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Equity in Health and Health Care

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Defining Terms

Health Equity: Valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.

Health Disparity: Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.

Source: HealthyPeople 2020

Our researchers actively seek to understand and address racial and ethnic disparities, social determinants of health

From its founding 75 years ago, Kaiser Permanente has held equity and inclusiveness for all its members, and the health of its communities, as guiding principles. And for nearly 60 years, the Division of Research has sought answers to support those goals.

In recent years, our investigators have sought to illuminate the social, biological, and environmental factors that contribute to racial and ethnic health disparities. And going a step farther, they identify evidence-based interventions to eliminate those differences.

This research portfolio is consistent and expanding. Investigators across our organization have taken variation by race, ethnicity, and health into account on a wide variety of topics, from medication adherence to diabetes prevalence to access to advanced surgeries.

We have long been focused on understanding the social drivers of health that have led to an increased risk for chronic health conditions, decreased access to medical care, and poorer health outcomes for our most vulnerable populations.

We know that:

Health Disparities Examples

  • A study showed starting annual colorectal cancer screening at age 45 in African Americans finds colorectal cancers at a rate similar to when screening starts after age 50” the age most guidelines currently recommend.
  • African American patients who were born in 1928 in states with the highest infant mortality rates among African American people faced a 86 percent higher risk of dementia than among white people born in states without high infant mortality rates.
  • Hypertension is devastating to communities of color, particularly among Blacks, where males have the highest hypertension death rates of any other racial, ethnic, or gender group.
  • Diabetes occurs 3 times more often among normal-BMI Native Hawaiians and Pacific Islanders than normal-BMI whites.
  • communities of historically underrepresented groups are disproportionately impacted by a lack of economic opportunity, living under sustained financial strain that creates barriers to good health.
  • inequities and disparities that have existed for people of historically underrepresented groups” women, the poor, and other marginalized groups” have been made more visible by the COVID-19 pandemic, with data showing that Latinx and African Americans are disproportionately affected by the disease as well as by its economic impacts.

The Division of Research will continue this mission to provide the data that allows high-quality health care to be accessible to everyone, no matter their social, economic, racial, or ethnic background.

Resources on Equity

Equality for All: Greg Adams, chairman and CEO, Kaiser Permanente

Equity, Inclusion, and Diversity Permanente Medicine Fact Sheet

Racism and Health Centers for Disease Control and Prevention Health Equity

Highlighted Recent Research

2022

Colorectal cancer screening program erases disparities in outcomes: Regional program eliminated disparities in colorectal cancer death rates between Black and white members in Kaiser Permanente Northern California

Colorectal cancer disparities between Black and white adults were eliminated in Kaiser Permanente Northern California (KPNC) members after the health care system instituted a regionwide, structured colorectal cancer screening program, new research shows.

Racial and ethnic disparities in COVID-19 infections are not explained by social risk factors: New Kaiser Permanente study suggests working and living conditions may be key contributors to disproportionate impact of COVID-19 in communities of color

Holding a public-facing job considered “essential” and living in a multigenerational household — both of which facilitate transmission of an airborne virus — may be key contributors to the higher COVID-19 infection rates seen early in the pandemic in the U.S. in Black, Latinx, and Asian adults, a new Kaiser Permanente study suggests.

Researchers expand understanding of hernia genetics: Kaiser Permanente analysis finds several novel genome locations associated with a frequently diagnosed lower abdominal condition

A Kaiser Permanente genetic analysis found 41 new locations on the human genome related to risk of hernia in the lower abdomen, known as inguinal hernia. The study, published in Human Molecular Genetics, also identified for the first time 2 locations associated with inguinal hernia risk in people with African ancestry and another 8 that show sex-specific effects.

2021

People with HIV are at increased risk for heart failure: Kaiser Permanente research finds risk difference more pronounced in women, Asians and Pacific Islanders, and people under 40

People with HIV are at higher risk of developing heart failure than people without HIV, a new study found.

