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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.
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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.
Ethnicity & Disease, Volume 29, Supplement 2, 2019
330
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.
Ethnicity & Disease, Volume 29, Supplement 2, 2019
332
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)
Ethnicity & Disease, Volume 29, Supplement 2, 2019
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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... Additionally, health equity is receiving increased attention within implementation science, underscoring the impact of the SDOH on mental health outcomes (Allen et al., 2014;Compton and Shim, 2015;Shim & Compton, 2020;World Health Organization & Calouste Gulbenkian Foundation, 2014). There are growing calls for improved integration of equity-related constructs into implementation methods, models, and measures (Baumann & Long, 2021;Brownson et al., 2021;Chinman et al., 2017;Douglas et al., 2019;Exworthy, 2008;Loper et al., 2021;Metz et al., 2021;Oh et al., 2021;Woodward et al., 2021). However, little is known about the current state of equity-related constructs in mental health policy implementation. ...
... Notably, health equity was assessed in few quantitative measures of mental health policy implementation, which has been reported in previous studies of policy measures . Moving forward, it will be vital to engage policymakers in this pursuit of equity, as they have considerable potential to impact health, such as allocating resources to and developing appropriate policies (Douglas et al., 2019). Connecting with community members and other stakeholders to identify and address health equity issues during implementation might also prove useful (Douglas et al., 2019). ...
... Moving forward, it will be vital to engage policymakers in this pursuit of equity, as they have considerable potential to impact health, such as allocating resources to and developing appropriate policies (Douglas et al., 2019). Connecting with community members and other stakeholders to identify and address health equity issues during implementation might also prove useful (Douglas et al., 2019). Additional work is needed to bridge health equity research and implementation science, both theoretically (e.g., within frameworks) and practically (e.g., pragmatic equity measures) Pollack Porter et al., 2018;Woodward et al., 2021). ...
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Background Mental health is a critical component of wellness. Public policies present an opportunity for large-scale mental health impact, but policy implementation is complex and can vary significantly across contexts, making it crucial to evaluate implementation. The objective of this study was to (1) identify quantitative measurement tools used to evaluate the implementation of public mental health policies; (2) describe implementation determinants and outcomes assessed in the measures; and (3) assess the pragmatic and psychometric quality of identified measures. Method Guided by the Consolidated Framework for Implementation Research, Policy Implementation Determinants Framework, and Implementation Outcomes Framework, we conducted a systematic review of peer-reviewed journal articles published in 1995–2020. Data extracted included study characteristics, measure development and testing, implementation determinants and outcomes, and measure quality using the Psychometric and Pragmatic Evidence Rating Scale. Results We identified 34 tools from 25 articles, which were designed for mental health policies or used to evaluate constructs that impact implementation. Many measures lacked information regarding measurement development and testing. The most assessed implementation determinants were readiness for implementation, which encompassed training ( n = 20, 57%) and other resources ( n = 12, 34%), actor relationships/networks ( n = 15, 43%), and organizational culture and climate ( n = 11, 31%). Fidelity was the most prevalent implementation outcome ( n = 9, 26%), followed by penetration ( n = 8, 23%) and acceptability ( n = 7, 20%). Apart from internal consistency and sample norms, psychometric properties were frequently unreported. Most measures were accessible and brief, though minimal information was provided regarding interpreting scores, handling missing data, or training needed to administer tools. Conclusions This work contributes to the nascent field of policy-focused implementation science by providing an overview of existing measurement tools used to evaluate mental health policy implementation and recommendations for measure development and refinement. To advance this field, more valid, reliable, and pragmatic measures are needed to evaluate policy implementation and close the policy-to-practice gap. Plain Language Summary Mental health is a critical component of wellness, and public policies present an opportunity to improve mental health on a large scale. Policy implementation is complex because it involves action by multiple entities at several levels of society. Policy implementation is also challenging because it can be impacted by many factors, such as political will, stakeholder relationships, and resources available for implementation. Because of these factors, implementation can vary between locations, such as states or countries. It is crucial to evaluate policy implementation, thus we conducted a systematic review to identify and evaluate the quality of measurement tools used in mental health policy implementation studies. Our search and screening procedures resulted in 34 measurement tools. We rated their quality to determine if these tools were practical to use and would yield consistent (i.e., reliable) and accurate (i.e., valid) data. These tools most frequently assessed whether implementing organizations complied with policy mandates and whether organizations had the training and other resources required to implement a policy. Though many were relatively brief and available at little-to-no cost, these findings highlight that more reliable, valid, and practical measurement tools are needed to assess and inform mental health policy implementation. Findings from this review can guide future efforts to select or develop policy implementation measures.
