Applying a Health Equity Lens to Evaluate and Inform Policy

Abstract

Health disparities have persisted despite decades of efforts to eliminate them at the national, regional, state and local levels. Policies have been a driving force in creat­ing and exacerbating health disparities, but they can also play a major role in eliminat­ing disparities. Research evidence and input from affected community-level stakeholders are critical components of evidence-based health policy that will advance health equi­ty. The Transdisciplinary Collaborative Cen­ter (TCC) for Health Disparities Research at Morehouse School of Medicine consists of five subprojects focused on studying and informing health equity policy related to maternal-child health, mental health, health information technology, diabetes, and leadership/workforce development. This article describes a “health equity lens” as defined, operationalized and applied by the TCC to inform health policy development, implementation, and analysis. Prioritizing health equity in laws and organizational policies provides an upstream foundation for ensuring that the laws are implemented at the midstream and downstream lev­els to advance health equity. Ethn Dis. 2019;29(Suppl 2):329-342; doi:10.18865/ed.29.S2.329.

Full text

Ethnicity & Disease, Volume 29, Supplement 2, 2019 329
TCC for Health
Disparities Research
IntroductIon
Despite eorts at the federal, re-
gional, state and local levels, health
disparities persist and continue to
widen in some populations.1,2 e
tangible and intangible costs associ-
ated with health disparities are signi-
cant, contributing to loss of life, early
death, disability and ineciencies in
the system.3 Social, behavioral, eco-
nomic, and environmental factors are
critical drivers of health and dispro-
portionately contribute to poor health
outcomes.4 Developing eective strat-
egies to improve health for vulnerable
and under-resourced populations
challenges researchers to examine how
policies, both historic and contem-
porary, perpetuate health disparities.
is article describes how the
Transdisciplinary Collaborative
Center (TCC) for Health Dispari-
ties Research at Morehouse School
of Medicine (MSM) operationalized
and applied a “health equity lens” to
health policy research, development,
and implementation. e MSM
TCC is an institution-wide research
initiative started in 2012 with fund-
ing from the National Institute on
Applying A HeAltH equity lens
to evAluAte And inform policy
Megan D. Douglas, JD1,2; Robina Josiah Willock, MPH, PhD2;
Ebony Respress, MSPH3; Latrice Rollins, PhD, MSW2,4;
Derrick Tabor, PhD5; Harry J. Heiman, MD, MPH6;
Jammie Hopkins, DrPH2,3; Daniel E. Dawes, JD7;
Kisha B. Holden, PhD, MSCR3,8
Health disparities have persisted despite
decades of efforts to eliminate them at the
national, regional, state and local levels.
Policies have been a driving force in creat-
ing and exacerbating health disparities, but
they can also play a major role in eliminat-
ing disparities. Research evidence and input
from affected community-level stakeholders
are critical components of evidence-based
health policy that will advance health equi-
ty. The Transdisciplinary Collaborative Cen-
ter (TCC) for Health Disparities Research at
Morehouse School of Medicine consists of
five subprojects focused on studying and
informing health equity policy related to
maternal-child health, mental health, health
information technology, diabetes, and
leadership/workforce development. This
article describes a “health equity lens” as
defined, operationalized and applied by the
TCC to inform health policy development,
implementation, and analysis. Prioritizing
health equity in laws and organizational
policies provides an upstream foundation
for ensuring that the laws are implemented
at the midstream and downstream lev-
els to advance health equity. Ethn Dis.
2019;29(Suppl 2):329-342; doi:10.18865/
ed.29.S2.329.
Keywords: Health Equity; Transdisciplinary;
Policy; Health Disparities
1 National Center for Primary Care,
Morehouse School of Medicine, Atlanta, GA
2 Department of Community Health and
Preventive Medicine, Morehouse School of
Medicine, Atlanta, GA
3 Satcher Health Leadership Institute,
Morehouse School of Medicine, Atlanta, GA
4 Prevention Research Center, Morehouse
School of Medicine, Atlanta, GA
5 National Institute on Minority Health and
Health Disparities, Washington, DC
6 School of Public Health, Georgia State
University, Atlanta, GA
7 H. Wayne Huizenga College of Business
and Entrepreneurship, Nova Southeastern
University, Fort Lauderdale, FL
8 Department of Psychiatry, Morehouse
School of Medicine, Atlanta, GA
Address correspondence to Megan
D. Douglas; 720 Westview Dr, NCPC
Bldg, Suite 300, Atlanta, GA 30310;
404.756.5275; mdouglas@msm.edu
Minority Health and Health Dispari-
ties (NIMHD); the TCC is focused
on developing, informing, and evalu-
ating health policies and health policy
leadership that advances health equi-
ty. Five subprojects focused on diverse
health equity issues, including mater-
nal-child health, mental health, health
information technology, chronic dis-
Five subprojects focused
on diverse health equity
issues, including maternal-
child health, mental
health, health information
technology, chronic
disease, and leadership
development.