Patients who need language interpretation less likely to initially choose a video visit: Kaiser Permanente research shows that once patients try talking to a clinician by video they will probably do it again

Patients with limited English proficiency who need a language interpreter for a telemedicine visit were less likely to choose a video visit for their first time than patients who did not need an interpreter, Kaiser Permanente research found.

Method found to remove race from controversial kidney function equations without losing accuracy: Kaiser Permanente study supports eventual use of test for cystatin C — instead of creatinine — to advance health equity

Researchers have identified an approach to remove race from equations used to estimate a person’s kidney function. These equations have been criticized for potentially perpetuating racial health disparities. The findings, reported September 23 in the New England Journal of Medicine, are expected to inform National Kidney Foundation-American Society of Nephrology Task Force guidelines on evaluating kidney function.

Stroke rate four times higher in Black young and middle-aged adults, compared to whites: Kaiser Permanente research shows the need for increased education about the dangers of high blood pressure

Black young and middle-aged adults have an incidence rate of stroke 4 times higher than that of white young and middle-aged adults, a large national multi-center prospective study by Kaiser Permanente researchers found.

American Indian, Alaska Native women less likely to start and complete hormone therapy for breast cancer: Kaiser Permanente study suggests lower rates of use my be contributing to higher breast cancer death rates

Women who identified as American Indian or Alaska Native were less likely than women of other racial and ethnic groups to start hormone therapy for breast cancer after surgery and stay on the treatment for the recommended 5 years, a new Kaiser Permanente study shows.

Analysis confirms racial disparities in COVID-19 infection: Kaiser Permanente study examines race, ethnicity and risk of infection, hospitalization, and death

An analysis of Kaiser Permanente members in Northern California early in the COVID-19 pandemic found racial and ethnic disparities in the likelihood of testing positive for the coronavirus, but no significant disparities in mortality among those who were hospitalized.

Heart failure hospitalizations and deaths vary by race and ethnicity: Kaiser Permanente study highlights need to identify reasons for these differences

Black patients with heart failure have higher rates of hospitalization for heart failure but lower rates of death than white patients with heart failure, a new Kaiser Permanente study shows.

2020

Unique genetic factors and ancestry, along with lifestyle, influence skin cancer risk: Investigators find clues in large database of Kaiser Permanente members

People can look to the Northern European side of their genetic heritage for increased risk of nonmelanoma skin cancer, according to the first large analysis of genetic risk factors for cutaneous squamous cell carcinoma in diverse populations with European ancestry from Kaiser Permanente researchers.

Girls who do not live with both parents more likely to start puberty early: New Kaiser Permanente study supports previous research suggesting link between early life family structure and onset of puberty

Girls who did not live in a 2-parent household from birth to age 2 were significantly more likely to start puberty earlier than girls who had both parents in their homes, with the association strongest among Black girls, new Kaiser Permanente research shows.

Teens, parents, physicians support screening young people for gender identity, study suggests: Kaiser Permanente physician researchers say screening could improve care for gender diverse adolescents

Teenagers who question their gender identity may not feel comfortable bringing up the issue with their doctors. New research suggests that adding gender identity questions to a pre-visit screening could make those conversations easier.

Early colorectal cancer screening benefits African Americans: Kaiser Permanente study supports starting screening at age 45 among this higher-risk population

A study by researchers at Kaiser Permanente Northern California showed starting annual colorectal cancer screening at age 45 in African Americans can find colorectal cancers at a rate similar to that seen when screening starts after age 50 — the age most guidelines currently recommend.

2019

Kaiser Permanente reduces racial disparities in who gets minimally invasive hysterectomies: Racial gap nearly disappears during project to train surgeons and establish best practices

Kaiser Permanente's northern California hospitals significantly increased minimally invasive surgery for hysterectomy and found the change also reduced racial disparities in the types of hysterectomies patients get.

