Characterizing Food Policy Councils' Network Partnerships and COVID-19 Responses

The COVID-19 pandemic pushed millions of Americans into food insecurity. Food policy councils (FPCs) across the country played a vital role in organizing coordinated food responses across multiple sectors. We used a social network analysis (SNA) approach to investigate: (1) the network of partnering organizations and agencies within FPCs; (2) how the characteristics of FPCs' network partnerships (i.e., degree, coreness, and density) related to programmatic, policy, and advocacy actions in response to the pandemic; and (3) how FPCs' use of a racial or social equity framework shifted their network partnerships and responses. Local government agencies and food supply chain actors were core in FPCs' network partnerships, while public utilities, correctional facilities, social justice groups, and others were non-core partners. Network density was more likely to be associated with any action by FPCs, and it was especially pronounced for advocacy actions taken by FPCs; trends were similar among FPCs that reported using a racial or social equity framework. The findings begin to uncover core actors in FPCs' partnerships and opportunities to establish new partnerships, particularly with social justice groups. The results also suggest that network density (interconnectedness) may be more important than other network characteristics when responding to food-related needs.

Workforce perspective on racial and ethnic equity in early childhood autism evaluation and treatment: "The cornerstone of everything we do"

LAY ABSTRACT

Black and non-White Latinx children tend to receive autism diagnoses later in life and with a higher degree of impairment than White children. The purpose of this study was to learn what is currently helping as well as preventing Black and non-White Latinx children from getting access to autism evaluation and services. We held virtual interviews with 26 experts who work with autistic children and their families, including clinical providers, researchers, advocates, and policymakers/government representatives. From these interviews, we identified four themes that have an impact on equity in autism services: (1) who makes up the workforce, (2) workforce capacity and accessibility, (3) workforce payment structure, and (4) changes due to the COVID-19 pandemic. These findings show the need for improved workforce diversity, autism-specific education, payment structures, and additional support for workforce members to avoid burnout. To make childhood autism services more equitable, diversity in recruitment across training levels, cultural awareness, increased autism education for all pediatric providers, and partnerships with caregivers as experts must be prioritized. These investments in the autism workforce will allow professionals in the field to better meet the needs of children and families from Black and non-White Latinx communities and achieve equity in early childhood autism services.

Infant Safe Sleep in the District of Columbia: Better for Both

Sudden unexpected infant death (SUID) rates within the District of Columbia (DC) vary, with rates 3 times higher in certain geographical areas than the cumulative rate in DC and 7 times higher than the national rate. The majority SUIDs are due to unsafe sleep practices. Although safe sleep education and resources are available in these areas, the high sleep-related infant mortality suggests unmet barriers to infant safe sleep. We sought to investigate potential contributions to local infant mortality through focus groups regarding infant sleep practices among DC caregivers. In this qualitative study, caregivers were probed regarding barriers and facilitators of infant sleep practices. Data were collected until thematic saturation was reached, then coded. Themes were developed and revised in an iterative manner. Fifteen caregivers participated in three focus groups. Themes included sources of infant sleep knowledge, challenges for infant sleep, and motivators for infant sleep choice. All caregivers reported knowledge of safe sleep practices. Infant sleep practices varied, and included unsafe practices such as bed sharing, co-sleeping, and use of swings or bouncers for infant sleep. Challenges of adhering to safe sleep practices included infant needs, competing family demands, the overwhelming nature of newborn sleep, threats, and conflicting information. Motivators for infant sleep practices included better sleep, convenience, safety, tradition, and needs of the infant and caregiver. Although caregivers report knowledge of safe sleep recommendations, actual infant sleep practices vary and include unsafe sleep practices. More focused interventions are needed to address this gap between safe sleep knowledge and practice.

Perspectives of Certified Nurse-Midwives and Physicians on the Structural and Institutional Barriers that Contribute to the Reproductive Inequities of Black Birthing People in the San Francisco Bay Area

INTRODUCTION

Black birthing people in the United States disproportionately endure inequitable experiences and outcomes during pregnancy and childbirth via structural, interpersonal, and obstetric racism. In this study, the researchers explore provider perspectives of how racism is perpetuated in institutional perinatal and reproductive health care.

METHODS

Critical Race Theory, Reproductive Justice, and midwifery theory were operationalized through secondary thematic analysis of existing qualitative data from the Community Racial Equity and Training Interventions and Evaluation of Current and Future Healthcare Clinicians Study. Twenty-four perinatal providers (certified nurse-midwives [n = 7] and physicians [n = 17]) voluntarily participated in interviews. A comparative approach was used to determine how professional identity and model of care influence physicians' and certified nurse-midwives' perceptions of equity.

RESULTS

Thematic analysis produced 5 themes: racism as a comorbidity, health care systems' inability to address the needs of Black birthing people, health care systems prioritizing providers over patients are failed systems, patients are the experts in the optimal health care model, and benefits of interprofessional teams grounded in Reproductive Justice. Additionally, both physicians and midwives expressed a need for a new care model.

DISCUSSION

With these findings, our team proposes a modification of the midwifery model for application by all provider types that could radically shift the experience and outcomes of perinatal and reproductive health care and reduce mortality. Using a human rights approach to care, a Reproductive Justice-Public Health Critical Race praxis-informed midwifery model may be operationalized by all perinatal and reproductive health care providers. This novel model reflects an iterative process that may offer institutions and providers methods to build on past research supporting midwifery-centered care for improving outcomes for all patients by specifically focusing on improving care of Black birthing people. The implications of this work offer broad application in current clinical practice, quality improvement, research, technology, and patient resources.

Current Practices in Operationalizing and Addressing Racial Equity in the Provision of Type 1 Diabetes Care: Insights from the Type 1 Diabetes Exchange Quality Improvement Collaborative Health Equity Advancement Lab

OBJECTIVE

Medical racism contributes to adverse health outcomes. Type 1 Diabetes Exchange Quality Improvement Collaborative (T1DX-QI) is a large population-based cohort engaged in data sharing and quality improvement to drive system changes in T1D care. The annual T1DX-QI survey included questions to evaluate racial equity in diabetes care and practices to promote equity.