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Evaluating Health Policy with Health Equity Lens - Douglas et al
have been described in the litera-
ture.5-7 However, to our knowledge,
the application of a health equity
lens to analyzing, developing, and
informing health-related policies
has not been previously described.
defInIng a He altH
equIt y lens focused on
PolIcy
Denitions of both health dispari-
ties and health equity have evolved
considerably since the World Health
Organization’s original denition
as dierences in health that “are not
only unnecessary and avoidable but,
in addition, are considered unfair and
unjust.”8 Soon after the project was
initiated in 2012, the TCC adopted
the Healthy People 2020 denition of
health disparity as “a particular type
of health dierence that is closely
linked with social, economic, and/
or environmental disadvantage.”9
is denition is broad in scope and
recognizes the breadth of population
ease, and leadership development.
TCC subproject problem and vision
statements are presented in Table 1;
and Table 2 provides details on the
specic aims of each TCC subproject.
e TCC’s explicit prioritization
of health equity within policy re-
search and the broad issues covered
necessitated development of a health
equity lens that provided a consistent
framework and approach, guiding
the work and supporting systematic
analysis across all subprojects. Varied
applications of a health equity lens
Table 1. Transdisciplinary Collaborative Center for Health Disparities Research: Subproject problem and vision statements
Collaborative Action
for Child Equity
(CACE)
Project THRIVE
Health Information
Technology (HIT)
Policya
Health360xaHealth Policy
Training
Project focus Maternal-Child
Health and Child
Academic Readiness
Mental Health HIT Diabetes Leadership/
Workforce
Development
Problem Disparities in
educational,
physical and mental
health outcomes
often surface in
childhood. Parents
who demonstrate
positive psychological
adjustment are better
positioned to support
the success of their
children.
Behavioral
health disparities
disproportionately
impact underserved
populations.
Ethnically and
culturally diverse
populations may
receive lower-
quality and poorly
coordinated
mental healthcare
compared with White
Americans.
Adoption and
utilization of HIT
has the potential
to reduce health
disparities, but it is
unclear whether and
to what extent HIT
policies advance and
support health equity.
Coupled with care
coordination and
other support, HIT,
including electronic
health records and
home monitoring
tools have been
shown to improve
adherence to care
plans and outcomes
for diabetic patients.
Use of culturally
tailored HIT
applications and peer
support may be more
effective in reducing
diabetes disparities.
Racial and ethnic
minority and health
disparity populations
would benefit from
better equipped
researchers, scientists
and policy makers.
All populations would
benefit by policies
and practices that
by design prevented
disparities in health
outcomes among and
within all populations.
Vision statement Building parental,
institutional and
community capacity
to promote behaviors
and policies that
ensure academic
readiness, behavioral
and physical health,
and wellness at the
community level.
Providing culturally
tailored mental
health screening and
treatment in locations
where racially
diverse populations
seek primary
care, empowering
providers and
patients to address
mental health needs
that reduce health
disparities.
Identifying gaps
in HIT policy that
exacerbate existing
health disparities and
facilitating bilateral
communication to
engage communities
and frontline
clinicians and inform
policy and practice.
Implementing a
technology-based,
patient-centered
diabetes management
program that
empowers racial and
ethnic minorities, and
providers that serve
them, to improve
diabetes outcomes
and reduce the
disparities.
Developing health
policy leaders who
value health equity,
understand the root
causes of health
disparities and have
the skills, knowledge
and abilities to inform
policies that will
achieve health equity.
a. These two subprojects were merged into a single project in the funding proposal. As the project period evolved, the project split into two subprojects in order to better
address the specific aims.

Ethnicity & Disease, Volume 29, Supplement 2, 2019 331
Evaluating Health Policy with Health Equity Lens - Douglas et al
groups experiencing health disparities
associated with race, ethnicity, sex,
preferred language, disability status,
sexual orientation, gender identity,
immigration status, socioeconomic
status, geography, military service,
mental health status and many oth-
er factors. is denition goes be-
yond health care disparities, clearly
grounding the fundamental drivers
of health disparities in the social de-
terminants of health: the conditions
in which people are born, grow, live,
work and play. e TCC also em-
braced the US Department of Health
and Human Services (HHS) deni-
tion of health equity, meaning attain-
ment of the highest level of health for
all people. Achieving health equity
requires removing systemic obstacles
such as poverty and discrimination,
and their consequences, includ-
ing powerlessness, poor access to
health care, un/underemployment,
poor quality education and hous-
ing, and unsafe neighborhoods.10
In a policy context, health equity
requires creation of the conditions
necessary for people to achieve their
optimal health potential. is is an
important distinction that acknowl-
edges the role (power and control)
policymakers have to remove systemic
barriers and prioritize health equity.
Yet, a disconnect persists when policy
solutions fail to: 1) allocate the nec-
essary resources to those at greatest
disadvantage; 2) give vulnerable com-
munities decision-making power; and
3) hold policymakers and other deci-
sion makers accountable for prioritiz-
ing health equity. Achieving health
Table 2. Transdisciplinary Collaborative Center for Health Disparities Research: Subproject specific aims
Collaborative Action
for Child Equity
(CACE)
Project THRIVE
Health Information
Technology (HIT)
Policy
Health360x Health Policy
Training
Project focus Maternal-Child Health
and Child Academic
Readiness
Mental Health HIT Diabetes Leadership/ Workforce
Development
Specific Aimsa1) Use quality
parenting as an
intervention for
addressing childhood
physical and mental
health inequities; 2)
Evaluate the extent
to which existing
policies in nine
southeastern states
ensure receipt of early
child development
resources and
effectiveness
of programs to
support community
participation in
decision-making
related to quality
parenting; 3)
Implement Smart &
Secure Children (SSC)
quality parenting
intervention in nine
southeastern states
and demonstrate
extent to which
this intervention
improves child and
parent outcomes in
vulnerable minority
communities.
1) Design, implement,
and evaluate the
effectiveness of a
culturally centered
integrated health care
model to address
depression and
selected co-morbid
chronic diseases
among underserved
ethnically and
culturally diverse
adults; 2) Assess the
impact of mental
health insurance
mandates and
coverage on access to
a community-based
integrated mental and
primary health care
model for vulnerable
populations.
1) Identify and
analyze existing state
and federal HIT
policies that impact
implementation of
HIT in high disparity
communities in
Georgia and other
similarly situated
states in the region; 2)
Build a collaborative
regionwide coalition
of community-
level health equity
advocates to
evaluate state and
federal policies that
positively affect HIT
implementation in
these communities.
1) Analyze electronic
health record (EHR)
patient data and
other clinical data to
evaluate adherence
to evidence-based
protocols and
disease-based quality
measures; use of
Physician Quality
Reporting System-
qualified EHR;
Meaningful Use
payments; health
promotion and
disease prevention;
and appropriate
data collection and
reporting; 2) Evaluate
effectiveness of a
customizable chronic
illness and decision
support EHR template
in improving clinical
diabetes outcomes,
among high-risk and
dual-eligible Medicare
beneficiaries.
1) Identify health
policy leaders’ training
needs for developing,
implementing, and
changing policies to
address disparities in
health; 2) develop
a range of health
policy leadership
training programs
in the Satcher
Health Leadership
Institute (SHLI) at
Morehouse School
of Medicine (MSM)
to meet the needs of
health professionals,
community leaders,
and students; 3)
evaluate the impact
of two SHLI health
policy training
programs: SHLI Health
Policy Leadership
Fellowship Program
for postdoctoral
professionals and the
SHLI Community
Health Leadership
Program for
community leaders
and students.
a. Specific aims shown here were developed as part of the funding proposal and have been edited for brevity. Project activities are described in Tables 3-7.