How to reduce racial disparities in surgery: Podcast

National figures show white women are more likely to get an advanced, minimally invasive version of hysterectomy than are Black women and Hispanic women. Kaiser Permanente Northern California found much of that difference disappeared when it carried out a quality improvement project.

Chronic disease prevalence varies by Asian subgroup, Kaiser Permanente research finds: Findings suggest value in identifying Asian patients' ethnic backgrounds in medical records

Asian-Americans from different parts of Asia have very different cardiovascular risk factors and chronic conditions such as diabetes, hypertension, and heart disease, research from the Kaiser Permanente Division of Research suggests. The study, published in BMC Public Health, used electronic health record (EHR) data for 1.4 million adults aged 45 to 84 who were Kaiser Permanente Northern California members during 2016.

Minority racial and ethnic groups get diabetes at lower weights: Diabetes occurs 3 times more often among normal-BMI Native Hawaiians and Pacific Islanders than normal-BMI whites, Kaiser Permanente research finds

Being overweight or obese is commonly associated with diabetes, but a Kaiser Permanente study finds the connection differs widely by race or ethnicity. Members of racial and ethnic minority groups were much more likely to have diabetes or prediabetes at lower weights — even at normal or below-normal body mass index (BMI), according to research published in Diabetes Care.

Large study links genetic marker of aging to greater neighborhood deprivation: Kaiser Permanente and UCSF researchers find strong connection between which neighborhood a person lives in, how much education they have, and the length of their telomeres

A large Kaiser Permanente study has identified links between a genetic marker of aging, how much education a person has, and the degree of socioeconomic deprivation in their neighborhood. Genetics research suggests that longer telomeres — the "end caps" of DNA that keep strands of chromosomes from unraveling — mean more years of healthy life ahead.

More Highlighted Research ≫

 Related Studies

 

 

