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Public Health

Research Article Volume 11 Issue 3

Building a culture of health in Kentucky to address racism a public health crisis

Naiya Patel

University of Louisville, School of Public Health and Information Sciences, Department of Health Management and Systems Sciences, Louisville, KY, US, USA

Correspondence: Naiya Patel, University of Louisville, School of Public Health and Information Sciences, Department of Health Management and Systems Sciences, Louisville, KY, U.S, USA

Received: October 20, 2021 | Published: May 27, 2022

Citation: Patel N. Building a culture of health in Kentucky to address racism a public health crisis. MOJ Public Health. 2022;11(3):75-81. DOI: 10.15406/mojph.2022.11.00379

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Abstract

Importance: Health disparities are the leading underlying cause for disproportionate pandemic effect. A sustainable solution must inculcate and address key community stake holders needs to implement strategies. Racism is recently identified as a public health crisis and in order to address it a sustainable multidisciplinary strategy calls for action. Clearly existing solutions are not sustainable and effective and is evident through the case study of Kentucky in the current research. The elimination of health disparities is a multidisciplinary and cross sector approach which the RWJF action framework inculcates.

Observations: Kentucky State has the Gini and Social Index Score that needs urgent attention. Racial segregation is prominent among the black versus white compared to other racial minorities. Income inequality is highest among the blacks than the other minorities and white in Kentucky. Infant mortality rate, premature deaths, preventable hospitalizations, and unhealthy behavior is highest among the black community members compared to their white counterparts.

Conclusions and Relevance: The identified sustainable strategy and entry points for key Kentucky stakeholders can help address the racism. The stakeholder analysis matrix of the research can help implement proposed strategy feasibly and effectively. The action framework itself is structured in a way that the issues framed utilizing the model can help disseminate and implement the strategy sustainably.

Keywords: racism, culture of health, RWJF framework, public health

Introduction

A nation’s asset is the health of its citizen because if the citizens are not well, the nation's economy and families struggle while the national security is at stake.1 Health inequity in the United States has led to a 4-year gap in life expectancy among different racial and ethnic groups.1 Although access to affordable and needed health care is not the only solution, one must also consider social determinants of health to narrow the gap.1 Hence, health equity could be defined as the perfect state in which individuals can achieve their full health potential without any barriers to achieving it.2,3 The opportunity to attain that full potential for well-being depends on the living and working conditions and other resources enabling people to achieve that potential to be healthy.4

Health Disparities serve as metrics for assessing progress towards health equity; hence, both concepts are interrelated.4 Poverty is not just about an individual's low income but about the combined effect of three cores like economic success, power and autonomy, and being valued in the community.5 To rise from poverty, i.e., mobility from poverty, all three areas mentioned must be measured and acted upon as ignoring one of these might leave the individual at struggle.5 Gini Index is one measure to determine income distribution equality among the population of a community.6 Social Capital Index measures a community’s social stability and well-being, both perceived and actual.7

Community-based solutions like an action, program, policy, or law that is driven by community-based organizations, faith-based organizations, “employers, healthcare systems and providers, public health agencies, policymakers, and others” have the potentials to improve health equity by influencing health and factors affecting inequities.2,8

The vital steps for achieving health equity includes identification of essential health disparities concerning affected stakeholders, changing law, environment, and practices to eliminate inequities, evaluating the short and long term efforts and outcomes, and finally reassessing those existing strategies to plan the next steps.4 Policies impact health factors, affecting health outcomes like length and quality of life.9 The elimination of health disparities is a multidisciplinary and cross sector approach which the RWJF action framework inculcates. Hence the objective of current review is to evaluate, frame and devise solution surrounding racism and health equity in Kentucky state utilizing RWJF action framework. To frame and devise solution the review first performs Kentucky state descriptive analysis by dividing raw data into categorizes (I-VI). After determining the assets, resources as well as health equity status at county level the RWJF action framework is utilized to frame and devise solution (Table 12) keeping in mind the status quo.