METHODS

The annual T1DX-QI survey was administered to participating clinics in fall 2022 and had a 93% response rate. There were 50 responses (pediatric: 66% and adult: 34%). Questions, in part, evaluated clinical resources and racial equity. Response data were aggregated, summarized, and stratified by pediatric/adult institutions.

RESULTS

Only 21% pediatric and 35% adult institutions felt that all their team members can articulate how medical racism contributes to adverse diabetes outcomes. Pediatric institutions reported more strategies to address medical racism than adult (3.6 vs 3.1). Organizational strategies to decrease racial discrimination included employee trainings, equity offices/committees, patient resources, and hiring practices. Patient resources included interpreter services, transportation, insurance navigation, and housing and food assistance. Hiring practices included changing prior protocols, hiring from the community, and diversifying workforces. Most institutions have offered antiracism training in the last year (pediatric: 85% and adult: 72%) and annually (pediatric: 64% and adult: 56%). Pediatric teams felt that their antiracism training was effective more often (pediatric: 60% and adult: 45%) and more commonly, they were provided resources (pediatric: 67% and adult: 47%) to help address inequities.

CONCLUSION

Despite increased antiracism training, insufficient institutional support and perceived subeffective training still represent obstacles, especially in adult institutions. Sharing effective strategies to address medical racism will help institutions take steps to mitigate inequities.

Striving for safety, impact, and equity: A critical consideration of AJCP publications on formal youth mentoring programs

In this virtual special issue (VSI) we curate and reflect upon 22 articles on formal youth mentoring previously published in the American Journal of Community Psychology (AJCP). First, we provide historical context and highlight AJCP's 2002 special issue on mentoring, which played an important role in establishing youth mentoring as a vibrant area of research. Next, we review and discuss findings from subsequent AJCP studies in three interrelated lines of inquiry: (1) the importance of facilitating high-quality mentoring relationships; (2) associations among youth's presenting needs, relationship quality, and outcomes; and (3) program practices leading to stronger, more impactful relationships. Throughout, we highlight and expand upon critical commentary from AJCP contributors, calling on the field to move away from paternalistic models that overly localize risk with youth and families without interrogating structural oppression. Our recommendations include: (1) centering critical consciousness, racial equity, and social justice in program curricula and mentor trainings; (2) respectfully engaging grassroots programs developed for and by communities of color that are underrepresented in research; (3) making meaningful efforts to recruit mentors from marginalized communities and removing barriers to their participation; and (4) examining youth's racial, ethnic, and other areas of identity development processes during mentoring.

Race matters in addressing homelessness: A scoping review and call for critical research

Structural racism contributes to homelessness in the United States, as evidenced by the stark racial disparities in who experiences it. This paper reviews research at the intersections of race and homelessness to advance efforts to understand and address racial inequities. Part 1 offers a synthesis of homelessness research from the 1980s to 2015, where several scholars examined the role of race and racism despite mainstream efforts to present the issue as race-neutral. Part 2 presents the results of a systematic scoping review of research at the intersections of race and homelessness from 2016 to 2021. The 90 articles included demonstrate a growing, multidisciplinary body of literature that documents how needs and trajectories of people experiencing homelessness differ by race, examines how the racialized structuring of society contributes to homelessness risk, and explores how programs, policies, and grassroots action can address inequities. In addition to charting findings and implications, included studies are appraised against research principles developed by Critical Race Theory scholars, mapping the potential of existing research on race and homelessness to challenge racism.

Addressing Equity Asymmetries in General Chemistry Outcomes Through an Asset-Based Supplemental Course

Undergraduate first-semester general chemistry (GC1) functions as a gatekeeper to STEM degrees, asymmetrically impacting students who are nonwhite, from lower socioeconomic groups, non-native English speakers, two-year college transfers, and first-generation in college. Nationally, just under 30% of students earn grades of D, F, or withdraw (termed DFW) in GC1; however, DFW rates are much higher for subgroups underrepresented in STEM occupations. Socioeconomic inequalities tend to increase over an individual's lifetime due to the magnification of cumulative disadvantage. Because undergraduate degrees correlate with higher employment and STEM occupations correlate with higher earnings, GC1 represents a critical path point where disparities can be interrupted. The most common strategy employed for GC1 is deficit remediation for students determined to be at risk of DFW. Unfortunately, extensive evidence demonstrates that the use of remediation strategies for GC1 does not sustain benefits for students. In this work, an asset-based approach, less prevalent in higher education than preuniversity, was employed to stress test theories about interrupting disparities in STEM education. This causal-comparative study involving 1,807 observations reports on a 1-credit asset-based supplemental course in which DFW-potential students at a minority-serving institution coenrolled during six semesters. The study outlines this intervention, its impact on GC1 outcomes, and its potential residual impact on progression to the next course in the general chemistry sequence (GC2). Descriptive and hierarchical inferential analysis of the data revealed socially important patterns. The asset-based intervention successfully attracted students with greater cumulative disadvantage. The intervention closed asymmetries between students identified as DFW-potential and ABC-potential in GC1 when a nontraditional curriculum was used but not when a traditional curriculum was used. Mixed results and contingent effects were found for the intervention's impact on subsequent course outcomes. Taking at least 11 credits in the semester of taking GC1 provided an inoculate for participants in the asset-based intervention, increasing the likelihood of passing GC2.