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Evaluating Health Policy with Health Equity Lens - Douglas et al
equity requires that all members of
society are valued equally, and ef-
forts are focused on advancing poli-
cies that create healthy, empowered
communities that have the resourc-
es to support health and wellness.
With these guiding denitions,
the TCC described its application
of a health equity lens as strategi-
cally, intentionally and holistically
examining the impact of an issue,
policy or proposed solution on un-
derserved and historically marginal-
ized communities and population
subgroups, with the goal of leverag-
ing research ndings to inform policy.
role of PolIcy to
advance Hea ltH equIty
Research shows that health equity
is possible through policy action.11,12
Health policies that radically changed
our approach to childhood immuni-
zations, breast cancer prevention and
treatment, tobacco control, and ma-
ternal and child health demonstrate
this fact.13,14 Each of these examples
of success included targeted ap-
proaches that were culturally tailored
to the specic groups experiencing
health disparities. Targeted policy ap-
proaches, particularly those focused
on the public health and health care
systems, have measurably improved
the health of many Americans. ere
is growing awareness, however, that
population health is aected by the
complex interaction of contextual
factors outside the traditional pur-
views of public health and health
care, such as housing, food security,
safe neighborhoods, access to healthy
food and economic security.15 Health
policy leaders are increasingly moving
upstream to embrace health-in-all-
policies and develop evidence-based
policies across non-health sectors as
a strategy for addressing the social
determinants of health and achieving
health equity.16 To eliminate health
disparities and move the needle to-
ward health equity, mechanisms
are needed to translate research to
inform evidence-based health pol-
icy development and evaluation.
tHe McKInl ay Model
for He altH ProMotIon
e McKinlay Model for Health
Promotion, initially developed to pro-
mote healthy behaviors such as physi-
cal activity and nutrition, has been
adapted for targeting the elimination
of health disparities.17,18 e TCC
grounded its work in the McKinlay
Model (Figure 1) and applied this
model to policy. e model identies
three levels of policy intervention—
the individual level (downstream),
the community level (midstream)
and the societal/decision-makers
level (upstream). e downstream
level encompasses individuals such
as patients, parents, health care pro-
viders and community members and
focuses on strategies to improve in-
dividual-level policies and behaviors.
e midstream level, which includes
schools, health care organizations and
institutions, and public health orga-
nizations, focuses on changes within
communities, organizations and in-
stitutions that reach the population
of people functioning within the
community or organization’s service
area. e upstream level focuses on
the public policies made by govern-
ing bodies that impact entire popu-
lations, including state and national
legislatures, school boards, and zon-
ing authorities. ese upstream en-
tities set an agenda through laws,
regulations, ordinances and bud-
gets, which are often implemented
at the midstream and downstream
levels. Identication and distinction
of these three levels provides a con-
tinuum of opportunities to intervene
for maximal and targeted impact.
aPPlyIng a HealtH
equIt y lens to PolIcy
e TCC’s health equity lens was
intended to clearly frame health in
the context of social, behavioral,
economic, and environmental de-
terminants, and to work collabora-
tively with community stakeholders
to increase knowledge and engage-
ment with policy processes. e
TCC’s application of a health eq-
uity lens consisted of ve steps: 1)
identify the health equity issue and
aected population; 2) analyze the
relevant policy impacts and oppor-
tunities for policy improvement;
3) develop policy-relevant research
strategies in partnership with com-
munity stakeholders; 4) measure
and evaluate policy outcomes and
impacts on heath disparities; and 5)
disseminate ndings to relevant au-
diences and stakeholders, including
policy makers, communities, public
health ocials, and health care pro-
viders. Each construct is described
below in Tables 3-7, providing an
overview of how the ve TCC sub-
projects applied a health equity lens.