Lifecourse health, cerebral pathology and ethnic disparities in dementia (KHANDLE Study)GP0|#2506a695-9f5e-487b-a029-728467597d51;L0|#02506a695-9f5e-487b-a029-728467597d51|Gilsanz, Paola;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae4The Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) Study, a collaborative study between DOR and UC Davis, follows a diverse cohort of Kaiser Permanente Northern California members who participated in at least one optional check-up (Multiphasic Health Checkups) during midlife. This study is evaluating differences in dementia incidence and rate of cognitive decline across racial/ethnic group and sexes. It uses over five decades of data to examine how early life experience, life course health, and genetics influence differences in cognitive decline and dementia by race/ethnicity and sex.GP0|#2506a695-9f5e-487b-a029-728467597d51;L0|#02506a695-9f5e-487b-a029-728467597d51|Gilsanz, Paola;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae42022-02-03T08:00:00Z
An Expanded National Cohort Study of Transgender PeopleGP0|#2382d353-6bcb-45e9-9e97-51424fb1236c;L0|#02382d353-6bcb-45e9-9e97-51424fb1236c|Silverberg, Michael;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae4The Study of Transition, Outcomes and Gender (STRONG) is an ongoing cohort study of transgender people enrolled in Kaiser Permanente (KP) integrated health care plans in Georgia (KPGA), Northern California (KPNC) and Southern California (KPSC), and includes 6,459 members for years 2006 through 2014. In this study, we add a new site at Kaiser Permanente Mid-Atlantic States (KPMAS) and extend cohort members and follow-up through 2022. We will study acute cardiovascular events in relation to gender affirming testosterone (HT), characterize mental health status of transgender people, and evaluate changes in clinical health indicators in relation to HT receipt.GP0|#2382d353-6bcb-45e9-9e97-51424fb1236c;L0|#02382d353-6bcb-45e9-9e97-51424fb1236c|Silverberg, Michael;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae42022-02-02T08:00:00Z
Influence of Comorbidities and Inflammatory Biomarkers in Disparities in Ovarian Cancer Treatment, Treatment Response, and SurvivalGP0|#f06105f5-8f6f-4451-8e2b-c6becb7835fc;L0|#0f06105f5-8f6f-4451-8e2b-c6becb7835fc|Kushi, Lawrence;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae4This project examines racial and ethnic disparities in ovarian cancer patients diagnosed and treated in KPNC from 2000 to 2023. It is an ancillary study to an NCI-funded research project (R01 CA243188) led by MPIs Kushi, Doherty (University of Utah), Bandera (Rutgers University), and Gomez (UCSF). This is the largest multiethnic cohort of ovarian cancer survival to date to examine clinical and medical care; neighborhood and geospatial factors; reclassification of subtypes with updated information; and, in a subset of cases, tumor characteristics. This ancillary study extends this project with collection of pre-diagnostic information to explore the role of comorbid conditions. It also supports additional tumor assays examining inflammation markers in contributing to disparities in ovarian cancer outcomes. GP0|#f06105f5-8f6f-4451-8e2b-c6becb7835fc;L0|#0f06105f5-8f6f-4451-8e2b-c6becb7835fc|Kushi, Lawrence;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae42022-02-02T08:00:00Z
Quantifying Racial/ethnic Differences in the Relationship Between Glucose Concentrations and Hemoglobin A1cGP0|#bd1fb4a9-4058-4c77-acf8-6b0b0b9b083e;L0|#0bd1fb4a9-4058-4c77-acf8-6b0b0b9b083e|Karter, Andrew;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae4Physicians rely on hemoglobin A1c (A1C), an integrated measure of glycemia (blood glucose), to make treatment decisions for patients with diabetes. There is evidence that, given comparable glycemia, A1C results in African Americans can be significantly higher than in whites with similar mean glucose. Racial differences in glycosylation (and thus differences in A1c results) could lead to inequities in diabetes diagnosis, performance measures (e.g., HEDIS), treatment (e.g., unnecessary treatment intensification), and hypoglycemia risk. It is unknown how the A1C-glucose relationship varies in other groups, e.g., Latinx or Asians. Further, it is unclear to what extent observed racial differences may be attributable to innate physiologic factors (e.g., sickle cell trait) or socioeconomics for which race may be a surrogate. We propose to collect glucose data from continuous glucose monitoring (CGM) devices and compare them to A1C data to better understand racial biases in the A1C-glucose relationship.GP0|#bd1fb4a9-4058-4c77-acf8-6b0b0b9b083e;L0|#0bd1fb4a9-4058-4c77-acf8-6b0b0b9b083e|Karter, Andrew;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae42022-02-02T08:00:00Z
Tailoring initial type 2 diabetes care to meet the needs of younger Latinx adults: A randomized pilot studyGP0|#170c785f-c4f5-49c0-b254-f00c9a08695b;L0|#0170c785f-c4f5-49c0-b254-f00c9a08695b|Gopalan, Anjali;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae4Our goal is to evaluate the effectiveness of a proactive, tailored care intervention in improving early outcomes for Latinx individuals with younger-onset type 2 diabetes. We will also conduct post-intervention interviews with study participants to identify components of the intervention that may have contributed to the observed outcomes and perform an environmental scan of type 2 diabetes care and resources in our partner Kaiser Permanente regions to lay the groundwork for future dissemination of the intervention. GP0|#170c785f-c4f5-49c0-b254-f00c9a08695b;L0|#0170c785f-c4f5-49c0-b254-f00c9a08695b|Gopalan, Anjali;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae42022-02-02T08:00:00Z
The Impact of Racial Residential Segregation on the Mental Health of Pregnant WomenGP0|#18fccf82-6f11-4a37-b04a-1d7db14865cb;L0|#018fccf82-6f11-4a37-b04a-1d7db14865cb|Avalos, Lyndsay;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae4We will create a large diverse cohort of more than 360,000 pregnant Black, Hispanic, Asian and white women to: examine the relationship between racial residential segregation and prenatal depression, anxiety and trauma (Aim 1); and prenatal depressive severity (Aim 2). Analyses will be stratified by race/ethnicity. This study has important public health, clinical and policy implications for addressing racial/ethnic mental health inequities in a vulnerable population, pregnant women.GP0|#18fccf82-6f11-4a37-b04a-1d7db14865cb;L0|#018fccf82-6f11-4a37-b04a-1d7db14865cb|Avalos, Lyndsay;GTSet|#51778822-a7d5-4a0f-a262-0d1c0d11dae42022-02-02T08:00:00Z