Descriptive statistics of Kentucky state

The data for the Kentucky state has been analyzed in STATA SE 16 for the descriptive analysis, the data utilized is collected from two data sources: Kentucky 2020 County Health Rankings10 and the opportunity insights website.11 The raw publicly available data was in csv format which was uploaded in STATA for cleaning and refinement. The data is categorized at the following levels to understand Kentucky demographics that might influence health disparity:

  1. Health outcomes
  2. Behavior
  3. Preventive and healthcare services outcome
  4. Educational and income outcomes
  5. Social and environmental outcomes
  6. Occupational and commute/work conditions

Health outcomes

The overall life expectancy in the Kentucky State is about 74 years lower than the national average, as depicted in Table 510 of the Appendix. By stratifying the life expectancy through the different races, Blacks have the lowest life expectancy years compared to other races, while the data for AIAN was missing in the file. The premature mortality is highest (about 582 deaths) among the blacks in Kentucky as of 2020, as depicted in Table 6 of Appendix. The Child Mortality among black seems to be the highest (about 111deaths per 100,000 population) among all races and the state average as depicted in Table 7 of Appendix. The infant mortality also appears to be disproportionately higher (14 deaths per 1000 live births) among Blacks than other available race data in the dataset, as depicted in Table 8.

Behavior

As depicted in Table 9, about 15% of the Kentucky population lacks adequate food access, while 4% of the population are low-income groups who do not live near a grocery store. The percentage of adults who report fewer than seven hours of sleep in Kentucky is high, making about 39% of the state's population. For emotional, physical, and mental well-being, it's essential to have sufficient sleep daily (about 7 hours).10

Preventive and healthcare services outcome

As depicted in Table 11, the average number of physically unhealthy days is higher than the national average for Kentucky (5.03). The percentage of low-birth-weight babies among Black and American Indian/Native Alaskan is the highest (about 16%) than state and national average. The rate of adults with obesity is higher than the national average (35%) in Kentucky. The reason might be a lower physical activity (31%) and limited access to exercise opportunities (56%), lower than the national average. The preventable hospitalizations among the blacks are the highest (9072) compared to other races in the Kentucky state, while the state is above (6648) the national average. About 5% of the population below age 65 are uninsured in Kentucky (Figure 2). The total number of households with at least one disabled family member is 571,016 in Kentucky (Figure 1). The total population above 65 years of age is 778,913 (Figure 1).

Figure 1 Kentucky State Demographics at a glance (Census Programs, 2021).

Figure 2 Kentucky State demographic snapshot.19

Figure 3 Proportion of business and employer sectors in KY where dots represent comparison to United States.

Figure 4 Types of Employer Establishments in Kentucky.

Educational and income outcomes

As per Table 4 of Appendix, the School expenditure per student seems to be low in Kentucky State than at the national level.11 The test score percentile is very low (-1.44), indicating other factors that might have impacted the lower scores. Only 0.5% of college students graduated college as of 2014 in Kentucky on an average. The median household income was the lowest ($45,279) in Kentucky compared to the national average, as depicted in Table 10. Among the racial income inequity, blacks have the most insufficient median household income ($34,503) than their counterparts, making it lower than the state average median household income. As depicted in Figure 1, 78.8% of the household has internet access.

Social and environmental outcomes

It is evident from Table 2 that there persist a problem of both racial segregation (5%) and higher poverty rates (19%) than at the national level in Kentucky.11 The Social Capital index is on an average negative (-0.5) which is not a good indication of Kentucky’s social stability and well-being. The Gini index is high (40%), indicating income inequality from the data. The local government expenditure seems to be relatively low on the local community welfare activities ($1393) in the Kentucky state as of 2014 (Table 4). The percentage of teens 16-19 years who are neither in school nor working in Kentucky in 2020 was high, making about 11% of the age group (Table 9). Among the racial residential segregation, the most significant segregation is among black and white races scoring the highest among all racial segregation (47.6). As depicted in Table 10, the proportion of the population living in the rural area is highest in the state of Kentucky (71%), meaning limited healthcare and other needed resources.12 The highest proportion of racial group comprising of Kentucky state population is black (about 4%) compared to other races.

Occupational and commute/work conditions

It is evident from Table 3 that a higher proportion of commuters (33%) commute to work for more than 15 minutes one way residing in Kentucky State.11 The diversity in terms of nonnative residents of Kentucky is low (1%), which could mean culturally less diverse. Finally, the inflow and outflow migration rate is slow (2%) in the state of Kentucky as of 2014, indicating fewer opportunities or interest for those who might be considering relocation for one or the other reason. Figure 1 reflects the total number of Kentucky households with cars and internet service.