Ethnicity & Disease, Volume 29, Supplement 2, 2019 333
Evaluating Health Policy with Health Equity Lens - Douglas et al
Identify Health Equity Issue
and Affected Population
(Table 3)
Identifying and characterizing the
specic areas of health inequity are
critical rst steps in developing the
research, outreach and dissemination
strategies necessary to mitigate the
issue. Because health disparities are
multi-faceted, intersectional, and af-
fect many populations, it is impera-
tive to develop targeted approaches.
Within the TCC, evidence-based
approaches including literature re-
views, expert panels and pilot studies
were used to identify key health eq-
uity issues and aected populations
and assess the existing evidence. Two
subprojects were able to leverage their
existing data to refocus and enhance
their programs. Two subprojects
used pilot data to inform their work.
A fourth project relied on existing
health disparities research and consul-
tation with an advisory board of na-
tional experts to guide its issue iden-
tication and research strategies. All
subprojects focused on engaging and
empowering the community, as de-
ned specically by each subproject,
in their research development, evalu-
ation and dissemination processes.
Analyze Relevant Policy
Impacts and Opportunities for
Policy Improvement (Table 4)
Systematic evaluation of the
policy landscape is critical for iden-
tifying and contextualizing factors
across the entire policy cycle that
exacerbate or fail to eliminate health
disparities. Policy evaluation estab-
lishes the evidence base for improv-
ing policy and involves studying the
policy content, implementation and
impact.19 TCC research projects and
collaborative partners employed an
iterative process to critically analyze
the policy environments associated
Upstream
•Increase decisionmakers'
knowledge and capacity on the
impact of policy on health
disparies
•Increase funding for advancing
health equity policy
•Inform new public policies and
changes to current policies that
address health disparies
•Serve as a naonal model for
addressing health disparies by
supporng collaborave health
policy research.
Midstream
•Increase organizaonal and
community knowledge and
capacity to implement policies
and pracces that advance
health equity
•Develop and implement
evidence-based pracces to
reduce health disparies and
advance health equity
•Collaborate with policy and
community organizaons to
implement programs and policies
that will reduce health disparies
and advance health equity.
Downstream
•Increase individual knowledge
and capacity on the impact of
health policies on health
disparies
•Increase behaviors that advance
health equity
TCC for Health Dis
p
aries Research
Advancing health equity through improved parenng that promotes early child development, HIT ulizaon
and outcomes, improved access and integraon of mental and behavioral health care, enhanced training of
health policy leaders, and promoon of other policies that support health equity in HHS Region IV
Figure 1. Application of the McKinlay Model for health promotion to policy by the TCC

Ethnicity & Disease, Volume 29, Supplement 2, 2019
334
Evaluating Health Policy with Health Equity Lens - Douglas et al
with their respective health equity
areas. is iterative process drew
upon multiple research method-
ologies: review and secondary data
analysis of epidemiological data;
literature reviews; environmental
scans; qualitative research with care
providers, administrators, patients
and community members; and com-
munity needs assessments. It also
required the use of policy research
methodologies: governmental policy
scans and gap analyses; legal epide-
miology; reviews of institutional and
organizational policies and bylaws;
and evaluation of system policies
and standard operating procedures.
e TCC’s policy evaluation ap-
proach included identication of
policy dilemmas where: 1) no poli-
cies existed to specically address the
health disparities; 2) policies were ad-
opted but poorly or inequitably im-
plemented; 3) implementation of ex-
isting policies resulted in deleterious
consequences for vulnerable popula-
tions; or 4) existing policies were not
suciently evaluated to determine
dierential impacts among vulner-
able populations. Once the policy
dilemma was fully assessed, identi-
cation of strategic policy opportu-
nities involved equity-focused dis-
covery and collaborative eorts that
informed the development of new
policies, engaged key policy stake-
holders, informed policy agenda set-
ting eorts, and guided evaluation of
the policies among populations with
established health disparities. e
McKinlay Model for Health Pro-
motion was utilized across the TCC
research portfolio to describe and
organize both policy dilemmas that
required deeper analysis, and op-
portunities to inform policy change
at three levels of inuence: down-
stream, midstream, and upstream.
Table 3. Applying a health equity lens to policy across five subprojects of the TCC: issue identification
Identify health
equity issue
and affected
population
Collaborative
Action for Child
Equity (CACE)
Project THRIVE
Health Information
Technology (HIT)
Policy
Health360x Health Policy
Training
Health equity issue Prevalence of
childhood obesity
and threats to positive
childhood mental
health
Prevalence of
depression and the
delivery of low quality
mental health services
Potential for HIT
to reduce existing
disparities, create new
disparities, or widen
disparities in health
outcomes
Prevalence and
severity of diabetes,
obesity and other
chronic conditions
Prevalence of policies
and practices that
create, sustain,
or widen health
disparities compared
with policies and
practices that create or
advance health equity
Health policy issue Parents and
policymakers have
the potential to
impact childhood
obesity, mental
health disparities and
academic success
through supportive,
culturally tailored
quality parenting
programs
Health care clinics and
system policies should
support culturally
centered models
of integrated care,
guiding staff training
and education,
clinical service
provision, and use of
health information
technology
HIT policies may be
exacerbating existing
disparities; community
stakeholders including
primary care
physicians, public
health professionals
are often not engaged
in the policymaking
process
Diabetic patients
are empowered to
manage their health
with support programs
including culturally
tailored peer support
and HIT
Health policy training
programs that integrate
health equity develop
leaders prepared to
advance health equity
Affected population African Americans
living in under-
resourced
communities as
compared with the
general population
Racial/ethnic
minority groups,
individuals with
low socioeconomic
status (SES) and other
vulnerable populations
with known mental
health disparities
Underserved
and vulnerable
populations,
including racial/
ethnic minorities,
LGBTQ, people
with disabilities,
rural populations,
Medicaid recipients
and the health care
providers serving these
populations
Racial and ethnic
minorities in the South
with diabetes, obesity
and other chronic
conditions
Health policy
leaders, health
professionals enrolled
in the SHLI Health
Policy Leadership
Fellowship and the
Community Health
Leadership Program
and the organizations/
communities they
serve

