Dimensionality and R4P: A Health Equity Framework for Research Planning and Evaluation in African American Populations

Instituting Racial Equity: The Allegheny County Racial and Ethnic Approaches to Community Health Initiative

INTRODUCTION

In 2018, The Live Well Allegheny: Lifting Wellness for African Americans (LWA2) Initiative was developed to support six priority, Black communities in Allegheny County, Pennsylvania to address health equity in chronic disease. The LWA2 coalition members participated in ongoing anti-racism and racial equity sessions with a nationally recognized anti-racist facilitation team. The sessions included a 2-days experience in January 2020 along with follow up meetings throughout 2020.

METHODS

Surveys were administered to understand their perceptions related to anti-racism and oppression and subsequent actions as a result of the sessions. Additionally, we conducted nine in-depth interviews with organizational partners (January -May 2020) to evaluate the overall effectiveness of the coalition and inform future activities.

RESULTS

Ten participants completed the post session surveys. Seven out of 10 survey respondents felt they had a good understanding of how oppression (racism, sexism, capitalism) influenced their life and work. However, the majority indicated needing the tools to implement anti-racist strategies in their work. The in-depth interviews with organizational partners revealed that racial equity was of concern to all partners but there was variability in intentionality around racial equity as a core element of each organization's mission, goals and subsequent actions.

DISCUSSION

As a result of the interviews, coalition members developed a racial equity statement and theory of change for implementation in the coalition work and within individual organizations along with a plan for implementing an equity audit of the coalition. Coalitions of this kind should be intentional about implementing continuous strategies related to anti-racism for structural changes toward achieving racial equity in their overall work.

Social Determinants of Health and Preoperative Care

Preoperative care exists as part of perioperative continuum during which anesthesiologists and surgeons optimize patients for surgery. These multispecialty efforts are important, particularly for patients with complex medical histories and those requiring major surgery. Preoperative care improves planning and determines the clinical pathway and discharge disposition. The role of nonmedical social factors in the preoperative planning is not well described in anesthesiology. Research to improve outcomes based on social factors is not well described for anesthesiologists but could be instrumental in decreasing disparities and advancing health equity in surgical patients.

Correlates of COVID-19 Vaccine Uptake in Black Adults Residing in Allegheny County, PA

Introduction

Efforts to address vaccine uptake and access among black adults will be relevant for continued coronavirus disease 2019 (COVID-19) eradication efforts and can be transferable to other prevention efforts in future pandemics. This study investigated factors related to COVID-19 vaccine uptake and access among black residents in Allegheny County, PA.

Methods

Surveys were administered electronically from October 2021 to January 2022 to black Allegheny County residents aged 18 and older. Questions included thoughts on COVID mitigation strategies (e.g., masking, social distancing), vaccination status, intention to vaccinate children, trust of COVID-19 information sources and vaccines, family needs, access to support services, and social media use to access information. Descriptive statistics and significant correlates of being vaccinated using adjusted logistic regression models are reported.

Results

Of the overall sample (N=397), the majority were fully vaccinated (n=306, 77%). Fully vaccinated participants were more likely to be female (62.5%, p=0.010), age 60 years or older (34.3%, p=0.0002), have some college education (23.2%, p<0.0001), and be employed full time (50.0%, p=0.0001) compared with nonvaccinated individuals. Among the unvaccinated participants (n=91), the primary reason was fear of illness (8.9%), long-term effects (6.5%), mistrust in the vaccine (6.3%), and needing more information (4.5%). Vaccine-hesitant participants were more likely to be unvaccinated (adjusted odds ratio=2.3, 95% confidence interval 1.25-4.14) after adjusting for age, education, employment, insurance, health status, and income.

Conclusion

Vaccine hesitancy may be improved by directly addressing fear of illness resulting from vaccines and improving clarity in the vaccine development and approval process to improve uptake among black adults.

Road to Equity in Maternal and Child Health: Honoring the Past and Blazing New Paths

PURPOSE

This paper is a historical account of an initiative, as recalled by the authors who were directly involved, that brought to the forefront the long-standing and unjust reproductive health inequities in the United States. It is composed of three distinct but interrelated parts that together map the past, present, and future of addressing racial inequities in Maternal and Child Health.

