INTRODUCTION
Health equity remains a persistent challenge in the United States, and ongoing work to counter inequities is central to health system research and delivery. Understanding and measuring health disparities are essential prerequisites for building health equity. Then, U.S. health policies, systems, and social structures must take action to build health equity. However, movement from concept to action remains a challenge in working to implement health equity. This article characterizes employees' understanding of the concept of health equity and its practical applications in a U.S. public hospital system and recommends action points for hospital leaders to enact more equitable care in their organizations.
Health equity has been defined as “the absence of systematic disparities in health (or in the major social determinants of health) between social groups who have different levels of underlying social advantage/disadvantage—that is, different positions in a social hierarchy” (Braveman, 2003, p. 254). Although health inequalities is often used as a synonym for health inequities, they refer to distinct phenomena: health inequalities (e.g., differences in health outcomes) are the result of health inequities (e.g., differential access to resources, racism, and timely access to appropriate health services; Braveman, 2003). Health equity conceptually builds on the social determinants of health or the fact that nonbiological factors affect health and health outcomes (Marmot & Wilkinson, 2005).
The social determinants of health approach to health equity has been widely adopted, but greater clarity on how hospitals can best contribute to this work is needed (Marmot & Allen, 2014). Indeed, the U.S. health system reflects its society, and deadly disparities became apparent during the COVID-19 pandemic (Evans, 2020).
The multivalent nature of health disparities and the corresponding health equity frameworks intended to address them illustrate the point that no one actor, institution, or policy exists in isolation. Thus, there is a need to understand the various roles that U.S. health sector leaders and staff can take to advance health equity. The comprehensive Health Equity Framework identifies physiological, individual, relationships and networks, and systems of power as the key areas for health equity action (Peterson et al., 2021). Other frameworks, including those proposed by the Centers for Medicare & Medicaid Services (CMS), emphasize the importance of shared goals between stakeholders and providers in enacting health equity, such as through programs that connect clinicians and communities (Centers for Medicare & Medicaid Services, 2022). The hospital system featured in the present study is working to operationalize the framework put forward by the Robert Wood Johnson Foundation, which asserts that health equity means, “everyone has a fair and just opportunity to be as healthy as possible” (Braveman et al., 2017, p. 2).
As difficult as defining health equity is, doing health equity is far more challenging. A particular point for hospital systems and leaders to consider in working toward health equity is how to balance community-serving programs with patient care. Hospital systems are increasingly focused on health equity as both a part of their commitment to patient care and community service and their recognition of the burden of health disparities on health systems in readmissions, advanced disease, and so forth (Chin, 2016; Wong et al., 2015). To advance their efforts in health equity, many hospital systems have added a health equity officer to their leadership team (America's Health Insurance Plans, 2022).
However, significant questions remain about how hospital systems can best enact practices, programs, and policies that advance health equity. A meta-analysis of ethnographic data from health providers in the United Kingdom indicated that individuals tend to replicate institutional definitions of social inequalities and struggle to identify ways to advance health equity within their roles in the health system. A study of Canadian health systems leaders identified challenges in talking with stakeholders about health equity because of different understandings of the concept, and other research has emphasized the importance of clarifying these concepts broadly (Braveman, 2006; Pauly et al., 2017). As health equity has become a buzzword in public health policy spheres and healthcare settings, further characterization of stakeholder understandings of the concept in other contexts, including at U.S.-based hospitals, is needed. Although there is extensive health disparities literature regarding the U.S. context, there are limited data on staff and leader understandings of health equity concepts. This shortfall compounds the challenges in reshaping hospital systems to achieve health equity. In addition, there is limited existing translational research in health equity that explores linkages between conceptual understanding and practical application within healthcare systems. This article's chief contribution to the body of knowledge is the characterization of employee conceptual understandings of health equity and linkages to practical applications in a U.S. safety net hospital.
This article explores hospital system employee knowledge of health equity concepts and applications of equity through hospital programs, drawing on data collected from employees of Grady Health System in Atlanta, Georgia.