Investigating root cause of racism and health inequity

The presence of racism at the individual and structural level impacts the ability to land good opportunities and results in overall poor physical and mental health.13 People of color, especially the black community, are more prone to bear the burden of disproportional health (Race, Racism and Health, n.d.), as evident in the Kentucky State data analysis. The black racial population tends to suffer from disproportional life expectancy, premature deaths, infant mortality, racial segregation of housing opportunity, and risks of chronic diseases/conditions compared to their White counterparts.13, 14 This health inequity exists partly from “the stress of being ignored, silenced or oppressed”.13,15 Health disparities tend to worsen among racial and ethnic minorities due to microaggression, stigma, racism, discrimination, conscious and implicit bias, ultimately contributing to poor health outcomes.16 It is also established that health inequities are closely related to historical and contemporary injustices like racism.15 Racism harms one’s educational attainment, ability to gain/seek employment and diminishing potential wages.15 Racial segregation is associated with higher deaths, exposure to environmental toxins, lower tax bases, fewer job opportunities, and fewer services like healthcare and others.15 Health inequities would decline significantly if racism is addressed/eradicated through a culture of health.15 The Robert Wood Johnson Foundation action framework helps frame such issues by identifying ways to create a culture of health.15 Individual’s, State’s, Businesses, and Community’s pathways to progress are framed through racial equity, diversity, and inclusion.17

Step 1 Stakeholders of Kentucky and their racism concerns

Potential solutions to eradicate racism at all levels includes the involvement of stakeholders of the particular state/county. Grassroots organizations and community members of any state serve as the heart of civil rights activities15. In the past, community and grassroots level activities have solved issues of local racial segregation.15

The key stakeholders of Kentucky State can be divided as described in Table 12. The group categorization has been informed by Economic tracker18 and Esri databases for Kentucky19data. The proposed entry points and actions for each stakeholder with Government above all seem appealing, as depicted in Table 12 of Appendix. The decision matrix guides the reasons being informed by the level of interest, influence, and impact. The impact and interest being the significant decision-maker for the reasons behind the agreement to implement the devised strategy. At the same time, the level of influence acts as a facilitator for implementing the devised strategy proposed for stakeholders.

Needs of stakeholders

Recently, businesses tend to adapt the stakeholder capitalism model where businesses and corporates care about consumers and the planet and their profits.20 The several ways in which racism is bad for any business is: it reduces creativity, encourages toxic work culture, causes higher health issues and absenteeism among vulnerable employees, tarnishes reputations of the business, and lose its customer who intends to discontinue giving business to those without anti-racist approach in their business model.20 Hence it is obvious that businesses cannot afford to lose their economic profits, which partially depends on their market reputation, thriving work culture, and efficient employees.20 It is also evident through a pandemic situation that a sustainable solution to address the business inequities needs to be implemented for inclusive growth and improved economic growth.21

Step 2 RWJF framework- Racism and culture of health in Kentucky

As proposed prior in this paper, building a culture of health can help address racism and health inequities associated with it. The stakeholder needs have been identified, and Table 12 in Appendix has been made, including the following constructs. Each construct of the action framework has been identified as entry points for identified stakeholders of Kentucky. The following section identifies guided determinants, root causes of health inequity associated with racism and proposes potential informed recommendations to address each root cause by devising informed strategies in Kentucky.

Variable

Obs

Mean

Std.Dev

Min

Max

High School Graduation Rate

121

94.54382

3.34823

84.0796

100

Unemployment Rate

121

5.189599

1.508778

3.089299

13.23993

Children in Poverty %

121

26.75124

9.049274

5.1

47.8

Income Inequality Ratio

121

4.992088

0.788185

3.418552

8.689388

% Single Parent Household

121

32.16366

6.735583

16.60583

59.37962

Social Association Rate

121

9.324993

4.763207

0

21.39249

Violent Crime Rate

121

96.99403

76.79928

0

611.9961

Injury Death Rate

121

52.52026

9.772699

28.17746

76.62735

Table 1 Descriptive Statistics of Kentucky County Health Ranking 2020 Data analyzed in STATA SE 16

Variable

Obs

Mean

Std. Dev.