... 19-22 24 25 Applying an equity lens to policies goes beyond disaggregating data by sociodemographics to considering 'social, behavioral, economic and environmental determinants, and (working) collaboratively with community stakeholders'. 26 Systematic reviews of population-level general tobacco control interventions and policies for youth and adults found a majority to have negative, mixed or unclear impacts on inequities. [27][28][29] This has led to calls to adopt an equity perspective to tobacco control policymaking 30 and use theory as a guide. ...
... The PROGRESS framework allows for the extension of analysis of prevalence data towards 'social, behavioral, economic and environmental determinants'. 26 Yet, even with the simple PROGRESS analysis, we found very little data that allow a determination of the impact of WTS policies on equity. Further, we found a disconnect between the equity indicators included in a policy and the prevalence data collected, and neither seemed to inform the other. ...
Article
Introduction The Framework Convention on Tobacco Control (FCTC) offers guidance on evidence-based policies to reduce tobacco consumption and its burden of disease. Recently, it has provided guidance for alternative tobacco products, such as the waterpipe. Waterpipe tobacco smoking (WTS) is prevalent worldwide and policies to address it need to take into consideration its specificities as a mode of smoking. In parallel, a growing body of literature points to the potential of evidence-based tobacco control policies to increase health inequities. This paper updates a previous global review of waterpipe tobacco policies and adds an equity lens to assess their impact on health inequities. Methods We reviewed policies that address WTS in 90 countries, including 10 with state-owned tobacco companies; 47 were included in our final analysis. We relied primarily on the Tobacco-Free Kids organisation’s Tobacco Control Laws website, providing access to tobacco control laws globally. We categorised country tobacco policies by the clarity with which they defined and addressed waterpipe tobacco in relation to nine FCTC articles. We used the PROGRESS (Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status and Social capital) framework for the equity analysis, by reviewing equity considerations referenced in the policies of each country and including prevalence data disaggregated by equity axis and country where available. Results Our results revealed very limited attention to waterpipe policies overall, and to equity in such policies, and highlight the complexity of regulating WTS. We recommend that WTS policies and surveillance centre equity as a goal. Conclusions Our recommendations can inform global policies to reduce WTS and its health consequences equitably across population groups.
... Without a health equity focus to policy, practice and research, health inequities will not be effectively reduced [61] through population-based PA promotion approaches. Rather, if health equity is neglected, our review of reviews shows that there is a risk that such approaches will not reach those who would need it most, potentially widening the health inequity gap. ...
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Background The extent to which people are physically active is dependent upon social gradients. Numerous studies have shown that especially people with social disadvantages do not meet the physical activity (PA) recommendations. A promising strategy to alleviate this issue are approaches that promote PA in the general population. In addition, several researchers have raised concerns that population-based health interventions may increase health inequities. The aim of the current review of reviews was therefore to identify successful population-based PA promotion approaches with a particular focus on health equity. Methods Six electronic databases were examined for systematic reviews on population-based PA promotion for the period 2015 to 2021. A reference list and grey literature search were also conducted. Two independent reviewers used inclusion/exclusion criteria to screen titles and abstracts of the potentially relevant literature and conducted a quality assessment for each identified review. All included reviews of population-based approaches for PA promotion with a focus on disadvantaged populations and/or health equity were narratively summarized. Results Our search resulted in 4,411 hits. After a systematic review process, six reviews met the inclusion criteria and were included after they were all rated as high quality. We identified that mass-media campaigns, point-of-decision prompts, environmental approaches, policy approaches, and community-based multi-component approaches can promote PA in the general population. Across populations with social disadvantages mass-media campaigns, point-of-decision prompts and policy approaches are likely to be effective as long as they are tailored. Regarding environmental approaches, the results are inconsistent. None of the reviews on community-based multi-component approaches provided evidence on health equity. Conclusion There are several effective approaches to promote PA in the general population but evidence regarding health equity is still sparse. Future studies should therefore pay more attention to this missing focus. Furthermore, there is a lack of evidence regarding the type of tailoring and the long-term impact of population-based approaches to PA promotion. However, this requires appropriate funding programmes, complex study designs and evaluation methods.