This project was designed as a descriptive study—part of a landscape analysis of health equity concepts, actions, and programs. The goal was to characterize how employees understand and apply the concept of health equity in their roles. Focus groups included a range of employees of different levels, job titles, and lengths of employment at the hospital. We anticipated that management and administration-level employees would generally have a higher level of understanding, but the results did not support this supposition.
METHODS
Study Design
This descriptive study used a mixed-methods approach with both closed-ended and open-ended questions. For qualitative analysis, we sought to explore understandings and working definitions of equality, equity, and health equity among hospital employees. The qualitative analysis included the participants' understandings of ways in which Grady Health System executes health equity as an organization through programs and initiatives. For quantitative analysis, we analyzed the relationship between the length of time employed at the hospital and job title and the ability to correctly define equity and health equity. We also analyzed the association between correct definitions of equity and health equity with various understandings of health equity implementation projects at Grady Health System.
Data and Sample
Our study used primary data collection involving 28 structured focus group discussions conducted for >4 months with employees of Grady Health System. The goal was to solicit respondent definitions of equity-related terms and understandings of equity implementation at the hospital, which were our outcome variables of interest and targets for qualitative analysis.
Individuals responded to questions via the response software Mentimeter; all responses were collected anonymously using a numerical participant ID. Focus groups were used to solicit information from a wide range of hospital employees on equity-related topics and allow individuals to ask clarification questions and engage in the discussion following their initial response (Stewart et al., 2007). Mentimeter's ease of use and accessibility has been shown to facilitate group learning and engagement (Hill, 2020).
Focus groups ranged from 2–22 participants who were employed by the hospital system. Employees included frontline workers, midlevel managers, and upper-level leadership. All 600 employees with relevant job titles were invited to participate. In total, 233 attended the focus group sessions; 212 respondents provided demographic information, which is described in Table 1. Our sample paralleled Grady Health System's overall employee population with regard to race and gender, though White and Black participants in the sample were over- and underrepresented, respectively (30.19% White individuals in the sample vs. 21.6% in Grady Health System's employee population, and 57.55% Black individuals in sample vs. 67.94% in Grady Health System's employee population). Also, our sample was older, on average, than Grady Health System's employee population, with our largest group represented in the age range of 40–55 years versus the age range of 25–40 years in Grady Health System's employee population. However, our sample resembled national averages for hospital employee demographics for gender and age, though Black employees were overrepresented compared with national averages (DataUSA, 2017; Salsberg et al., 2021; U.S. Bureau of Labor Statistics, n.d.).
TABLE 1 -
Sample Demographics
|
Count |
Percentage |
| Gender |
| Female |
143 |
67.5 |
| Male |
60 |
28.3 |
| Not disclosed |
9 |
4.2 |
| Age (years) |
| 25–40 |
29 |
13.7 |
| 40–55 |
108 |
50.9 |
| 55+ |
66 |
33.1 |
| Not disclosed |
9 |
4.2 |
| Race |
| Black |
122 |
57.6 |
| White |
64 |
30.2 |
| Other |
26 |
12.3 |
Individuals were dropped from the data set if there were missing values at any of the variables of interest for the quantitative analysis (all responses were kept for the qualitative analysis), resulting in a data set of 191 respondents for quantitative analysis.
Measures
Dependent Variables/Qualitative Measures of Interest
Respondents initially answered open-ended questions regarding their understanding of various terms of interest related to equity. They were asked to define equality, equity, and health equity, and were asked to describe health equity successes that they were aware of at Grady Health System. These questions were intended to gauge the understanding of basic concepts and how those concepts were applied practically by the organization. Responses ranged from a single word to multiple sentences. Individuals answered by typing on their personal mobile phones and were advised not to consult others when typing their responses (Hill, 2020). Drawing from the current literature and health equity frameworks described earlier, we defined equity as the recognition that individuals have unique needs and circumstances, and treatment must be tailored to the individual to truly reach an equal outcome (Braveman, 2003). The respondents' definitions of equity and health equity were recoded dichotomously as “Correctly Defined Equity/Health Equity” or “Did Not Correctly Define Equity/Health Equity” for ease of quantitative analysis. Based on our conceptual understanding of equity, we defined a “correct” definition as one which acknowledged the importance of individual needs and tailored treatment to achieve equality.
