Characterizing Organizational Health Equity Capacity Assessments for Public Health Organizations: A Scoping Review

Abstract

Objective:

Organizational health equity capacity assessments (OCAs) provide a valuable starting point to understand and strengthen an organization’s readiness and capacity for health equity. We conducted a scoping review to identify and characterize existing OCAs.

Methods:

We searched the PubMed, Embase, and Cochrane databases and practitioner websites to identify peer-reviewed and gray literature articles and tools that measure or assess health equity–related capacity in public health organizations. Seventeen OCAs met the inclusion criteria. We organized primary OCA characteristics and implementation evidence and described them thematically according to key categories.

Results:

All identified OCAs assessed organizational readiness or capacity for health equity, and many aimed to guide health equity capacity development. The OCAs differed in regard to thematic focus, structure, and intended audience. Implementation evidence was limited.

Conclusions:

By providing a synthesis of OCAs, these findings can assist public health organizations in selecting and implementing OCAs to assess, strengthen, and monitor their internal organizational capacity for health equity. This synthesis also fills a knowledge gap for those who may be considering developing similar tools in the future.

States, counties, cities, and towns across the United States are increasingly identifying racism as a public health crisis, often declaring their corresponding intent to promote equity-oriented approaches in their public health policies and programs. ¹ Health inequities are systematic health disparities between groups with different levels of social power ² ; differences in health outcomes are inequitable when they are unnecessary, avoidable, unfair, and unjust. ³ The COVID-19 pandemic has highlighted the “longstanding inequities that have systematically undermined the physical, social, economic, and emotional health of racial and ethnic minority populations and other population groups that are bearing a disproportionate burden of COVID-19.” ⁴ In addition to race and ethnicity, demographic characteristics such as gender, sexual identity and orientation, geographic location, disability, and other factors influence health inequities in the United States. ⁵ Public health organizations play a key role in achieving health equity.^6,7 Public health equity work must be explicitly incorporated, prioritized, and resourced. Building the health equity capacity of public health departments can improve their ability to develop, implement, and sustain equity-centered work. ⁸

The Public Health National Center for Innovations defines health equity organizational competence as the “ability to strategically coordinate health equity programming through a high level, strategic vision and/or subject matter expertise which can lead and act as a resource to support such work across the department.” ⁹ Internal-facing capacity strategies, on topics such as organizational culture, readiness for change, policy development and program-planning processes, organizational infrastructure, staff training, and others,^10,11 are central to transforming health equity–oriented public health practice. ¹² Previous articles have identified the need to focus on organizational factors in public health and health care organizations to reduce disparities, ¹³ yet most inequity reduction frameworks lack guidelines on internal organizational assessments and do not “provide guidance on translation of equity across multiple organizational departments and levels.” ¹⁴ Organizational health equity capacity assessments (OCAs) are increasingly used by public health organizations to assess and improve their capacities to improve equity.^15,16 These assessments can serve as the foundation for organizational capacity for health equity action. Currently, however, OCAs can be challenging to locate, have varied structure and content, and have limited implementation evidence. These issues can hinder OCA uptake.

OCAs can be particularly useful for state health departments, county health departments, and local health departments (LHDs). A scan of government public health capacity recommended that health departments develop internal infrastructure to advance equity, ¹⁷ and equity is now 1 of the 8 foundational capabilities described in the Foundational Public Health Services framework. ¹⁸ LHDs, for example, are well positioned to address health equity disparities locally ¹⁹ but must have “an understanding of health equity, have the means to realize facilitators of health equity work, and recognize the complex context in which health equity work exists.” ²⁰ The OCA implementation process provides a foundation for understanding current equity capacity and where there is room for growth. In a 2019 survey ²¹ evaluating the Health Equity Guide ²² —a platform that provides strategic practices and case studies to help health departments advance health equity—86% (54 of 63) of respondents from state health departments and 73% (161 of 220) of respondents from LHDs reported that they were working to build organizational capacity to advance health equity and that guidance on which practices to consider or which organizational assessment to use would be useful. In the Public Health Accreditation Board’s Standards and Measures Version 2022, health equity is emphasized across every domain. ²³ OCAs have the potential to help organizations progress and monitor change along the 4 stages of transformation described by the Public Health Accreditation Board toward committed equity-centered work—moving from the status quo to committed, active, equity-centered work. ²⁴

