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Rural Health Information Hub

Root Causes of Health Inequities

Social, environmental, economic, and structural factors contribute to health inequities in rural communities. These factors may reduce opportunities for rural residents to improve and maintain their health. Two related concepts guide health experts' discussions about the root causes of health inequities: power distribution and the social determinants of health.

Power Distribution

Power refers to political, social, institutional, and economic power and involves resources like money, knowledge, culture, and social networks. Power can have positive and negative effects on health. It influences all aspects of how we think about and promote health, such as funding, legislative and programmatic priorities, and decision-making processes.

Discrimination and Racism

Discrimination and racism affect the distribution of power and, in turn, health, on interpersonal and systemic levels. Power and resources are unequally distributed across different population groups based on race/ethnicity, gender identity, geography, sexual orientation, income, class, gender identity, and other factors. When allocated inequitably, power can exclude certain groups from having equitable access — or any access — to health-promoting resources, such as jobs, healthcare, food, housing, and transportation. Discrimination and racism also affect health more directly, such as increasing exposure to stressors.

Historical Roots of Unequal Power

The unequal distribution of power and resources from early in the nation's history has evolved and compounded over time. Human rights abuses such as slavery and forced displacement of American Indian and Alaska Native people have limited the ability of these communities to build wealth and power over generations. Unjust practices and inequitable power distributions have changed over time and continue to shape recent history and the present day. Examples of these practices include mass incarceration and redlining. Redlining is a discriminatory housing practice wherein neighborhoods with high concentrations of Black residents and other people of color were labeled as less safe for investment by the federal government. Black residents were denied mortgages in these neighborhoods, contributing to disproportionately low rates of homeownership, and consequently limited opportunities to build wealth.

Power and Structural Factors that Affect Health

Shifting these power imbalances requires addressing the underlying structural causes of inequities, rather than focusing on a single health issue or condition. Structural factors that influence health include laws, policies, systems, economic factors, and cultural norms. These factors influence the social determinants of health and can systematically marginalize and exclude specific populations and prevent them from gaining power and resources.

Social Determinants of Health

There are numerous definitions of social determinants of health. These determinants are broadly understood to reflect the conditions in all settings and life stages from birth to death that influence people's health and ability to thrive. Working toward health equity in rural areas involves addressing the social determinants of health in rural communities. The distribution of power influences all social determinants of health, so strategies to advance health equity should focus on both concepts. For more information about rural social determinants of health, see the Social Determinants of Health in Rural Communities Toolkit and Topic Guide.

Resources to Learn More

Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop
Examines the demographic, economic, and social issues affecting health equity in rural communities. Discusses asset-based approaches to reduce health disparities and improve the health and well-being of rural populations.
Organization(s): National Academies of Sciences, Engineering, and Medicine
Date: 3/2018

Health Equity
Provides reports, guides, case studies, and webinars supporting public health agencies in the development of programs and services to advance health inequities and advance population health.
Organization(s): Association of State and Territorial Health Officials (ASTHO)

Health Equity: Moving Beyond “Health Disparities”
Discusses the concept of health equity and the economic, social, and physical factors including the availability of services that impact health. Demonstrates how the discrepancies in systems and structures increase health disparities. Highlights how place-based approaches affect health outcomes and offers strategies that may be beneficial in developing a health equity agenda.
Organization(s): PolicyLink
Date: 2014

Roots of Health Inequity
Provides a free training on the structural factors that drive health inequities.
Organization(s): National Association of County and City Health Officials (NACCHO)

Social Determinants of Health
Provides an overview of the five domains of the social determinants of health: economic stability, education access and quality, healthcare access and quality, neighborhood and the built environment, and social and community context.
Organization(s): Healthy People 2030, Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services

Structural Racism In Historical And Modern US Health Care Policy
Describes how structural racism has affected and continues to impact health status and outcomes in the U.S.
Author(s): Yearby, R., Clark, B., & Figueroa, J. F.
Citation: Health Affairs, Vol. 41, No. 2
Date: 2/2022