Independent Variables
Individuals were asked to provide their length of employment at the hospital and job title, as we hypothesized that these factors may be associated with an increased understanding of equity-related concepts. Both questions were asked in a closed, multiple-choice format. For length of employment, responses included <1 year, 1–5 years, 5–10 years, and >10 years for a total of four response categories. For job title, response options included nurse, physician, administrative or clinical staff, manager/supervisor, director, vice president or higher, and other. Because of a relatively small sample size for certain job titles, job titles were recoded as a dichotomous variable. The two new variable groups were (1) frontline or midlevel staff, which included nurse, physician, manager/supervisor, and administrative or clinical staff, and (2) upper-level staff, which included director and vice president or higher.
Analyses
Quantitative Analysis
We used Stata software for quantitative analysis. Logit regressions were performed using the length of time employed and job title as the predictor variables, whereas correctly defining equity and correctly defining health equity were the outcome variables. Two separate logit regression analyses were performed for equity and health equity.
As noted earlier, equity and health equity were recoded into the dichotomous categories “did not correctly define” and “correctly defined” for each variable. Chi-squared analysis was performed to determine the association between correctly defining equity and health equity and naming various health equity successes implemented by the hospital. Listwise deletion was performed such that only those respondents with complete data on all variables of interest were included in the analyses.
Qualitative Analysis
The qualitative analysis for this study involved thematic analysis using a grounded theory approach for the provided definitions of equality, equity, and health equity, and participant understandings of health equity successes at the hospital. Grounded theory is a well-established qualitative research methodology that involves discovering and constructing theory from data, in which hypotheses and theories are generated as patterns emerge through ongoing analysis of data (Strauss & Corbin, 1997). Grounded theory is particularly appropriate for this study, as little is currently known about how individuals working in hospital settings define and understand topics related to health equity and its practical applications.
For each outcome term of interest (equality, equity, health equity, relevant hospital programming), data from all respondents were aggregated and each respondent-provided definition was analyzed as a single data point, regardless of length of response. Each aggregated set of responses was analyzed through an iterative process in which codes were generated on the basis of major themes present in the aggregate response data. Two members of the study team independently examined the data and determined codes.
RESULTS
Descriptive Characteristics of Sample
The total sample size used for quantitative analysis was 191 respondents; 113 were frontline or midlevel staff, whereas 78 were upper-level staff (Table 2). Thirteen respondents had been employed at the hospital for <1 year, whereas 60, 58, and 60 respondents had been employed for 1–5 years, 5–10 years, and >10 years, respectively (Table 3). For qualitative findings, all responses were included, such that those with missing data at variables used in quantitative analysis were still included in qualitative analysis (n = 233).
TABLE 2 -
Job Position Descriptive Statistics
| Position at Grady Hospital |
Count |
Percentage |
| Frontline or midlevel staff (nurse, doctor, manager/supervisor, other) |
113 |
59.2 |
| Upper-level staff (director, vice president, or higher) |
78 |
40.8 |
| Total |
191 |
100 |
TABLE 3 -
Time Employed Descriptive Statistics
| Time Employed at Grady Hospital |
Count |
Percentage |
| <1 year |
13 |
6.8 |
| 1–5 years |
60 |
31.4 |
| 5–10 years |
58 |
30.4 |
| 10+ years |
60 |
31.4 |
| Total |
191 |
100 |
Defining Equality
Most participants exhibited a clear, well-defined understanding of equality, though definitions provided varied among participants. The most common themes present in the responses defining equality were mentions of equal and fair treatment by others (n = 69) and equal access to resources and opportunities (n = 91). For example, many respondents mentioned receiving equal treatment regardless of individual characteristics such as race, gender, or socioeconomic status. One respondent defined equality as, “All persons have the same opportunity in whatever the situation to achieve, receive or become regardless of their situation” (FGD5 P2). Other major themes among responses included defining equality as equal access to healthcare, the state of life and outcomes being broadly equal, and recognition of the inherent equalness of all persons. Responses were coded as “other” that did not fit well into any of the coded categories, and one individual stated that they did not know how to define equality. In addition, eight respondents did not respond.