... • explicit criteria for why race and ethnicity are being used as variables in research 34 • collection of biological and socioeconomic variables • examination and discourse when whiteness is used as a reference value • intention and deliberate action to not use whiteness as reference value • application of an equity lens to research design and clinical implications 35,36 • opportunity for research subjects to self-identify their demographic information to include qualitative descriptions of their known genetic ancestry Reframe medical education with a health equity lens Assure there is: ...
Article
Over the past several years, in both clinical and academic medicine, there seems to be a growing consensus that racial/ethnic health inequities result from social, economic and political determinants of health rather than from nonexistent biological markers of race. Simply put, racism is the root cause of inequity, not race. Yet, methods of teaching and practicing medicine have not kept pace with this truth, and many learners and practitioners continue to extrapolate a biological underpinning for race. To achieve systemic change that moves us toward racially/ethnically equitable health outcomes, it is imperative that medical academia implement policies that explicitly hold us accountable to maintain a clear understanding of race as a socio-political construct so that we can conduct research, disseminate scholarly work, teach, and practice clinically with more clarity about race and racism. This short commentary proposes the use of a socioecological framework to help individuals, leadership teams, and institutions consider the implementation of various strategies for interpersonal, community-level, and broad institutional policy changes. This proposed model includes examples of how to address race and racism in academic medicine across different spheres, but also draws attention to the complex interplay across these levels. The model is not intended to be prescriptive, but rather encourages adaptation according to existing institutional differences. This model can be used as a tool to refresh how academic medicine addresses race and, more importantly, normalizes conversations about racism and equity across all framework levels.
... The commitment of the AAP to the well-being of all children requires that it not only address a wide spectrum of adversities but, also, that it speak against public policies, social constructs, and societal norms that perpetuate the ongoing, chronic precipitants of toxic stress responses such as poverty 87,88 and racism 166 and for public policies that promote relational health, inclusion, and equity. 111,[188][189][190][191] ...
Article
By focusing on the safe, stable, and nurturing relationships (SSNRs) that buffer adversity and build resilience, pediatric care is on the cusp of a paradigm shift that could reprioritize clinical activities, rewrite research agendas, and realign our collective advocacy. Driving this transformation are advances in developmental sciences as they inform a deeper understanding of how early life experiences, both nurturing and adverse, are biologically embedded and influence outcomes in health, education, and economic stability across the life span. This revised policy statement on childhood toxic stress acknowledges a spectrum of potential adversities and reaffirms the benefits of an ecobiodevelopmental model for understanding the childhood origins of adult-manifested disease and wellness. It also endorses a paradigm shift toward relational health because SSNRs not only buffer childhood adversity when it occurs but also promote the capacities needed to be resilient in the future. To translate this relational health framework into clinical practice, generative research, and public policy, the entire pediatric community needs to adopt a public health approach that builds relational health by partnering with families and communities. This public health approach to relational health needs to be integrated both vertically (by including primary, secondary, and tertiary preventions) and horizontally (by including public service sectors beyond health care). The American Academy of Pediatrics asserts that SSNRs are biological necessities for all children because they mitigate childhood toxic stress responses and proactively build resilience by fostering the adaptive skills needed to cope with future adversity in a healthy manner.
Article
Background For informal carers of people with life-limiting illness, social welfare policy related to income support and housing has been associated with varied psychosocial issues, yet remains relatively under-explored. An intersectional approach offers potential to illuminate diverse experiences and implications. Aim To explore the way in which caring in the context of life-limiting illness is framed within welfare policy, to articulate inequities encountered by carers, and to identify policy and practice recommendations. Design The Intersectionality-Based Policy Analysis (IBPA) Framework was used to situate findings of a broader qualitative study. Setting/participants Data were collected via semi-structured interviews with participants who were bereaved carers ( n = 12), welfare workers ( n = 14) and palliative care workers ( n = 7), between November 2018 and April 2020, in an Australian region associated with socioeconomic disadvantage. Five elements of IBPA were applied to the products of analysis of this data. Results Use of the IBPA Framework revealed that representations of carers and causes of their welfare needs in policy were underpinned by several assumptions; including that caring and grieving periods are temporary or brief, and that carers have adequate capacity to navigate complex systems. Policy and processes had differentiated consequences for carers, with those occupying certain social locations prone to accumulating disadvantage. Conclusions This intersectional analysis establishes critical exploration of the framing and consequences of welfare policy for carers of people with life-limiting illness, presented in a novel conceptual model. Implications relate to intersectoral development of structural competency, responsiveness to structurally vulnerable carers in clinical practice, and needed policy changes.
