Equality Is Not Fair: Imaging and Imagining the Road to Health Equity

INTRODUCTION

Health equity offers the opportunity for all individuals to have equitable and just opportunities to be as healthy as possible. Achieving health equity requires radiology to recognize existing inequities in radiologic care that may exacerbate current health disparities. Although breast, lung, and colon cancer screening highlight disparities in radiologic care, disparities in imaging extend well beyond cancer screening and have been documented in at-risk populations, including racial and ethnic minorities, rural populations, and sexual and gender minorities across the spectrum of radiologic care [1].

As the field of radiology embarks on the road to advancing health equity, key strategies for success will include (1) understanding the roots of health inequities and the social and economic determinants of health; (2) recognizing existing health disparities and health inequities that impact radiology; and (3) implementing systemic change at the individual, institutional, and national levels to provide equitable care.

UNDERSTANDING THE ROOTS OF HEALTH AND HEALTH CARE INEQUITIES

The conditions into which we are born, live, work, play, and age compose the social and economic determinants of health [2]. These conditions influence the opportunities and resources (or lack of opportunities and resources) individuals have to protect, improve, and maintain their health. These determinants include the quality of available schools and education, public safety, and access to healthy foods, good jobs with fair pay, high-quality medical care, and reliable transportation. These determinants also include existing social norms such as discrimination and racism. These social and economic determinants are often the roots causes of illness. From these roots grow the consequences of health disparities (differences in health outcomes for populations) and health inequities (differences in health outcomes in populations due to systemic, avoidable, unjust factors) (Fig. 1).

Fig. 1.

Health disparities grow from the roots of inequities.

To address the roots of inequity and advance health equity, different types of support and resources are necessary for different populations. The concept of equity, offering variable resources to achieve desirable outcomes for all, differs from that of equality, offering the same resources for all to achieve variable outcomes.

RECOGNIZING EXISTING HEALTH DISPARITIES

Health care disparities affect those seeking radiology care across a range of services, driven by factors at patient, provider, and system levels. Patient-level factors, including cultural beliefs, health literacy, and language proficiency, are important determinants of health behavior. These factors have been shown to directly impact effective patient-physician communication, influencing adherence to recommendations, utilization of preventive screening, and navigation through the health care system [3]. Limited English proficiency and low health literacy are significant barriers to health and have been correlated with delayed follow-up after an abnormal imaging [4]. Language and health literacy are factors that can make the pursuit of imaging services more difficult, as patients are tasked with maneuvering through a complex health care system.

Provider-level factors influence patient-physician interactions, shaping how information is exchanged and guiding expectations. The effectiveness of these interactions is built on a foundation of trust. Having trust in the health care system and with providers is essential for patients, given that trust is correlated with adherence to physician recommendations and patient satisfaction. As a provider, establishing a relationship of trust requires an understanding of how patients’ cultural beliefs and experiences impact their health behaviors, including their understanding of imaging recommendations. Provider stereotyping, defined as the process by which social categories (eg, race, gender) are used in acquiring, processing, and recalling information about others, can further influence clinical interactions. These biases may be overt; however, often they are implicit. Research suggests that health care providers’ diagnostic and treatment decisions, as well as their feelings about patients, can be influenced by patients’ race or ethnicity. Radiologists are no exception. Priming of stereotypes can occur when radiologists are reviewing radiologic images that may contain patient descriptors such as race, ethnicity, age, or gender or when radiologists see photographs of patients presented in the electronic medical record [4].

System-level factors impacting equitable care include access to high-value care and health insurance, electronic health record capabilities, and the potential for bias in national guideline recommendations [5]. Health care disparities epitomize low-value health care, care that is below quality standards in terms of efficiency, health outcomes, and cost [4]. In radiology care, missed appointments or missed care opportunities increase the inefficiencies of the system, in addition to increasing costs related to delays in diagnosis or treatment that may be dependent on diagnostic imaging [4,6]. Furthermore, many health care resources are not proportionately distributed to sufficiently meet the needs of vulnerable populations [3]. These inadequacies in efficiency and capacity primarily impact individuals from low socioeconomic backgrounds, ethnic minorities, and rural populations. And although the future is sure to bring technological advances to radiology, there is growing concern that the introduction of advanced imaging technologies may worsen the existing health disparities among underserved populations [3].