 Recent Publications

 

 

No Title335122/2/2022 4:26:15 PMhttps://divisionofresearch.kaiserpermanente.org/sites/DORCatalog/Lists/Publications/AllItems.aspxFalseAdvancing Diversity, Equity, and Inclusion in Scientific Publishing34740579Gastroenterology. 2021 Nov 03.Corley, Douglas
No Title335142/2/2022 4:26:15 PMhttps://divisionofresearch.kaiserpermanente.org/sites/DORCatalog/Lists/Publications/AllItems.aspxFalseDisparities in Use of Video Telemedicine Among Patients With Limited English Proficiency During the COVID-19 Pandemic34735015JAMA Netw Open. 2021 11 01;4(11):e2133129. Epub 2021-11-01.Hsueh, Loretta||Huang, Jie||Millman, Andrea K||Gopalan, Anjali||Parikh, Rahul K||Teran, Silvia||Reed, Mary E
No Title334782/2/2022 4:26:11 PMhttps://divisionofresearch.kaiserpermanente.org/sites/DORCatalog/Lists/Publications/AllItems.aspxFalseThe COVID-19 pandemic has heightened concerns about the impact of depression, anxiety, alcohol, and drug use on public health. Mobile apps to address these problems were increasingly popular even before the pandemic, and may help reach people who otherwise have limited treatment access. In this review, we describe pandemic-related substance use and mental health problems, the growing evidence for mobile app efficacy, how health systems can integrate apps into patient care, and future research directions. If equity in access and effective implementation can be addressed, mobile apps are likely to play an important role in mental health and substance use disorder treatment.Opportunities to Integrate Mobile App-Based Interventions Into Mental Health and Substance Use Disorder Treatment Services in the Wake of COVID-1934652971Am J Health Promot. 2021 Oct 15:8901171211055314.Satre, Derek D||Iturralde, Estibaliz M
No Title334232/2/2022 4:26:04 PMhttps://divisionofresearch.kaiserpermanente.org/sites/DORCatalog/Lists/Publications/AllItems.aspxFalseRacial and Ethnic Differences in Age at Diabetes Diagnosis-A Call for Action34491279JAMA Intern Med. 2021 Sep 07.Gopalan, Anjali||Grant, Richard W
No Title334322/2/2022 4:26:06 PMhttps://divisionofresearch.kaiserpermanente.org/sites/DORCatalog/Lists/Publications/AllItems.aspxFalseInadequate or excessive intake of micronutrients in pregnancy has potential to negatively impact maternal/offspring health outcomes. The aim was to compare risks of inadequate or excessive micronutrient intake in diverse females with singleton pregnancies by strata of maternal age, race/ethnicity, education, and prepregnancy BMI. Fifteen observational cohorts in the US Environmental influences on Child Health Outcomes (ECHO) Consortium assessed participant dietary intake with 24-h dietary recalls (n = 1910) or food-frequency questionnaires (n = 7891) from 1999-2019. We compared the distributions of usual intake of 19 micronutrients from food alone (15 cohorts; n = 9801) and food plus dietary supplements (10 cohorts with supplement data; n = 7082) to estimate the proportion with usual daily intakes below their age-specific daily Estimated Average Requirement (EAR), above their Adequate Intake (AI), and above their Tolerable Upper Intake Level (UL), overall and within sociodemographic and anthropometric subgroups. Risk of inadequate intake from food alone ranged from 0% to 87%, depending on the micronutrient and assessment methodology. When dietary supplements were included, some women were below the EAR for vitamin D (20-38%), vitamin E (17-22%), and magnesium (39-41%); some women were above the AI for vitamin K (63-75%), choline (7%), and potassium (37-53%); and some were above the UL for folic acid (32-51%), iron (39-40%), and zinc (19-20%). Highest risks for inadequate intakes were observed among participants with age 