Putting the system in systemic racism: A systems thinking approach to advancing equity

Generations of scholars and activists have argued that racial inequities emerge not only because of racist ideologies but also from a hierarchical system of racial oppression. This theoretical tradition has highlighted numerous ways in which systemic racism manifests itself, from racist policies to differential access to material conditions and power. However, given that by definition systemic racism is focused on systems, theories of systemic racism would be more comprehensive and actionable by drawing on scholarship related to systems thinking. Systems thinking is a conceptual orientation that aims to understand how different types of systems function over time. This paper builds on the work of previous scholars to propose a systems thinking approach to understand and strategically disrupt racist systems. We provide a typology of system characteristics (organized into the categories of paradigms, structures, elements, and feedback loops) that together can be used to help understand the operation of systemic racism in different system contexts. The paper also provides an approach to identify and strategically target multiple system leverage points to simultaneously disrupt the status quo of racial inequity and promote the emergence of conditions enabling racial equity. This systems thinking approach can be used to guide learning and action within an ongoing process of antiracist praxis.

Race, criminalization and urban mental health in the United States

PURPOSE OF REVIEW

As efforts to increase policing and roll back criminal legal system reforms in major U.S. cities rise, the collateral consequences of increased criminalization remain critical to document. Although the criminalization of mental illness has been well studied in the U.S., the mental health effects of criminalization are comparatively under-researched. In addition, despite extreme racial disparities in U.S. policing, there is limited understanding of how criminalization may contribute to racial disparities in mental health.

RECENT FINDINGS

Literature included in this review covers various types of criminalization, including direct and indirect impacts of incarceration, criminalization of immigration, first-hand and witnessed encounters with police, and the effects of widely publicized police brutality incidents. All forms of criminalization were shown to negatively impact mental health (depression, anxiety and suicidality), with evidence suggestive of disproportionate impact on Black people.

SUMMARY

There is evidence of significant negative impact of criminalization on mental health; however, more robust research is needed to address the limitations of the current literature. These limitations include few analyses stratified by race, a lack of focus on nonincarceration forms of criminalization, few longitudinal studies limiting causal inference, highly selected samples limiting generalizability and few studies with validated mental health measures.

Using Collective Impact to Develop a Community-Led Initiative for Improving Black Infant Mortality

The United States has one of the highest infant mortality rates among developed countries. When stratified by race, disparities are more evident: Black infant mortality rates are 2.5 times higher than non-Hispanic white infants. Structural, systemic racism is a contributing cause for these racial disparities. Multisector collaborations focused on a common agenda, often referred to as collective impact, have been used for infant mortality reduction interventions. In addition, community-based participatory approaches have been applied to incorporate those with lived experience related to adverse pregnancy outcomes. This article critically describes the transition of an infant mortality collective impact initiative from being led by a multisector organizational group to being community led over a 5-year period, 2015-2020. A 34-member community leaders group was developed and determined four priorities and corresponding strategies for the initiative. Findings show that community participatory approaches are a way to address racial equity for public health initiatives.

The Association of Racial and Ethnic Concordance in Primary Care with Patient Satisfaction and Experience of Care

BACKGROUND

The lack of racial and ethnic concordance between patients and their physicians may contribute to American health disparities.

OBJECTIVE

To examine the level of racial and ethnic concordance for patients and primary care clinicians and its association with measures of patient experience.

DESIGN

Multivariate cross-sectional analysis of nationally representative data.

PARTICIPANTS

Adults 18 to 64 in the 2019 Medical Expenditure Panel Survey who had at least one medical visit in the past year.

MAIN MEASURES

Key independent variables include having a racially/ethnically concordant primary care clinician, lacking a usual source of care, and having a usual source that is a place rather than a person. Outcomes include overall satisfaction with health care, number of medical visits, having enough time in care, ease of understanding the clinician, and receiving respect.

KEY RESULTS

The comparison between the actual level of concordance with an expected distribution if all patients had the same probability of having a clinician of a given race or type indicates that Black, Latino, and Asian patients are three or more times as likely to have a concordant clinician than expected, suggesting a strong preference for clinicians of the same race or ethnicity. Racial or ethnic concordance has a modest positive association with overall health care satisfaction and respect but is not significantly associated with the number of medical visits or other outcomes. Poor health status, being uninsured, and lacking a usual source of care are more strongly associated with patient experience.

DISCUSSION

Efforts to increase the diversity of the primary care workforce could increase racial/ethnic concordance but may have only modest effects on patients' experience of care. Policies like lowering the number of uninsured or increasing those with a usual source of care may be more salient in improving experience of care.

"We're Constantly Learning": Identifying and Disrupting White Supremacy Within a Victim Services Organization

Many victim service organizations are seeking to realign service delivery around principles of racial equity. Dismantling institutional racism is a complex, intensive, and long-term process. Therefore, despite this imperative from the field, our knowledge about how social service organizations can effectively advance anti-oppressive practice is limited. This study examined victim advocate perspectives on the role institutional racism played within their work and the supports needed to undo institutional racism within their organization. Six focus groups were conducted with a meaningful cross section of staff members (n = 53) across the organization. Semi-structured interview guides included questions in four domains: (1) racism within client work, (2) challenges to addressing racism, (3) effective solutions, and (4) helpful organizational supports. Transcripts were thematically analyzed using modified constructivist grounded theory methods. Two overarching themes, Identifying Institutional Racism in the Workplace and Advancing Anti-racist Practice, and six subthemes emerged from the analysis. Advocates identified that naming and becoming comfortable talking about race was essential. Further, they believed it was important to acknowledge the ways in which that racism was implicitly built into helping systems at large. Advocates explored how internalized racial stereotypes influenced interactions between black, indigenous, and people of color (BIPOC) and white advocates and their clients in complex ways. Advocates highlighted organizational efforts that supported ongoing personal reflection, the creation of an accountable community, and staff empowerment within the organization as being critical to advancing anti-racist practice. Some advocates also wanted to see the organization move further in the direction of standing with BIPOC communities, particularly around criminal justice concerns. Findings provide important timely insights into how institutional racism manifests within victim service organizations and what organizational actions encourage anti-oppressive practices and culture.

