to their needs and requirements. The paper has reviewed the significant literature pertaining to the key concepts and has synthesized the relevant ones, in an order to build a discussion around public service delivery, enhanced access to health care and increasing health equity.

Getting to the Root of the Problem: Health Promotion Strategies to Address the Social Determinants of Health

Although extensive research shows that the social determinants of health influence the distribution and course of chronic diseases, there is little programming in public health that addresses the social determinants as a disease prevention strategy. This paper discusses different types of health promotion initiatives and differentiates them based on whether they attempt to impact intermediate (environmental) determinants of health or structural determinants of health. We argue for the importance of programming targeted at the structural determinants as opposed to programming targeted solely at the immediate environment. Specifically, the former has more potential to create significant improvements in health, contribute to long-term social change and increase health equity. We urge public health leaders to take this distinction into consideration during public health program planning, and to build capacity in the public health workforce to tackle structural mechanisms that lead to poor health and health inequities.

Book Review: Yellow Dirt: An American Story of a Poisoned Land and a People Betrayed

Nurses and other health professionals working to reduce health disparities and promote policies to increase health equity need to know about contemporary issues that impact minority populations. This book review details one such issue, told by Judy Pasternak in Yellow Dirt: An American Story of a Poisoned Land and a People Betrayed. In the book review, the history of uranium mining in Navajo communities is described, highlighting the minimization of health impacts on the Diné (Navajo) people by the U.S. government, health agencies and the Atomic Energy Commission. It outlines the struggle of Navajo people and other advocates today to clean up the devastating environmental impacts and cope with the health impacts, which include exponentially increased rates of cancer and syndromes related to in utero exposure to uranium. This is a story that few outside of Navajo Country know about. It is a cautionary tale to health care workers demonstrating how unethical and practices dangerous to the health of workers and future generations of their families can happen in our nation even today, and how health care workers can be unwitting participants.