© 2014 Springer Publishing Company
Hispanic Health Care International, Vol. 12, No. 1, 2014
http://dx.doi.org/10.1891/1540-4153.12.1.3
Editorial Advocating for Health Equity Policy: Reflections and Opportunities for Collaborative Engagement Holly Mata, PhD, CHES The University of Texas at El Paso
H
ealth equity is social justice in health—where all people have a fair opportunity to achieve their full health potential (Braveman et al., 2011). More specifically, health equity exists when “all people have the opportunity to thrive and no one is limited in achieving comprehensive health and wellness because of their social position or any other social factors/determinant of health” (Association of State and Territorial Health Officials, 2011, p. 1). In terms of Hispanic health disparities, regardless of our research or practice focus, we know from our individual and collective experience that improving health care is not enough; we need to strive for health equity through improved policy at every level of health determinants. As clinicians, we are well trained to address individual determinants such as family history or risk behaviors but we’re often less prepared to address social and contextual factors such as educational inequities, disparities in incarceration, social norms around substance use, or workplace safety. As a certified health education specialist (CHES), I am credentialed based on a set of competencies that define our roles and responsibilities (National Commission for Health Education Credentialing [NCHEC], 2011). Seven “areas of responsibility” define our roles as CHES; Area of Responsibility VII is “communicate and advocate for health and health education.” This area includes several competencies and subcompetencies in the policy arena, such as “lead advocacy initiatives”; “evaluate advocacy efforts”; “use evidence-based research to develop policies to promote health”; and “advocate for health-related policies, regulations, laws, or rules” (NCHEC, 2011).
As a postdoctoral research fellow focusing on translating research results into policies that promote health equity, I work within a School of Nursing and collaborate with nurses and public health educators working to reduce HIV-related disparities among Hispanics, and with a diverse group of stakeholders committed to reducing tobacco-related disparities. Every day I am challenged, motivated, and inspired by my nurse colleagues. Their commitment to promoting health and health equity influences my own research and practice, and recently, I’ve had the opportunity to participate in two policy conferences driven by nurses. What better time to reflect on our shared challenges, resources, and opportunities as we move into a new year and new provisions of health reform? Scope of practice, professional preparation, and quality improvement are policy issues within the profession with which we are all familiar. But what about policies to promote educational attainment, increase access to safe and affordable housing, and reduce exposure to environmental toxins? With whom do we collaborate outside of the health sector? And how do we ensure that our interventions span across levels of social determinants and pathways in ways that will promote health equity? One useful framework (Sadana & Blas, 2013) helps identify entry points for action and intervention along levels of analysis including socioeconomic context and position, differential exposure, differential vulnerability, differential health care, and differential consequences. At each of these levels are common social determinants that influence conditions, risk factors, and outcomes. Based on these determinants, entry points and interventions can then be mapped out and prioritized for action (Blas & Kurup, 2010). 3
Editorial
Aligning our Efforts Across the Spectrum of Determinants
Health Disparities—I benefit tremendously from my work with the nursing community. Attending the American Academy of Nursing (AAN) Transforming Health Care: Driving Policy conference recently, during our poster session, I shared our experiences working with our local public health department to improve sexual and reproductive health services access in our region with nurses from across the country. From every conversation, I gained new insights, new strategies, and new ideas. Although I expected innovation in clinical arenas from my nursing colleagues, I was particularly excited to learn the extent to which nursing is at the forefront of health equity policy innovation. From nurses in Tennessee, I learned that communities are using local government resolutions to advocate for Medicaid expansion. That may be a useful strategy for us in Texas, where approximately 1.5 million people will be left with no coverage directly as a result of legislative failure to expand Medicaid (Center for Public Policy Priorities, 