Article
Objective: We provide guidance for considering equity in rapid reviews through examples of published COVID-19 rapid reviews. Study design and setting: This guidance was developed based on a series of methodological meetings, review of internationally renowned guidance such as the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for equity-focused systematic reviews (PRISMA-Equity) guideline. We identified Exemplar rapid reviews by searching COVID-19 databases and requesting examples from our team. Results: We proposed the following key steps: 1. involve relevant stakeholders with lived experience in the conduct and design of the review; 2. reflect on equity, inclusion and privilege in team values and composition; 3. develop research question to assess health inequities; 4. conduct searches in relevant disciplinary databases; 5. collect data and critically appraise recruitment, retention and attrition for populations experiencing inequities; 6. analyse evidence on equity; 7. evaluate the applicability of findings to populations experiencing inequities; and 8. adhere to reporting guidelines for communicating review findings. We illustrated these methods through rapid review examples. Conclusion: Implementing this guidance could contribute to improving equity considerations in rapid reviews produced in public health emergencies, and help policymakers better understand the distributional impact of diseases on the population.
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The National Academy of Medicine (NAM) recently released the Future of Nursing 2020-2030 focused on charting a path to achieve health equity. This article focuses on the critical role of nursing education in this call for action. Most specifically, we provide an overview of the process of developing a diversity, equity, and civility council in a school of nursing to promote equity, inclusivity, and diversity grounded in social justice within the culture of the school for faculty, staff, and students. In addition, we describe the council's work to date highlighting goals and the council's plans for future work based on data-driven processes.
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Caring for and bereavement following the death of someone with a life-limiting illness may precipitate social welfare needs related to income support and housing. Nevertheless, carer experiences of welfare policy and institutions have not received significant attention. This qualitative study explored experiences of carers who navigated social welfare policy while caring for someone with a life-limiting illness, and in bereavement. In-depth interviews were conducted with 12 bereaved carers in an area associated with socioeconomic disadvantage. Carers differentially encountered precariousness, with some experiencing structural vulnerability. These positionalities appeared to be shaped by policy and process-related burdens, perceptions of the welfare state, and degrees of legitimisation or disenfranchisement of forms of capital and coping orientations. Recommendations that may improve carer experience were identified. Implications relate to the need for an expanded conceptualisation of vulnerability in health and welfare practice, policy that authentically validates caring and grieving, and upstream strategies that address inequity.
Article
There is growing recognition that health and well-being improvements have not been shared across populations in the Americas. This article analyzes 32 national health sector policies, strategies, and plans across 10 different areas of health equity to understand, from one perspective, how equity is being addressed in the region. It finds significant variation in the substance and structure of how the health plans handle the issue. Nearly all countries explicitly include health equity as a clear goal, and most address the social determinants of health. Participatory processes documented in the development of these plans range from none to extensive and robust. Substantive equity-focused policies, such as those to improve physical accessibility of health care and increase affordable access to medicines, are included in many plans, though no country includes all aspects examined. Countries identify marginalized populations in their plans, though only a quarter specifically identify Afro-descendants and more than half do not address Indigenous people, including countries with large Indigenous populations. Four include attention to migrants. Despite health equity goals and data on baseline inequities, fewer than half of countries include time-bound targets on reducing absolute or relative health inequalities. Clear accountability mechanisms such as education, reporting, or rights-enforcement mechanisms in plans are rare. The nearly unanimous commitment across countries of the Americas to equity in health provides an important opportunity. Learning from the most robust equity-focused plans could provide a road map for efforts to translate broad goals into time-bound targets and eventually to increasing equity.