DESCRIPTION

This paper is composed of three distinct but interrelated parts that together map the past, present, and future of addressing racial inequities in Maternal and Child Health. Part I recounts the history and achievements of a Centers for Disease for Control and Prevention initiative in the 1980-90's, led by the Prematurity Research Group in the Division of Reproductive Health, Pregnancy and Infant Health Branch. This initiative stimulated a paradigm shift in how we understand and address black infant mortality and the inequities in this outcome. Part II illustrates examples of some exemplary programmatic and policy legacies that stemmed either directly or indirectly from the Centers for Disease for Control and Prevention paradigm shift. Part III provides a discussion of how effectively the current practice in Maternal and Child Health applies this paradigm to address inequities and proposes a path for accelerating Title V agencies' progress toward birth equity.

ASSESSMENT

This CDC initiative was transformative in that it raised the visibility of African American researchers, moved the field from a focus on traditional epidemiologic risks such as personal health promotion and medical interventions, to include racism as a risk factor for inequitable birth outcomes. The paradigm examined the specific roles of historical and structural racism, and the racialized, contextualized, and temporal exposures that are unique to Black women's experiences in the United States.

CONCLUSION

The initiative radically changed the narratives about the underlying factors contributing to inequities in birth outcomes of Black women, altered the way we currently approach addressing inequities, and holds the keys for transforming practice to a more holistic and systematic approach to building sustained organizational structures in maternal and child health that accelerate the achievement of birth equity.

Protocol for a scoping review of health equity frameworks and models applied in empirical studies of chronic disease prevention and control

BACKGROUND

Chronic diseases, such as cancers and cardiovascular diseases, present the greatest burden of morbidity and mortality worldwide. This burden disproportionately affects historically marginalized populations. Health equity is rapidly gaining increased attention in public health, health services, and implementation research, though many health inequities persist. Health equity frameworks and models (FM) have been called upon to guide equity-focused chronic disease and implementation research. However, there is no clear synthesis of the health equity FM used in chronic disease research or how these are applied in empirical studies. This scoping review seeks to fill this gap by identifying and characterizing health equity FM applied in empirical studies along the chronic disease prevention and control continuum, describing how these FM are used, and exploring potential applications to the field of implementation science.

METHODS

We follow established guidance for conducting scoping reviews, which includes six stages: (1) identify the research question; (2) identify relevant studies; (3) select studies for inclusion; (4) data extraction; (5) collating, summarizing, and reporting the results; and (6) consultation. This protocol presents the iterative, collaborative approach taken to conceptualize this study and develop the search strategy. We describe the criteria for inclusion in this review, methods for conducting two phases of screening (title and abstract, full text), data extraction procedures, and quality assurance approaches taken throughout the project.

DISCUSSION

The findings from this review will inform health-equity focused chronic disease prevention and control research. FM identified through this review will be added to an existing website summarizing dissemination and implementation science frameworks, and we will offer case examples and recommendations for utilizing a health equity FM in empirical studies. Our search strategy and review methodology may serve as an example for scholars seeking to conduct reviews of health equity FM in other health disciplines.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework Registration https://doi.org/10.17605/OSF.IO/SFVE6.

Principles to operationalize equity in cancer research and health outcomes: lessons learned from the cancer prevention and control research network

Reflecting their commitment to advancing health equity, the Cancer Prevention and Control Research Network (CPCRN) established a Health Equity Workgroup to identify and distill guiding principles rooted in health equity, community-engaged participatory research (CBPR), social determinants of health, and racial equity frameworks to guide its collective work. The Health Equity Workgroup utilized a multi-phase, participatory consensus-building approach to: (1) identify recurrent themes in health and racial equity frameworks; (2) capture perspectives on and experiences with health equity research among CPCRN members through an online survey; (3) engage in activities to discuss and refine the guiding principles; and (4) collect case examples of operationalizing equity principles in cancer research. Representatives from all CPCRN centers endorsed nine core principles to guide the Network's strategic plan: (1) Engage in power-sharing and capacity building with partners; (2) Address community priorities through community engagement and co-creation of research; (3) Explore and address the systems and structural root causes of cancer disparities; (4) Build a system of accountability between research and community partners; (5) Establish transparent relationships with community partners; (6) Prioritize the sustainability of research benefits for community partners; (7) Center racial equity in cancer prevention and control research; (8) Engage in equitable data collection, analysis, interpretation, and dissemination practices; and (9) Integrate knowledge translation, implementation, and dissemination into research plans. Dissemination products, such as toolkits and technical assistance workshops, reflecting these principles will foster knowledge transfer to intentionally integrate health and racial equity principles in cancer prevention and control research.