Ethnicity & Disease, Volume 29, Supplement 2, 2019 335
Evaluating Health Policy with Health Equity Lens - Douglas et al
Develop Policy-relevant
Research Strategies in
Partnership with Community
Stakeholders (Table 5)
Key features of the TCC’s applica-
tion of a health equity lens were in-
clusivity of aected stakeholders, use
of innovative approaches to conduct
health policy-relevant research and
multidisciplinary research teams. is
required the TCC to understand how
individual and community health
were both a product and predictor of
community capacity so that commu-
nity-level engagement in solutions to
achieve health equity were incentiv-
ized. Academic and community part-
ners each contributed signicantly to
research design and implementation.
e TCC research activities were
strategically designed to: 1) lead ef-
forts to educate priority populations
about health equity issues and em-
power these communities to engage
in the policymaking process; and 2)
build strategic partnerships and col-
laborations that address health equity
issues to develop strength in numbers
and a unied voice to inform po-
tential solutions. Opportunities for
cross-sector collaboration were em-
phasized and strategically developed
to inform and develop health-related
policies that improved priority popu-
lation health across multiple health
outcomes. e TCC intentionally
worked to integrate research nd-
ings into policy development and
implementation to evaluate impact
and eectiveness of health policies
and build community capacity for
sustaining the health equity eort.
Measure & Evaluate Policy
Outcomes and Impacts on
Health Disparities (Table 6)
Measuring and providing suf-
cient evidence of the eectiveness
Table 4. Applying a health equity lens to policy across five subprojects of the TCC: policy analysis and identify opportunities
for informing policy
Analyze relevant
policy impacts
and opportunities
for policy
improvement
Collaborative Action
for Child Equity
(CACE)
Project THRIVE
Health Information
Technology (HIT)
Policy
Health360x Health Policy
Training
McKinlay
Model Level of
Intervention
Downstream,
Midstream, Upstream
Downstream,
Midstream, Upstream
Downstream,
Midstream, Upstream
Downstream,
Midstream
Downstream,
Midstream, Upstream
Level of Policy
Research/
Intervention
Evaluate impact of
SSC quality parenting
program on childhood
obesity and mental
health (downstream);
Assess impact of
state and local
policies on childhood
obesity and mental
health (midstream
& upstream);
Inform current and
proposed policies to
enhance provision of
equitable early child
development programs
(upstream)
Activate patients to
seek mental health
care through data
and shared decision-
making (downstream);
Inform provider and
practice-level policies
that ensure integration
between primary
care and behavioral
health providers,
sharing clinical
information and team-
based coordination
(downstream &
midstream); Evaluate
impact of culturally
centered integrated
care model on system/
clinic policies related
to quality, safety,
efficiency and disparity
reduction (midstream);
Analyze population-
level characteristics of
Medicaid patients with
depression (upstream)
Assess state and
federal laws for impact
on health equity
(upstream); Analyze
implementation of
HIT policies by health
care providers and
systems (midstream);
Inform, engage
and activate health
care providers and
communities to inform
HIT policies regarding
impact on health
equity (midstream &
downstream)
Assess provider,
practice and system
barriers and facilitators
to implementing
a technology-
based chronic care
management program
in an accountable
care organization
(downstream &
midstream); Evaluate
effectiveness of
a technology-
based chronic
care management
program on diabetes
outcomes and
patient management
(downstream)
Examine the workforce
and training needs for
health policy leaders
focused on health
equity (midstream &
upstream); Evaluate
training outcomes
for a health policy
fellowship program
focused on health
equity (downstream)

