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National Collaborating Centre for Determinants of Health

Glossary of Essential Health Equity Terms

Print date: August 08, 2022

The Glossary of Essential Health Equity Terms is intended to enhance effective communication and action on the social and structural determinants of health and health equity. Having consistent terminology and understanding of concepts allows for greater clarity on points of influence and impact for action on health equity.

This 2022 version of the Glossary of Essential Health Equity Terms (an evolution and expansion of the  2014 version) contains 32 terms  identified through consultation with public health practitioners and other key informants across Canada. Descriptions for each term were developed through an extensive review of existing glossaries from other sources, academic and grey literature. These were validated via survey feedback from public health colleagues across Canada. A number of citations are included within each definition – each citation number will link to the full citation within the reference list.

Recognizing that language is influenced by context and culture, we undertook separate development processes for the English and French glossaries, which are complementary but are not direct translations of each other. This process was extremely powerful and enlightening for both the developers of this glossary and for those who provided feedback, revealing new understandings of concepts and resulting in a higher quality of both the English and French versions. You can access the French glossary here.

Terms are organized into four groupings – Core Concepts, Roots of Health, Relative Influences, and Interventions & Strategies. Each grouping includes a number of related terms. Each term has a drop down option to reveal the description and related NCCDH resources to support further understanding and application of the concept.

We’d love to hear from you! Did you find the term you were looking for? If you have any comments or feedback on the glossary, e-mail us at nccdh@stfx.ca.

 


Acknowledgements & Suggested Citation  

Thank you to the public health professionals who provided feedback through the initial user survey, validation, and focus testing phases. It is this guidance from the field that resulted in the terms selected and descriptions written.

Research, writing, and conceptualization by Dianne Oickle, Knowledge Translation Specialist. Developmental work, internal scoping and external partner consultations by Claire O’Gorman, formerly with NCCDH.

Webpage and content support by Caralyn Vossen, Knowledge Translation Coordinator. Internal guidance and review by Claire Betker, Scientific Director.

Thank you to our partner RÉFIPS (Réseau francophone international pour la promotion de la santé) in the development of the French version of the glossary Glossaire des principaux concepts liés à l’équité en santé

 

Please cite information contained in the document as follows: National Collaborating Centre for Determinants of Health. (2022). Glossary of essential health equity terms.  Antigonish, NS: National Collaborating Centre for Determinants of Health, St. Francis Xavier University. 

 

ISBN: 978-1-989241-84-4

Production of this document has been made possible through a financial contribution from the Public Health Agency of Canada through funding for the NCCDH. The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada. 

Last updated March 2022  

Key concepts

These terms represent how health is shaped and determined by structural and social forces environments that surround individuals, families, groups, and communities.

Health is more than the absence of disease. Health is the physical, spiritual, mental, emotional, environmental, social, cultural and economic wellness of the individual, family and community. Individuals and groups define health differently depending on their values, culture, experiences and world view. Health is not an endpoint; rather, it is considered a resource for everyday living to support people to live dignified and fulfilling lives, despite the presence or absence of disease.

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Population health is the health status of an entire population that results from interrelated factors including policy, primary care, public health, social and environmental factors and the distribution of inequities.1 The three main components of population health are health outcomes, determinants and policies.2 Population health strategies use diverse forms of knowledge and evidence to develop policies and interventions that improve the health and well-being of an entire population rather than of individuals.2

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Health equity means that all people (individuals, groups and communities) have fair access to, and can act on, opportunities to reach their full health potential and are not disadvantaged by social, economic and environmental conditions,3 including socially constructed factors such as race, gender, sexuality, religion and social status.4 Achieving health equity requires acknowledging that some people have unequal starting places, and different strategies and resources are needed to correct the imbalance and make health possible.5 Health equity is achieved when disparities in health status between groups due to social and structural factors are reduced or eliminated.

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Health inequity refers to differences in health associated with structural and social disadvantage that are systemic, modifiable, avoidable and unfair.4 Health inequities are rooted in social, economic and environmental conditions4 and power imbalances,3 putting groups who already experience disadvantage at further risk of poor health outcomes.6

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Health disparity is a measurable difference in health outcomes between groups, communities and populations who experience relative advantage and disadvantage due to structural and social determinants of health.37 A disparity that exists across socioeconomic categories occurs when disadvantaged groups experience worse health outcomes and greater health risks than advantaged groups. Reduced health disparities between groups are evidence of progress toward reaching health equity.7


When used, the term health disparity should be clearly distinguished as the measure to indicate the level of health inequity.

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Roots of health

These concepts name the structural and social forces that are at the root of population, public, community, and individual health outcomes.