Public Health Workforce Perceptions About Organizational Commitment to Diversity, Equity, and Inclusion: Results From PH WINS 2021

OBJECTIVE

In response to calls to achieve racial equity, racism has been declared as a public health crisis. Diversity, equity, and inclusion (DEI) is an approach public health organizations are pursuing to address racial inequities in health. However, public health workforce perceptions about organizational commitment to DEI have not yet been assessed. Using a nationally representative survey of public health practitioners, we examine how perceptions about supervisors' and managers' commitment to DEI and their ability to support a diverse workforce relate to perceptions of organizational culture around DEI.

METHODS

Data from the 2021 Public Health Workforce Interests and Needs Survey (PH WINS) to examine the relationship between public health employees' perceptions about their organization's commitment to DEI and factors related to those perceptions. PH WINS received 44 732 responses (35% response rate). We calculated descriptive statistics and constructed a logistic regression model to assess these relationships.

RESULTS

Findings show that most public health employees perceive that their organizations are committed to DEI; however, perceptions about commitment to DEI vary by race, ethnicity, gender identity, and organizational setting. Across all settings, White respondents were more likely to agree with the statement, "My organization prioritizes diversity, equity, and inclusion" (range, 70%-75%), than Black/African American (range, 55%-65%) and Hispanic/Latino respondents (range, 62.5%-72.5%). Perception that supervisors worked well with individuals with diverse backgrounds had an adjusted odds ratio (AOR) of 5.37 ( P < .001); organizational satisfaction had an AOR of 4.45 ( P < .001). Compared with White staff, all other racial and ethnic groups had lower AOR of reporting their organizations prioritized DEI, with Black/African American staff being the lowest (AOR = 0.55), followed by Hispanic/Latino staff (AOR = 0.71) and all other staff (AOR = 0.82).

CONCLUSIONS

These differences suggest that there are opportunities for organizational DEI commitment to marginalized public health staff to further support DEI and racial equity efforts. Building a diverse public health workforce pipeline will not be sufficient to achieve health equity if staff perceive that their organization does not prioritize DEI.

Group vs traditional prenatal care for improving racial equity in preterm birth and low birthweight: the Centering and Racial Disparities randomized clinical trial study

BACKGROUND

The United States has persistently high rates of preterm birth and low birthweight and is characterized by significant racial disparities in these rates. Innovative group prenatal care models, such as CenteringPregnancy, have been proposed as a potential approach to improve the rates of preterm birth and low birthweight and to reduce disparities in these pregnancy outcomes.

OBJECTIVE

This study aimed to test whether participation in group prenatal care would reduce the rates of preterm birth and low birthweight compared with individual prenatal care and whether group prenatal care would reduce the racial disparity in these rates between Black and White patients.

STUDY DESIGN

This was a randomized controlled trial among medically low-risk pregnant patients at a single study site. Eligible patients were stratified by self-identified race and ethnicity and randomly allocated 1:1 between group and individual prenatal care. The primary outcomes were preterm birth at <37 weeks of gestation and low birthweight of <2500 g. The primary analysis was performed according to the intent-to-treat principle. The secondary analyses were performed according to the as-treated principle using modified intent-to-treat and per-compliance approaches. The analysis of effect modification by race and ethnicity was planned.

RESULTS

A total of 2350 participants were enrolled, with 1176 assigned to group prenatal care and 1174 assigned to individual prenatal care. The study population included 952 Black (40.5%), 502 Hispanic (21.4%), 863 White (36.8%), and 31 "other races or ethnicity" (1.3%) participants. Group prenatal care did not reduce the rate of preterm birth (10.4% vs 8.7%; odds ratio, 1.22; 95% confidence interval, 0.92-1.63; P=.17) or low birthweight (9.6% vs 8.9%; odds ratio, 1.08; 95% confidence interval, 0.80-1.45; P=.62) compared with individual prenatal care. In subgroup analysis, greater attendance in prenatal care was associated with lower rates of preterm birth and low birthweight. This effect was most noticeable for the rates of low birthweight for Black participants in group care: intent to treat (51/409 [12.5%]), modified intent to treat (36/313 [11.5%]), and per compliance (20/240 [8.3%]). Although the rates of low birthweight were significantly higher for Black participants than White participants seen in individual care (adjusted odds ratio, 2.00; 95% confidence interval, 1.14-3.50), the difference was not significant for Black participants in group care compared with their White counterparts (adjusted odds ratio, 1.58; 95% confidence interval, 0.74-3.34).

CONCLUSION

There was no difference in the overall rates of preterm birth or low birthweight between group and individual prenatal care. With increased participation in group prenatal care, lower rates of preterm birth and low birthweight for Black participants were observed. The role of group care models in reducing racial disparities in these birth outcomes requires further study.

Designed to Do Good: Key Findings on the Development and Operation of First Responder Deflection Programs

Opioids and drug overdoses have claimed more than 750 000 American lives since the late 1990s. Overdoses since the mid-2010s have risen dramatically, due to synthetic opioids such as fentanyl whose lethality is disproportionately greater than street drugs of earlier decades. Until recently, most police and other first responders lacked resources beyond arrest to respond to overdoses and other nonviolent crimes. Largely in response to the opioid crisis and synthetic opioid-related overdoses, first responder deflection (FRD) has emerged as an alternative. First responder deflection has enabled first responders across the United States to save lives by training them to administer naloxone, a medication that blocks opioid receptors after overdose, then linking these individuals to community-based treatment and services. Consequently, FRD has helped keep many citizens out of the justice system entirely, giving them a chance to rebuild their lives and become productive members of their communities. To this end, TASC's Center for Health and Justice and National Opinion Research Center at The University of Chicago collaborated on a national FRD survey encompassing a comprehensive overview of the field and its role in responding to the opioid crisis. The findings reveal how FRD offers alternatives to traditional policing, including its role in advancing racial and social equity by aligning public health and public safety for those who otherwise might enter the justice system. This article will discuss the methodology, key findings, and policy implications of this national survey (encompassing more than 300 active FRD programs). We will present results on the development of FRDs and how they operate. Results will cover the extensive involvement of law enforcement agencies in initiating FRD initiatives; the role of non-first responder partners in providing treatment and services through FRD; and the scope of Medication-Assisted Treatment in these programs, among other important findings.

