Health inequality refers to a known disparity in health status or access to care that characterizes a disproportionate burden of disease or utility of services among persons or groups within a population.² In contrast, a health inequity reflects the social justice lens of defining a disparity that is avoidable, unjust, and unfair. In essence, a moral value judgment is attached to the drivers of health inequities. Although health inequalities and health inequities are distinct and nuanced, both terms have been used interchangeably with the discourse commonly infused with concepts related to social structure, institutional and environmental racism, and neighborhood disadvantage.

Health inequities are best understood within a complex, multi-level framework that incorporates determinants that are both social—including the impact of normative and cultural values—and structural—including those policies that influence social position, access to quality education, and residential segregation. Addressing health inequities begins, then, with understanding the challenges that often occur at birth, that continue on in early childhood and adolescence, and evolve into greater likelihoods of pervasive social and health disadvantages in adulthood and in future generations of children born into this cycle. Critical to understanding the confluence of these factors on each other and on future generations of children requires a life course perspective. This approach relies on the strength of partnership building, community mobilizing, and developing shared goals and initiatives with non-health sectors and policymakers to systematically address and eliminate social and structural inequities across the life span.

In our own work at CSAAH, we perceive substantial overlap in the scope of health inequalities and health inequities, while understanding them to reflect slightly different facets of the challenges our research approach seeks to address. Reducing health inequalities requires contextualizing interventions at the individual, organizational, and community levels to ensure improved and sustainable behavioral change and access to care. For many Asian American communities which reflect a largely immigrant population, there is an added complexity of understanding the role of migration experiences, acculturative stress, and familial obligations from their home countries on social position and health. For instance, our efforts to reduce health inequalities are focused on closing current gaps in health status experienced by disadvantaged populations, through community health worker interventions that seek to improve positive health contexts, behaviors, and outcomes at the individual and family level while recognizing the role of global factors on local Asian American communities, many of whom have extended ancestral and familial roots in their countries of origin.^3–10

In contrast, reducing health inequities requires a targeted focus on tackling social determinants of health that are structural in nature at the PSE level and influence the life course trajectories of risk for individuals and their communities. For example, CSAAH supports advocacy and policy change efforts that support improved access to basic healthcare, education, and other social programs (such as early childhood) for socially disadvantaged and immigrant populations. These efforts are rooted in a worldview towards altering the conditions and risks that occur across the lifespan and that engender social and health inequities for entire communities and future generations of children.

Health equity aims at achieving the highest attainment of health for all populations. The population health approach recognizes that there are multiple determinants of health.¹¹ Kindig and Stoddart define population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within a group,” at its core however, the concept of population health is varied.¹² Central to both health equity and population health frameworks are that they underscore the significance of understanding and addressing the social (and structural) determinants of access to care, health status and health inequities through community-engaged and multi-sectorial approaches. Secondly, both frameworks promote the use of models that bridge the interface between socially disadvantaged and medically underserved communities with complex health care delivery systems—emphasizing the need to streamline linkages between medicine and public health.¹³

This perspective recognizes that the conditions in which people live, work and play are primary drivers of health inequalities and inequities.¹⁹ Social determinants include socioeconomic status, social structure, social position, racism and discrimination as well as factors such as housing, transportation, political environment and cultural beliefs and norms. These individual and socioeconomic contextual factors interact to influence the health of populations.

NYC is home to the largest Asian American population in the US. There are more than one million Asian Americans in NYC, making up 13% of the total population.²⁰ The largest Asian subgroups are Chinese (48%), followed by Asian Indian (19%), Korean (8%), and Filipino (6%). Asian Americans in NYC experience a binomial distribution when it comes to economic and educational indicators. Approximately 25% of Asian Americans in NYC have no high school diploma, while 41% hold a bachelor’s degree or higher, and an additional 10% have a graduate or professional degree.²¹ While median household income is $53,384, nearly one quarter (23%) of families with children under 18 years of age live in poverty. Additionally, there are unique cultural and language barriers that impede access to healthcare and adherence to provider recommendations for disease prevention and management.²¹ Over 71% of the Asian American population in NYC is foreign born, while 81% of Asian Americans in NYC speak a language other than English at home. Nearly half of Asian Americans in NYC have limited English proficiency (47%), nationally the Census reports that less than 50% of those who spoke Korean, Chinese, or Vietnamese spoke English “very well.”^22,23 NYC’s Asian senior population has more than doubled in the last decade and statewide has grown by 75%, representing the fast growing senior citizen population in the city.²¹