Access to What for Whom? How Care Delivery Innovations Impact Health Equity

Achieving health equity (where every person has the opportunity to attain their full health potential) requires the removal of obstacles to health, including barriers to high-quality medical care. Innovations in service delivery can inadvertently maintain, worsen, or introduce inequities. As such, implementation of innovations must be accompanied by a dual commitment to evaluate impact on marginalized groups and to restructure systems that obstruct people from health and healthcare. Understanding the impact innovations have on access to high-quality care is central to this effort. In this Perspective, we join conceptual models of healthcare access and quality with health equity frameworks to conceptualize healthcare receipt as a series of interactions between people and systems unfolding over time. This synthesized model is applied to illustrate the effects of telemedicine on patient, population, and system outcomes. Telemedicine may improve or worsen health equity by altering access to care and by altering quality of care once it is accessed. Teasing out these varied effects is complex and requires considering multilevel influences on the outcome of a care-seeking episode. This synthesized model can be used to inform research, practice, and policy surrounding the equity implications of care delivery innovations more broadly.

Addressing Health Inequities: An Exploratory Assessment of Extension Educators' Perceptions of Program Demand for Diverse Communities

Land grant universities are a key provider of community-based health promotion programs through the Cooperative Extension Service. However, Extension's current approach to addressing systemic social determinants of health is incomplete and inconsistent. The purpose of this study was to explore Extension health educators' perceptions of demand for health promotion programming targeting audiences most likely to experience health inequities. Health educators within 2 state Extension systems were invited to complete an online survey based on a capacity building model. Survey questions included rating perceptions of demand for programming for health disparate populations: low-income; Black and African American; Hispanic, Latino/a, Latinx; persons with disabilities; immigrants and refugees; and lesbian, gay, bisexual, and transgender. Analysis of variance and Bonferroni post hoc testing was used to determine differences in perceived demand between populations. Ninety-six educators completed the survey. Perceived demand for low-income population programming was significantly higher than for other populations. Perceived programming demand for immigrants and refugees and lesbian, gay, bisexual, and transgender people was significantly lower than for other populations. Individual and organizational-level factors, including racism and Extension's historical scope, likely contribute to the results. Engaging historically excluded Extension audiences requires time and resources to improve the Extension system and educator capacity for relationship building, trust building, and communication.

Advancing Health Equity Efforts to Reduce Obesity: Changing the Course

Population-based solutions are needed to stabilize and then reverse the continued upward trends in obesity prevalence in the US population and worldwide. This review focuses on the related, urgent issue of disparities in obesity prevalence affecting US racial/ethnic minority and other socially marginalized populations. The review provides background on these disparities from a health equity perspective and highlights evidence of progress in equity-focused obesity efforts. Five recommendations for advancing equity efforts are offered as potential approaches to build on progress to date: (a) give equity issues higher priority, (b) adopt a health equity lens, (c) strengthen approaches by using health equity frameworks, (d) broaden the types of policies considered, and (e) emphasize implementation science concepts and tools. Potential challenges and opportunities are identified, including the prospect of longer-term, transformative solutions that integrate global and national initiatives to address obesity, undernutrition, and climate change.

Exploring Extension Agent Capacity and Readiness to Adopt Policy, Systems and Environmental Change Approaches

Introduction

Enhanced Extension outreach strategies combine traditional direct education programs with public health approaches like policy, systems, and environmental (PSE) change. However, the Cooperative Extension system and county-based Family and Consumer Sciences (FCS) Extension agents have historically prioritized direct education programming and diffusion of enhanced outreach strategies has varied. Extension personnel may lack capacity and readiness for successful PSE change implementation. This study explored perceived acceptability, capacity, and readiness for PSE change work among FCS Extension agents in two states.

Method

A survey was developed framed by selected domains from the Consolidated Framework for Implementation Research: Intervention Characteristics, Inner Setting, Characteristics of Individuals, and Process. All questions utilized a 5-point Likert scale, except for an item examining respondents' stage of change regarding PSE change strategies. Descriptive statistics and response frequencies for all variables were calculated.

Results

Survey responses (n = 116) indicated PSE change work was perceived as valuable. Potential barriers included perceived complexity, organizational readiness issues (e.g., reporting and evaluation structures; performance incentives), and worries about stakeholder responses in shifting away from direct education. Responses indicated self-efficacy for skills important in implementing PSE change. Most respondents (53%) indicated being at the pre-contemplation or contemplation stage of change in pursuing PSE change work.

