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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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Communities in Action

Pathways to Health Equity

Committee on Community-Based Solutions to Promote
Health Equity in the United States

James N. Weinstein, Amy Geller, Yamrot Negussie,
and Alina Baciu, Editors

Board on Population Health and Public Health Practice

Health and Medicine Division

A Report of

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THE NATIONAL ACADEMIES PRESS
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www.nap.edu

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
×

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was supported by the Robert Wood Johnson Foundation under contract number 72444. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

Library of Congress Cataloging-in-Publication Data

Names: Weinstein, James N., editor. | Geller, Amy (Amy B.), editor. | Negussie, Yamrot, editor. | Baciu, Alina, editor. | National Academies of Sciences, Engineering, and Medicine (U.S.). Committee on Community-Based Solutions to Promote Health Equity in the United States, issuing body.

Title: Communities in action : pathways to health equity / James N. Weinstein, Amy Geller, Yamrot Negussie, and Alina Baciu, editors.

Description: Washington, DC : National Academies Press, 2017. | Includes bibliographical references.

Identifiers: LCCN 2017005055| ISBN 9780309452960 (paperback) | ISBN 0309452961 (paperback) | ISBN 9780309452977 (pdf)

Subjects: | MESH: Health Equity | Healthcare Disparities | Community Health Planning | Health Promotion | Socioeconomic Factors | United States

Classification: LCC RA418 | NLM W 76 AA1 | DDC 362.1—dc23 LC record available at https://lccn.loc.gov/2017005055

Digital Object Identifier: 10.17226/24624

Additional copies of this publication are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.

Copyright 2017 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2017. Communities in action: Pathways to health equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
×

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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COMMITTEE ON COMMUNITY-BASED SOLUTIONS TO PROMOTE HEALTH EQUITY IN THE UNITED STATES

JAMES N. WEINSTEIN (Chair), Dartmouth-Hitchcock Health System

HORTENSIA DE LOS ANGELES AMARO, University of Southern California School of Social Work and Keck School of Medicine

ELIZABETH BACA, California Governor’s Office of Planning and Research

B. NED CALONGE, University of Colorado and The Colorado Trust

BECHARA CHOUCAIR, Kaiser Permanente (formerly Trinity Health until November 2016)

ALISON EVANS CUELLAR, George Mason University

ROBERT H. DUGGER, ReadyNation and Hanover Provident Capital, LLC

CHANDRA FORD, University of California, Los Angeles, Fielding School of Public Health

ROBERT GARCÍA, The City Project and Charles Drew University of Medicine and Science

HELENE D. GAYLE, McKinsey Social Initiative

ANDREW GRANT-THOMAS, EmbraceRace

SISTER CAROL KEEHAN, Catholic Health Association of the United States

CHRISTOPHER J. LYONS, University of New Mexico

KENT McGUIRE, Southern Education Foundation

JULIE MORITA, Chicago Department of Public Health

TIA POWELL, Montefiore Health System

LISBETH SCHORR, Center for the Study of Social Policy

NICK TILSEN, Thunder Valley Community Development Corporation

WILLIAM W. WYMAN, Wyman Consulting Associates, Inc.

Study Staff

AMY GELLER, Study Director

YAMROT NEGUSSIE, Research Associate

SOPHIE YANG, Research Assistant (from June 2016)

ANNA MARTIN, Senior Program Assistant

ALINA BACIU, Senior Program Officer (from October 2016)

MICAELA HALL, Intern (from June 2016 to August 2016)

HOPE HARE, Administrative Assistant

ROSE MARIE MARTINEZ, Senior Board Director

DORIS ROMERO, Financial Associate

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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National Academy of Medicine/American Academy of Nursing/American Nurses Association/American Nurses Foundation Distinguished Nurse Scholar-in-Residence

SUZANNE BAKKEN, Columbia University School of Nursing

James C. Puffer, M.D./American Board of Family Medicine Fellowship

KENDALL M. CAMPBELL, East Carolina University, Brody School of Medicine

Consultants

ARIEL COLLINS, The City Project

DEBORAH KIMBELL, The Dartmouth Institute for Health Policy and Clinical Practice

NANCY NEGRETE, The City Project

RON SUSKIND, Harvard Law School

MAKANI THEMBA, Higher Ground Change Strategies

CESAR DE LA VEGA, The City Project

SUNMOO YOON, Columbia University

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

DOLORES ACEVEDO-GARCIA, Brandeis University

MARION DANIS, National Institutes of Health Clinical Center

JOSÉ J. ESCARCE, University of California, Los Angeles

RAUL GUPTA, West Virginia Bureau for Public Health

MEGAN HABERLE, Poverty and Race Research Action Council (PRRAC)