2013; Kaiser Family Foundation, 2013; National Health Law Program, 2013). From a Nursing Outlook article given to me by a new colleague at the conference, I learned about AAN’s “Have you ever served in the military?” campaign that is part of the national Joining Forces initiative, prioritizing employment, education, and wellness among our veterans and their families (Collins, Wilmoth, & Schwartz, 2013). Again, a useful policy strategy to share with my colleagues in public health and nursing at home, where we have a large active duty military and veteran population. Several weeks prior to the AAN conference, many of us participated in the 2nd annual Mano y Corazón Binational Conference of Multicultural Healthcare Solutions sponsored by the El Paso Chapter of the National Association of Hispanic Nurses (NAHN) and the Office of State Senator Jose Rodriguez (District 29). The conference brings together nurses, social workers, mental health professionals, physicians, community health advocates, and public health educators committed to improving policy and practice in our region. In planning for the conference, we realized that we could facilitate increased interdisciplinary interaction and collaboration by offering continuing education credits for health education specialists and community health workers as well as for nurses and mental health professionals. In session after session with colleagues from diverse disciplines, I again realized the importance of making sure our policy efforts span the spectrum of health determinants. In previous work, we have called for health education specialists to use their training and experience to facilitate collaborations that promote translation of health disparities research into improved practice and policy in our communities (Mata & Davis, 2012) and to diversify the next generation of public health researchers through strategic mentoring opportunities (Hernandez, Bejarano, Reyes, Chavez, & Mata, 2013). Similarly, nurses have been
Using tobacco-related disparities as an example, how might programs or policies across multiple levels reduce smoking and secondhand smoke exposure among vulnerable populations? At the social and contextual level, smoke-free policies in multiunit housing and clean indoor acts that ban smoking in bars and restaurants are effective approaches. Reducing differential exposure can be impacted through reduced marketing of tobacco products and increased advertising and pricing regulation, while differential vulnerability can be addressed through increased social support and access to cessation services. Differential health care outcomes and differential consequences might be addressed through prioritization of services for people most at risk and provision of these services within their own neighborhoods. Mapping our efforts may seem like an academic rather than a practical exercise, but it forces us to look across the spectrum of determinants and identify areas for improvement and collaboration. In my own recent work with our local public housing authority, we are developing smoke-free policies that are designed to reduce smoking and secondhand smoke exposure, and that respond to community-level disparities in smoking rates and access to smoking cessation services. Using a social determinants framework helps us to identify gaps in data, changes in social norms, psychosocial stressors that impact smoking, and accessibility of culturally and linguistically appropriate services to promote cessation. It also provides us with multiple entry points for interventions and collaboration. For example, smoke-free housing policies are known to reduce secondhand smoke exposure and promote cessation attempts (Pizacani, Maher, Rohde, Drach, & Stark, 2012). We also know that most of our public housing residents have household incomes far below the poverty level and most have no health insurance (Mata et al., 2013). With an underfunded state Quitline and no Medicaid expansion, it is our responsibility as nurses and public health educators to advocate for programs and policies across the spectrum of health determinants that will promote healthy environments and accessible health services.
Partners in Policy Advocacy My work with nurses makes me a better researcher, practitioner, and advocate. In addition to the mentored research support from my colleagues at the Hispanic Health Disparities Research Center (HHDRC; http://hhdrc.utep. edu) and our collaborations with El Centro (http://www. miami.edu/sonhs/index.php/elcentro)—both Centers of Excellence funded by the National Institute on Minority 4
Editorial
called upon to expand their education and advocacy efforts by using their leadership roles to improve policy by addressing social determinants of health (Lathrop, 2013) and by supporting emerging health disparities researchers (Mitrani, 2012).
