Islands Health Equity Framework
Health equity models, such as those from the World Health Organization and Bay Area Regional Health Inequities Initiative, have proven foundational to advancing health equity globally and in the states. As the U.S. territories and freely associated states—collectively referred to as the Island Areas—begin to define their vision and ramp up health equity efforts, a framework that reflects the island context and builds upon existing models is crucial. The Island Areas face a unique and shared set of challenges, including scarce resources, limited land, and geographic isolation from the continental United States and other countries. Their strengths—emphasizing the well-being of community versus individualism, resilience through harsh conditions, a pre-colonial history of healthy lifestyles and diets, and using data to navigate the oceans—are also considerations for an islands’ health equity framework. As such, in 2022, ASTHO initiated a process with the health agencies in the Island Areas, involving multiple rounds of review and input, to create this Islands Health Equity Framework.
The purpose of ASTHO’s Islands Health Equity Framework is to create a shared understanding of how to move towards health equity in an island context. The starting point of this framework—visualized in these graphics—builds on and recontextualizes current health equity frameworks to reflect the culture, experiences, and strengths of island communities more authentically.* ASTHO’s island members can use these graphics to build buy-in and shared understanding with health agency staff, partners, and funders. ASTHO will continue to review these graphics with island jurisdictions as their health equity and human rights efforts continue to grow.
Resources for the Atlantic
Click on the Atlantic image to go to an interactive version of the graphic.
This framework and the accompanying visual designed for the Atlantic Jurisdictions are available for download as a zip file.
Resources for the Pacific
Click on the Pacific image to go to an interactive version of the graphic.
This framework and the accompanying visual designed for the Pacific Jurisdictions are available for download as a zip file.
Defining Key Terms
Foundational Conditions
Individual characteristics, including age, communicable and non-communicable diseases, geographic location, race/ethnicity, and language/literacy. Geographic location is critical given the Island Areas’ distance from the continental United States and other countries, which impacts imports, service delivery, and program availability. Additionally, the Island Areas have multiple islands within their jurisdictions, and some may be more difficult to reach. One must also acknowledge that there is often different access to services based on race and/or ethnicity due to exclusion and biases. Language is also important within the Island Areas as they host migrants from other islands and countries who speak a different primary language. Finally, literacy refers to the importance of all island residents understanding the health information health agencies share with them.
Strengths and Supports
Community characteristics and factors that can support the Island Areas in working towards health equity, including community-based organizations, community mobilization and ownership, shared culture and history, and strong community ties and support.
Many island communities value the support they find in faith-based organizations, their culture, tradition, and family. Family support is an important strength and oral traditions help to tell the story of their past and present, sharing important data and information. The geographic distance of Island Areas between one another, the continental United States, and other countries means island communities rely on each other to overcome challenges, leading to strong community ties and connections within the islands.
Societal Conditions
Changeable characteristics shaped by society that affect health and health equity, including community safety, economic stability and employment opportunities, environmental protection, internet/broadband access, reliable power, safe drinking water access, and religious affiliations/beliefs.
Institutional Influences
Institutions and conditions that influence social determinants of health and peoples’ opportunities to be as healthy as possible. These include healthcare and specialized services, workforce development, housing, laws and regulations, schools, transportation, and workplaces. Public health, healthcare and specialized services are especially important to consider in the Island Areas where there is limited access to medical equipment, diagnostic testing, providers and trained public health staff, requiring people to seek care off-island. Further complicating this is limited flights off-island. Given these constraints, people may be more reluctant to seek care early, making it more difficult and expensive to provide preventative care. Additional on-island workforce development and training could help address this issue by supporting public health staff in their prevention efforts and increasing the availability of specialized care on-island. Finally, the imposition of Western administrative practices can cause lengthy procurement and hiring processes. Because these practices do not align with traditional island decision-making processes for resource distribution, it can lead to funding going unspent or not going where it is needed most. Finally, allocation formulas based on population size or status cause under-funding.
External Factors
Factors that are controlled or strongly influenced by institutions and governments outside of the Island Areas. These include centralized care models, climate change, reliance on food imports, and state-centric funding and programs. Given centuries of colonialism and continued outside influence for geopolitical and military interests, the Island Areas have become increasingly reliant on imported foods as they moved away from sustainably utilizing natural resources in farming and fishery, which has limited fresh produce and impacted healthy diets. Also, the Island Areas have moved to using centralized care models based on Western influences, which means people must seek healthcare away from their communities and families instead of having services where they live. The increasing number and intensity of natural disasters, such as typhoons and hurricanes, due to climate change also impacts the Island Areas, resulting in loss of water, electricity, physical infrastructure, and health services, which contribute to higher rates of homelessness, exposure to illnesses and hospitalization. Finally, the Island Areas are not always included in federal grant eligibility, and grant allocations based on populations do not consider the increased cost of service delivery in the islands due to their remote populations and higher costs of business. There are also policies that limit federal benefit access in the territories. This means that the Island Areas often do not receive sufficient funding to meet their communities’ needs.
Facilitating Factors
Factors that can support the Island Areas in moving toward health equity, including data for decision-making, policy development and advocacy, and community partnerships and engagement.
While this graphic highlights major considerations for health equity in the Island Areas, it is important to fully acknowledge the historic and current inequities. The Island Areas have endured centuries of colonization for geopolitical and military interests that have created structural inequities, introduced disease, changed their way of life, and destroyed natural resources and places of cultural importance. The Island Areas continue to be strongly influenced by the United States, other nations, and funders due to the need for resources given past underinvestment and the imposition of Western practices and food imports. Even so, island peoples remain resilient through strong community ties, supporting each other within and across island jurisdictions to address barriers to health as they face COVID-19 and other emerging diseases.
*These graphics highlight a number of key factors that are organized into categories for clarity but is not an exhaustive list of factors that can influence health equity. Some factors may also fit into multiple categories. A single factor may also have the potential to benefit or hinder health equity work.
This product was supported by funds made available from the Centers for Disease Control and Prevention, National Center for STLT Public Health Infrastructure and Workforce, through cooperative agreement OT18-1802, Strengthening Public Health Systems and Services Through National Partnerships to Improve and Protect the Nation’s Health award # 6 NU38OT000317-04-01 CFDA 93.421. Its contents are solely the responsibility of ASTHO and do not necessarily represent the official views of the U.S. Department of Health and Human Services/Centers for Disease Control and Prevention.