Access barriers to healthcare are multiple and different across the nation, they go from the impossibility to obtain healthcare among the uninsured to the scarcity of health professionals (particularly in primary care) and the reduced cultural humility that the systems shows in many places to minorities and people living in poverty (Nervi, 2016). Access barriers have been proven to have a direct effect in hospitalization rates, morbidity, and mortality.
Digital Divide
Despite the widespread use of the Internet and social media platforms, a persistent digital divide exists. Studies have concluded that Internet access and use vary by individual characteristics and geographic location. There is also evidence of disparities in online health-seeking behavior (Din et al., 2019; Walker et al., 2020).
High-speed Internet is essential for obtaining health information, and healthcare services, which contribute to people’s well-being and human rights. From this perspective, the digital divide is a matter of social injustice. While there are many reasons why some individuals use the Internet and others do not, availability and affordability are two main factors contributing to the digital divide. Related to those is computer and new technologies literacy. These factors must be explored and addressed in the context of perpetuated societal and educational inequities, and keeping in mind that those groups most disenfranchised by the digital divide are the same groups suffering the most from socio-economic and political marginalization. In the United States, while nine in ten American adults use the Internet, adoption gaps remain based on factors such as age, income, education, and community type. Rural Americans are more likely than those who live in urban or suburban settings to never use the Internet. Racial minorities, older adults, rural residents, and those with lower levels of education and income are less likely to have broadband service at home. Internet non-adoption is linked to a number of demographic variables, including age, educational attainment, household income, and community type. Minority serving schools, where over 50 percent of the student population belongs to minority racial or ethnic groups, have smaller ratios of high-speed, Internet-accessible computer for every student. Similarly, in high-minority and/or high-poverty communities, student access to this resource is limited (Anderson et al., 2019).
Actions to Advance Health Equity and Social Justice
What can health promotion and health education practitioners do to properly address health inequities? Since health inequities are the result of policies and practices that create unequal societies, we must propose interventions that assure everyone’s opportunity to attain their highest level of health. This can be achieved by addressing the social determinants of health and equity. In other words, we must pay attention to the roots causes of inequity. There is sufficient evidence on the role of macro social, political, and economic factors on the pathogenesis of disease, not only in individuals but also in entire populations. From this perspective, sensitive governmental actions can reduce health inequity by ensuring basic services such as education and healthcare. Government can also address social and health inequity by protecting and promoting human rights such as affordable housing, equal employment opportunities for all, gender equity, and minimum wages that allow workers to keep up with cost of living (Blas et al., 2008).
Name and Address Racism
Acknowledge racism as a system of structured inequity and not an individual character flaw. Name racism as a determining force in the distribution of the social determinants of health and equity. Identify the structures, policies, practices, norms, and values in which racism may be operating. Among the variety of causes of racial and ethnic disparities in health, racism is the one factor that needs some explanation. Race is a social construct, not a biological reality. Unlike age, neither race nor ethnicity have fixed, objective referents—that is, they have no scientific markers for anyone to verify but are terms that are self-adopted or imposed (EqualHealth, n.d.). In general in the United States, one is assigned to a race based on the color of one’s skin, which does not begin to capture the genetic and cultural differences among those residing in the United States who are assigned to the racial category of Black (Jones, 2001).
While we often characterize our American society as a great melting pot and while the relationships between individuals assigned to different racial categories have improved dramatically, race still governs the distribution of risks and opportunities in our society to a great degree. Jones (2001) describes three types of racism that affect health outcomes: institutionalized racism, personally mediated racism, and internalized racism. Institutionalized racism is described as differential access to goods, services, resources, and opportunities by race. For example, the majority of minority children attend high-poverty, under-resourced schools, while the percentage of White children attending this type of school is much lower. Personally mediated racism is discrimination in which the majority racial group treats members of a minority group as inferior and views the minorities’ abilities, motives, and intents through a lens of prejudice based on race. This type of racism is what most individuals think of when they hear the term racism. It manifests as lack of respect, suspicion, devaluation, scapegoating, and dehumanizing. Internalized racism is acceptance by members of the stigmatized race of negative messages about their own abilities and intrinsic worth. It manifests as self-devaluation, helplessness, and hopelessness, potentially leading to risky behaviors that can endanger a person’s health.
Racism has brought suffering and misery to the United States and the world, and has had a direct effect on health inequity. The Campaign Against Racism led by the Social Medicine Consortium states that is critical that we implement an anti-racist agenda that overcomes the legacy of colonialism and racism through: 1) naming racism; 2) asking how racism is operating; and 3) organizing and strategizing to act (EqualHealth, n.d.).
The difference between past and present calls for racial equity is that advocates are demanding that Americans choose sides: are you racist or antiracist? This concept has roots in critical race theory, which was developed in the 1970s in law schools (Delgado & Stefancic, 2017). Its supporters say that America is fundamentally racist and call for white people to acknowledge the advantages of being born white. A consequence of COVID-19 in the United States was to intensify the conversation on race that has not been a priority since the 1970s, when a series of court orders forced urban school districts around the nation to bus students to integrate schools. While the term “antiracist” has long been used by activists and academics to mean that a person or organization doesn’t solely condemn racism, they actively fight it, little consensus exists on what antiracism means in other sectors including human services, education, and business. It could include building more-diverse leadership teams, paying livable wages, and supporting policies to change policing. However, the term is little more than marketing if not accompanied by years of deliberate work.
Prior to the pandemic, in health promotion programs efforts such as diversity and cultural diversity training for health promotion program staff were institutionalized responses that were accepted as standard practice without broader organizational and societal support to address racism. Expectations have now changed with multiple levels of systematic actions including policy, operating procedures, and training. An example of such work is the Roots of Health Inequity Project, which explores the root causes of inequity in the distribution of disease, illness, and death. Funded by the National Center for Minority Health and Health Disparities, National Institutes of Health, its audience is primarily the local public health and health promotion workforce. It seeks to ground participants in the concepts and strategies that lead to effective action for organizations and professionals to be anti-racist to lead the broad efforts to impact health promotion program planning, implementation, and evaluation (NACCHO, 2021).