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336
Evaluating Health Policy with Health Equity Lens - Douglas et al
of interventions is one of many bar-
riers to implementing actionable
health policies.20 is is especially
true when evaluating complex sys-
tems, issues and interventions lead-
ing to health disparities. erefore,
it was critical to determine how pol-
icy outcomes and impacts would be
measured and evaluated early in the
planning process. e TCC imple-
mented a participatory approach to
develop evaluation plans that would
eectively measure not just the pres-
ence or change to a policy, but how
the TCC’s multi-level policy inter-
ventions impacted health disparities.
Stakeholders were engaged and expert
input from community, research, and
health policy leaders were used to
determine TCC outcome measures.
Project-specic logic models were
developed collaboratively to align
project activities with expected pol-
icy impacts. Quarterly plans and re-
ports were submitted to continuously
track the key strategies, outputs and
outcomes associated with projected
impacts. Evaluation of the TCC sub-
projects also focused on creating or
revising quantitative and qualitative
assessment measures associated with
the policy impact of TCC projects.
Assessment tools were identied, re-
vised, or developed to include down-
stream, midstream, and upstream
policy outcomes in the TCC McKin-
lay model; Table 6 provides specic
examples. Some of the overarching
downstream policy outcomes across
Table 5. Applying a health equity lens to policy across five subprojects of the TCC: developing policy-relevant research
strategies
Develop policy-
relevant research
strategies in
partnership
with community
stakeholders
Collaborative Action
for Child Equity
(CACE)
Project THRIVE
Health Information
Technology (HIT)
Policy
Health360x Health Policy
Training
Research/
Intervention
Strategy
Community-based
participatory research
(CBPR) approaches
empower and activate
parents to deepen
their understanding
of quality parenting
strategies and impact
on childhood obesity
and mental health.
CBPR changed the
current paradigm
of external policy
advocacy to one in
which historically
disenfranchised
communities provide
leadership in policy
development and
advocacy.
Mixed methods
research, including
focus groups, clinical
intervention and
secondary data
analysis, and a CBPR
approach inform a
patient-centered and
iterative research
strategy to implement
a culturally centered
integration treatment
intervention in primary
care community
health clinic.
Mixed methods
research, including
content analysis,
secondary data
analysis, key informant
interviews and gap
analysis identified
policy barriers and
facilitators to use of
HIT to advance health
equity. Guidance
from the literature,
key informants and
a national advisory
board resulted in
research questions
related to priority
areas.
Mixed methods
research, including
focus groups, a clinical
intervention and
a CBPR approach
were used to inform
a patient-centered
and iterative
research strategy to
implement Heath
360x, a culturally
tailored diabetes
support program
and technology
intervention in the
Morehouse Healthcare
ACO and community
practices.
Conduct a health
policy leaders’
needs assessment
survey informed
by an advisory
board composed
of institutional
and community-
based stakeholders
and experts. This
evaluation of
fellowship outcomes
was unique in its focus
on career trajectories,
subsequent leadership
roles, engagement in
and impact on health
policy and health
equity-relevant work.
Community
Engagement
Community cores are
developed in each
SSC site to serve as
points-of-contact
for establishing
local TCCs and
building community
infrastructure and
capacity for the
implementation of SSC
to address childhood
obesity, mental health,
and school readiness
by promoting quality
parenting.
Patients, providers
and practice
administrators inform
the intervention
design and strategy
through key informant
interviews and focus
groups.
A coalition of primary
care providers and
clinics, policymakers
and community
organizations were
leveraged to bilaterally
communicate the
impact of existing HIT
policies and potential
impacts of proposed
state and federal HIT
policies.
Patients, community
leaders, providers
and practice
administrators inform
the intervention
design and strategy
through key informant
interviews and focus
groups.
Collaborate with
organizational
partners, health policy
leaders and health
policy fellows to
identify health equity
issues and develop
projects and resources
to inform policies that
advance health equity.

Ethnicity & Disease, Volume 29, Supplement 2, 2019 337
Evaluating Health Policy with Health Equity Lens - Douglas et al
the TCC and its subprojects includ-
ed: changes in individual knowl-
edge and capacity on the impact of
health policies on health disparities;
and changes in individual behaviors
that advance health equity. Over-
arching midstream policy outcomes
included: changes in organizational
and community knowledge; changes
in capacity to implement policies
and practices; development and
implementation of evidence-based
practices to reduce health dispari-
ties and collaborations to implement
programs; and introduction/adop-
tion of policies that would reduce
health disparities and advance health
equity. Overarching upstream policy
outcomes were: change in knowl-
edge and capacity on the impact of
policy on health disparities by deci-
sion makers and government o-
cials; change in funding for advanc-
ing health equity policy; and change
in public and organizational poli-
cies that address health disparities.
Disseminate Findings to
Relevant Audiences and
Stakeholders (Table 7)
Broad dissemination of research
evidence and outcomes is critical to
policy development and implemen-
tation that address health dispari-
ties. Gaps between policy, research
and practice are well understood
Table 6. Applying a health equity lens to policy across five subprojects of the TCC: measurement and evaluation
Measure and
evaluate policy
outcomes on
health disparities
Collaborative Action
for Child Equity
(CACE)
Project THRIVE
Health Information
Technology (HIT)
Policy
Health360x Health Policy
Training
Downstream
outcomes
Changes in parent
knowledge about
healthier lifestyles;
Changes in parent
motivation to change
their own and their
family’s health
behaviors; Changes
in parent knowledge
and desire to advocate
for improved policies
relating to healthy
child development.
Patient outcomes after
exposure to culturally
tailored intervention;
perceived care-seeking
behaviors of targeted
patients; Knowledge
of integrated care
models; Awareness
and attitudes related
to culturally tailored
integrated care
models.
Types & characteristics
of providers adopting
EHR; characteristics
of Medicaid enrollees
receiving telemedicine
services.
# of patients enrolled;
Effectiveness of
intervention in
improving diabetes
management;
Provider-level
workflow issues.
# of and
characteristics
of fellows who
completed program;
# of fellows with full-
time employment by
sector; Promotions/
leadership roles since
fellowship completion;
Importance of/role
of health disparities
and health equity in
current position.
Midstream
outcomes
Extent to which
existing local policies
ensure receipt of
appropriate early
child development
resources and program
effectiveness in
supporting community
participation.
Perceived barriers/
facilitators to
incorporating culturally
tailored integrated
care models into
clinical practice.
System and
community-level
barriers and facilitators
to adoption and
implementation of
HIT in underserved
communities.
# of practices enrolled
and connected to data
warehouse; Amount
of data flowing;
System-level barriers
and facilitators to
integration.
Service on local, state,
and national health
advisory boards;
Promotions/leadership
roles since fellowship
completion; Develop,
implement or change
public policy that
address health
disparities.
Upstream
outcomes
Extent to which
existing state policies
ensure receipt of
appropriate early
child development
resources; Post-
implementation
demonstration of
improvement in
mental health, school
readiness, reduction
in child neglect
and obesity among
vulnerable children in
minority communities.
Secondary data
analysis of Medicaid
claims including
patients similar to
study sample (racial/
ethnic minority,
Depression diagnosis,
1+ chronic condition).
Categories of
demographic data
included in federal
EHR technology
programs; Inclusion
of health equity
language in proposed,
final policies; Health
equity implications
of proposed/ final
policies.
N/A Service on local, state,
and national health
advisory boards;
Promotions/leadership
roles since fellowship
completion; Develop,
implement or change
public policy that
address health
disparities.