Braveman, P. A., Kumanyika, S., Fielding, J., LaVeist, T., Borrell, L. N., Manderscheid, R., & Troutman, A. (2011). Health disparities and health equity: The issue is justice. American Journal of Public Health, 101(S1), S148–S155. Center for Public Policy Priorities. (2013). Texas and the ACA: Fewer uninsured, more federal health care dollars with Medicaid expansion. Retrieved from http://library. cppp.org/files/3/MedEx%20county%20level%20data%20 combined.pdf Collins, E., Wilmoth, M., & Schwartz, L. (2013). “Have you ever served in the military?” campaign in partnership with the Joining Forces initiative. Nursing Outlook, 61(5), 375–376. Hernandez, K., Bejarano, S., Reyes, F., Chavez, M., & Mata, H. (2013). Experience preferred: Insights from our newest public health professionals on how internships/practicums promote career development. Health Promotion Practice, Advance online publication. http://dx.doi. org/10.1177/1524839913507578. Retrieved from http:// hpp.sagepub.com/content/early/2013/10/15/15248399135 07578 Kaiser Family Foundation. (2013). Status of state action on the Medicaid expansion decision as of October 22, 2013. Retrieved from http://kff.org/health-reform/state-indicator/stateactivity-around-expanding-medicaid-under-the-affordablecare-act/ Lathrop, B. (2013). Nursing leadership in addressing the social determinants of health. Policy, Politics, & Nursing Practice, 14(1), 41–47. Mata, H., & Davis, S. (2012). Translational health research: Perspectives from health education specialists. Clinical and Translational Medicine, 1(27). Mata, H., Flores, M., Castañeda, E., Medina-Jerez, W., Lachica, J., Smith C., & Olvera, H. (2013). Health, hope, and human development: Building capacity in public housing communities on the U.S.–Mexico border. Journal of Health Care for the Poor and Underserved, 24(4), 1432–1439. Mitrani, V. B. (2012). The next generation of health disparities science. Hispanic Health Care International, 10(1), 4–6. National Commission for Health Education Credentialing. (2011). Responsibilities and competencies for health education specialists. Retrieved from http://www.nchec.org/credentialing/responsibilities/ National Health Law Program. (2013). State resources. Retrieved from http://healthlaw.org/index.php?option=com_content &view=article&id=701:state-advocacy-resources&catid= 51:health-reform&Itemid=176 Pizacani, B. A., Maher, J. E., Rohde, K., Drach, L., & Stark, M. J. (2012). Implementation of a smoke-free policy in subsidized multiunit housing: Effects on smoking cessation and secondhand smoke exposure. Nicotine & Tobacco Research, 14(9), 1027–1034. Sadana, R., & Blas, E. (2013). What can public health programs do to improve health equity? Public Health Reports, 128(S3), 12–20.
Not Such a Paradox, After All For too long, the Hispanic Health Paradox has characterized our field. By definition, a paradox is incongruent, inconsistent, and inexplicable. The more we understand and elucidate the complex pathways that contribute to Hispanic health disparities across the spectrum of health determinants, the more our policy advocacy efforts will be grounded in science rather than politics or power. Recent analyses suggest that most of the Hispanic advantage in life expectancy in the United States has been because of lower smoking rates and lower smoking-related mortality among Hispanic adults (Blue & Fenelon, 2011). There goes a piece of the paradox. But with little difference in smoking rates by Hispanic ethnicity among youth in the United States, that smoking-related mortality advantage will diminish within the next generation. How we, as health professionals, engage in health equity policy advocacy becomes increasingly important as our science improves. Better evidence will highlight the need for better policy, and now more than ever, we need to be effective policy advocates. In his keynote address at the 2013 American Public Health Association (APHA, 2013) meeting, Michael Marmot chastised U.S. policy decisions that leave millions of children in poverty and challenged the audience saying, “You have a functioning democracy, so this must be what you want.” Our health equity policy advocacy efforts need to reflect a resounding No! Structural and societal barriers to health are not what we want! I look forward to our collective response to this challenge, and I’m g rateful for the leadership NAHN has provided to the nursing profession, to our emerging health disparities researchers, and to our larger public health community.
References American Public Health Association. (2013). Michael Marmot speaks at the APHA 141st Annual Meeting in Boston (Part 2). Retrieved from http://www.youtube.com/watch?v=eFIB1k0EDEg Association of State & Territorial Health Officials. (2011). Position statement on health equity. Retrieved from http://www.astho. org/WorkArea/DownloadAsset.aspx?id=6876 Blas, E., & Kurup, A. S. (Eds.). (2010). Equity, social determinants, and public health programmes. Geneva, Switzerland: World Health Organization. Blue, L., & Fenelon, A. (2011). Explaining low mortality among US immigrants relative to native-born Americans: the role of smoking. International Journal of Epidemiology, 40(3), 786–793.