14-18 y (6 nutrients), non-White race or Hispanic ethnicity (10 nutrients), less than a high school education (9 nutrients), or obesity (9 nutrients). Improved diet quality is needed for most pregnant females. Even with dietary supplement use, >20% of participants were at risk of inadequate intake of ≥1 micronutrients, especially in some population subgroups. Pregnancy may be a window of opportunity to address disparities in micronutrient intake that could contribute to intergenerational health inequalities.Disparities in Risks of Inadequate and Excessive Intake of Micronutrients during Pregnancy34494118J Nutr. 2021 Sep 07.Hedderson, Monique M||Avalos, Lyndsay A||Zhu, Yeyi
No Title334152/2/2022 4:25:13 PMhttps://divisionofresearch.kaiserpermanente.org/sites/DORCatalog/Lists/Publications/AllItems.aspxFalseResearch on COVID-19 during pregnancy has mainly focused on women hospitalized for COVID-19 or other reasons during their pregnancy. Little is known about COVID-19 in the general population of pregnant women. To describe the prevalence of COVID-19, symptoms, consequent healthcare use, and possible sources of COVID-19 exposure among a population-based sample of pregnant women residing in Northern California. We analyzed data from 19,458 members of Kaiser Permanente Northern California who were pregnant between January 2020 and April 2021 and responded to an online survey about COVID-19 testing, diagnosis, symptoms, and their experiences during the COVID-19 pandemic. Medical diagnosis of COVID-19 during pregnancy was defined separately by self-report and by documentation in electronic health records (EHR). We examined relationships of COVID-19 with sociodemographic factors, underlying comorbidities, and survey measures of COVID-19-like symptoms, consequent healthcare utilization, and possible COVID-19 exposures. Among 19,458 respondents, the crude prevalence of COVID-19 was 2.5% (n = 494) according to self-report and 1.4% (n = 276) according to EHR. After adjustment, the prevalence of self-reported COVID-19 was higher among women aged <25 years compared with women aged ≥35 years (prevalence ratio [PR], 1.75, 95% CI: 1.23, 2.49) and among Hispanic women compared with White women (PR, 1.91, 95% CI: 1.53, 2.37). Prevalence of self-reported COVID-19 was higher among women affected by personal or partner job loss during the pandemic (PR, 1.23, 95% CI: 1.02, 1.47) and among women living in areas of high vs. low neighborhood deprivation (PR, 1.74, 95% CI: 1.33, 2.27). We did not observe differences in self-reported COVID-19 between women with and without underlying comorbidities. Results were similar for EHR-documented COVID-19. Loss of smell or taste was a unique and common symptom reported among women with COVID-19 (42.3% in self-reported; 54.0% in EHR-documented). Among women with symptomatic COVID-19, approximately 2% were hospitalized, 71% had a telehealth visit, and 75% quarantined at home. Over a third of women with COVID-19 reported no known exposure to someone with COVID-19. Observed COVID-19 prevalence differences by sociodemographic and socioeconomic factors underscore social and health inequities among reproductive-aged women. Women with COVID-19 reported unique symptoms and low frequency of hospitalization. Many were not aware of an exposure to someone with COVID-19.COVID-19 prevalence, symptoms, and sociodemographic disparities in infection among insured pregnant women in Northern California34478463PLoS One. 2021;16(9):e0256891. Epub 2021-09-03.Ames, Jennifer L||Ferrara, Assiamira||Avalos, Lyndsay A||Badon, Sylvia||Greenberg, Mara B||Hedderson, Monique M||Kuzniewicz, Michael W||Qian, Yinge||Young-Wolff, Kelly C||Zerbo, Ousseny||Zhu, Yeyi||Croen, Lisa A