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.

Environmental Justice in Greater Los Angeles: Impacts of Spatial and Ethnic Factors on Residents' Socioeconomic and Health Status

Environmental justice advocates that all people are protected from disproportionate impacts of environmental hazards. Despite this ideal aspiration, social and environmental inequalities exist throughout greater Los Angeles. Previous research has identified and mapped pollutant levels, demographic information, and the population’s socioeconomic status and health issues. Nevertheless, the complex interrelationships between these factors remain unclear. To close this knowledge gap, we first measured the spatial centrality using sDNA software. These data were then integrated with other socioeconomic and health data collected from CalEnvironScreen, with census tract as the unit of analysis. Finally, structural equation modeling (SEM) was executed to explore direct, indirect, and total effects among variables. The results show that the White population tends to reside in the more segregated areas and lives closer to green space, contributing to higher housing stability, financial security, and more education attainment. In contrast, people of color, especially Latinx, experience the opposite of the environmental benefits. Spatial centrality exhibits a significant indirect effect on environmental justice by influencing ethnicity composition and pollution levels. Moreover, green space accessibility significantly influences environmental justice via pollution. These findings can assist decision-makers to create a more inclusive society and curtail social segregation for all individuals.

What Is a "Racial Health Disparity"? Five Analytic Traditions

What exactly is a "racial health disparity"? This article explores five lenses that have been used to answer that question. It contends that racial health disparities have been presented-by researchers both within academia and outside of it-as problems of five varieties: biology, behavior, place, stress, and policy. It also argues that a sixth tradition exploring class-and its connection to race, racism, and health-has been underdeveloped. The author examines each of these conceptions of racial disparities in turn. Baked into each interpretive prism is a set of assumptions about the mechanisms that produce disparities-a story, in other words, about where racial health disparities come from. Discursive boundaries set the parameters for policy debate, determining what is and is not included in proposed solutions. How one sees racial health disparities, then, influences the strategies a society advocates-or ignores-for their elimination. The author ends by briefly discussing problems in the larger research ecosystem that dictate how racial health disparities are studied.

Expanding the Reach of an Evidence-Based, System-Level, Racial Equity Intervention: Translating ACCURE to the Maternal Healthcare and Education Systems

The abundance of literature documenting the impact of racism on health disparities requires additional theoretical, statistical, and conceptual contributions to illustrate how anti-racist interventions can be an important strategy to reduce racial inequities and improve population health. Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) was an NIH-funded intervention that utilized an antiracism lens and community-based participatory research (CBPR) approaches to address Black-White disparities in cancer treatment completion. ACCURE emphasized change at the institutional level of healthcare systems through two primary principles of antiracism organizing: transparency and accountability. ACCURE was successful in eliminating the treatment completion disparity and improved completion rates for breast and lung cancer for all participants in the study. The structural nature of the ACCURE intervention creates an opportunity for applications in other health outcomes, as well as within educational institutions that represent social determinants of health. We are focusing on the maternal healthcare and K-12 education systems in particular because of the dire racial inequities faced by pregnant people and school-aged children. In this article, we hypothesize cross-systems translation of a system-level intervention exploring how key characteristics of ACCURE can be implemented in different institutions. Using core elements of ACCURE (i.e., community partners, milestone tracker, navigator, champion, and racial equity training), we present a framework that extends ACCURE's approach to the maternal healthcare and K-12 school systems. This framework provides practical, evidence-based antiracism strategies that can be applied and evaluated in other systems to address widespread structural inequities.

Structural Inequities, Fair Opportunity, and the Allocation of Scarce ICU Resources

The September-October 2021 issue of the Hastings Center Report highlights the important topic of allocating scarce critical care resources during the Covid-19 pandemic. The article by Alex Rajczi and colleagues urges that policy-makers use public reasoning, not private reasoning, when developing triage policies. We completely agree. We show how the allocation framework we developed as private scholars, the "Pittsburgh framework," has been supported by public reasoning. The article by MaryKatherine Gaurke and colleagues criticizes rationing based on maximizing life-years saved and mistakenly claims that our framework recommended this approach. We explain that our framework never contained such a criterion but instead included a more limited consideration of near-term prognosis. In December 2020, in response to emerging data and important criticisms, we modified our framework to further strengthen equity. We are committed to improving allocation guidelines during crisis standards of care through reflective discussions and debates.

Unconscious Bias and Its Impact on Public Health and Health-Care Systems

The U.S. public health system has been challenged in constructive ways over the past year, from fighting a novel virus to managing the resulting pandemic, and surmounting pressure from the general public to reconcile past and present trauma fueled by health and racial inequities that claim lives and perpetuate physical, mental, and emotional harm in predominantly Black, Indigenous, and other non-white communities. Through term definitions, discussion of the current literature, and content expert opinions, this article reveals the casual yet calculated manner in which unconscious bias saturates health care and the governing public health systems in the United States, and presents a call to action for professionals in the public health field to keep racial and health equity at the forefront of solutions to the "wicked problems" faced in this field.

