The ability, opportunity and means to approach, consult, and utilize an organization’s services and organizational structure1.
Discrimination based on a person’s social class (e.g. education, income, occupation) 2.
Closing the gap
Closing the gap involves targeting programs and services to disadvantaged individuals, groups and communities so that the health of less advantaged populations improves and the difference between the most and least advantaged decreases3.
Refers to a learned system of shared meanings, values, beliefs and norms and is expressed in interpersonal interactions, customs, rituals, symbols, art and artifacts and social systems. While most people perceive culture in terms of ethnicity, culture is a concept that is applicable to any social group with commonalities; e.g. street youth, gays and lesbians, residents of Peel, etc2.
Determinants of Health
The Determinants of health are factors which influence health status and determine health differentials or health inequalities. They are many and varied and include, for example, natural, biological factors (e.g. age, gender and ethnicity); behaviour and lifestyles (e.g. smoking, alcohol consumption, diet and physical exercise), physical and social environment (e.g. housing equality, the workplace and the wider urban and rural environment), a access to health care (Lalonde, 1974; Labonte 1993). All of these are closely interlinked and differentials in their distribution lead to health inequalities4.
Disability is an umbrella term for impairments, activity limitations, and participation restrictions, denoting the negative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors)5.
Disadvantaged populations are groups of people who do not have the same access to social and material resources compared to more advantaged social groups6.
Diversity includes all the ways people are unique and different from others6.
Education is a learning process that plays a crucial role in the development of healthy, inclusive and equitable social, psychological and physical environments. It is informed by best practice and is multi-dimensional in its design and learner-centred in its approach. It empowers individuals and communities with knowledge, motivation, skills and confidence (self-efficacy) conductive to positive societal engagement and the benefit of all7.
Equity is an ethical principle that recommends that resources be allocated based on need, not based on underlying social advantage; that is, wealth, power and prestige8.
Equity in Health Care
Equity in health care is when health care resources are allocated to groups proportionate to their need. Groups can access these resources in a manner that reflects their cultural and linguistic backgrounds8.
Using an equity lens means considering the ways in which actions and their consequences are experienced by and distributed among different groups in our societies. Equity in health is achieved when everyone has equal opportunities for good health8.
Ethnicity includes multi-faceted characteristics of a group sharing certain social and cultural traits in common. Ethnicity is associated with ancestry, cultural traditions and languages. Ethnicity is based on self-identification, whereas race is imposed on a population by society. Ethnicity may affect the experience of health and disease8.
Evaluation involves making a judgement as to how successful (or otherwise) a project has been, with success commonly being measured as the extent to which the project has met its original objectives. Both the “process” (activities) and “outcomes” (what is produced, for example in terms of changes in the health of those targeted by the project) can be monitored and evaluated9.
Equity in Health
Inequity- as opposed to inequality – has a moral and ethical dimension, resulting from avoidable and unjust differentials in health status. Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential if it can be avoided. (WHO EURO, 1985). More succinctly, Equity is concerned with creating equal opportunities for health and with bringing health differentials down to the lowest possible level. (Whitehead, 1990). HIA is usually underpinned by an explicit value system and a focus on social justice in which equity plays a major role so that not only both health inequalities and inequities in health are explored and addressed whatever possible (Barnes and Scott-Samuel, 1999) 4.
The evidence bases refers to a body of information, drawn from routine statistical analyses, published studies and “grey” literature, which tells us something about what is already known about factors affecting health4.
The feeling and experience of being disempowered, degraded or disenfranchised through intentional or systemic discrimination10.
The absolute and relative differences in status between or amongst groups in a population8.
Gender is used to describe those characteristics of women and men, which are socially constructed, while sex refers to those which are biologically determined11.
Gender discrimination refers to any distinction, exclusion or restriction made on the basis of socially constructed gender roles and norms which prevents a person from enjoying full human rights12.
Gender equality is the absence of discrimination on the basis of gender in opportunities, in the allocation of resources or benefits, or in access to services. It is thus the full and equal exercise by men and women of their human rights. Gender disparities are inequalities or differences based on gender12.
Gender equity refers to fairness and justice in the distribution of benefits and responsibilities between women and men. The concept recognises that women and men have different needs and power and that these differences should be identified and addressed in a manner that rectifies the imbalance between the sexes11.
Gender minorities are those persons who do not conform to the binary male/female dichotomy or the gender assigned to them at birth. Gender minorities include transgender, intersex, transsexual, Two Spirit, cross dresser, drag performers, questioning persons as well as those who do not subscribe to those identities but express themselves outside of cultural norms (e.g.,effeminate boy, masculine women). Social, political and cultural changes may affect definitions8.