Min

Max

Income Segregation

120

0.018153

0.023173

-0.01336

0.122421

Poverty Segregation

120

0.016597

0.022584

-0.0195

0.111999

Affluent Segregation

120

0.017671

0.024328

-0.00023

0.133435

Racial Segregations

120

0.054975

0.049676

0

0.314367

Gini Index

119

0.395363

0.073873

0.256237

0.667314

Poverty Rate

120

0.189644

0.081844

0.040617

0.453801

Social Capital Index

120

-0.50087

0.943469

-2.81523

2.296285

Total Crime Rate

111

0.00486

0.003034

0.000557

0.014219

Table 2 Descriptive Statistics of Kentucky in terms of segregation, social capital and criminal rates 2001-2014 data obtained from opportunity insights data11

Variable

Obs

Mean

Std. Dev.

Min

Max

Percent Foreign Born

120

1.03499

0.948933

0.024123

5.929861

Migration Inflow Rate

120

0.026091

0.016796

0

0.087285

Migration Outflow Rate

120

0.024942

0.013259

0.005352

0.096035

Fraction with commute <15 min

120

0.326861

0.081253

0.131928

0.520546

Table 3 Diversity, Work Commute and Migration rate in Kentucky11

Variable

Obs

Mean

Std. Dev.

Min

Max

School Expenditure per Student

120

6.027548

0.980357

4.542789

11.69031

Student Teacher Ratio

120

16.43781

1.587526

13.23408

23.48847

Test Score Percentile

120

-1.44589

6.588962

-16.3302

17.73723

High School Drop Out Rate

119

0.000446

0.016195

-0.03697

0.06976

College Tuition

38

5103.171

4400.208

760

16900

Percent College Grads

38

0.0054

0.166465

-0.23421

0.493859

Local Government Expenditures

120

1393.42

483.3133

773.7278

4035.796

Table 4 Schooling and Community expenditure Factors11

Variable

Obs

Mean

Std. Dev.

Min

Max

Life Expectancy by County

121

74.44711

2.191061

69.01621

79.68335

Life Expectancy AIAN

0

Life Expectancy Asian

7

86.08179

4.157813

79.79357

91.63269

Life Expectancy Black

27

74.9775

3.604984

70.09911

86.30023

Life Expectancy Hispanic

14

92.79797

6.084781

84.78469

105.5274

Life Expectancy White

28

76.33139

1.457072

73.52878

79.34388

Table 5 Additional Measures (Life Expectancy) of County Health Ranking 2020 Kentucky Data10

Variable

Obs

Mean

Std. Dev.

Min

Max

 Number of Premature Deaths

121

1228.083

6795.902

46

74299

AIAN Premature mortality

0

Asian Premature mortality

4

208.9392

96.01848

112.7282

326.7715

Black Premature mortality

36

582.124

162.1248

282.478

1012.808

Hispanic Premature mortality

5

219.4172

26.38932

185.7101

258.5937

White Premature mortality

36

461.0584

80.76389

289.3517

725.9396

Table 6 Premature Death and mortality as per Kentucky County Rankings Data 202010

Variable

Obs

Mean

Std. Dev.

Min

Max

Child Mortality Rate

72

65.43214

19.11389

30.92242

114.8954

Child Mortality AIAN

0

Child Mortality Asian

1

48.98359

.

48.98359

48.98359

Child Mortality Black

5

111.4401

43.67059

73.23944

163.4715

Child Mortality Hispanic

2

57.4164

3.305798

55.07885

59.75395

Child Mortality White

5

55.44347

15.37643

35.74641

73.11615

Table 7 Child Mortality in Kentucky and by race as per Kentucky 2020 county ranking data

Variable

Obs

Mean

Sd

Min

Max

Infant Mortality Rate

30

7.130549

1.632914

4.685917

10.09009

Infant Mortality Rate AIAN

0

Infant Mortality Rate Asian

0

Infant Mortality Rate Black

4

13.60842

3.569996

10.32702

18.28154

Infant Mortality Rate Hispanic

2

5.493827

0.087297

5.432099

5.555556

Infant Mortality Rate White

4

6.510473

2.423547

4.219409

9.651239

Table 8 Infant Mortality in Kentucky and by race as per Kentucky 2020 county ranking

Variable

Obs

Mean

Std. Dev.