'It's like you don't have a roadmap really': using an antiracism framework to analyze patients' encounters in the cancer system

Background: Cancer patients can experience healthcare system-related challenges during the course of their treatment. Yet, little is known about how these challenges might affect the quality and completion of cancer treatment for all patients, and particularly for patients of color. Accountability for Cancer Care through Undoing Racism and Equity is a multi-component, community-based participatory research intervention to reduce Black-White cancer care disparities. This formative work aimed to understand patients' cancer center experiences, explore racial differences in experiences, and inform systems-level interventions.Methods: Twenty-seven breast and lung cancer patients at two cancer centers participated in focus groups, grouped by race and cancer type. Participants were asked about what they found empowering and disempowering regarding their cancer care experiences. The community-guided analysis used a racial equity approach to identify racial differences in care experiences.Results: For Black and White patients, fear, uncertainty, and incomplete knowledge were disempowering; trust in providers and a sense of control were empowering. Although participants denied differential treatment due to race, analysis revealed implicit Black-White differences in care.Conclusions: Most of the challenges participants faced were related to lack of transparency, such that improvements in communication, particularly two-way communication could greatly improve patients' interaction with the system. Pathways for accountability can also be built into a system that allows patients to find solutions for their problems with the system itself. Participants' insights suggest the need for patient-centered, systems-level interventions to improve care experiences and reduce disparities.

Creating structural community cohesion: Addressing racial equity in older adult homelessness

Older adults and racial minorities are overrepresented in homeless populations. Shelter and housing options for homeless older adults who have complex health and social needs are necessary, but not readily available. Older homeless adults that require, but do not receive, health-sensitive, age-sensitive, and racial equity housing, remain vulnerable to poor outcomes and premature mortality. Accordingly, this study examines the development of a coalition to better address older adult homelessness within a racial equity framework. A community coalition was established to better address older adult homelessness within the lens of age-sensitivity and racial equity, due to a disconnect between healthcare and senior housing placement programs, creating unaddressed multifaceted health issues/complications. The community coalition development is described, including the coalition process, activities, and outcomes. Local rehoused older adults are also interviewed and described to better understand their central life circumstances.

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.

Diversity, equity, and inclusion interventions to support admissions have had little benefit to Black students over past 20 years

The United States has a history of systemic racism and violence toward minority communities. Unfortunately, the last year has demonstrated that systemic racism, and its consequences, persist. The dental profession has also failed to adequately resolve known issues of racial inequity and systemic racism, with persistent disparities in oral health outcomes for Black Americans compared to all other Americans, underrepresentation of minorities in the profession, and barriers to entry. However, dental education has the opportunity to address these issues. Current accreditation standards do not specifically address racial diversity among the student body, yet it is clear that representation of a population matters and the lack of representation may exacerbate race and racism as public health issues in dentistry. To explore the issue, we curated American Dental Education Association (ADEA) data on the race of students admitted and enrolled into dental programs across the United States. We used data visualization techniques to present the data and study trends. While the number of Black and African American (BAA) enrollees in dental schools has increased between 2000 and 2019, this population continues to make up a disproportionately small percentage of all enrollees, relative to the BAA percentage in the U.S. population. Much of the increase in BAA enrollment is attributable to increased places (due to the opening of new schools and increased class size in established schools) and the rate of acceptance of BAA students has had limited improvement. Very little progress has been accomplished in growing the enrollment of BAA applicants to dental school in 20 years. As a profession, we also fail to grow interest among our graduates in careers that may support historically underrepresented and marginalized racial groups-public health, rural practice, population research, academia, and health policy. This may be a contributing factor to the oral health disparities faced by Black Americans and have implications for dental education.

Heart Failure Admission Service Triage (H-FAST) Study: Racialized Differences in Perceived Patient Self-Advocacy as a Driver of Admission Inequities

Background

Racial inequities in mortality and readmission for heart failure (HF) are well documented. Inequitable access to specialized cardiology care during admissions may contribute to inequity, and the drivers of this inequity are poorly understood.

Methodology

This prospective observational study explored proposed drivers of racial inequities in cardiology admissions among Black, Latinx, and white adults presenting to the emergency department (ED) with symptoms of HF. Surveys of ED providers examined perceptions of patient self-advocacy, outreach to other clinicians (e.g., outpatient cardiologist), diagnostic uncertainty, and other active co-morbid conditions. Service census, bed availability, prior admission service, and other structural factors were explored through the electronic medical record.

Results

Complete data were available for 61/135 patients admitted with HF during the study period, which halted early due to coronavirus disease 2019. No significant differences emerged in admission to cardiology versus medicine based on age, sex, insurance status, education level, or perceived race/ethnicity. White patients were perceived as advocating for admission to cardiology more frequently (18.9 vs. 5.6%) and more strenuously than Black patients (p = 0.097). ED clinicians more often reported having spoken with the patient’s outpatient cardiologist for whites than for Black or Latinx patients (24.3 vs. 16.7%, p = 0.069).

Conclusions

Theorized drivers of racial inequities in admission service did not reach statistical significance, possibly due to underpowering, the Hawthorne effect, or clinician behavior change based on knowledge of previously identified inequities. The observed trend towards racial differences in coordination of care between ED and outpatient providers, as well as in either actual or perceived self-advocacy by patients, may be as-yet undemonstrated components of structural racism driving HF care inequities.

How Can We PrEP? Exploring Black MSM's Experiences With Pre-Exposure Prophylaxis Through Photovoice

Pre-exposure prophylaxis (PrEP) can reduce the risk of HIV infection by over 90% among those at high risk via sexual transmission. PrEP acceptance and adherence remains low among those at highest risk of HIV, including Black men who have sex with men (MSM) in the southern U.S. This community-based participatory research project explored Black MSM's experiences with PrEP in North Carolina through photovoice, a methodology using photography and discussion. Our findings highlighted challenges and opportunities with PrEP, including intersectional stigma, the need for improved patient-provider education, and the role of community-based organizations in closing patient-provider gaps. This work is a first step towards understanding the daily lives of Black MSM on PrEP in the Triangle Region of North Carolina, including barriers and facilitators to PrEP use. Implications for public health practice highlight the need for conducting community-level interventions, integrating PrEP into primary care, and normalizing PrEP through community conversations.