Defining Equity
When asked to define equity, there was less coherence and more variation among responses. For these definitions, responses were coded as to whether equity was correctly defined per our definition for the study, which was coded as correct if a respondent mentioned individual needs or tailored treatment. Overall, 39 participants were coded as correctly defining equity, whereas 182 participants were coded as incorrectly defining equity (Table 4).
TABLE 4 -
Correctly Defining Equity
| Provided Definition of Equity |
Number of Respondents |
| Correctly defined |
39 |
| Incorrectly defined |
182 |
| Total |
221a |
|
Regression Coefficient (p) |
| Correct definition predicted by job title |
0.501 (.20) |
| Correct definition predicted by length of time employed |
–0.078 (.70) |
aTotal N includes all respondents who answered this question. However, for quantitative analysis, total used was n = 191.
Some respondents defined equity as tailored treatment based on individual needs, in line with our study's definition of equity. For example, one respondent defined equity as, “Ensuring everyone is at the same level, taking into account that different people may need more, or less, assistance” (FGD25 P196). Another respondent said, “Equity is providing the support needed for an individual to achieve their best health based on their individual needs. Meaning people are not simply treated equally but instead commensurate with what will enable them to achieve the same outcome as others” (FGD8 P1). Several respondents gave responses with similar themes to definitions of equality, including equal access to opportunities and resources—the most common theme among responses.
Many respondents explicitly conflated equity with equality in their responses or mentioned the quality of sameness as the definition. For example, responses included definitions such as “everyone is seen as the same” (FGD19 P122), or the state of all resources distributed equally regardless of individual characteristics.
Many other respondents mentioned fairness or fair treatment alone, another common theme. This theme contrasted with responses to equality, which often mentioned fairness only in conjunction with equal treatment, indicating that there was a greater emphasis on fair treatment rather than equal treatment when defining equity compared with equality. Other themes included defining equity as economic value or ownership, or value in general without specification.
There were also unique responses that were not coded under any of the major themes, such as one respondent who defined equity as a state of excess. Three respondents reported that they did not know how to define equity, and 12 respondents gave no response.
Defining Health Equity
As with the definitions of equity, responses for definitions of health equity were also coded according to whether the definition provided was in line with our study's definition. Overall, 43 participants provided a correct definition, whereas 172 did not (Table 5). Logit regressions revealed that neither length of time employed by the health system nor job title was a significant predictor of correctly defining equity or health equity (p > .05; Tables 4 and 5). There was an indication of a trend that higher-level employees were more likely to define equity correctly, though this was not statistically significant (p > .05; Table 4).
TABLE 5 -
Correctly Defining Health Equity
| Provided Definition of Health Equity |
Number of Respondents |
| Correctly defined |
43 |
| Incorrectly defined |
172 |
| Total |
215a |
|
Regression Coefficient (p) |
| Correct definition predicted by job title |
0.217 (.95) |
| Correct definition predicted by length of time employed |
0.070 (.72) |
aTotal N includes all respondents who answered this question. However, for quantitative analysis, total used was n = 191.
In the health equity definitions, there were three major themes among responses. Equal access to healthcare and resources was the most common, in line with major themes present in the definitions of equality and equity. Several respondents specified that this access would be available to all persons, regardless of individual factors such as socioeconomic resources. One participant defined health equity as, “Fair access to healthcare notwithstanding individual differences in capacity, resources, other possessions” (FGD14 P10).
Access to resources that influence health and illness prevention was another major theme. This theme included responses that mentioned social determinants of health. Many respondents did not specifically mention interface with the healthcare system but rather spoke broadly of individuals being able to live their healthiest lives through access to resources such as healthy food and having an adequate level of health literacy.