Min

Max

Frequent Physical Distress (%)

121

15.51022

1.904002

10.79672

20.97173

Frequent Mental Distress (%)

121

15.593

1.586537

11.53725

19.99661

Adults with Diabetes (%)

121

13.72231

3.309896

7.5

24.7

HIV Prevalence rate (%)

17

159.9882

101.2132

35

431.3

Percent Food Insecure

121

15.42479

2.846117

7.6

22.5

Limited Access to Healthy Food (%)

118

4.781071

4.692959

0

35.17923

Insufficient Sleep (%)

121

38.69624

2.263514

30.74122

45.27671

Disconnected Youth (%)

40

10.74516

5.404002

2.111267

25.05285

Segregation index black/white

82

47.60081

13.97617

18.36352

88.64501

Segregation index non-white/white

109

34.5095

12.53157

5.615755

65.6262

Severe Housing Cost burden (%)

121

11.31339

2.545547

6.135511

20.25247

Percent Homeowners

121

71.51902

6.441346

46.90834

85.02012

Table 9 Kentucky 2020 General community profile

Variable

Obs

Mean

Std. Dev.

Min

Max

Median Household Income

121

45279.43

11843.9

26278

102136

Median Household Income AIAN

18

48146.17

21881.17

11823

94688

Median Household Income Asian

25

71812.44

37812.8

21250

183661

Median Household Income Black

76

34503.46

10919.63

13056

72045

Median Household Income Hispanic

61

45558.28

21981.95

17431

133389

Median Household Income White

90

47040.73

11994.28

25201

99695

Percent Black

121

3.736202

4.220934

0.23459

23.83987

Percent AIAN

121

0.329734

0.122453

0.133557

0.763359

Percent Native Hawaiian/oth PI

121

0.664836

0.718751

0.052802

4.587701

Percent Hispanic

121

0.067152

0.080369

0

0.419765

Percent Non-Hispanic White

121

2.643442

1.706549

0.792034

9.988046

Percent Proficient in English

121

0.499671

0.605748

0

2.852676

Female

121

50.25458

1.576835

42.84751

52.86134

Percent Rural

121

71.39901

27.90377

1.373101

100

Table 10 Median Household Income

Variable

Obs

Mean

Std. Dev.

Min

Max

Average # of Physically Unhealthy days

121

5.032718

0.523298

3.668336

6.401534

Average # of Mentally Unhealthy days

121

4.964295

0.396525

3.937529

5.903129

% Low birth Weight

121

8.909034

1.237462

5.960265

11.95241

% Low birth Weight AIAN

1

16.34615

.

16.34615

16.34615

% Low birth Weight Asian

9

8.251192

1.206448

6.27907

10.09464

% Low birth Weight Black

37

16.02849

4.928407

8.333333

28.94737

% Low birth Weight Hispanic

23

7.729874

1.442941

5.783582

11.18012

% Low birth Weight White

40

8.281533

1.00553

6.892684

10.8229

% Smokers

121

22.31011

2.71156

15.98312

31.8777

% Adults with obesity

121

35.23967

4.242454

21.6

46.3

% Physically Inactive

121

31.65702

4.721437

20.2

40.3

Food Environment Index

118

7.373729

0.65456

4.3

8.6

% with access to exercise opportunity

121

55.57868

25.92602

0

100

% Excessive drinking

121

15.68306

1.870427

12.67322

24.16173

Teen Birth Rate

120

41.65585

12.1327

8.728474

70.05189

Chlamydia Cases

121

301.9017

161.2173

35.8

1056.7

Primary Care Physician Ratio

0

Mental Health Provider Ratio

0

Preventable hospitalizations

121

6648.182

2497.551

2891

15420

Preventable hospitalization Asian

5

3287.6

872.0601

2201

4283

Preventable hospitalization Black

54

9072.852

10181.12

829

63636

Preventable hospitalization Hispanic

8

5960.375

4151.787

1519

12532

Preventable hospitalization White

54

6365.315

2696.022

3325

15215

% with annual mammogram

121

36.4876

6.452539

19

50

% with annual mammogram Asian

9

31.33333

8.558621

19

41

% with annual mammogram Black

55

41.78182

10.25542

20

73

% with annual mammogram Hispanic

11

34.45455

13.08712

20

61

% with annual mammogram White

55

39.65455

5.686951

26

50

 % Vaccinated

121

40.99174

8.390963

14

55

Table 11 Kentucky 2020 health profile

Stakeholders of Kentucky

Predominant ccupations in KY counties 2018 by Esri*
(Community members perspective)

Leisure and hospitality*

Education/Health*

Professional and Business*

Retail and transport*

Construction

Office/Admin

Production

Management

Sales

Transportation

Employer Perspective (Derived from Economic tracker data: trackerrecovery.com)