A Multilevel Model of the Association Between School Climate and Racial Differences in Academic Outcomes

This study examined the relationships between school-level school climate and race differences in student grades, accounting for school sociodemographic composition. We found that schools with more positive school climates had smaller race differences in student self-reported grades. The moderating effect of school climate remained after accounting for the sociodemographic composition of the school and students' own perceptions of climate at their school. This moderating effect was confounded by school grade band (i.e., elementary, middle, or high) since perception of positive school climate was lower in middle and high schools than in elementary schools. Despite the difficulty of disentangling school climate from grade band, the findings suggest school improvement strategies focused on school climate may promote racial equity in academic outcomes. School practitioners' efforts to improve the school climate may also contribute to racial equity in academics.

Justice System Reform for Health Equity: A Mixed Methods Examination of Collaborating for Equity and Justice Principles in a Grassroots Organizing Coalition

Recent critiques of collective impact have provided a conceptual alternative that emphasizes the necessity of community organizing, and more explicit emphasis on advancing equitable systems and policy changes. This article reports results from a study of a citywide coalition in Chicago, IL that espoused many of these same principles. The coalition focused on justice system reform-systems and policy change that would dismantle punitive policies disproportionately affecting people of color-but also sought to connect these efforts with broader social determinants of health. The organizations that comprised the coalition were a pairing of those traditionally involved in restorative justice practice, and those traditionally involved in grassroots organizing. An action research partnership provided an opportunity to investigate processes and outcomes of a coalition created to advance equitable systems and policy changes. This analysis of the coalition's functioning employs a mixed methods approach. We utilize two waves of interorganizational social network data and qualitative data including participant observation, in-depth interviews, and archival document review to examine the coalition's successes and challenges related to each of the six core principles of Collaborating for Equity and Justice. This analysis provides practical insights into the benefits and challenges of implementing deeply participatory processes to address policy and systemic drivers of social determinants of health. Findings show that fully integrating all six principles is challenging, especially when a coalition represents broad constituencies across race, geography, and organizational philosophy. In such diverse settings, considerable time must be spent to build relationships and a strong foundation for sustainable processes.

Building Governmental Public Health Capacity to Advance Health Equity: Conclusions Based on an Environmental Scan of a Local Public Health System

Vast health inequities persist in cities across the United States. Although recommendations exist to guide governmental public health institutions seeking to advance population health equity, local contexts are likely to influence how these pursuits take shape. We review recommendations for pursuing equity that were developed from an environmental scan conducted in the city of New Orleans. The recommendations, which are based on perspectives provided by city and state public health leaders, leaders from other city governmental departments, and community-based health department partners, center around the enduring impact of systemic racism, working across sectors, and prioritizing community engagement.

Ethics and Racial Equity in Social Welfare Policy: Social Work's Response to the COVID-19 Pandemic

The COVID-19 pandemic has been particularly overwhelming for communities of color in the United States. In addition to the higher levels of underlying health conditions, circumstances related to a history of oppression and unequal access to opportunities and services are apparent. Social service programs will need to be re-developed to accommodate a new reality, both in terms of how people connect with services and how social work professionals provide them. Professional social work organizations' codes of ethics are analyzed, along with the theoretical framework of structural competency. It is an ethical imperative that social welfare policy and practice advance as culturally competent, racial equity, and empowerment-based programs. Child welfare is portrayed as an example where the pandemic could provide an opportunity to learn from the past to construct a more compassionate, competent, and ethical future.

Defining and Measuring Sustainability in the Food & Fitness Initiative

Several frameworks for defining and measuring sustainability in public health have been documented in the literature. For the Food & Fitness Initiative, sustainability was a central aim at the outset and was defined broadly throughout the project. Sustainability included not only funding and resources necessary to support organizational structures but was a core function of how these partnerships were able to focus their work, build capacity, forge lasting relationships, execute the work, and produce systems and policy changes that would endure over time. In this article, we present findings from an online survey assessing partners' views on 10 distinct dimensions of sustainability and several key themes from a set of key informant interviews with partnership leaders. Of the 10 dimensions, participants reported having the most success in creating (1) community ownership, where initiatives are led by and reflect the needs of community residents; (2) a vision that is shared across partners and developed collaboratively; and (3) leadership that includes a diverse team of skilled, credible people. A key learning in this project was that sustainability needs to be intentional and clearly defined and that evaluations should include multiple and ongoing methods to capture several dimensions of sustainability.

We Treat Everybody the Same: Race Equity in Child Welfare

For several decades, child welfare researchers have explored the issue of disproportionality in child welfare. Top-level government reports have confirmed that African-American children are disproportionately represented in the child welfare system. This knowledge led to the concern that equity standards are not being implemented in child welfare systems partially due to implicit bias and insufficient data to track services to this population of children. The lack of data and recognition of the disparate entry of African Americans into care will continue unless systems move to having the child welfare system understand overrepresentation and the need for equity in the provision of services. This article shares findings of a research study and is focused on the use of data as a strategy to improve racial equity in child welfare. It uses critical race theory (CRT) to explain how racism can impact equity in the provision of child welfare services.

Transmutation and Community | Social | Systems Change in Boston

The impact of transparent leadership and a deliberate focus on the work through a community-determined lens is discussed in the Boston Collaborative for Food & Fitness (BCFF) case study. Restructuring of BCFF focused on housing the work in the community and providing leadership opportunities to community members. The birth, growth, collapse, and rebirth of BCFF, is outlined, and the reimagining of BCFF's vision and action are described as a "healing and connection-centered approach to community resilience and systems change that centers community leadership and voice and challenges prevailing models of how change happens, particularly in communities of color."

Working Together to Improve Community-Level Health: The Evolution of the New York City Food & Fitness Partnership

The New York City Food & Fitness Partnership case study discusses how the scope and abundance of diverse community stakeholders can create difficulties when addressing and conducting work in a large city landscape. We describe our 9-year journey, from initial citywide planning, to early challenges, to rebirth as a Central Brooklyn-focused effort led by a community development corporation. We describe difficult and transparent conversations, and the various leadership changes and organizational transitions that have helped the partnership embrace equity frameworks. We illustrate how these principles have been demonstrated in their efforts to be community driven, ensuring that intended beneficiaries would be involved in every stage of decision making.