Discussion

Combining PSE change strategies and direct education programming allows Extension to do what it does best – provide effective programs to improve and sustain health and wellbeing of individuals and families. Findings are informative for others aiming to build capacity within community educators, Extension and public health professionals to implement PSE change.

A Framework for Femtech: Guiding Principles for Developing Digital Reproductive Health Tools in the United States

The United States has abysmal reproductive health indices that, in part, reflect stark inequities experienced by people of color and those with preexisting medical conditions. The growth of "femtech," or technology-based solutions to women's health issues, in the public and private sectors is promising, yet these solutions are often geared toward health-literate, socioeconomically privileged, and/or relatively healthy white cis-women. In this viewpoint, we propose a set of guiding principles for building technologies that proactively identify and address these critical gaps in health care for people from socially and economically marginalized populations that are capable of pregnancy, as well as people with serious chronic medical conditions. These guiding principles require that such technologies: (1) include community stakeholders in the design, development, and deployment of the technology; (2) are grounded in person-centered frameworks; and (3) address health disparities as a strategy to advance health equity and improve health outcomes.

Applications of an Equity Framework in COVID-19 Vaccine Trial and Distribution Planning

There are a disproportionate number of cases, hospitalizations, and deaths among Black and Latinx communities, a result of a history of structural racism and exploitation. An equity framework and approach are critical but have been lacking in the COVID-19 response, including vaccine dissemination. We provide an overview and application of remove, repair, remediate, restructure, and provide (R4P), an equity framework, in examining COVID-19 vaccine trial development and related interventions. R4P is an equity framework and tool that applies critical race theory, intersectional, and dimensionality in planning, assessment, and research for creating action to eliminate inequities.

Pervasive structural racism in environmental epidemiology

BACKGROUND

Epistemological biases in environmental epidemiology prevent the full understanding of how racism's societal impacts directly influence health outcomes. With the ability to focus on "place" and the totality of environmental exposures, environmental epidemiologists have an important opportunity to advance the field by proactively investigating the structural racist forces that drive disparities in health.

OBJECTIVE

This commentary illustrates how environmental epidemiology has ignored racism for too long. Some examples from environmental health and male infertility are used to illustrate how failing to address racism neglects the health of entire populations.

DISCUSSION

While research on environmental justice has attended to the structural sources of environmental racism, this work has not been fully integrated into the mainstream of environmental epidemiology. Epidemiology's dominant paradigm that reduces race to a mere data point avoids the social dimensions of health and thus fails to improve population health for all. Failing to include populations who are Black, Indigenous, and people of color (BIPOC) in health research means researchers actually know very little about the effect of environmental contaminants on a range of population health outcomes. This commentary offers different practical solutions, such as naming racism in research, including BIPOC in leadership positions, mandating requirements for discussing "race", conducting far more holistic analyses, increasing community participation in research, and improving racism training, to address the myriad of ways in which structural racism permeates environmental epidemiology questions, methods, results and impacts.

The Health Equity Framework: A Science- and Justice-Based Model for Public Health Researchers and Practitioners

In this article, we describe a science- and justice-based framework for promoting health equity designed for researchers and practitioners working across public health and social science fields. We developed the health equity framework (HEF; etr.org/healthequityframework) in two phases of iterative development. Building on existing models, the HEF illustrates how health outcomes are influenced by complex interactions between people and their environments. The framework centers on three foundational concepts: equity at the core of health outcomes; multiple, interacting spheres of influence; and a historical and life-course perspective. Health equity is defined as having the personal agency and fair access to resources and opportunities needed to achieve the best possible physical, emotional, and social well-being. By centering population outcomes, the HEF encourages researchers and practitioners to think beyond traditional approaches that focus on individual behaviors and choices to assess and identify their gaps in acknowledging and addressing factors from multiple spheres of influence. We identified four, interacting spheres of influence that represent both categories of risk and protective factors for health outcomes as well as opportunities for strategies and interventions that address those factors. The HEF highlights the explicit and implicit interactions of multilevel influences on health outcomes and emphasizes that health inequities are the result of cumulative experiences across the life span and generations. The HEF is a practical tool for leaders and professionals in public health research and practice to reflect on and support a shift toward addressing health inequities resulting from the interplay of structural, relational, individual, and physiological factors.