This scoping review responds to the research question “How can we characterize existing organizational health equity capacity assessment tools for public health organizations?” We were unable to identify any systematic reviews that answer this question by collating and synthesizing information about extant OCAs. Practitioners must conduct individual searches to identify and compare available OCAs. This scoping review synthesizes and characterizes the OCAs in the gray and peer-reviewed literature, providing a baseline for researchers and practitioners searching for and selecting among the tools that have been developed to assess or review organizational health equity capacity. This scoping review can serve as a precursor to a future systematic review on this topic.

Objective

We conducted a scoping review to identify and characterize existing OCAs. Scoping reviews provide an overview of the evidence related to a particular concept—in this case, an overview of existing OCA tools to explore commonalities or key characteristics among these assessments. ²⁵ We conducted a search among the peer-reviewed and gray literature to identify as many OCAs as possible, with the objective of understanding similarities, differences, and key characteristics of each.

Methods

Our methods were based on the 6-stage standard scoping study framework proposed by Arksey and O’Malley, which included identifying the research question and relevant studies, selecting studies, charting the data, collating and summarizing the results, and validating the findings with practitioners. ²⁶

Eligibility Criteria

Inclusion criteria were OCAs published in peer-reviewed or gray literature and in the English language, with no restrictions on geographic origin or publication year. Articles, reports, and tools had to measure or assess the development of the health equity–related capacity of any public health organization. Organizational health equity capacity could be described by using terms such as health inequities, inequalities, and/or disparities. We did not restrict the structure of the OCAs.

We excluded sources if they did not address organizational-level capacity related to health equity or did not include any measurement or assessment of such capacity. We excluded 147 articles for not meeting multiple inclusion criteria; for example, we excluded some articles for not focusing on capacity building and for not including relevant assessment tools or approaches. It was not sufficient to describe other aspects of health equity work (eg, the measurement of inequities or the implementation of equity-oriented policies and programs) without an approach to assessing health equity capacity building at the organizational level.

Information Sources

We conducted the search in the PubMed, Embase, and Cochrane databases. Using a strategy of snowball and purposive sampling, ²⁶ we identified practitioner literature via the following practitioner websites and resources: the Health Equity Guide, the National Association of County and City Health Officials (NACCHO) Toolbox, the Racial Equity Tools website, Government Alliance on Race and Equity Toolkit, the Minnesota Department of Health’s Health Equity Resources list, and the Bay Area Equity Atlas. We hand searched reference lists.

Search Strategy

We developed and used a 3-step search strategy to be as comprehensive as possible within the constraints of time and resources. ²⁷ A search in PubMed and Embase used preliminary limited keywords to elicit potentially relevant articles. We reviewed the titles, abstracts, and keywords of these initial articles to develop a comprehensive list of keywords. We also compiled search terms with the help of partners at NACCHO and Human Impact Partners. We engaged with NACCHO and Human Impact Partners on search terms because of our knowledge of their ongoing work and expertise in the development of organizational health equity capacity. We then conducted a second search using all identified keywords and corresponding MeSH (Medical Subject Headings) and Emtree terms using the following databases: PubMed (on December 30, 2021), Embase (on January 15, 2022), and Cochrane (on January 15, 2022) (Box). As a quality control measure, we confirmed that preidentified relevant preliminary citations were identified through the full searches. After selecting sources for inclusion, we examined these reference lists to identify additional potential sources.

Box.

Final PubMed search string for articles related to organizational health equity capacity assessments, December 30, 2021