ROBERT A. HAHN, U.S. Centers for Disease Control and Prevention, Community Guide Branch

VALARIE BLUE BIRD JERNIGAN, University of Oklahoma Health Sciences Center

HOWARD KOH, Harvard T.H. Chan School of Public Health

MARGARET LEVI, Stanford University

MAHASIN S. MUJAHID, University of California, Berkeley

ADEWALE TROUTMAN, University of South Florida

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WILLIAM A. VEGA, University of Southern California School of Social Work

CHRISTOPHER WILDEMAN, Cornell University

EARNESTINE WILLIS, Medical College of Wisconsin

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by JACK EBELER and SARA ROSENBAUM, the George Washington University Milken Institute School of Public Health. They were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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Preface

Our nation’s founders wrote that all people are created equal with the right to “life, liberty, and the pursuit of happiness.” Therefore, the principles of equality and equal opportunity are deeply rooted in our national values, and in the notion that everyone has a fair shot to succeed with hard work. However, our nation’s social and economic well-being depends in part on the well-being of its communities, and many are facing great and evolving challenges. Across the country there are communities with insufficient access to jobs, adequate transit, safe and affordable housing, parks and open space, healthy food options, or quality education—the necessary conditions and opportunities to fully thrive. This lack of opportunity is particularly evident in the disparities that exist in health status and health outcomes between different zip codes or census tracts.

Other wealthy developed countries outperform the United States in health status, despite our high level of spending on health care. For example, not only does the nation’s life expectancy when compared to peer nations lag behind,1 but life expectancy in the United States also varies dramatically—by roughly 15 years for men and 10 years for women—depending on income level, education, and where a person lives. In the poorest parts of the country, rates of obesity, heart disease, cancer, diabetes, stroke, and kidney disease are substantially higher than in more affluent regions. Tragically, infant mortality—the number of deaths under

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1 National Research Council and Institute of Medicine. 2013. U.S. health in international perspective: Shorter lives, poorer health. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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1 year of age per 1,000 live births—is much higher in certain populations. In 2013, among non-Hispanic whites, 5.06 infants of every 1,000 live births died before their first birthday; among African Americans, that rate was double, at 11.1 per 1,000.2 Rates were also higher for Native American (7.61 per 1,000) and Puerto Rican (5.93 per 1,000) infants, as well as for low-income white infants in the Appalachian region, where in 2012, 7.6 infants died for every 1,000 live births.3 Research has shown that access to health care is important, but it is not sufficient to improve health outcomes (see, for example, Hood et al., 20164). To change the current state will require addressing the underlying social, economic, and environmental factors that contribute to health inequities. This report has examined the evidence on the current status of health disparities as well as the research examining the underlying conditions that lead to poor health and health inequities.

It will take local, state, and national leadership in the public and private sectors to improve the underlying conditions of inequity, and that will take time. However, there is great promise in communities that are taking action against health inequities across the United States. Moreover, advancements in the use of large disparate, population-based data with sophisticated analytic tools allow us to be more focused on possible solutions that tackle the multiple factors that shape health in communities. New partners in education, transportation, housing, planning, public health, business, and beyond are joining forces with community members to promote health equity. In this report the committee examines and shares examples of solutions implemented in several communities in the hope that other communities might adapt relevant elements and lessons learned to foster community-based approaches in their own unique environments. The report presents thorough evidence that health equity adds an important perspective in trying to improve community well-being, economic vitality, and social vibrancy.

During the committee’s time together, while reviewing the large body of scientific evidence and hearing from expert researchers on the social, economic, and environmental factors that affect health, several public health crises surfaced, including lead-contaminated water poisoning of children and other residents in Flint, Michigan, and the worsening opioid

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2 Mathews, T. J., M. F. MacDorman, and M. E. Thoma. 2015. Infant mortality statistics from the 2013 period linked birth/infant death data set. Hyattsville, MD: National Center for Health Statistics.