In many respects, the study of Asian Americans in NYC and nationally is the study of the health of immigrant populations. A substantial proportion of Asian Americans are first- and second-generation immigrants (66%) are foreign born overall in the U.S).²² Moreover, immigrants and their children now comprise over 24% of the US population.²⁴ Thus a cross-national social determinants framework for immigrant health²⁵ can provide understanding of how and why disparities occur and persist in Asian American and other immigrant populations. A cross-national lens that integrates both a social determinants and life course perspective recognizes the distinct and interacting contextual factors that shape and influence health that are rooted in the context of both source and destination countries, taking into account the layered complexity of the immigrant experience, including migration context and processes.

The life course perspective is the study of long term effects that risk and cumulative exposures have on health over the lifespan.²⁶ Underlying a life course perspective is the worldview of the inherent role of social position and social structure on health over time. The cumulative effects of negative exposures on health imply an increasing vulnerability to such influences on health outcomes that differs across age groups.²⁷ For example, the very young and older populations experience increased vulnerability compared to middle-aged adults. A life course approach provides an important opportunity to explore health and disease both vertically (downstream vs. upstream determinants) and horizontally (impact on individuals and communities over time). Moreover, for immigrant populations, it allows for the important consideration of socioeconomic status in source and destination countries. The socioeconomic conditions as well as the infectious and environmental exposures experienced in an immigrant child’s source country may influence the health of the immigrant adult in destination country.

CSAAH’s community partnerships and coalitions that guide the research reflect diverse community perspectives allowing us to consider factors such as nativity and immigration history that inform life course perspectives, as well as including intergenerational approaches, to health promotion and disease prevention. For example, in our diabetes management initiative in the Bangladeshi community,⁵ we have found that engaging a diverse range of stakeholders has been an important means of ensuring the project represents both first and second generation immigrant concerns and needs. The project coalition has worked closely with traditional partners such as faith-based organizations and ethnic media outlets to engage largely first generation immigrant communities, but also partners with student associations and ethnic sport leagues (such as cricket leagues) to support an intergenerational approach that reaches a wide spectrum of Bangladeshi men and women at different ages. These partnerships have been particularly important in engaging the community around diabetes prevention and management of the disease in younger populations, as well as promoting family-based intervention models and dialogues around diabetes.

Paralleling the emergence of population health frameworks is the recognition that there is an enormous time gulf from the development and validation of evidence-based therapies, dissemination of recommended guidelines for prevention and treatment, and finally their adoption and uptake in clinical and community settings. The emergence of translational research reflects this concern and the importance of engaging communities in the research process in order to improve the development of relevant interventions and, ultimately, more effective adoption of evidence-based interventions. Often, interventions found to be effective in rigorously controlled clinical trials fail in the uptake, practice, and adoption in real world community and clinical settings because these trials often to do not account for the contextual factors that regulate or mediate behavior, health status, and access to care. As a consequence, community engagement and the practice of CBPR is increasingly viewed as a vital part of translational research science, as well for efforts to improve population health, eliminate health inequalities, and achieve health equity.

The lack of data disaggregated by Asian ethnic sub-group is a critical and persistent gap in understanding, addressing, and advocating for funding and resources that support identified community needs. Disaggregated data is needed to identify the most prevalent disparities, the sub-groups that are experiencing them, the nature of why they exist and persist, and the best strategies for mitigating them given limited resources. To address this gap, CSAAH developed and implemented two rounds (2004 and 2014) of a large-scale Community Health Resource and Needs Assessments (CHRNA) in diverse, low-income Asian American communities in NYC using a participatory and community venue-based approach to assess existing health issues, available resources, and best approaches to meet community needs. The CHRNA survey was developed through the adaptation of existing surveys, such as the National Health and Nutrition Examination Survey (NHANES), in partnership with key community leaders and community-based organizations who identified and prioritized health topic areas for survey inclusion, and guided and review the translation to ensure comprehension and cultural relevancy into multiple Asian languages, including Vietnamese, Khmer, Korean, Tibetan, Bengali, Nepali, and Chinese. Partnering with community groups, surveys are administered in-language at community venues during cultural events, community meetings, and faith-based gatherings. This method ensures that underserved and hard-to-reach immigrant populations are surveyed. Importantly, the second round of surveys will allow CSAAH to assess population health improvements, changes in risk and protective factors, and population changes in the last decade, including newly arriving communities such as the Bhutanese and Burmese, thereby filling a large gap in our understanding of the health needs and priorities of emerging Asian communities.