((“Health equity”[mesh] OR “Healthcare Disparities”[mesh] OR “health equity”[tw] OR “health inequit*”[tw] OR “Healthcare Disparit*”[tw] OR “Health care Disparit*”[tw] OR “health equal*”[tw] OR “healthcare equal*”[tw] OR “health inequal*”[tw] OR “healthcare inequal*”[tw] OR “vulnerable populations”[mesh] OR “Social Determinants of Health”[mesh] OR “health status disparities”[tw] OR “health status disparities”[mesh] OR “racial equity”[tw] OR “social justice”[tw])) AND (“organizational culture”[mesh] OR “organizational culture”[tw] OR “organizational innovation”[mesh] OR “organizational innovation”[tw] OR “organizational objectives”[mesh] OR “organizational objectives”[tw] OR “organizational culture”[tw] OR “organizational change”[tw] OR “organizational capacity”[tw] OR “capacity building”[mesh] OR “capacity building”[tw] OR “Decision Making, Organizational”[mesh]) AND (“public health systems research”[mesh] OR “public health systems research”[tw] OR “Public Health Administration”[mesh] OR “public health practice”[mesh] OR “Public Health Administration”[tw] OR “public health practice”[tw] OR “health services research”[mesh] OR “health services research”[tw] OR “organizational case studies”[mesh] OR “organizational case studies”[tw])

To identify relevant OCAs in the gray literature, we searched the previously described websites and common databases. We applied the same inclusion and exclusion criteria. We recognized that we had reached saturation when citation searching and reviews of practitioner resources consistently referenced the same OCAs. We deduplicated results across the peer and gray literature databases. Once we made final inclusion decisions, we searched again for each tool by name to capture examples of implementation. We also contacted the owner of every tool by email to request additional information on where and how OCAs had been implemented. Most owners did not respond; those who replied did not track information beyond what was available publicly. One organization indicated anecdotal awareness of some uses but did not share further information.

Selection of Sources of Evidence

For the published literature, we based the first round of source selection on title and abstract examination and the second round on full-text review. We performed source selection based on the inclusion and exclusion criteria. One author (R.M.) reviewed all articles at both stages. A second author (N.M.N.) reviewed a subset of articles at the full-text stage to reach consensus on articles that were included for data extraction. Both authors reviewed all articles that were included in the final review. For the gray literature, 1 author (R.M.) conducted the initial search and screening, and both authors (R.M., N.M.N.) reviewed the findings to reach consensus on which sources to include. For gray and published literature, a third author (K.M.P.P.) provided oversight of the process and reviewed a subset of full-text articles and tools to ensure consensus among all authors. Final articles from the peer-reviewed literature were deduplicated in EndNote and uploaded into Covidence for extraction. We extracted data from the gray literature into a Microsoft Excel spreadsheet with the same categories as the Covidence template.

Data-Charting Process and Data Items

The analysis phase of the scoping review involved charting the extra data in Excel to sort through and synthesize qualitative material according to key issues and themes and to capture a set of predefined characteristics of the identified OCAs. One author (R.M.) conducted the initial data extraction, and a second author (N.M.N.) reviewed the data to reach consensus on the extraction. For each OCA, we captured and summarized the following information: aims, structure or methods, themes, intended audience (if any), and definition of health equity capacity (if included). Where possible, we documented suggestions for implementation, such as resources required, or examples of implementation (geographic location, population served, capacity findings/results, or other implementation information). Charted data for each source of evidence are also available (eTable in the Supplement). Aligned with long-standing guidance for scoping reviews,^26,28 we did not consider the quality of the assessments and tools.

Synthesis of Results

We organized and described the findings thematically according to the previously described categories (ie, aim, structure or methods, themes, audience, and definitions). The analysis and presentation of findings align with the PRISMA for scoping reviews (Preferred Reporting Items for Systematic Reviews and Meta-analyses). ²⁹

Results

Selection of Sources of Evidence

The PRISMA flow diagram details the number of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at the full-text stage (Figure).

Figure.

PRISMA flow diagram (Preferred Reporting Items for Systematic Reviews and Meta-analyses) illustrating the results of a search conducted in January–February 2022 for organizational health equity capacity assessments.

Characteristics of Sources of Evidence

We found consistency across major themes. All OCAs assessed equity-oriented internal capacities, such as institutional leadership and governance, policies and guidelines, budget alignment and resource allocation, commitment and shared visions, internal structures, use of data, staff training and support, and/or staff diversity. However, each OCA differed in which themes were included and how they were described (Table 1). The level of detail ranges from 3 to 9 overarching domains per tool. Most but not all include measures or indicators aligned with each domain or subdomain. Some OCAs distinguished between individual staff competencies and organizational competencies, while other OCAs assessed staff competencies holistically as part of the organization’s workforce measurement. Some OCAs included measures related to external-facing capacity, such as the strength of collaboration with community partners, noting that external and internal capacity can be intertwined and that evaluating the internal capacity component requires awareness of the external enabling environment. ³⁵ An organization exploring OCA implementation must review OCA content to ensure that the focal areas and approach will align with organizational needs.

