Health Equity Glossary

Ableism

Prejudice against people with disabilities based on society’s constructed norms of what is considered "normal."1 Like racism and sexism, ableism structures opportunities to advantage some and disadvantage others.

Ally

A person who recognizes and acknowledges their unearned privileges and actively takes responsibility for changing society's patterns of injustice.1 Allies work with and for others to end oppression and promote equality. Being an ally often requires stepping out of one's comfort zone. An ally understands their power and privilege and uses it to act for justice.1,2

Anti-racism (also spelled “antiracism”)

Refers to identifying and confronting racism by changing organizational structures, systems, policies, practices, and attitudes to create a more equitable distribution of power.1 An anti-racist is someone who supports anti-racist policies and expresses anti-racist ideas to achieve racial justice.

Per Ibram X. Kendi: “The opposite of racist isn’t ‘not racist.’ It is ‘antiracist.’ What’s the difference? One endorses either the idea of racial hierarchy as a racist, or racial equality as an antiracist. One either believes problems are rooted in groups of people, as a racist, or locates the roots of problems in power and policies, as an antiracist. One either allows racial inequities to persevere, as a racist, or confronts racial inequities, as an antiracist. There is no in-between safe space of ‘not racist.”3

Centering 

Giving emphasis and priority to the voices of historically marginalized individuals and communities in decision-making by valuing and uplifting the lived experiences of those most impacted by inequities.1

Disability 

Any physical or mental impairment that creates difficulties for a person in performing certain activities and interacting with the world around them.4 The traditional healthcare model views disability as a problem residing in the person's body, a view that has been criticized for disempowering people with disabilities.1,5 In contrast, the social model of disability focuses on systemic barriers and social exclusion that require structural solutions, such as universal design, to meet the needs of everyone.1

Discrimination

Unjust or prejudicial treatment of an individual or group based on their actual or perceived membership in a social category.1,6 This treatment is often based on factors such as age, race, gender, ability, socioeconomic class, immigration status, national origin, or religion. When discrimination occurs, certain groups may be granted more advantages, opportunities, resources, or protections than others based on specific social characteristics or combinations of social characteristics that are differentially valued.

Diversity 

Refers to the recognition and acceptance of the different identities of people based on factors that include race, gender, sexual orientation, class, age, country of origin, education, religion, geography, physical or cognitive abilities, or other distinguishing characteristics.1,6 Valuing diversity means recognizing these differences as an asset and emphasizing the importance of diverse representation to achieve equity.

Equity 

Equity is different from equality as it involves considering fairness and justice while acknowledging that not everyone starts from the same place due to an uneven distribution of power.1 Achieving equity requires an ongoing process of identifying and addressing intentional and unintentional barriers arising from bias or structural root causes and overcoming the uneven distribution of power.

Health Disparities 

The Office of Disease Prevention and Health Promotion (ODPHP) defines health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. 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.”7

Health Equity 

The Office of Disease Prevention and Health Promotion (ODPHP) defines health equity as the highest level of health attainment for all individuals.7 To achieve health equity, it is necessary to value everyone equally and work towards eliminating avoidable inequalities, historical and contemporary injustices, and healthcare disparities.

Implicit Bias

Implicit bias, also called unconscious bias, is a negative attitude or social stereotype about a social group that we are not consciously aware of.8,9 If left unchecked, unconscious biases we all carry from past experiences (e.g., culture, environment, caregivers, media) can negatively influence our decision-making, our interactions with others, and our ability to create a welcoming environment, even when we have the best intentions. Actively disrupting unconscious biases by building awareness and taking action can help align our behaviors with our values to create a more equitable, diverse, and inclusive environment for everyone.

Inclusion 

Defined by the acceptance of our defining identities within the social circles we navigate.1 In order to feel a sense of belonging, we must feel included and be able to fully engage in all aspects of our lives. Inclusion is the state of being supported, respected, and valued. It involves the creation of a workplace culture and environment that recognizes, appreciates, and effectively utilizes the unique skills, talents, and perspectives of every employee. Inclusion fosters collaboration, flexibility, and fairness by valuing distinct qualities people have and creating a sense of belonging.