The social determinants of health are the interrelated social, political and economic circumstances in which people are born, grow up, live, work and age.8 The social determinants of health (see below) do not operate as a list or in isolation. It is how these determinants intersect that causes conditions of daily living to shift and change over time and across the life span, impacting the health of individuals, groups and communities in different ways.9

• disability
• early child development
• education
• employment and working conditions
• food insecurity
• gender
• geography
• globalization
• health services
• housing
• immigration
• income and income distribution
• Indigenous ancestry
• race
• social inclusion/exclusion
• social safety net
• unemployment and job security

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Structural determinants of health are processes that create inequities in money, power and resources. They include political, cultural, economic and social structures; natural environment, land and climate change; and history and legacy, ongoing colonialism and systemic racism.10 Structural determinants, also known as structural drivers,8 shape the conditions of daily life (social determinants of health) including education, work, aging, income, social protections, housing, environment and health systems.10

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Intersectionality considers how systems such as racism, classism, sexism, homophobia and other forms of discrimination overlap and interact with one another to put some people at an advantage and others at a disadvantage at an individual and structural level.511 An intersectional orientation recognizes that the experience of multiple forms of discrimination and disadvantage has a cumulative negative effect that is greater than the sum of the parts.12 The intersectional nature of oppression and privilege means that people may have privilege in one or more forms even if they experience oppression in other domains.13

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Racism is the race-based allocation of value, resources, opportunities and status14151617  in cultural, political, institutional, economic and social forms.1415 Racism is subtle, 1415 reinforced by White supremacy and normalized by dominant White culture and practices.18 Racism differs from prejudice, hatred or discrimination in that it requires one racial group to have systematic power and superiority over other racialized groups.5 Racism interacts with other systems of oppression (e.g., homophobia, sexism, classism, Islamophobia) to influence the distribution of material (e.g., income and wealth) and symbolic or cultural resources (e.g., decision-making power, cultural images, values).19

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Marginalization occurs when people are excluded based on social identities such as race, gender, sexuality and social class as well as the inequitable distribution of social, economic, physical and psychological resources.20 Individuals and communities are marginalized by, live in marginalized conditions or are forced into marginalization rather than being labelled as marginalized people/populations/groups.

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Vulnerability occurs when people are exposed to multiple layers of marginalization, including barriers to social, economic, political and environmental resources21 that overlap to increase the risk of poor health.22 Individuals and communities are vulnerable to, live in vulnerable conditions or are forced into vulnerability rather than being labelled as vulnerable people/populations/groups.

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Relative influences

These conditions describe the relative ways to consider both approaches to and outcomes of the roots of health.

Advantage refers to having enough opportunities and resources (social, political, economic) and therefore not being at risk of exposure to health-damaging factors.8 

Disadvantage refers to having not enough opportunities and resources (social, political, economic) and therefore being at risk of exposure to health-damaging factors.8 

Groups and populations with higher socioeconomic status (advantaged) have greater access to resources and services, allowing them to be healthier than those with lower socioeconomic status and less access (disadvantaged), a pattern that exists at every level of the socioeconomic spectrum.823 

Health inequities are reduced when power and resources are shifted to address the needs of those who are disadvantaged due to inadequate resources and supports8 and the inequitable distribution of the structural and social determinants of health.

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Privilege represents power,423 advantage and entitlement4 granted without question based on structural and social determinants of health, including race, gender, economic status and sexual orientation.4 Privilege is usually invisible to those who have it because they are not taught to recognize and address it. 423  Privilege is also known as structurally enabled or embedded advantage to reflect that it is a result of systems influence not individual characteristics.24

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Oppression is “a system of supremacy and discrimination … where a socially constructed … ‘dominant group’ [holds] power, wealth, and resources … [creating] a lack of access, opportunity, safety, security, and resources for non-dominant populations".5 p8 Dominant groups include those who are White, heterosexual, English speaking, male, high income and high social status, among others. Oppression reflects current and historical processes,5 including racism, colonization and discrimination based on gender and sexual diversity, as well as denial of health services based on social status.

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Assets are opportunities and resources that ensure the chances for health and well-being for an individual, group or community compared to broader society. Deficits are risk factors and risk conditions that impede the chances for health and well-being for an individual, group or community compared to broader society. Assets and deficits are created by unequal power and resource distribution at individual, group, community and societal levels.

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Protective factors and conditions increase the chances of good health by enhancing our ability to cope with challenges, mitigate the effects of negative influences and reduce the likelihood of poor health. A population health equity approach focuses on building protective factors to decrease the likelihood of experiencing the negative impact of risk conditions.25 A focus on protective factors aligns with an asset-based approach to health.

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Risk factors and conditions decrease the chances of good health by increasing the risk, severity and duration of disease, injury or premature death. They may be individual characteristics and behaviours as well as environmental and social factors that increase the chance of having poor health.25 Focusing on risk factors and conditions aligns with a deficit-based approach; attention to protective factors is necessary in addition to reducing risk.

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Social inclusion improves participation in society of people who experience marginalization and vulnerability through equitable access to material (economic) and non-material resources required for living,27 including power and rights. 