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Background: Among children, there are substantial ethno-racial minority disparities across a broad range of health-related behaviors, experiences, and outcomes. Addressing these disparities is important, as childhood and adolescence establish health trajectories that extend throughout life. Methods: The current study employed a community-based participatory research approach to gain community insight on child health priorities and to frame an intervention aimed at improving the health of minority children. Eight focus groups were conducted among seventy-five African American parents in a Southeastern city. The current study was guided by an ecological theoretical framework. Results: Although the focus of this investigation was on community identification of child health priorities, participants cited, as root determinants, contextual factors, which included lack of healthy food options, lack of spaces for physical activity, and community violence. These co-occurring factors were related to limited engagement in outdoor activities and physical activity, increased obesity, and poor mental health and coping. Poor parenting was cited as the most substantial barrier to improving child health outcomes, and quality parenting was identified as the most important issue to address for community programs focused on promoting the health and success of children. For improving health outcomes for children in their neighborhoods, establishment of positive social capital and constructive activities were also cited. Conclusions: These results reinforce social determinants of health as influences on child health outcomes and describe how community engagement can address potential solutions through interventions that resonate with program participants.
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The context within which health care and public health systems operate is framed by health policies. There is growing consensus about the need for increased health policy leadership and a health professional workforce prepared to assume these leadership roles. At the same time, there is strong evidence supporting the need for a broader policy lens and the need to intentionally target health disparities. We reviewed the published literature between 1983 and 2013 regarding health policy training. From 5124 articles identified, 33 met inclusion criteria. Articles varied across common themes including target audience, goal(s), health policy definition, and core curricular content. The majority of articles were directed to medical or nursing audiences. Most articles framed health policy as health care policy and only a small number adopted a broader health in all policies definition. Few articles specifically addressed vulnerable populations or health disparities. The need for more rigorous research and evaluation to inform health policy training is compelling. Providing health professionals with the knowledge and skills to engage and take leadership roles in health policy will require training programs to move beyond their limited health care-oriented health policy framework to adopt a broader health and health equity in all policies approach.
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US breast cancer deaths have been declining since 1989, but African American women are still more likely than white women to die of breast cancer. Black/white disparities in breast cancer mortality rate ratios have actually been increasing. Across 762 US counties with enough deaths to generate reliable rates, county-level, age-adjusted breast cancer mortality rates were examined for women who were 35 to 74 years old during the period of 1989-2010. Twenty-two years of mortality data generated twenty 3-year rolling average data points, each centered on a specific year from 1990 to 2009. Mixed linear models were used to group each county into 1 of 4 mutually exclusive trend patterns. The most recent 3-year average black breast cancer mortality rate for each county was also categorized as being worse or not worse than the breast cancer mortality rate for the total US population. More than half of the counties (54%) showed persistent, unchanging disparities. Roughly 1 in 4 (24%) had a divergent pattern of worsening black/white disparities. However, 10.5% of the counties sustained racial equality over the 20-year period, and 11.7% of the counties actually showed a converging pattern from high disparities to greater equality. Twenty-three counties had 2008-2010 black mortality rates better than the US average mortality rate. Disparities are not inevitable. Four US counties have sustained both optimal and equitable black outcomes as measured by both absolute (better than the US average) and relative benchmarks (equality in the local black/white rate ratio) for decades, and 6 counties have shown a path from disparities to health equity. Cancer 2015. © 2015 American Cancer Society. © 2015 American Cancer Society.
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A National Center for Health Statistics report shows that U.S. life expectancy has decreased for 2 years. Age-adjusted mortality (1999–2016) shows that progress over the past decade in reducing disparities between blacks and whites has stalled and may be reversing.
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Background Public health leaders in Yellowstone County, Montana, formed an alliance to address community-wide issues. One such issue is Complete Streets, with its vision of safe streets for all. This case study focuses on development and adoption of a Complete Streets policy. It examines how a community coalition, Healthy By Design, infused a gender focus into the policymaking process. Methods An incremental and nonlinear policymaking process was aided by a focus on gender and health equity. The focus on a large constituency helped to frame advocacy in terms of a broad population's needs, not just special interests. Results The city council unanimously adopted a Complete Streets resolution, informed by a gender lens. Healthy By Design further used gender information to successfully mobilize the community in response to threats of repeal of the policy, and then influenced the adoption of a revised policy. Conclusions Policies developed with a focus on equity, including gender equity, may have broader impact on the community. Such policies may pave the way for future policies that seek to transform gender norms toward building a healthier community for all residents.