Also, equal and fair treatment within the healthcare system was a major theme. Some respondents specifically mentioned receiving care that is free of biases, and others mentioned receiving the highest level of care available regardless of an individual's ability to pay.
Some responses did not fit under any of these major themes, including one response about justice, one about innovation, and another referring to “mental awareness.” Four individuals stated that they did not know how to define health equity, and 18 participants did not respond.
Defining Health Equity Efforts Implemented by the Hospital
Respondents provided a wide range of responses when asked about their knowledge of health equity successes at Grady Health System. Responses generally fell into the thematic categories of (1) community presence and collaboration, (2) staff and job diversity, (3) provision of care to all individuals in need, (4) specialized programs and clinics, and (5) hospital infrastructure and communication.
Responses related to Grady Health System's community presence and collaboration included comments that highlighted partnerships with community organizations and Grady Health System's medical presence in the community. Respondents noted that the diversity of the staff reflected the community served, in addition to the presence of designated staff for health equity expansion. Others reported that Grady Health System's ability to serve all individuals regardless of ability to pay was an example of a health equity success—one respondent specifically mentioned the ability to provide dialysis services to those in need. Furthermore, respondents mentioned Grady's array of specialized care clinics and medical programs, with many specifying the Food as Medicine program and Grady's specialty clinics. Respondents also highlighted infrastructural aspects of Grady, including the electronic health record and patient communications system and clear signage in hallways. Generally, respondents did not describe why they believed their response was an example of a health equity success and instead simply listed their response.
Chi-squared analysis was performed to assess the association between correctly defining equity or health equity and naming successes that fell into a particular category. We were interested in this question because we considered the possibility that those who could correctly define equity or health equity would have more specific understandings of practical applications of equity concepts. Interestingly, the chi-squared analysis revealed no association between correctly defining equity or health equity and reporting a success that fell into any particular category (p > .05; Table 6).
TABLE 6 -
Correctly Defining Terms and Naming Practical Successes
|
Chi-Squared Coefficient (p) |
| Correctly defining equity and naming of categories of practical successes. |
1.60 (.95) |
| Correctly defining health equity and naming of categories of practical successes. |
2.41 (.88) |
DISCUSSION
Our study yielded surprising results, with no significant differences between the type of staff member, knowledge of health equity concepts, and knowledge of current relevant programs. These findings indicate the need for a deeper and more nuanced understanding of health equity terminologies and their practical applications in a hospital setting among hospital leadership and staff.
Common Terminology and Its Practical Applications
Although the term health equity has become prominent in hospital systems discourse, employees in our study struggled to define it. Less than one-fourth of respondents were able to correctly define either equity or health equity, indicating a lack of deep or nuanced understanding of these concepts. Previous research has emphasized the need for a broad consensus and conceptual understanding of health equity among healthcare providers and leaders to meaningfully discuss barriers and then enact health equity (Braveman, 2006; Pauly et al., 2017).
Our findings highlight the inability of healthcare leaders and providers to accurately define these concepts. For the work of health equity promotion to be effective, there must be a fundamental understanding of common terminology, and definitions must be rooted within the hospital's geographic, socioeconomic, and cultural context (Dover & Belon, 2019).
Before undertaking health equity work within and for a health system, it is vital to level-set what health equity means to health system employees at all levels and roles within the organization. Although we found no statistically significant differences in the ability to define health equity across type of employment or length of employment by the health system, healthcare providers and leaders have different roles in enacting health equity (Doherty et al., 2022; Moghadam & Leal, 2021). Armed with a baseline understanding of essential concepts, the deeper work of analyzing the gaps and solutions for health equity can begin.
Our research and previous research suggest that before the implementation of a health equity agenda, it is prudent to establish a common understanding of the terminology used to determine how these concepts may be implemented practically (Braveman, 2003).