3 Children’s Defense Fund. 2016. Ohio’s Appalachian children at a crossroads: A roadmap for action. Columbus, OH: Children’s Defense Fund-Ohio.

4 Hood, C. M., K. P. Gennuso, G. R. Swain, and B. B. Catlin. 2016. County health rankings: Relationships between determinant factors and health outcomes. American Journal of Preventive Medicine 50(2):129–135.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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drug epidemic primarily affecting low-income people in rural communities across the country. These events are not the first of their kind, but they underscore the potential to galvanize public attention on health inequity at the community level.

In preparing this report, the committee took seriously its charge to review the state of health disparities and explore the underlying conditions and root causes that contribute to health inequity in order to inform much-needed efforts to reverse such inequities. The committee urges looking at disparities through the lens of health equity, as well as from other perspectives, to inform the changes necessary to improve the wellbeing of communities and our nation. The committee’s recommendations are offered with a focus on health equity as an essential component of health and well-being, but also with an awareness of the work at many levels necessary to address the myriad of challenges facing those most in need.

Health inequities are a problem for us all: the burden of disparities in health adversely affects our nation’s children, our business efficiency and competitiveness, our economic strength, national security, our standing in the world, and our national character and commitment to justice and fairness of opportunity.

This committee is grateful to the Robert Wood Johnson Foundation for the opportunity to delve deeply into the nature and causes of health inequity, to understand the critical need for solutions, and to examine the inspirational work that is being done in many communities to improve their well-being for themselves and for generations to come. It is the committee’s hope that this report will inform, educate, and ultimately inspire others to join in efforts across the nation so that members of all communities can enjoy life, liberty, and the pursuit of happiness undeterred by poor health.

James N. Weinstein, Chair
Committee on Community-Based Solutions to Promote Health Equity in the United States

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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Acknowledgments

The committee wishes to acknowledge and thank the many individuals and organizations that contributed to the study process and the development of Communities in Action: Pathways to Health Equity. Their contributions significantly enriched the committee’s information gathering and enhanced the quality of this report.

To begin, the committee would like to thank the sponsor of this study. Support for the committee’s work was provided by the Robert Wood Johnson Foundation.

The committee found the perspectives of multiple individuals and groups immensely helpful in informing its deliberations through presentations and discussions that took place at the committee’s public meetings. The speakers whose presentations informed the committee’s work include, in order of appearance, Steven H. Woolf, Camara Jones, Rachel Davis, Richard Hofrichter, Edward Ehlinger, Martha Halko, Gregory Brown, Anna Ricklin, Sam Zimbabwe, Robert Bullard, Marianne Engelman Lado, Thomas LaVeist, David Zuckerman, Michelle Chuk Zamperetti, Katie Loovis, Doran Schrantz, Nina Wallerstein, Manal Aboelata, Beatriz Solís, and David Erickson. The public meeting agendas are provided in Appendix C.

The committee also greatly appreciated the input of the Association of State and Territorial Health Officials, National Association of County and City Health Officials, Mildred Thompson at PolicyLink, Prevention Institute, Liz Welch at Thunder Valley Community Development Corporation, and Richard Wood at the University of New Mexico.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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The committee extends its utmost gratitude to the individuals who served as consultants to the committee by sharing their time and expertise during the writing of this report. They were instrumental to the study process as the committee explored the complex issues of health inequity and the role of community-based solutions in advancing equity. These individuals include Ariel Collins, Deborah Kimbell, Nancy Negrete, Ron Suskind, Makani Themba, Julie Troccio, Cesar De La Vega, William Weeks, and Sunmoo Yoon.

The committee is especially grateful to the nine inspiring communities highlighted in this report for generously sharing their experiences, challenges, and achievements. Specifically, the committee would like to thank Sasha Cotton and Gretchen Musicant (Minneapolis Blueprint for Action to Prevent Youth Violence); John Fairman and Neuaviska Stidhum (Delta Health Center); Juan Leyton, Andrew Seeder, and Harry Smith (Dudley Street Neighborhood Initiative); Mary Ellen Burns, Henrietta Muñoz, Sebastian Schreiner, and Jeniffer Richardson (Eastside Promise Neighborhood); Shoshanna Spector (Indianapolis Congregation Action Network); Patricia Bowie, Ron Brown, and Lila Guirguis (Magnolia Community Initiative); Trisha Chakrabarti and Dana Harvey (Mandela MarketPlace); Clarke Gocker, Ahmad Nieves, and Julia White (People United for Sustainable Housing, Buffalo); and Peggy Shepard (WE ACT for Environmental Justice).