Role

Building infrastructure

Conducting processes and procedures

Producing output demanded

Managing the process and services demanded by KY population

Selling the products generated to generate revenue

Facilitate activities in and out of state

Generate revenue/product to serve KY populations need/demand

Educate the population, serve the healthcare needs of KY population

Generate revenue/product to serve KY populations need/demand

Generate revenue/product to serve KY populations need/demand

Level of Interest

Moderate given the low social association rate

High

Level of Influence

Moderate

High given the predominance of occupations in the state

Perspective/Need

Earn and live healthy life

Earn and live healthy life

Earn and live healthy life

Earn and live healthy life

Earn and live healthy life

Earn and live healthy life

Profit maximization

Depends on their mission/vision

Profit maximization

Profit maximization

Level of Impact of racism

High to community of color (black more), Low to White

As described in the literature if the institution is not implementing anti-racism approach it might impacts its profits, turnovers or sustainability, absenteeism of employees, loss of creativity etc.

Entry points from the constructs of Action Framework

1-          Making Health a Shared Value for the reason as described in text

1-          Making Health a Shared Value for the reason as described in text

2-          Education Stakeholder- Creating Healthier, More Equitable Communities

3-          Health Stakeholders- Strengthening Integration of health services and systems

What potential actions can they implement?

1-          Civil rights activities, supporting black owned business

1-          Evaluating barriers to black owned business, improving workforce diversity, talent pipeline expansion etc

2-          Educational Stakeholders- diversifying teaching workforce and expansion of dual enrollment

3-          Health Stakeholders- Provider Patient congruence and better transportation service

Would it appeal to each stakeholder to implement proposed entry points and actions?

Yes or Maybe given the moderate influence and interest but higher impact to black community members of KY

Yes given higher interest, influence, and impact

Table 12 Decision Maker Stakeholder Analysis Matrix to decide the level of influence and role each stakeholder play. The content is derived from Figures 3-7 in Appendix19