Intersectionality 

First coined by professor Kimberlé Crenshaw,10 intersectionality refers to the ways in which race, class, gender, and other identity markers interact with one another, informing the simultaneous experiences of oppression and privilege in their daily lives interpersonally and systemically. Intersectionality provides a basis for understanding how these individual identity markers work with one another, instead of existing separately.11

Microaggression

First coined in 1978 by Chester M. Pierce to describe a phenomenon of subtle insults and dismissals against African Americans.12 In the 21st century, the term was applied to any socially marginalized group.13 Psychologist Derald Wing Sue defined microaggressions as "brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults to the target person or group."14 Microaggressions, seeming more subtle (even though not always) than overt discrimination, hatred, or bigotry, are considered as "modern" forms of racism or sexism. Microaggressions have a significant impact on people's well-being and should not be considered "micro" by any means.3 Sue et al. (2007) classified microaggressions into three main types. The definitions for each type with examples are below:

Microinsults are communications that convey rudeness and insensitivity and demean a person's heritage or identity.13 Microinsults are sometimes unknown to the perpetrator but convey a hidden and insulting message to the recipient.14

Examples: 

• “The lack of diversity among faculty reflects the demographics of the field's senior leadership. As time passes, these demographics will change.”
• Message: Faculty who are not white and not men are not leaders in the field. There are no further actions I need to take to ensure diversity in awardees.
• Faculty, staff, or students of color being questioned whether they belong in their own building. 
• Message: People of color don't belong here. You cannot be faculty, staff, or a student.
• An instructor tends to call on male students more frequently than female ones.
• Message: The contributions of female students are less worthy than the contributions of male students.
• “Do you have a wife/husband?”
• Message: I am expecting you to be heterosexual or straight because that is normal.
• When a White employer tells a prospective candidate of color “I believe the most qualified person should get the job, regardless of race” or “How did you get your job?”
• Message: People of color are not qualified and must have obtained the position through affirmative action quota or program and not because of ability. Such statements are not necessarily aggressions, but context is important. Hearing these statements frequently when used against affirmative action makes the recipient likely to experience them as aggressions.

Microinvalidations are comments made to invalidate/eliminate/undermine someone's experience, thoughts, or feelings related to their identity.14

Examples:

• “Racism isn’t an issue in our department, students just need to take better advantage of the resources on campus.”
• Message: Racially minoritized students’ experiences with racism or bias do not matter.
• Asian Americans, or Latine Americans being repeatedly asked “Where are you really from?”  “Where were you born?,” or told “You speak good English”
• Message: negate their U.S. American heritage and convey that they are perpetual foreigners.
• A Black person is told “I don’t see color” or “We are all human beings”
• The effect is to negate their different lived experiences as a Black individual 
• Refusal to acknowledge intra-ethnic differences​​. For example, generalize all Latino people as Mexican. 
• Message: ignores intra-ethnic differences and assumes a broad homogeneity over multiple ethnic groups.
• “We don't need anti-racism training, race isn't an issue in our department. We have one Black faculty member.”
• Message: ignores the experience of the one faculty member, who is being tokenized, and any Black students or staff in the department, or the experiences of other people of color.
• A Latino couple shares their experience of being discriminated against at a restaurant with White friends only to be told “Don’t be so over-sensitive” or “Don’t be so petty”
• Message: the experience of the couple is being nullified, and its importance is being diminished.
• “I don't believe that was a sexist comment, you're blowing this out of proportion.”
• Message: You are being too sensitive, and I understand your experience better than you.
• “As a woman, I know what you go through as a racial minority.”
• Message: Your racial oppression is no different than my gender oppression. 
• “You’re not a typical gay guy.”
• Message: All gay/transgender/queer people are the same and have the same experiences.

Microassaults are explicit derogations characterized by a verbal or nonverbal attack with the intention to hurt through name-calling, exclusion, or purposeful discriminatory actions.14 Also known as “old fashioned” racism conducted on an individual level.

Examples:

• “It's a shame you are having kids in graduate school, your research must not be that important to you.”
• Message: Parents cannot have children and succeed in science.
• “You only got that fellowship because you are a minority.”
• Message: Membership in a minoritized group confers a special advantage, and this individual did not deserve the fellowship on their own merit.
• Scholars of color stereotyped as being angry or aggressive.
• Message: This comment reflects the discomfort of white people with the presence and expressions of people of color, which may be interpreted as hostile when in fact they are just conveying emotions differently, and it can also be used to dismiss and negate identification or rejection of stereotypes and racism.