Health inequalities are often observed along a social gradient, which is a “stepwise or linear decrease in health that comes with decreasing social position” (Marmot 2004).This gradient exists in all countries, either rich or poor, and the pattern can observed when looking at factors such as income, level of education, geographic region, gender, or ethnicity. This means that the more favourable your circumstances are, the better your chances of enjoying good health and a longer life13.
Health is the physical, spiritual, mental, emotional, environmental, social, cultural and economic wellness of the individual, family, and community3.
Health equity asserts that all people can reach their full health potential and should not be disadvantaged from attaining it because of their social and economic status, social class, racism, ethnicity, religion, age, disability, gender, gender identity, sexual orientation or other socially determined circumstance8.
Improvement in health status4.
The differences in health between the worst off and everybody else14.
Health Equity Audit (HEA)
A Health Equity Audit (HEA) is a review procedure, which examines how health determinants, access to relevant health services, and related outcomes are distributed across the population, relative to need. An HEA advises decision-makers at all levels of governance to prioritize resources in the planning of policies, strategies and projects in a way that reduces health inequities.
A HEA distinguishes between health inequalities and health inequities, and the overall objective is thus not to allocate resource equally across the population, but to prioritize these according to actual needs of different segments or geographic locations13.
A health impact can be positive or negative. A positive health impact is an effect which contributes to good health or to improving health. For example, having a sense of control over one’s life and having choices is known to have a beneficial effect on mental health and well being, making people feel “healthier” (Wilkinson, 1996). A negative health impact has the opposite effect, causing or contributing to ill health. For example, working in unhygienic or unsafe conditions or spending a lot of time in an area with poor air quality is likely to have an adverse effect on physical health status13.
Health Impact Assessment (HIA)
Health Impact Assessment (HIA) is a practical tool, which allows for evaluating the health impact of policies, strategies and initiatives in sectors that indirectly affect health. Such as transportation, employment and the environment.
The overall goal of HIA is to inform decision-makers of adverse health effects of proposed actions, and support identification of appropriate policy options13.
Health in All Policies (HiAP)
Health in All Policies (HiAP) is a policy strategy, which targets the key social determinants of health through integrated policy response across relevant policy areas with the ultimate goal of supporting health equity. The HiAP approach is thus closely related to concepts such as ‘inter-sectoral action for health’, ‘healthy public policy’ and ‘whole-of-government approach’13.
Health Indicators (Population Based)
Health indicators include the various signs, counts, rates and statistics through which assessment and interpretation of the health of a population is conducted14.
Health Inequality and Inequity
Health inequalities can be defined as difference in health status or in the distribution of health determinants between different population groups. For example, differences in mobility between elderly people and younger populations or differences in mortality rates between people from different social classes. It is important to distinguish between inequality in health and inequity. Some health inequalities are attributable to biological variations or free choice and others are attributable to the external environment and conditions mainly outside the control of the individuals concerned. In the first case it may be impossible or ethically or ideologically unacceptable to change the health determinants and so the health inequalities are unavoidable. In the second, the uneven distribution may be unnecessary and avoidable as well as unjust and unfair, so that the resulting health inequalities also lead to inequity in health15.
Health literacy is the ability to access, understand, evaluate and communicate information as a way to promote, maintain and improve health in a variety of settings across the life-course14.
Healthy Public Policy
Healthy Public Policy is a key component of the Ottawa Charter for Health Promotion (1986). The concept includes policies designed specifically to promote health (for example banning cigarette advertising) and policies not dealing directly with health but acknowledged to have a health impact (for example transport, education, economics) (Lock, 2000)4.
Impact assessment is about judging the effect that a policy or activity will have on people or places. It has been defined as the “prediction or estimation of the consequences of a current or proposed action” (Vanclay and Bronstein, 1995)4.
Measurable differences or variation in some condition such as health or income levels16.
Inequity in health refers to systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage – that is, wealth, power, or prestige. Inequalities in health systematically put groups of people who are already socially disadvantaged (for example, by virtue of being poor, female, and/or members of a disenfranchised racial, ethnic, or religious group) at further disadvantage with respect to their health17.
Inequalities Audit/Equity Audit
A review of inequalities within an area or of the coverage of inequalities issues in a policy, programme or project, usually with recommendations as to how they can be addressed4.
Leveling up is a policy strategy focused on the fair distribution of resources to individuals and groups at all social and economic levels with the intent of improving the overall health of the population. The end result is equitable access to the resources needed for health, especially for the most disadvantaged3.