Our findings regarding the Grady Health System's health equity successes indicate that conceptual understanding alone is not enough. There were no consistent patterns between understandings of the terminology and knowledge of practical applications of equity. In our data, some thematic examples of successes were more explicitly aligned with our study's definition of equity, such as providing specialized care to those with fewer resources. However, there was no association between correctly defining health equity with clearer examples of health equity successes, indicating that conceptual knowledge was an insufficient indicator for comprehension of how health equity can be enacted.
Strategy Development
Our findings make it clear that hospital systems need to build a shared fundamental understanding of key terminology at the organizational level to begin health equity work in earnest. Action plans should be developed after performing an environmental scan and analysis that incorporate many variables. On this basis, priority-need areas can be identified and an implementation plan developed.
Health equity is a broad concept and has many areas that hospitals can choose from to meet their community needs (Baum et al., 2009; Wilkinson et al., 2017). For instance, previous recommendations and research have centered on access to healthcare, food supplies, community educational programs, workforce development efforts, and patient safety and quality improvement efforts (Baum et al., 2009). In line with these studies, we emphasize the importance of a specific plan that is attainable, given the organization's resources, and focused on maximizing success (Pauly et al., 2018).
Professional Development
Professional development at all levels is necessary to understand health equity in the context of organizational mission and vision. This development must be pursued not only in tandem with the establishment of fundamental terminology and action plans but also with the social climate of the organization. Frontline health system staff, managers, or leaders cannot act on health equity if their notions of health equity are vague.
Only when a shared understanding of health equity is developed can meaningful programming be implemented, as noted earlier in recommendations that emphasize developing the competency of staff and providing the resources necessary to make health equity–based decisions (van Roode et al., 2020). Suggestions made during our focus groups indicated a multipronged approach that included single didactic sessions, longitudinal courses, applied experiences, and evaluation and assessment tools, highlighting the importance of a mixed-methods approach.
Health Equity Office Development
To close the health disparities gap, health systems are adding new positions in health equity and diversity, equity, and inclusion (DEI; Raths, 2020). The number of organizations creating DEI offices, equity officers, and other commitments to formal improvement (both internally from a staff perspective and externally from a client or patient perspective) has exploded. Between May and September 2020, the number of DEI-related job postings increased by 123% (Igoe, 2022).
Because many health equity offices are in the inaugural phases, it is important to determine the appropriate infrastructure of such offices and their roles within hospital systems. Hospital system landscape analysis should shape a health equity–focused strategic plan. That plan should cover the required infrastructure, including health equity–centered office space, staff, and programming. However, it is also important to note that creating a role or even an office within a healthcare system is not itself a solution to a systemic problem. Health equity and DEI offices carry a significant burden in addressing change within health systems within broader societal contexts of deeply rooted inequities. Hospital systems must meaningfully support and give power to health equity efforts to create institutional change.
Study Limitations
Although the study design of this work enabled breadth of participation across employment categories, limitations included few opportunities to further discuss understandings of health equity that may have revealed further nuance and areas of potential intervention. In addition, our demographic information was not linked to individual responses, though linking race, age, and gender to health equity understanding is an important consideration. Furthermore, both our sample and Grady Health System's overall employee trends indicate a higher proportion of Black hospital employees compared with national averages within other hospital systems, an important criterion limiting the generalizability of these.
CONCLUSION
Hospital systems in the United States are at the front lines of healthcare and are positioned to enact approaches, practices, and policies that support health equity. However, it cannot be assumed that leaders and staff, however skilled and dedicated to their work, know exactly what health equity is and how to implement it in their roles. Much of the research in the health equity literature either works to conceptualize health equity or describes program efforts toward health equity without interrogating its meaning. Based on our findings, there is a lack of coherence about what health equity means conceptually and difficulty with connecting the concept to practical actions.
As health equity becomes a more widely used terminology, knowledge of the term to promote consistency and clarity across all levels of healthcare delivery is needed, and our study's findings highlight the fact that consistent understanding is lacking. Meaningful hospital systems programs to improve health equity will start with staff education and facilitate dialogue across the organization on how health equity can move from principle to practice.