  1. Making Health a Shared Value: “How can individuals, families, and communities work to achieve and maintain health?”22
  • Civic Engagement:“Participating in activities that advance the public good”.22 A civic can be engaged by casting a vote or volunteering for suitable public activities, raising their voice for the good of the community health and well-being to bring change.22 Kentuckians' volunteer service was worth an estimated $2.3 billion monetary value.23 About 97.6% of residents regularly talk or spend time with friends and family, and 51.2% of residents favor neighbors, while 15.9% of residents do something positive for the neighborhood.23
  • Sense of Community:“Strong Social connections help communities thrive”.22 People who feel a sense of belonging, happiness, and trust in the community they live in have improved health and well-being.22 If they feel connected, they are more inclined to work healthy ways and work with others to improve health.22 As per county health ranking 2020 data,24 the mean Social Association rate in Kentucky was 9.3%. It seems to be a lower rate but varies among counties of Kentucky. The descriptive statistics for overall Kentucky in terms of Social Association rate is depicted in appendix Table 1. Due to the lower social association rate, it seems less feasible to improve the rating unless an intervention is introduced by a community-based organization and addresses its concerns. Black business owners tend to suffer a loss of wealth in adversity like pandemics due to limited knowledge, access to capital, and support from the local community.25 Evaluating existing inclusive growth strategies and supporting black-owned businesses might help elevate the business inequity and improve the State economy.25 This construct serves as an entry point for community members,26 government, and non-government stakeholders of Kentucky.
  1. Fostering Cross-Sector Collaboration: This construct measures how we can motivate cooperation across all sectors22
  • Policies that support collaboration: Collaboration through policies targeting influential non-health sectors like law enforcement provides significant population health results by encouraging health-related policies.22 Collaboration among Communities and Law enforcement and Support for Working Families can be measured in two ways.22This entire construct serves as an entry point for the Kentucky State government.17,26
  1. Creating Healthier, More Equitable Communities: This component measures how we can support and offer equitable access to healthy choices and develop a safe environment that nurtures children and supports aging adults.22
  • Built Environment:Built environment and physical condition include where we live, learn, work and play, determining and impacting our health and well-being.22 Several indicators like walkability index measure it, youth safety (Table 1-3 for KY), and Public libraries. 
  • Social and Economic Environment:The amount of money someone earns, the place where they live impacts their social connection and establishes barriers to living a healthier life because of where they live.22 This is measured by residential segregation (for KY, refer to Table 2 & 9) that puts people away from opportunities because of their race and accessibility to healthcare.22 “More racially integrated neighborhoods integrate equitable opportunities to education and economic opportunities”.22 For housing burden and affordability among Kentuckians, refer to Table 9. Kentucky's educational environment and opportunities could be found in Tables 1 & 4. There is racial inequality among Kentucky public schools and teachers where the proportion of Whites is disproportionately higher in participation.17 About 31% of Black students compared to 59.3% White students scored proficient on elementary school reading tests.17 A significantly lower rate of Black students than their White counterparts receive opportunity and support for Post-High School preparation and CTE industry certificates in Kentucky.17 Several recommendations have been made to solve the issue at hand, which includes diversifying the teaching workforce and expanding dual credit enrollment.17
  • Policy and Governance:Policies help enhance collaboration between community, government, and organizations and include policies like addressing air quality, climate change to create healthier environments for all and equitable to all.22 However, Kentucky fails to implement air quality policies surrounding smoking, compared to other states, and it's important to note the impacts it might cause on health outcomes. This entire construct serves as an entry point for Educational and Government/Policy Maker stakeholders of Kentucky.26
  1. Strengthening Integration of health services and systems: It measures how healthcare providers can work with institutional partners to address patient needs and realities.22
  • Access to care:Access means more than affordability for healthcare, so it means one can access high-quality care at affordability. It can be measured by the availability of public health systems, Dental visits, and Insurance coverage.22 Kentucky has 22% of the smoker’s population (Table 11), less percentage of the population is screened for a mammogram, and only about 41% of the population is vaccinated for a flu shot (Table 11). The proportion of preventable hospitalizations is high, meaning there is a gap in providing preventive services and utilization. The rural hospitals in Kentucky during the COVID-19 pandemic were on the verge of closure which is the primary source of healthcare for those uninsured and public insurance rural beneficiaries.27 Governmental interventions like subsidizing might help in eradicating the problem.This entire construct serves as an entry point for Healthcare and Government Stakeholders of Kentucky.28,29
  1. Outcome: Improved population health, well-being, and equity action area.22 This construct of the framework helps us understand if our efforts to build the culture of health have been practical.22
  • Enhanced Individual and community Well-Being: Better health-related quality of life and the perspective of an individual on how they view their life can help determine if the individual well-being is served or not. Several scales are available to measure well-being and one’s life satisfaction, like the OECD better life index.22 The access to services domain of the OECD index puts Kentucky at the bottom 32%. The Jobs domain puts Kentucky in the bottom 42%, and Community domain scores Kentucky in the bottom 44%, Health scores Kentucky into the bottom 9%. Safety domain scores Kentucky into the bottom 19% compared to other regions of the world.30
  • Reduced Health care Costs: There are several ways to measure this construct, including preventable hospitalization rates.22 For Kentucky, the proportion of preventable hospitalization is relatively high. Among blacks is the highest surfacing that needed primary care for better disease management is absent22 in Kentucky (Table 11).

Conclusion

It is evident through our understanding of Health equity and factors affecting it in this paper that for any effort to be effective and sustainable, a multifactorial approach involving multiple stakeholders is necessary. The first step to any need assessment for implementing an effective strategy is determining the community's key stakeholders and needs. Through community profiling, once it is determined what they need, it becomes feasible to strategize the policies and actions evolving around the needs. If the needs of the stakeholders, factors impacting their needs aren’t addressed, feasibility for strategy implementation might go in vain. Utilizing the RWJF action framework after determining the community's needs, its existing status for that component affecting racism and health equity, determining key entry points of stakeholders helps us develop a sustainable solution for acting stakeholders. We are identifying the underlying cause of issue to solve it and framing the issue in the context of the needs and feasibility of the proposed actions in the RWJF action framework. The framework allows determining where the community stands in terms of each construct affecting population health, where the root causes of racism stand in terms of development or sustainability for devised actions, and the key stakeholders that could serve as implementers of proposed actions entry points. There are several limitations to this existing review including granularity of data as well as missingness of data values for some county. Future studies might want to utilize social determinants of health data from area health resource files to determine health care infrasturure in framing solutions.

Acknowledgments

None.

Conflicts of interest

The author declares there is no conflict of interest.

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