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Appalachia-a region that stretches from Mississippi to New York-has historically been recognized as a socially and economically disadvantaged part of the United States, and growing evidence suggests that health disparities between it and the rest of the country are widening. We compared infant mortality and life expectancy disparities in Appalachia to those outside the region during the period 1990-2013. We found that infant mortality disparities widened for both whites and blacks, with infant mortality 16 percent higher in Appalachia in 2009-13, and the region's deficit in life expectancy increased from 0.6 years in 1990-92 to 2.4 years in 2009-13. The association between area poverty and life expectancy was stronger in Appalachia than in the rest of the United States. We found wide health disparities, including a thirteen-year gap in life expectancy among black men in high-poverty areas of Appalachia, compared to white women in low-poverty areas elsewhere. Higher mortality in Appalachia from cardiovascular diseases, lung cancer, chronic lower respiratory diseases or chronic obstructive pulmonary disease, diabetes, nephritis or kidney diseases, suicide, unintentional injuries, and drug overdose contributed to lower life expectancy in the region, compared to the rest of the country.Widening health disparities were also due to slower mortality improvements in Appalachia. © 2017 Project HOPE-The People-to-People Health Foundation, Inc.
Article
In the United States, steps to advance health equity often take place at the state and local levels rather than the national level. Using publicly available data sources, we developed a scorecard for all fifty states and the District of Columbia that measures indicators of the use of five evidence-based policies to address domains related to health equity. The indicators are the cigarette excise tax rate, a state's Medicaid expansion status and the size of its coverage gap, percentage of four-year olds enrolled in state-funded pre-kindergarten, minimum wage level, and the presence of state-funded housing subsidy programs and homelessness prevention and rapid rehousing programs. We found that states varied significantly in their implementation of the selected policies and concluded that a variety of approaches to encourage policy changes at the state level will be needed to create healthier and more equitable communities. We describe promising, feasible state-level approaches for states to "do something, do more, do better" when they take action on the five selected policies that can promote health equity. © 2017 Project HOPE-The People-to-People Health Foundation, Inc.
Article
Introduction: Addressing the multifaceted health and mental health needs of ethnically and culturally diverse individuals is a challenge within the current health care system. Integrated care provides a promising approach to improve mental health treatment-seeking disparities; however, adaptation of care models to impact African Americans is lacking. Although resources to support engagement of diverse populations in depression care exist, little has been developed to tailor patient preferences in accessing and engaging mental health services that are integrated into primary care. Objective: Our research seeks to add a cultural focus to the existing literature concerning integrated health care models to help address depression and selected co-occurring chronic health conditions in primary care settings. Methods: Thirty-two adult patients of an integrated primary care clinic participated in focus groups discussing their individual health experiences. Nine health care practitioners/administrators from five different integrated practice settings in the Atlanta, GA, area participated in key informant interviews. Main outcome measures: Transcripts were analyzed for key themes related to depression care, perceived unmet cultural needs, and desired adaptations. Results: Common themes emerged such as the importance of peer-support and community engagement as areas of patient interest. Participants had good knowledge in recognizing depressive symptoms but were less knowledgeable about treatment options and expectations of treatment. The administrative and practitioner perspective suggests that patient preferences are valued and perceived as valid. Conclusion: It is critical that strategies and models are developed to improve health care among underserved minorities because current models offer variable efficacy among this population.
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A whole population (or purportedly “new”) public health approach is emerging which is characterized by (a) the promotion of health through upstream planned sociopolitical change; (b) appreciation of the ontologic and epistemologic limitations of risk-factor epidemiology to inform this new approach; (c) application of more appropriate methodologies (including both quantitative and interpretive methods); and (d) the incorporation of multi-level outcomes (including broader measures of qualities of life). Confronting this new public health, established epidemiology and community health methods are limited in three key ways: a dominant paradigm which produces atheoretical studies and the equation of infinite risks with causation; a restrictive focus on downstream individual behavior and interventions; and methodologies that produce a rigid adherence to positivist approaches which devalue complementary interpretive approaches. This paper considers the potential of the “new” public health approach to promote increased physical activity (and thereby autonomy and improved quality of life) among sedentary older adults.
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The science of eliminating health disparities is complex and dependent on demographic data. The Health Information Technology for Economic and Clinical Health Act (HITECH) encourages the adoption of electronic health records and requires basic demographic data collection; however, current data generated are insufficient to address known health disparities in vulnerable populations, including individuals from diverse racial and ethnic backgrounds, with disabilities, and with diverse sexual identities. We conducted an administrative history of HITECH and identified gaps between the policy objective and required measure. We identified 20 opportunities for change and 5 changes, 2 of which required the collection of less data. Until health care demographic data collection requirements are consistent with public health requirements, the national goal of eliminating health disparities cannot be realized.