These multilevel factors result in health care disparities before, during, and after radiologic examinations. Before imaging, certain populations may face barriers limiting their ability to present for imaging including access to reliable transportation, insurance, educational level, or language of materials explaining examinations, trust, and geographic proximity to high-value care. During imaging, patients may encounter conscious or unconscious bias from providers and staff, limited understanding of cultural needs, and language and educational-level barriers. After radiologic care, current methods for delivery of results and recommendations for follow-up or postprocedural care may not meet the needs of our diverse population and may result in confusion or inappropriate follow-up or postprocedural care.

IMPLEMENTING SYSTEMIC STRATEGIES TO PROVIDE EQUITABLE CARE

Strategies to address inequities in radiologic care are necessary at national, institutional, departmental, and individual levels (Table 1).

Table 1.

Multilevel systemic strategies to provide equitable care

Level	Strategies
National	Develop national society support for health equity including seminars, workshops, and speaker sessions.  Support career development opportunities related to health equity.  Increase federal and national society funding opportunities for health equity research.  Revise national policy to better support payment models for equitable care.
Institutional and departmental	Identify and support a leader to champion health equity efforts.  Design accessible health equity learning opportunities for all team members.  Provide antiracism, cultural competency, and unconscious bias training for all team members.  Tailor clinic operations to meet the needs of the community served.  Foster a diverse and inclusive workplace environment.  Support career development for those interested in health equity.  Offer pilot funding to support early career researchers focused on health equity.  Develop community–academic partnerships.
Individual	Continue to learn about health disparities and inequities.  Understand that different individuals and populations have different needs with regard to health care.  Listen to patients and family members to better understand their individual needs.  Pursue antiracism, cultural sensitivity, and bias training.

National Level

National policy must recognize and support the needs of diverse and underrepresented populations. National radiology societies should embrace the opportunity to propagate the importance of health equity and drive our field’s commitment to health equity. These organizations can offer career development opportunities for radiology team members interested in furthering this work and offer grants supporting research in health equity. Federal, society, and institutional grants designed to support equity-driven research can support studies that both explore disparities in radiologic care and design strategies to address these disparities. Furthermore, national policy can support payment models designed to provide more equitable care.

Institutional and Departmental Levels

Radiology organizations can reinforce the importance of health equity by embedding the principles of health equity into all aspects of the organization’s mission: facilitating lifelong learning needs of team members, providing high-quality clinical care, promoting diversity and inclusion, and supporting research. Identifying and supporting a champion to oversee health equity initiatives is a key initial step that can drive an institution’s health equity efforts.

Offering accessible health equity curricula for trainees, faculty, and staff can provide individuals in an institution with a stronger understanding of the importance of health equity. Furthermore, institutions and departments should also provide adequate antiracism, cultural competency, and unconscious bias training for providers, staff, and leadership.

Clinical operations should be tailored to meet the needs of the diverse community each institution serves. Understanding the needs of the community, from the perspective of the community, is key to delivering appropriate care.

Efforts to increase the diversity of the radiologic workforce are critical to improving the equitable care we provide to our increasingly diverse patient populations. Broadening the diversity of thought, backgrounds, and gender and race or ethnicity of radiology teams can drive the future of equitable care through innovative thought and approachability [7].

Supporting career development for researchers with interest in addressing health disparities is necessary to produce robust research addressing health disparities. This support can include offering pilot grant funding, supporting faculty members in pursuit of career development awards, and providing protected time for academic endeavors related to health equity. Community–academic partnerships offer an opportunity to drive community-centric health equity-focused research [8].

Individual Level

Individual radiology team members bear the responsibility of providing equitable patient care at the instance of care. To do so, individuals should improve their understanding of existing disparities and barriers to care and pursue antiracism, cultural competency, and bias training. Through dedicated efforts to understand the individual needs of a complex, diverse patient population, radiology team members can provide high-quality, equitable care.

CONCLUSION

Strategies to understand and address existing health and health care inequities are necessary as radiology embraces and navigates the road to health equity. Initial strategies include understanding the roots of health inequities, recognizing existing health inequities in radiology, and implementing multilevel systemic change at the individual, institutional, and national levels to provide equitable care.