There are resources available to reduce microaggressions. The University of California Santa Cruz developed Tool: Interrupting Microaggressions and the National Equity project developed Responding to Microaggressions and Unconscious Bias. University of California  San Francisco (UCSF) Clinical Psychologist and Clinical Director of the Wavefront CBT Clinic Natalie Todd, PsyD described in a UCSF panel discussion on microaggressions overarching themes of racial discrimination such as assumption of intelligence or skillset; treated like a foreigner; sameness and denial of difference; denial of racial experiences; invisibility and hypervisibility, and provided some strategies to reduce microaggressions. 

Here are some strategies mentioned:

• Reflect on your own stereotypes and expectations of different marginalized/underrepresented groups. We ALL have them!
• Practice identifying your assumptions about different marginalized or underrepresented groups.
• Confront your own hesitancies - what do you avoid discussing or asking about? Why?
• If someone makes you aware that your remark offended them, start by listening to them. Learn to separate your intention from the impact, and focus on understanding the impact.
• Make a commitment to do better.

People of Color

The American Medical Association’s (AMA) Guide to Language, Narrative and Concepts describes people of color as a “term used mostly, but not exclusively, in the U.S. to describe people not considered “white.” The term emphasizes shared experiences of structural racism, and opposes reference to people as “nonwhite” or “minority.” In recent years, the related term BIPOC (Black, Indigenous, and People of Color) has also been used. Not to be confused with the pejorative “colored people”.” 1

People-Centered Language

The Principles for Inclusive Communication by the Center for Disease Control and Prevention defines people-centered language as a form of inclusive communication that refers to individuals as having a condition or circumstance rather than being defined by it.15 To humanize those being referred to use "people" or "persons" and in healthcare settings, use "patient" to describe someone receiving healthcare.

Here are some key inclusive communication tips from this resource as a start:

• Instead of “underserved populations”, try “people who face financial/transportation/etc. barriers to care”
• Instead of “low-SES populations”, try “people with lower income” or “people experiencing poverty”
• Instead of “Medicaid patients”, try “people with Medicaid”
• Instead of “disabled people”, try “people with an intellectual or developmental disability”
• Note that some populations prefer identity-first terminology, such as Autistic people. 
• Instead of using racial identity as a noun (e.g., Blacks, Latinos, Whites), use it as an adjective (e.g., Black/Latino/White people/adults/children)

Racism

As defined by Camara Jones, “racism is a system of structuring opportunity and assigning value based on phenotype (“race”), that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and undermines the realization of the full potential of the whole society through the waste of human resources.”16 Racism can function at different levels: personally mediated, internalized, and institutional.16,17

Personally-mediated racism, or interpersonal racism refers to the act of intentionally or unintentionally discriminating against someone based on their race. This type of racism is often characterized by a lack of respect, suspicion, devaluation, scapegoating, and dehumanization of individuals belonging to a particular race.11,16,17

Internalized racism refers to a personal bias that occurs when a person's beliefs, attitudes, fears, behaviors, and actions are both based on and driven by racial biases/prejudices.11,16 Individual/personal racism is the conscious and unconscious belief that considers Whiteness to be superior.11

Institutional racism, sometimes referred to as structural racism or systemic racism can be described as differential access to services, opportunities, information, and resources, which is reflected in material conditions and access to power.11,16 Institutional racism refers to practices that continue to support racial disparities, maintain White supremacy, and serve to the detriment and harm people of color by keeping them in negative cycles.11 Institutional/systemic racism also refers to policies that result in different outcomes for people of different races.16 These laws, policies, and practices are not necessarily explicit in mentioning a particular racial group, but they function to create advantages for White persons and disadvantages for people of color.11

All types of racism can affect people's emotional and physical well-being, but institutional racism is the most significant.17,18 It has a profound impact on social determinants of health because it enables systems to continue perpetrating injustices with deep historical roots.

Social Determinants of Health

The U.S. government's Healthy People 2030 initiative states the social determinants of health “are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”19 Social determinants of health have a significant impact on people's health, well-being, and quality of life. Examples of social determinants of health include access to safe housing, transportation, and neighborhoods; racism, discrimination, and violence; education, job opportunities, and income; access to nutritious foods, and physical activity; polluted air and water; and language and literacy skills.