The OCAs ranged widely in publication dates (from 2006 to 2020), place of origin, and intended audience. We identified implementation case examples or published studies (Table 2) in the following geographic locations: Maricopa County, Arizona; Prince George’s County and Baltimore City, Maryland; Ingham County, Michigan; Hennepin County (Minneapolis) and Rice County, Minnesota; Missouri; North Carolina; Multnomah County, Oregon; Harris County, Texas; Kenosha County, Wisconsin; the Veterans Integrated Service Networks in the US Western Region; Ontario, Canada; local and regional health units in 7 Canadian provinces; and Australia. Six OCAs were intended for any public health organization.^30,33,35,38,46 Three OCAs were intended for LHDs^32,36,44; 3 for any type of public health department but with implementation information only at the county level^31,40,41; 1 for state health departments ³⁷ ; 2 for faith-based organizations, specifically churches^39,45; 1 for the US Department of Veterans Affairs service networks ⁴³ ; and 1 for public health coalitions. ⁴²

Table 1.

Common characteristics of OCAs for public health organizations as identified through a scoping review, January–February 2022

First author (year)	Article title	OCA aim and audience, if specified	Definition of health equity capacity	Structure	Themes
Annie E. Casey Foundation (2006) 30	Race Matters: Organizational Self-Assessment	Aim: assess an organization through a racial lens, offer next steps for equity action plans, and help track organizational change Audience: any organization	Not included	An organizational self-assessment tool that includes a series of questions with a set of possible responses that total to a racial equity score	Domains: staff competencies, organizational operations Staff themes (not comprehensive): staff knowledge, understanding, cultural competency, and ability to disaggregate data to conduct racial equity analyses Organizational themes: barriers to opportunity; explicit equity goals, aligned resource allocations, and investments; deliberate plan to center and promote staff of color and foster multicultural environment; internal team to guide this work; regular internal trainings and assessments; and mechanism to address complaints
Balajee (2012) 31	Equity and Empowerment Lens: First Version	Aim: help an organization assess programs or policies for equity impacts and implement an action plan to improve equity; help assess organizational level of readiness to implement the equity and empowerment lens and identify strategies that would increase the level of readiness Audience: public health departments	To serve the immediate needs of communities while striving toward collective empowerment and equity	Within the equity and empowerment lens, the “organizational readiness reflection” uses pieces of the BARHII’s toolkit and creates a reflection where respondents score the organization on characteristics and competencies	Themes: institutional commitment; hiring diverse employees; structure to support community partnerships; institutional support for staff and innovation; transparent and inclusive, responsive communication; creative use of funding; community-accessible data and planning; and streamlined administration processes Competencies: knowledge of the right areas, knowledge of SDH, community knowledge and organizing skills, leadership skills, problem-solving skills, cultural responsiveness, and humility
BARHII (2010) 32	Local Health Department Organizational Self-Assessment for Addressing Health Inequities: Toolkit and Guide to Implementation	Aim: serve as baseline measure of capacity, skills, and areas for improvement; guide strategic planning processes; serve as an ongoing tool to assess progress Audience: LHDs	Not included	Self-assessment toolkit with templates for a staff survey, collaborating partner survey, staff focus groups, management of staff interviews, internal document review guidelines, and implementation guide	The whole toolkit covers the following: health department planning and policies; collaboration within the LHD; collaboration with external partners and policy makers; collaboration with community groups; and supporting staff to address the environmental, social, and economic conditions that impact health. Topics within the staff survey instrument include health department planning and policies, program planning, internal collaboration, collaboration with external partners and policy makers, working with communities, and offering support to staff. Domains related to organizational characteristics in the survey: institutional commitment, hiring practices, community partnerships, support to staff, communication, support for innovation, data and planning, and administrative process.
Bloss et al (2018) 33	Health Equity and Social Justice in Public Health—A Dialogue-Based Assessment Tool	Aim: help take stock of an organization’s readiness and capacity to address health equity and social justice Audience: any health organization	Readiness and capacity to address health equity and social justice. Health equity is defined as “a fair and just opportunity to be healthier” 2	Assessment matrix with discussion topics across domains	Four domains: leadership, workforce, community, and systems change