Social exclusion is when people are not able to participate in society through inequitable access to resources, capabilities, power and rights, leading to inequitable health impacts and outcomes.28 

Social inclusion and exclusion are intersectional, dynamic and simultaneous social determinants of health that are relational and context specific. They depend on location as well as social and institutional structures.29 Interventions for inclusion and social justice (strength based) are different than those to address exclusion and social injustice (deficit based) — they are not opposite sides of the same coin.30

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Interventions and strategies

These approaches intend to indicate courses of action and levels of impact for action on the structural and social forces that determine population health equity.

Upstream interventions and strategies dismantle and change the fundamental social and economic systems (structural determinants of health) that distribute the root causes of health inequities including wealth, power and opportunities. These changes generally happen at the provincial, territorial, national and international levels. They are about changing the cause of the causes of health and health inequities.32333431

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Midstream interventions and strategies reduce exposure to risk by improving material conditions or by promoting healthy behaviours. These changes generally occur where individuals who live with inequities are directed or referred to resources that support health at the regional, local, community or organizational level. Midstream approaches are about changing the root causes of health inequities. 32333431

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Downstream interventions and strategies seek to address immediate needs and mitigate the negative impacts of disadvantage on health at an individual or community level through the availability of health and social services. These changes generally occur at the service or access-to-service level. Downstream strategies are about changing the effects of the causes. 32333431

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Levelling up involves efforts to improve the health of groups who experience disadvantage by bringing their health closer to that of groups with advantage, thus reducing health inequities between groups.3 Levelling up is a concept closely tied to closing the gap.

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Closing the health gap between the most and least advantaged involves interventions and strategies designed to improve health outcomes of groups who are experiencing disadvantage. The result is that the difference in health status and outcomes between those who are advantaged and disadvantaged (the health gap) decreases.35 Closing the gap is a concept closely tied to levelling up.

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Proportionate universalism is an approach where programs and services are delivered universally but strategies include a range of responses to address different levels of disadvantage (rather than just targeting the least disadvantaged groups) 36, as well as planning for impact that is proportionate to the level of disadvantage that is experienced.37

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Targeted universalism is an approach where programs and services are provided to everyone (universal) and strategies are tailored to meet the needs of specific groups who experience the most marginalization and vulnerability (targeting).523

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Advocacy is a critical population health strategy for health equity that combines individual, organizational and societal actions to influence change at a systems level (across sectors and organizations). Advocacy for health equity focuses on changing factors related to the structural and social determinants of health.40 Advocacy explicitly recognizes the importance of engaging in political processes to effect desired policy changes at organizational and system levels (municipal, regional, provincial, territorial, national, international).4142

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Community engagement for health equity is based on meaningful and authentic existing and ongoing relationships with communities, which is a core public health practice,44 allowing people who live with inequities to influence health system priorities45 and inform decisions about population and public health initiatives.46 Public health considers community members as partners47  rather than ‘service recipients’, recognizing that community members know best about what they need to be healthy and the solutions to address inequities.44

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Decolonization means dismantling colonial power systems, including political, knowledge and social structures.48 Also known as deconstructing colonial oppression, decolonization includes active resistance and actions to restore power, land and independence to Indigenous Peoples; emphasize Indigenous knowledge; and critically assess White, Western-centric practices5 at individual, organizational and systems levels across all sectors.23

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An asset- or strength-based approach promotes the skills, values, knowledge and connectedness of individuals and communities as a resource for health. An asset-based approach focuses on building protective factors to promote health and well-being by drawing on collective individual and community capacities.38

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deficit-based approach identifies problems and risk factors or conditions that increase the chances of poor health.38 This approach focuses on decreasing risk and addressing deficiencies at an individual, group or community level.

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Health in all policy (HiAP) is a policy development approach that considers the population health implications of decisions and policies, including those outside of the formal health sector.49 HiAP explicitly recognizes the accountability of policy-makers for equity, health and the health impacts of any policy, including those outside of traditional health sectors.22 A HiAP approach reflects collaboration, transparency, participation and sustainability across sectors and levels of government50 and is necessary to both maximize positive health impacts and avoid harm.

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Intersectoral action, also known as intersectoral collaboration, refers to various sectors of society working together toward a common goal. This approach includes government departments (e.g., health, education, environment, justice); community members; non-profit organizations and businesses.51 Relationships are key to intersectoral action and can be vertical (across organizational levels) or horizontal (within organizational levels).52 This approach is based on principles of co-development, co-ownership and co-accountability.

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Movement-building includes efforts to achieve health equity by strengthening community efforts to influence broad systems change.53 Movement-building for health equity needs an inside–outside strategy, where public health builds internal capacity for health equity action (inside) as well as ongoing relationships and intentional cross-sector alliances with organizations invested in social justice (outside).54 Movement-building includes synergistic efforts to disrupt power imbalances and structural factors at the root of health inequities.55

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