The committee thanks the National Academies of Sciences, Engineering, and Medicine staff who contributed to the production of this report, including study staff Amy Geller, Yamrot Negussie, Sophie Yang, Anna Martin, Alina Baciu, Micaela Hall, Hope Hare, and Rose Marie Martinez. The committee thanks the National Academies communications and report production staff, including Greta Gorman, Nicole Joy, Sarah Kelley, and Tina Ritter. Thanks also to other staff of the Board on Population Health and Public Health Practice who provided occasional support. The committee was also fortunate to have support from Suzanne Bakken and Kendall Campbell, who contributed their time and expertise throughout the report development. This project received valuable assistance from Daniel Bearss and Ellen Kimmel (National Academies Research Center); Dana Korsen and Jennifer Walsh (Office of News and Public Information); Doris Romero (Office of Financial Administration); and Clyde Behney, Chelsea Frakes, Lauren Shern, and colleagues (Health and Medicine Division Executive Office and Office of Review and Communications).

Finally, the National Academies staff offers additional thanks to the executive assistants of committee members, without whom scheduling the multiple committee meetings and conference calls would have been nearly impossible: Sandra Aponte, Tiffany Eckert, Robbie Fox-Dunigan, Maria Gallegos, Chandra Halstead, Faith Johnston, Ruth Ann Keister, Lorena Maldonado, Cheryl Mance, Justin Nguyen, and Lauren Pell.

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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Acronyms and Abbreviations

AA

associate of arts

ACA

Patient Protection and Affordable Care Act

ACLU

American Civil Liberties Union

ACS

American Community Survey

AHA

American Hospital Association

AHRQ

Agency for Healthcare Research and Quality

AIDS

acquired immune deficiency syndrome

APA

American Planning Association

APHA

American Public Health Association

API

academic performance index

ASPPH

Association of Schools and Programs of Public Health

BPA

bisphenol A

CBA

community benefits agreement

CBO

Congressional Budget Office

CBPR

community-based participatory research

CCCEH

Columbia Center for Children’s Environmental Health

CCP

Community College Pathways

CCPH

Community–Campus Partnerships for Health

CDA

child development associate

CDC

U.S. Centers for Disease Control and Prevention

CDC

community development corporation

CDE

common data element

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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CEHNM

Center for Environmental Health in Northern Manhattan

CHNA

community health needs assessment

CI:Now

Community Information Now

CLT

community land trust

CMS

Centers for Medicare & Medicaid Services

COPC

community-oriented primary care

COR

Council of Representative

CPED

Community Planning and Economic Development

CPLC

Chicanos Por La Causa, Inc.

CTSA

Clinical and Translational Science Award

DEP

New York City Department of Environmental Protection

DHC

Delta Health Center, Inc.

DOT

U.S. Department of Transportation

DSNI

Dudley Street Neighborhood Initiative

EBALDC

East Bay Asian Local Development Corporation

ED

U.S. Department of Education

EHJLT

Environmental Health and Justice Leadership Training

EITC

earned income tax credit

EJI

Environmental Justice Institute

EPA

U.S. Environmental Protection Agency

EPN

Eastside Promise Neighborhood

ESSA

Every Student Succeeds Act

FIHET

Federal Interagency Health Equity Team

FQHC

federally qualified health center

GDP

gross domestic product

GED

General Education Development

GPRA

Government Performance Results Act

HEZ

health enterprise zone

HHS

U.S. Department of Health and Human Services

HIAP

Health In All Policies

HIV

human immunodeficiency virus

HRSA

Health Resources and Services Administration

HUD

U.S. Department of Housing and Urban Development

IHI

Institute for Healthcare Improvement

IHS

Indian Health Service

IndyCAN

Indianapolis Congregation Action Network

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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IOM