Marginalized populations are groups and communities that experience discrimination and exclusion (social, political and economic) because of unequal power relationships across economic, political, social and cultural dimensions3.
Minority populations are populations or groups with similar ethnic, racial, cultural, religious or linguistic characteristics and are a smaller proportion to the rest of the population in a given area14.
Monitoring is the process of keeping track of events. For example, the monitoring of a project may involve counting the number of people coming into contact with it over a period of time or recording the way in which the project is administered and developed13.
Population health refers to the health of a population as measured by health status indicators and as influenced by social, economic and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development, and health services.
As an approach, population health focuses on the interrelated conditions and factors that influence the health of populations over the life course, identities systematic variations in their patterns of occurrence, and applies the resulting knowledge to develop and implement policies and actions to improve the health and well-being of those populations18.
Public health is a professional practice aimed at improving health, prolonging life and enhancing the quality of life among whole populations14.
Quality of Life
Quality of life is defined as individual’s perceptions of their position in life in the context of the culture and value system where they live, and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept, incorporating in a complex way a person’s physical health, psychological state, level of independence, social relationships, personal beliefs and relationship to salient features of the environment18.
Qualitative and Quantitative
Health Impact Assessment tries to balance qualitative and quantitative evidence. It involves an evaluation of the quantitative, “scientific” evidence where it exists but also recognises the importance of more qualitative information. This may include the opinions, experience and expectations of those people most directly affected by public policies and tries to balance the various types of evidence (Barnes and Scott Samuel, 1999). Generally speaking, qualitative evidence is based on what can be counted or measured objectively whilst qualitative evidence cannot be measured in the usual ways and may more objective, for example, encompassing people’s perceptions, opinions and views4.
Race is an arbitrary classification of individuals and groups based on physical and cultural characteristics. Race includes socially constructed differences among people based on characteristics such as accent or manner of speech, name, clothing, diet, beliefs and practices, leisure preferences and/or places of origin. The concept of race is imposed on populations whereas ethnicity is based on self-identification14.
Racism is an ideology, action or conduct that either directly or indirectly conveys that one racial groups is inherently superior to another. Racial classifications are socially constructed views of arbitrary physical and cultural distinctions14.
Racialization is the process by which societies construct races as real, different and unequal in ways that matter to economic, political and social life14.
Social Determinants of Health
The conditions in which people are born, grow, live, work, and age, including the health system. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities. This term is also shorthand for the wider social, political, economic, environmental, and cultural forces that determine people’s living conditions18.
Socioeconomic status is the relative social and economic position of a family, individual, group or geography within a hierarchical social structure, based on their access to, or control over, wealth, prestige, and power. It is usually operationalized as a composite measure of income, level of education, and occupational prestige18.
Social inclusion/ Social exclusion
Social inclusion/social exclusion refer to the dynamic and multi-dimensional social process at all levels (individual, group and community) that is driven by unequal power relationships across economic, political, social and cultural dimensions. Unequal access to resources, capacities and rights leads to health inequities3.
The term strategy usually refers to a series of broad lines of action intended achieve a set of goals and targets set out within a policy or programme (Ritsatakis et al., 2000)4
Vulnerable populations refer to groups that have increased susceptibility to adverse health outcomes as a result of inequitable access to the resources needed to address risks to health14.
Well-being is a self-perceived satisfactory state of existence. Well-being is subjective but may include the presence of health and a sense of empowerment enabling an individual to influence their determinants of health14.
- Hamilton Centre for Civic Inclusion. (n.d.). Developing a culture of change. Retrieved from http://www.hcci.ca/hcci1/images/hamilton/developing-a-culture-of-change-week-5.pdf.
- World Health Organization. World Report on Disability. Geneva: WHO Press; 2011. Available at: http://www.who.int/disabilities/world_report/2011/en/index.html.
- Tri-Project Glossary Working Group. Towards an Understanding of Health Equity: Glossary. Edmonton: Alberta Health Services; 2011. Available at: http://www.albertahealthservices.ca/poph/hi-poph-surv-shsa-tpgwgglossary.pdf.
- World Health Organization. Health Promotion Glossary. 1998; Available at: http://www.who.int/hpr/NPH/docs/hp_glossary_en.pdf.
- World Health Organization. World Report on Disability. Geneva: WHO Press; 2011. Available at: http://www.who.int/disabilities/world_report/2011/en/index.html.
Achutha Menon Centre For Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Thiruvananthapuram, Kerala – 695011, India
Telephone : 91-471-2443152
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