The Cycle to Respectful Care: A Qualitative Approach to the Creation of an Actionable Framework to Address Maternal Outcome Disparities

Despite persistent disparities in maternity care outcomes, there are limited resources to guide clinical practice and clinician behavior to dismantle biased practices and beliefs, structural and institutional racism, and the policies that perpetuate racism. Focus groups and interviews were held in communities in the United States identified as having higher density of Black births. Focus group and interview themes and codes illuminated Black birthing individual’s experience with labor and delivery in the hospital setting. Using an iterative process to refine and incorporate qualitative themes, we created a framework in close collaboration with birth equity stakeholders. This is an actionable, cyclical framework for training on anti-racist maternity care. The Cycle to Respectful Care acknowledges the development and perpetuation of biased healthcare delivery, while providing a solution for dismantling healthcare providers’ socialization that results in biased and discriminatory care. The Cycle to Respectful Care is an actionable tool to liberate patients, by way of their healthcare providers, from biased practices and beliefs, structural and institutional racism, and the policies that perpetuate racism.

THRIVE Conceptual Framework and Study Protocol: A Community-Partnered Longitudinal Multi-Cohort Study to Promote Child and Youth Thriving, Health Equity, and Community Strength

BACKGROUND

Given the profound inequities in maternal and child health along racial, ethnic, and socioeconomic lines, strength-based, community-partnered research is required to foster thriving children, families, and communities, where thriving is defined as optimal development across physical, mental, cognitive, and social domains. The Pittsburgh Study (TPS) is a community-partnered, multi-cohort study designed to understand and promote child and youth thriving, build health equity, and strengthen communities by integrating community partners in study design, implementation, and dissemination. TPS launched the Tracking Health, Relationships, Identity, EnVironment, and Equity (THRIVE) Study to evaluate children's developmental stages and contexts from birth through completion of high school and to inform a child health data hub accessible to advocates, community members, educators, health professionals, and policymakers.

METHODS AND ANALYSIS

TPS is rooted in community-partnered participatory research (CPPR), health equity, antiracism, and developmental science. Using our community-informed conceptual framework of child thriving, the THRIVE Study will assess cross-cutting measures of place, environment, health service use, and other social determinants of health to provide longitudinal associations with developmentally appropriate child and youth thriving outcomes across participants in six cohorts spanning from pregnancy through adolescence (child ages 0-18 years). Data from electronic health records, school records, and health and human services use are integrated to assess biological and social influences of thriving. We will examine changes over time using paired t-tests and adjusted linear regression models for continuous thriving scores and McNemar tests and adjusted logistic regression models for categorical outcomes (thriving/not thriving). Data analyses will include mixed models with a random intercept (in combination with the previously-specified types of regression models) to account for within-subject correlation.

DISCUSSION

By enhancing assessment of child and youth well-being, TPS will fill critical gaps in our understanding of the development of child and youth thriving over time and test strategies to support thriving in diverse communities and populations. Through CPPR and co-design, the study aims to improve child health inequities across multiple socioecological levels and developmental domains.

Intention to Engage in Maternal and Child Health Home Visiting

Home visiting (HV) programs have the potential to improve maternal and child health. As federal and state initiatives expand the reach of these programs, understanding what factors enhance uptake and retention of the services becomes increasingly important. This qualitative study used a Reasoned Action Model (RAM) and a cultural lens to explore factors influencing the engagement of women with low-income in HV programs. We conducted 21 semi-structured interviews in both English and Spanish in a prenatal clinic in an urban public health department. The constructs most salient for participants were emotions and affect, behavioral beliefs, and self-efficacy. In the context of an urban public health prenatal clinic, HV marketing and outreach should highlight convenience and social support, as well as clearly communicate program content and intent. In practice, HV programs must be flexible to work around work and home schedules; marketing and outreach should emphasize that flexibility.

Addressing Health Equity in Public Health Practice: Frameworks, Promising Strategies, and Measurement Considerations

This review describes the context of health equity and options for integrating equity into public health practice. We first discuss how the conceptualization of health equity and how equity considerations in US public health practice have been shaped by multidisciplinary engagements. We then discuss specific ways to address equity in core public health functions, provide examples of relevant frameworks and promising strategies, and discuss conceptual and measurement issues relevant to assessing progress in moving toward health equity. Challenges and opportunities and their implications for future directions are identified.