Institute of Medicine

IVE

Integrated Voter Engagement

KCHD

Kansas City Health Department

LACDPH

Los Angeles County Department of Public Health

LEED

Leadership in Energy and Environmental Design

LGBT

lesbian, gay, bisexual, and transgender

LIHTC

Low Income Housing Tax Credit

LOC

local organizing committee

MCI

Magnolia Community Initiative

MST

military sexual trauma

MTA

Metropolitan Transit Authority

MTS

marine transfer station

NAACP

National Association for the Advancement of Colored People

NACCHO

National Association of County and City Health Officials

NAMI

National Alliance on Mental Illness

NASEM

National Academies of Sciences, Engineering, and Medicine

NCHS

National Center for Health Statistics

NIEHS

National Institute of Environmental Health Sciences

NIH

National Institutes of Health

NPA

National Partnership for Action to End Health Disparities

NPA

National People’s Action

NPS

National Park Service

NRC

National Research Council

NRDC

Natural Resources Defense Council

NSDUH

National Survey on Drug Use and Health

NTFAI

National Task Force on Anchor Institutions

NVSS

National Vital Statistics Survey

NYPIRG

New York Public Interest Research Group

NYSDOH

New York State Department of Health

NYSTEA

New York State Transportation Equity Alliance

OEO

Office of Economic Opportunity

PACE

Program of All-inclusive Care for the Elderly

PaCT

Promise and Choice Together

PACT

Partnership of Academicians and Communities for Translation

PAD

Parks after Dark

PICO

People Improving Communities through Organizing

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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PRAPARE

Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences

PTSD

posttraumatic stress disorder

PUSH

People United for Sustainable Housing

QCDO

Quitman County Development Organization

RBA

results-based accountability

RHEC

regional health equity council

RWJF

Robert Wood Johnson Foundation

SAISD

San Antonio Independent School District

SAMHSA

Substance Abuse and Mental Health Services Administration

SES

socioeconomic status

SKCHD

Seattle & King County Health Department

SNAP

Supplemental Nutrition Assistance Program

SPARCC

Strong, Prosperous, and Resilient Communities Challenge

SQUIRE

Standards for Quality Improvement Reporting Excellence

SSI

Supplemental Security Income

STD

sexually transmitted disease

STEM

science, technology, engineering, and mathematics

TCEP

tris(2-carboxyethyl)phosphine hydrochloride [flame retardant]

TCI

Transforming Communities Initiative

TRAC

Transit Riders Action Committee

UDS

Uniform Data System

USDA

U.S. Department of Agriculture

UWPHI

University of Wisconsin Population Health Institute

VA

U.S. Department of Veterans Affairs

VHA

Veterans Health Administration

VSAT

Veterans Sustainable Agriculture Training Program

WHO

World Health Organization

YMCA

Young Men’s Christian Association

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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Key Terms

community Any configuration of individuals, families, and groups whose values, characteristics, interests, geography, and/or social relations unite them in some way.
community-based solution An action, policy, program, or law driven by the community that impacts community-level factors and promotes health equity.
health A state of complete physical, mental, and social well-being and not merely the absence of disease.
health disparities Differences that exist among specific population groups in the United States in the attainment of full health potential that can be measured by differences in incidence, prevalence, mortality, burden of disease, and other adverse health conditions.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/24624.
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health equity The state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance.
public policy A law, regulation, procedure, administrative action, incentive, or voluntary practice of governments and other institutions that affects a whole population.
social determinants of health The conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. For the purposes of this report, the social determinants of health are education; employment; health systems and services; housing; income and wealth; the physical environment; public safety; the social environment; and transportation.
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In the United States, some populations suffer from far greater disparities in health than others. Those disparities are caused not only by fundamental differences in health status across segments of the population, but also because of inequities in factors that impact health status, so-called determinants of health.

Only part of an individual’s health status depends on his or her behavior and choice; community-wide problems like poverty, unemployment, poor education, inadequate housing, poor public transportation, interpersonal violence, and decaying neighborhoods also contribute to health inequities, as well as the historic and ongoing interplay of structures, policies, and norms that shape lives. When these factors are not optimal in a community, it does not mean they are intractable: such inequities can be mitigated by social policies that can shape health in powerful ways.

Communities in Action: Pathways to Health Equity seeks to delineate the causes of and the solutions to health inequities in the United States. This report focuses on what communities can do to promote health equity, what actions are needed by the many and varied stakeholders that are part of communities or support them, as well as the root causes and structural barriers that need to be overcome.

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