Correspondence regarding this article should be directed to Holly Mata, PhD, CHES, Hispanic Health Disparities Research Center, School of Nursing, The University of Texas, 500 W. University Avenue, El Paso, TX 79968. E-mail: [email protected] 5
Hispanic Health Care International, Vol. 12, No. 1, 2014
http://dx.doi.org/10.1891/1540-4153.12.1.3
Editorial Advocating for Health Equity Policy: Reflections and Opportunities for Collaborative Engagement Holly Mata, PhD, CHES The University of Texas at El Paso
H
ealth equity is social justice in health—where all people have a fair opportunity to achieve their full health potential (Braveman et al., 2011). More specifically, health equity exists when “all people have the opportunity to thrive and no one is limited in achieving comprehensive health and wellness because of their social position or any other social factors/determinant of health” (Association of State and Territorial Health Officials, 2011, p. 1). In terms of Hispanic health disparities, regardless of our research or practice focus, we know from our individual and collective experience that improving health care is not enough; we need to strive for health equity through improved policy at every level of health determinants. As clinicians, we are well trained to address individual determinants such as family history or risk behaviors but we’re often less prepared to address social and contextual factors such as educational inequities, disparities in incarceration, social norms around substance use, or workplace safety. As a certified health education specialist (CHES), I am credentialed based on a set of competencies that define our roles and responsibilities (National Commission for Health Education Credentialing [NCHEC], 2011). Seven “areas of responsibility” define our roles as CHES; Area of Responsibility VII is “communicate and advocate for health and health education.” This area includes several competencies and subcompetencies in the policy arena, such as “lead advocacy initiatives”; “evaluate advocacy efforts”; “use evidence-based research to develop policies to promote health”; and “advocate for health-related policies, regulations, laws, or rules” (NCHEC, 2011).
As a postdoctoral research fellow focusing on translating research results into policies that promote health equity, I work within a School of Nursing and collaborate with nurses and public health educators working to reduce HIV-related disparities among Hispanics, and with a diverse group of stakeholders committed to reducing tobacco-related disparities. Every day I am challenged, motivated, and inspired by my nurse colleagues. Their commitment to promoting health and health equity influences my own research and practice, and recently, I’ve had the opportunity to participate in two policy conferences driven by nurses. What better time to reflect on our shared challenges, resources, and opportunities as we move into a new year and new provisions of health reform? Scope of practice, professional preparation, and quality improvement are policy issues within the profession with which we are all familiar. But what about policies to promote educational attainment, increase access to safe and affordable housing, and reduce exposure to environmental toxins? With whom do we collaborate outside of the health sector? And how do we ensure that our interventions span across levels of social determinants and pathways in ways that will promote health equity? One useful framework (Sadana & Blas, 2013) helps identify entry points for action and intervention along levels of analysis including socioeconomic context and position, differential exposure, differential vulnerability, differential health care, and differential consequences. At each of these levels are common social determinants that influence conditions, risk factors, and outcomes. Based on these determinants, entry points and interventions can then be mapped out and prioritized for action (Blas & Kurup, 2010). 3
Editorial
Aligning our Efforts Across the Spectrum of Determinants
Health Disparities—I benefit tremendously from my work with the nursing community. Attending the American Academy of Nursing (AAN) Transforming Health Care: Driving Policy conference recently, during our poster session, I shared our experiences working with our local public health department to improve sexual and reproductive health services access in our region with nurses from across the country. From every conversation, I gained new insights, new strategies, and new ideas. Although I expected innovation in clinical arenas from my nursing colleagues, I was particularly excited to learn the extent to which nursing is at the forefront of health equity policy innovation. From nurses in Tennessee, I learned that communities are using local government resolutions to advocate for Medicaid expansion. That may be a useful strategy for us in Texas, where approximately 1.5 million people will be left with no