Ethnicity & Disease, Volume 29, Supplement 2, 2019
338
Evaluating Health Policy with Health Equity Lens - Douglas et al
Table 7. Applying a health equity lens to policy across five subprojects of the TCC – strategic dissemination
Disseminate
findings to
relevant audiences
& stakeholders
Collaborative Action
for Child Equity
(CACE)
Project THRIVE Health IT Policy Health360x Health Policy
Training
Academic
dissemination
Publication in peer-
reviewed journals;
Presentation at
national conferences
Publication in peer-
reviewed journals;
Presentation at
national, state
conferences
Publication in peer-
reviewed journals;
Presentation at
national, state
conferences
Publication in peer-
reviewed journals;
Presentation at
national, state
conferences
Publication in peer-
reviewed journals;
Presentation at
national, state and
local conferences
Community
dissemination
Development of
policy briefs for
targeted audiences;
Community/
coalition meetings &
presentations
Development of policy
briefs, infographic
targeted for lay
audience, trivia game
focused on cultural
competency and
integrated care;
Community education
Continuous
cycle of bilateral
communication
with health care
providers, community
organizations and
policymakers to
inform existing and
developing policies
using social media,
webinars, public
comments
Community-level
presentations and
forums
Inclusion of outcome
data in marketing/
promotion materials
Policy
dissemination
Development of policy
briefs for targeted
audiences; Webinar
with partners
Development of policy
briefs, infographic
targeted for lay
audience, trivia game
focused on cultural
competency and
integrated care
Continuous
cycle of bilateral
communication
with health care
providers, community
organizations and
policymakers to
inform existing and
developing policies
using social media,
webinars, public
comments, advisory
board meetings
N/A Inclusion of outcome
data in marketing/
promotion materials
and the evolution of dissemination
and implementation science seeks to
bridge across these silos. One foun-
dational challenge is the incentive
by funding agencies and academic
institutions to publish research nd-
ings in scientic journals, which are
not accessible to many individuals,
communities, health care providers
and policymakers. Broad methods of
dissemination including social me-
dia, webinars and blogs are promis-
ing to get scientic evidence into
the hands of those most aected.
e TCC prioritized broad dis-
semination of its research ndings
through an established dissemina-
tion and implementation core, which
worked directly with the subprojects
to ensure strategic and intentional
early planning for broad dissemina-
tion. All subprojects published nd-
ings in scientic journals, but dissem-
ination did not stop there.21-24 Social
media (eg, Twitter pages/handles: @
MSMTCCPolicy, @TCC_HITPo-
licy, @Kennedy-Satcher, @Satch-
erHP) , webinars, blogs, infograph-
ics, and policy briefs were developed
to inform downstream, midstream
and upstream policy.25-27 As shown
in Figures 2 and 3, the TCC devel-
oped infographics to help communi-
cate complex ndings from the TCC
subprojects to multiple audiences. In
addition, the Health Equity Leader-
ship and Exchange Network (http://
www.nationalcollaborative.org/
our-programs/health-equity-lead-
ership-exchange-network-helen/), a
collaborative eort between the Na-
tional REACH Coalition, Morehouse
School of Medicine, and the Na-
tional Collaborative for Health Eq-
uity, was established to share research
ndings and policy opportunities.
exPandIng tHe HealtH
equIt y lens
Although challenges remain rela-
tive to the advancement of health
equity in all policies, it nonethe-

Ethnicity & Disease, Volume 29, Supplement 2, 2019 339
Evaluating Health Policy with Health Equity Lens - Douglas et al
Project THRIVE
Phase I
Qualitative Data
Collection (Focus
Groups and Key
Informant Interviews
Phase I Outcomes
Provided the
building blocks for
development of
integrated care model
Phase II Implementation
Behavioral health consultant
(BHC) introduced into each of
the 3 Grady Primary Care clinics
Phase II
Intervention introduced
at 3 community-based
primary care clinics
affiliated with Grady
Health System
Technology
Culturally centered training
video developed; M3 and
Healthify used in clinics for
patients screening
Patient Engagement
330 adults referred for
consultation
174 seen by the BHC
136 have co-occurring chronic
diseases with depressive
symptoms
Leadership
Development
Two of the collaborating
Grady clinics enroll in the
SHLI Integrated Care
Leadership Program
Communication and
Dissemination
23 professional & community
presentations
9 publications
7 media engagement
1 secondary data analysis of
HHS Region IV Medicaid data
1 health policy/issue brief
Sustainability
Continuing to explore
and submit to several
funding opportunities
toward project
sustainability
Overall Health and Wellness
TCC Subproject 2
For more information, contact: Kisha Holden, PhD, MSCR at kholden@msm.edu or Allyson Belton, MPH at abelton@msm.edu
There is no health without mental health
~David Satcher, MD, PhD
Towards Health Recovery and
Integrated Vital Engagement
What’s My M3
Figure 2. TCC Project THRIVE infographic