Healthy People 2020 identifies health information communication as an important concept for improving the health of all Americans and includes “Increase social marketing in health promotion and disease prevention” as one of its developmental objectives²⁸ and the CDC includes social marketing as a key framework in the dissemination of evidence-based health promotion practices.²⁹ Social marketing is the application of principles drawn from the commercial sector to influence a target audience to engage in beneficial behavioral change for the promotion of health and well-being.³⁰ Social marketing principles are especially well-suited for translating complex educational messages and behavior change techniques into concepts and products that will be received and acted upon by a specific segment of the audience.³¹ A meta-analysis of tailored health behavior change interventions reported a significant effect for using tailored health messages over a generic "one-size-fits-all" approach.³² The application of social marketing principles have been a key CSAAH strategy in culturally tailoring health education and outreach materials and intervention strategies across health initiatives including hepatitis B, mammography screening campaigns, and PSE protocols and strategies. It has also informed all CSAAH dissemination activities to ensure that research and intervention findings and outcomes are being presented in a meaningful and user-friendly way for real world application.

The complexity of social and health inequities indicate that a trans-sectorial approach is needed for improved population health and reduction of health disparities and health inequities. Essentially, a health in all policies approach is a collaborative approach that recognizes that health and prevention are impacted by policies that are managed by non-health government and non-government entities. This approach recognizes that while health is not an outcome of social policies, social policies indeed exert direct and indirect influences on health. Integration of health objectives in social and other public planning can ultimately have far greater impact on advancing both population health and health equity for socially disadvantaged populations. In that vein, CSAAH leadership has participated on the New York State Department of Health Medicaid Redesign Team to provide feedback and guidance on policies that influence Medicaid delivery and reimbursement and have implications for reducing health disparities and improving access to care for minority and medically underserved communities. Efforts have included improved disaggregated health data collection for racial and ethnic minority communities, strategies to integrate community health workers in strengthening community-clinical linkages, workforce development, and stable housing for health disparity and vulnerable populations.

CSAAH is also active with Project CHARGE (Coalition for Health Access to Reach Greater Equity), a health collaborative founded in 2007 by the Coalition for Asian American Children and Families (CACF) consisting of 16 community partners that work together to address health access for Asian Pacific Americans in New York City.³³ Through participation in the Coalition, CSAAH has been able to educate city and state elected officials on the needs of Asian American communities, and advocate for data disaggregation, language access, health care access, and targeted health outreach and education. Through our relationship with CACF and Project CHARGE, CSAAH and 8 additional community-based organizations serving Asian American communities across the city have received funding to serve as In-Person Assistors (IPAs)/Navigators for the NY State of Health insurance marketplace, providing culturally competent, linguistically appropriate, in-person enrollment assistance to individuals, families, small businesses and their employees.

A key research priority for CSAAH is to develop interventions that improve access to health care for prevention and better management of health disparity conditions. Community health worker (CHW) approaches are central to many of CSAAH’s protocols and resonate for communities served by CSAAH. CHWs play a critical role in bridging clinical practice and community-based health promotion for many underserved and immigrant populations, including Asian American communities. We have seen in our own work the efficacy and effectiveness of CHW interventions in the community.^4,5,7 We are now moving towards better integration and sustainability of CHWs in clinical care teams and care coordination models.³⁴ For example, through the recently funded NYU-City University of New York Prevention Research Center (NYU-CUNY PRC), we are implementing an integrated CHW-electronic health record intervention to address hypertension management in South Asian populations, working closely with a range of health systems partners, including payer organizations, state and local departments of health, and provider networks, with the ultimate goal of enhancing sustainability and scalability of the CHW model (See Figure 2).