Additional determinants of health include:

Commercial determinants, defined by the World Health Organization (WHO) as “key social determinant, and refer to the conditions, actions and omissions by commercial actors that affect health. Commercial determinants arise in the context of the provision of goods or services for payment and include commercial activities, as well as the environment in which commerce takes place. They can have beneficial or detrimental impacts on health.”20

Political determinants, as defined by Professor Daniel E. Dawes, “involve the systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that either advance health equity or exacerbate health inequities.”21 Public policies can either bring up or tear down a community.17 For example, historical policies, such as segregation and redlining, which have been abolished, encouraged racial discrimination. These policies initiated a lasting cycle of determinants that resulted in continued racial inequities affecting health.

Other terminology

CDC’s National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) and the American Medical Association (AMA) provide additional health equity terminology.  

References

1. AMA Center for Health Equity. Advancing Health Equity: A Guide to Language, Narrative and Concepts glossary. October 2021. Available at: https://www.ama-assn.org/about/ama-center-health-equity/advancing-health-equity-guide-language-narrative-and-concepts-0

2. Akbar, Maysa. Beyond ally: The pursuit of racial justice. Publish Your Purpose Press, 2020.

3. Kendi, Ibram X. How to be an Antiracist. New York: One World, 2019.

4. Centers for Disease Control and Prevention. Disability and Health Overview. September 2020. Available at: https://www.cdc.gov/ncbddd/disabilityandhealth/disability.html

5. Kres-Nash I. Racism and Ableism. n.d. Available at: https://www.aapd.com/racism-and-ableism/

6. Race Forward. Race Reporting Guide. June 2015. Available at: https://www.raceforward.org/sites/default/files/Race%20Reporting%20Guide%20by%20Race%20Forward_V1.1.pdf

7. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Health Equity in Healthy People 2030. n.d. Available at: https://health.gov/healthypeople/priority-areas/health-equity-healthy-people-2030

8. American Psychological Association. Implicit Bias. November 2022. Available at: https://www.apa.org/topics/implicit-bias

9. University of San Francisco Office of Diversity and Outreach. Unconscious Bias Training. n.d. Available at: https://diversity.ucsf.edu/programs-resources/training/unconscious-bias-training

10. Crenshaw K. Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. Univ Chicago Legal Forum. 1989;1989(1):Article 8. Available at: https://chicagounbound.uchicago.edu/uclf/vol1989/iss1/8/

11. Fleming E, Reynolds J, Kim F, Warren J. From a call to action to taking action: Exploring the science, education, practice, and policy implications of dental public health as an antiracist discipline. J Public Health Dent. 2022 Mar;82(Suppl 1):5-7. 

12. Pierce, C. M., Carew, J. V., Pierce-Gonzalez, D., & Wills, D. An Experiment in Racism: TV Commercials. Education and Urban Society. 1977;10(1):61-87. 

13. Capodilupo, C. M., Nadal, K. L., Corman, L., Hamit, S., Lyons, O. B., & Weinberg, A. The manifestation of gender microaggressions. Microaggressions and marginality: Manifestation, Dynamics, and Impact. 2010;193-216.

14. Sue DW, Capodilupo CM, Torino GC, Bucceri JM, Holder A, Nadal KL, Esquilin M. Racial microaggressions in everyday life: implications for clinical practice. Am psychol. 2007 May;62(4):271-286.

15. Centers for Disease Control and Prevention. Health Equity Guiding Principles for Inclusive Communication. September 2023. Available at: https://www.cdc.gov/healthcommunication/Health_Equity.html

16. Jones CP. Levels of racism: a theoretic framework and a gardener’s tale. Am J of Public Health. 2000 Aug;90:1212–1215.

17. American Association of Public Health Dentistry. Anti‐racism in dental public health: a call to action [white paper]. July 2021. Available at: https://www.aaphd.org/assets/Webinars/White%20paper%20FINAL%20July%202021.pdf

18. Paradies Y, et al. Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. PLOS ONE. 2015 Sep 23;10(9):e0138511.

19. Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. n.d. Available at: https://health.gov/healthypeople/objectives-and-data/social-determinants-health 

20. World Health Organization. Commercial determinants of health. March 2023. Available at: https://www.who.int/news-room/fact-sheets/detail/commercial-determinants-of-health

21. Dawes DE. The political determinants of health. Johns Hopkins University Press, 2020.