Understanding Health Equity and Steps for Improvement

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.

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). Health equity conceptually builds on the social determinants of health or the fact that nonbiological factors affect health and health outcomes.

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. Indeed, the U.S. health system reflects its society, and deadly disparities became apparent during the COVID-19 pandemic.

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. Other frameworks, including those proposed by the Centers for Medicare & Medicaid Services, emphasize the importance of shared goals between stakeholders and providers in enacting health equity, such as through programs that connect clinicians and communities. 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.”

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. To advance their efforts in health equity, many hospital systems have added a health equity officer to their leadership team.

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.

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.

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.

Learn more from the authors about whether healthcare leaders understand the concept of equity and can link the concepts to practical applications within healthcare systems.

Editor’s Note: This content has been excerpted from “Advancing Equity in U.S. Hospital Systems: Employee Understandings of Health Equity and Steps for Improvement,” Journal of Healthcare Management, vol. 68, no. 5, by Melissa Uehling, Rachel Hall-Clifford, PhD, Crystal Kinnard, Yolanda Wimberly, MD. It has been edited down for length. The full article received the 2025 Edgar C. Hayhow Award, and the authors will be recognized during the Congress on Healthcare Leadership.

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