Ethnicity & Disease, Volume 29, Supplement 2, 2019
340
Evaluating Health Policy with Health Equity Lens - Douglas et al
1
2
3
6
5
4
Informing Health Equity Policy
The Public Comment Process
Congress passes law
with health equity language (ex. Hitech Act)
or with health equity implications (ex. MACRA)
Administrative agency proposes how it should be implemented
Proposed Rule
All administrative agencies propose regulations via this process. The
proposed rule is published in the Federal Register for the public to review.
PUBLIC COMMENTS
STAKEHOLDERS
YOUR
VOICE
MATTERS
ORGANIZATIONSLAYTECH
PEOPLE
HOSPITALSPROVIDERS
VENDORS
OPEN TO
PUBLIC
30-60 days
Public Com-
ment Period
(Anyone can
submit)
Agency
considers
all public
comments
Agency
publishes
nal rule
Stakeholders
tasked with
implementing
the regulation
Opportunities for Health Equity
- Apply a health equity lens to proposed rule provisions
(vs. analysis of impact on general population)
- Provide evidence-base for all recommendations
- Clearly articulate impact of proposed rule on disparity populations
(as compared with general population)
- Disseminate analysis broadly via webinars, social media, direct outreach
Current Barriers to Engagement
- Proposed rules are lengthy and dense
- Each agency has dierent public comment submission protocols
- Many stakeholders lack policy capacity (esp. small, rural, underserved)
- Prioritization of health equity makes message unication challenging
NATIONAL CENTER
FOR PRIMARY CARE
Figure 3. TCC HIT policy infographic

Ethnicity & Disease, Volume 29, Supplement 2, 2019 341
Evaluating Health Policy with Health Equity Lens - Douglas et al
less remains a national priority, as
evidenced by its inclusion in federal,
state, and local governmental poli-
cies.28 Alignment of public health,
social services and health care -
nance and delivery is challenging and
needed to accomplish sustainable im-
provement. As demonstrated by the
TCC’s work, policies play a major
role in the achievement of health eq-
engaging, informing and empowering
community members to understand
the role of policy and mechanisms
for informing policy improvements.
Community organizers and non-
prot organizations are the experts on
issues relevant to their communities
and excel at activating their stake-
holders and academic institutions
and researchers. Partnering with aca-
demic institutions creates a bridge for
the evidence to ow into communi-
ties and to identify the role of policy.
In order to achieve health equity,
the current policy landscape and in-
centive structures require signicant
changes. e TCC found that lan-
guage and context are important and
that including health equity language
in laws and organizational policies
provides an upstream foundation for
ensuring the laws are implemented
at the midstream and downstream
levels to advance health equity.
conclusIon
Achieving health equity is not
merely a moral imperative but ben-
ets all communities. e nancial
and social costs of health disparities
are signicant and will continue to
grow without application of a health
equity lens to research, practice and
policy. e TCC for Health Dispari-
ties Research at Morehouse School of
Medicine applied a health equity lens
by employing these ve steps: 1) iden-
tify the health equity issue and aect-
ed population; 2) analyze the relevant
policy impacts and opportunities for
policy improvement; 3) develop poli-
cy-relevant research strategies in part-
nership with community stakehold-
ers; 4) measure and evaluate policy
outcomes and impacts on heath dis-
parities; and 5) disseminate ndings
to relevant audiences and stakehold-
ers, including policy makers, com-
munities, public health ocials, and
healthcare providers. is strategy
leveraged transdisciplinary research
teams and empowered community
members to engage in the research
and policy processes. e TCC’s re-
search resulted in important ndings
for policy development and imple-
mentation that advance health equity.
acKnowledgMents
Research reported in this publication was
supported by the National Institute on Mi-
nority Health and Health Disparities of the
National Institutes of Health under Award
Number U54MD008173. e content is
solely the responsibility of the authors and
does not necessarily represent the ocial
views ofthe National Institutes of Health.
e authors acknowledge the TCC subproj-
ect principle investigators, research and ad-
ministrative sta and the TCC Research Core
for their contributions to this manuscript.
C  I
No conicts of interest to report.
A C
Research concept and design: Douglas,
Rollins, Tabor, Heiman, Hopkins, Holden;
Acquisition of data: Douglas, Respress,
Hopkins; Data analysis and interpretation:
Douglas, Josiah Willock, Dawes, Holden;
Manuscript draft: Douglas, Josiah Willock,
Respress, Rollins, Tabor, Heiman, Hopkins,
Dawes, Holden; Statistical expertise: N/A;
Acquisition of funding: Dawes; Adminis-
trative: Douglas, Josiah Willock, Respress,
Tabor, Heiman, Hopkins, Dawes, Holden;
Supervision: Douglas, Tabor, Hopkins,
Holden
R
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