coverage directly as a result of legislative failure to expand Medicaid (Center for Public Policy Priorities, 2013; Kaiser Family Foundation, 2013; National Health Law Program, 2013). From a Nursing Outlook article given to me by a new colleague at the conference, I learned about AAN’s “Have you ever served in the military?” campaign that is part of the national Joining Forces initiative, prioritizing employment, education, and wellness among our veterans and their families (Collins, Wilmoth, & Schwartz, 2013). Again, a useful policy strategy to share with my colleagues in public health and nursing at home, where we have a large active duty military and veteran population. Several weeks prior to the AAN conference, many of us participated in the 2nd annual Mano y Corazón Binational Conference of Multicultural Healthcare Solutions sponsored by the El Paso Chapter of the National Association of Hispanic Nurses (NAHN) and the Office of State Senator Jose Rodriguez (District 29). The conference brings together nurses, social workers, mental health professionals, physicians, community health advocates, and public health educators committed to improving policy and practice in our region. In planning for the conference, we realized that we could facilitate increased interdisciplinary interaction and collaboration by offering continuing education credits for health education specialists and community health workers as well as for nurses and mental health professionals. In session after session with colleagues from diverse disciplines, I again realized the importance of making sure our policy efforts span the spectrum of health determinants. In previous work, we have called for health education specialists to use their training and experience to facilitate collaborations that promote translation of health disparities research into improved practice and policy in our communities (Mata & Davis, 2012) and to diversify the next generation of public health researchers through strategic mentoring opportunities (Hernandez, Bejarano, Reyes, Chavez, & Mata, 2013). Similarly, nurses have been
Using tobacco-related disparities as an example, how might programs or policies across multiple levels reduce smoking and secondhand smoke exposure among vulnerable populations? At the social and contextual level, smoke-free policies in multiunit housing and clean indoor acts that ban smoking in bars and restaurants are effective approaches. Reducing differential exposure can be impacted through reduced marketing of tobacco products and increased advertising and pricing regulation, while differential vulnerability can be addressed through increased social support and access to cessation services. Differential health care outcomes and differential consequences might be addressed through prioritization of services for people most at risk and provision of these services within their own neighborhoods. Mapping our efforts may seem like an academic rather than a practical exercise, but it forces us to look across the spectrum of determinants and identify areas for improvement and collaboration. In my own recent work with our local public housing authority, we are developing smoke-free policies that are designed to reduce smoking and secondhand smoke exposure, and that respond to community-level disparities in smoking rates and access to smoking cessation services. Using a social determinants framework helps us to identify gaps in data, changes in social norms, psychosocial stressors that impact smoking, and accessibility of culturally and linguistically appropriate services to promote cessation. It also provides us with multiple entry points for interventions and collaboration. For example, smoke-free housing policies are known to reduce secondhand smoke exposure and promote cessation attempts (Pizacani, Maher, Rohde, Drach, & Stark, 2012). We also know that most of our public housing residents have household incomes far below the poverty level and most have no health insurance (Mata et al., 2013). With an underfunded state Quitline and no Medicaid expansion, it is our responsibility as nurses and public health educators to advocate for programs and policies across the spectrum of health determinants that will promote healthy environments and accessible health services.
Partners in Policy Advocacy My work with nurses makes me a better researcher, practitioner, and advocate. In addition to the mentored research support from my colleagues at the Hispanic Health Disparities Research Center (HHDRC; http://hhdrc.utep. edu) and our collaborations with El Centro (http://www. miami.edu/sonhs/index.php/elcentro)—both Centers of Excellence funded by the National Institute on Minority 4
Editorial
called upon to expand their education and advocacy efforts by using their leadership roles to improve policy by addressing social determinants of health (Lathrop, 2013) and by supporting emerging health disparities researchers (Mitrani, 2012).