Phoenix Rising: The Evolution of Holyoke's Collaborative Organizing for Healthy Food Resilience

In the Holyoke Food & Fitness Policy Council (HFFPC) case study, the challenges of providing equitable multistakeholder organizing are examined. The importance of housing the work in the community, power sharing, and having community representation in the leadership is made clear. The HFFPC partnership began with vigor, encountered challenges of trust, transparency, aligned goals and values; it dissolved, and reformed. Because it began with shared values of strong communities and healthy people, the partnership continues to evolve, build local leadership, change narratives, and articulate the need for racial equity in their food system, while shifting local systems and policies that frame who has access to healthy food and safe spaces to exercise in a low-income Latino community.

Food & Fitness: Lessons Learned for Funders

Communities face issues that are complex, affect diverse stakeholders who hold conflicting perspectives, involve historical systems, and have long delays between the time action is taken and results of the actions become obvious. In order to improve outcomes some funders have begun to shift their priorities to support systems change, rather than activities or programs that address discrete short-term needs and problems. In 2007, W.K. Kellogg Foundation funded Food & Fitness, a 9-year initiative designed to address the then-emerging concerns about childhood obesity and health inequities from a system perspective. Funded partnerships in communities with inequities across the United States created community-based approaches to increase access to locally grown food and healthy places for physical activity. This 9-year systems change initiative provided a unique opportunity to document lessons that can inform funders and communities seeking to create places that will support the health of children and families, as well as those leading other systems change initiatives.

Prioritizing Racial Equity: How Efforts to Advance Racial Equity Helped Shape the W.K. Kellogg Food & Fitness Initiative

Racial equity is closely linked to principles of fairness and justice. It is distinct from the concept of racial equality. Community engaged strategies aimed at creating racial equity have generated effective ways to dismantle structural racism-the racialized policies and practices that have shaped economic and social institutions in the United States throughout its history. In crafting the Food & Fitness Initiative, the W.K. Kellogg Foundation made advancing racial equity a top priority. By doing so, it encouraged the community partnerships funded under the initiative to apply theories of expanding equity to real-world situations in order to reduce racial disparities in their neighborhoods. This article reviews the methods that were employed over the course of the initiative to support the partnerships with their efforts. It highlights three key components: (1) being intentional about maintaining a focus on racial equity, (2) concentrating on changing policies and systems, and (3) consistently incorporating meaningful and authentic community engagement into the work. The importance of making the concept of equity concrete and measurable is explored. Furthermore, the article discusses strategies that strengthened the capacity of the partnerships to navigate the policy-making process and to build leadership and shift power to community residents. The article concludes by detailing measures that could guide future efforts to make racial equity a priority and emphasizes that doing so is crucial given the rapid demographic shifts underway across the country.

The Food & Fitness Community Partnerships: Results From 9 Years of Local Systems and Policy Changes to Increase Equitable Opportunities for Health

The Food & Fitness (F&F) community partnerships, funded by the W.K. Kellogg Foundation from 2007 to 2016, were established to create community-determined change in the conditions that affect health and health equity in neighborhoods. The focus of the work has been to increase access to locally grown good food (food that is healthy, sustainable, fair, and affordable), and safe places for physical activity for children and families in communities with inequities across the United States through changes in policies, community infrastructure, and systems at the local level. This article describes the outcomes related to systems and policy change over 9 years of community change efforts in the F&F partnerships. Characteristics of the F&F communities where the work took place; the change model that emerged from the work; efforts and changes achieved related to community food, school food, and active living/built environment; overall factors in the community that helped or hindered the work of the partnerships; and a depiction of the community-determined process for change employed by the partnerships are described. Local systems and policy change is a long-term process. Community-determined efforts that build capacity for systems change, commitment to long-term funding, and provision of technical assistance tailored to community needs were elements that contributed to success in the F&F work. Achieving intermediate outcomes on the road to policy and systems change created a way to monitor success and make midcourse corrections when needed.

Lessons Learned From Food & Fitness About Building Successful Partnerships: Focus, Capacity, and Sustainability

Approaches undertaken by the Food & Fitness (F&F) community partnerships demonstrate that engaging community residents in the process of creating systems change strengthens the ability of neighborhoods, organizations, and institutions to foster and sustain those changes over time. The F&F partnerships were established to increase access to locally grown food and safe places for physical activity for children and families in communities with inequities across the United States. A critical focus of this initiative has been to use community-determined approaches to create changes in policies, infrastructures, and systems that will lead not only to change but also to sustainable change that positively influences health equity. During the 9 years of the initiative, lessons were learned about the fundamental elements that built the foundation for success across all partnership work. Data were extracted from the systems and policy change tracking forms related to efforts for all F&F sites over the entire implementation period (2009-2016). Documentation related to both the process and outcomes of the efforts were qualitatively analyzed to determine factors related to success. The following factors have emerged from our analyses and uncover a deeper understanding of what actions and factors were critical for the work: focus of the work over time, capacity built in the partnerships, and sustainability of the work and outcomes.

The Social Structure of Mortgage Discrimination

In the decade leading up to the U.S. housing crisis, black and Latino borrowers disproportionately received high-cost, high-risk mortgages-a lending disparity well documented by prior quantitative studies. We analyze qualitative data from actors in the lending industry to identify the social structure though which this mortgage discrimination took place. Our data consist of 220 depositions, declarations, and related exhibits submitted by borrowers, loan originators, investment banks, and others in fair lending cases. Our analyses reveal specific mechanisms through which loan originators identified and gained the trust of black and Latino borrowers in order to place them into higher-cost, higher-risk loans than similarly situated white borrowers. Loan originators sought out lists of individuals already borrowing money to buy consumer goods in predominantly black and Latino neighborhoods to find potential borrowers, and exploited intermediaries within local social networks, such as community or religious leaders, to gain those borrowers' trust.