Braveman, P. A., Kumanyika, S., Fielding, J., LaVeist, T., Borrell, L. N., Manderscheid, R., & Troutman, A. (2011). Health disparities and health equity: The issue is justice. American Journal of Public Health, 101(S1), S148–S155. Center for Public Policy Priorities. (2013). Texas and the ACA: Fewer uninsured, more federal health care dollars with Medicaid expansion. Retrieved from http://library. cppp.org/files/3/MedEx%20county%20level%20data%20 combined.pdf Collins, E., Wilmoth, M., & Schwartz, L. (2013). “Have you ever served in the military?” campaign in partnership with the Joining Forces initiative. Nursing Outlook, 61(5), 375–376. Hernandez, K., Bejarano, S., Reyes, F., Chavez, M., & Mata, H. (2013). Experience preferred: Insights from our newest public health professionals on how internships/practicums promote career development. Health Promotion Practice, Advance online publication. http://dx.doi. org/10.1177/1524839913507578. Retrieved from http:// hpp.sagepub.com/content/early/2013/10/15/15248399135 07578 Kaiser Family Foundation. (2013). Status of state action on the Medicaid expansion decision as of October 22, 2013. Retrieved from http://kff.org/health-reform/state-indicator/stateactivity-around-expanding-medicaid-under-the-affordablecare-act/ Lathrop, B. (2013). Nursing leadership in addressing the social determinants of health. Policy, Politics, & Nursing Practice, 14(1), 41–47. Mata, H., & Davis, S. (2012). Translational health research: Perspectives from health education specialists. Clinical and Translational Medicine, 1(27). Mata, H., Flores, M., Castañeda, E., Medina-Jerez, W., Lachica, J., Smith C., & Olvera, H. (2013). Health, hope, and human development: Building capacity in public housing communities on the U.S.–Mexico border. Journal of Health Care for the Poor and Underserved, 24(4), 1432–1439. Mitrani, V. B. (2012). The next generation of health disparities science. Hispanic Health Care International, 10(1), 4–6. National Commission for Health Education Credentialing. (2011). Responsibilities and competencies for health education specialists. Retrieved from http://www.nchec.org/credentialing/responsibilities/ National Health Law Program. (2013). State resources. Retrieved from http://healthlaw.org/index.php?option=com_content &view=article&id=701:state-advocacy-resources&catid= 51:health-reform&Itemid=176 Pizacani, B. A., Maher, J. E., Rohde, K., Drach, L., & Stark, M. J. (2012). Implementation of a smoke-free policy in subsidized multiunit housing: Effects on smoking cessation and secondhand smoke exposure. Nicotine & Tobacco Research, 14(9), 1027–1034. Sadana, R., & Blas, E. (2013). What can public health programs do to improve health equity? Public Health Reports, 128(S3), 12–20.
Not Such a Paradox, After All For too long, the Hispanic Health Paradox has characterized our field. By definition, a paradox is incongruent, inconsistent, and inexplicable. The more we understand and elucidate the complex pathways that contribute to Hispanic health disparities across the spectrum of health determinants, the more our policy advocacy efforts will be grounded in science rather than politics or power. Recent analyses suggest that most of the Hispanic advantage in life expectancy in the United States has been because of lower smoking rates and lower smoking-related mortality among Hispanic adults (Blue & Fenelon, 2011). There goes a piece of the paradox. But with little difference in smoking rates by Hispanic ethnicity among youth in the United States, that smoking-related mortality advantage will diminish within the next generation. How we, as health professionals, engage in health equity policy advocacy becomes increasingly important as our science improves. Better evidence will highlight the need for better policy, and now more than ever, we need to be effective policy advocates. In his keynote address at the 2013 American Public Health Association (APHA, 2013) meeting, Michael Marmot chastised U.S. policy decisions that leave millions of children in poverty and challenged the audience saying, “You have a functioning democracy, so this must be what you want.” Our health equity policy advocacy efforts need to reflect a resounding No! Structural and societal barriers to health are not what we want! I look forward to our collective response to this challenge, and I’m g rateful for the leadership NAHN has provided to the nursing profession, to our emerging health disparities researchers, and to our larger public health community.
References American Public Health Association. (2013). Michael Marmot speaks at the APHA 141st Annual Meeting in Boston (Part 2). Retrieved from http://www.youtube.com/watch?v=eFIB1k0EDEg Association of State & Territorial Health Officials. (2011). Position statement on health equity. Retrieved from http://www.astho. org/WorkArea/DownloadAsset.aspx?id=6876 Blas, E., & Kurup, A. S. (Eds.). (2010). Equity, social determinants, and public health programmes. Geneva, Switzerland: World Health Organization. Blue, L., & Fenelon, A. (2011). Explaining low mortality among US immigrants relative to native-born Americans: the role of smoking. International Journal of Epidemiology, 40(3), 786–793.
Correspondence regarding this article should be directed to Holly Mata, PhD, CHES, Hispanic Health Disparities Research Center, School of Nursing, The University of Texas, 500 W. University Avenue, El Paso, TX 79968. E-mail: [email protected] 5