Centers for Disease Control and Prevention (2013) 34	A Practitioner’s Guide for Advancing Health Equity: Community Strategies for Preventing Chronic Disease. Chapter: Building Organizational Capacity to Advance Health Equity	Aim: offer ideas on how to maximize the effects of several policy, systems, and environmental improvement strategies with a goal to reduce health inequities and advance health equity Audience: any health organization	Opportunities to “improve health for all”	Self-assessment questions and a case example	Organizational commitment, funding, workforce, operations, community partnerships, and next steps (in the questions for reflection)
Cohen et al (2013) 35	A Conceptual Framework of Organizational Capacity for Public Health Equity Action	Aim: guide research, dialogue, reflection, and action on public health capacity development to achieve health equity goals Audience: any health organization	The capability of a public health organization to identify health inequities, mobilize resources, and take effective action to reduce inequities	Journal article with conceptual framework	Internal context domains: values, commitment and will, and organizational infrastructure
Cohen et al (2018) 36	Indicators to Guide Health Equity Work in Local Public Health Agencies: A Locally Driven Collaborative Project in Ontario	Aim: guide health equity work in local public health agencies Audience: any health organization	To address the SDH to reduce health inequities across population groups	Set of indicators	Domains/themes: how the public health agency assesses and reports data; how the agency modifies/orients its programs and services; how it engages in community/multisectoral collaboration; whether policy and position statements reflect advocacy for priority populations; and areas in organization and system development (eg, whether a strategic plan is in place and has identified targets for desired equity outcomes)
Region V Collaborative Improvement and Innovation Network on Infant Mortality (2016) 37	Foundational Practices for Health Equity: A Learning and Action Tool for State Health Departments	Aim: assist state public health organizations to evaluate and document current capabilities to advance health equity, track improvements, and transform practice Audience: state health departments	The public health organization’s ability to translate theory into action and transform their practices to address SDH and advance health equity	Seven foundational practices, each of which has a list of questions for assessment	Expand the understanding of health; assess and influence the policy context; equity focus of leadership; data analysis and use; continuous health equity learning; support of successful partnerships and community capacity; and strategic use of resources and accountability
Curry-Stevens and Reyes (2014) 38	Protocol for Culturally Responsive Organizations	Aim: determine their profile and identity along a continuum of degrees to which the organization is and is not culturally responsive Audience: all organizations addressing racial inequities; includes health as a focus area	Not included	Protocol and matrix, produces an organizational profile	Nine domains include commitment, governance, and leadership; racial equity policies and implementation practices; organizational climate, culture, and communications; service-based equity; service user voice and influence; workforce composition and quality; community collaboration; resource allocation and contracting practices; and data, metrics, and quality improvement
De Marco et al (2011) 39	Assessing the Readiness of Black Churches to Engage in Health Disparities Research	Aim: evaluate church readiness to engage in health disparities research Audience: faith-based organizations engaging in health disparities research	Not included	Instrument with 2 one-page scenarios, each followed by 15 items to gauge readiness to conduct intervention and assessment activities; items measured on a Likert scale	For each scenario, themes in the instruments’ questions included the following: staffing (who is responsible for this work? has leadership promoted health equity activities? do you have a lay advisor for this work?), budget (do you have a budget available?), policies (do you have relevant policies or goals for the congregation?), and guidelines (do you have guidelines?)
Hennepin County Public Health Department (2019) 40	Public Health Department Health Equity Assessment	Aim: involve all staff to understand organization-wide picture of attitudes, practices, and competencies that indicate departmental capacity to address root causes of health inequities, and identify priority areas Audience: public health departments	Not included	Two tools—an initial survey and a follow-up survey—adapted from the BARHII toolkit	Themes: the public health department’s commitment to SDH, the level of focus on health inequities, the incorporation of health inequities in strategic planning, the role of community partners, the role of the individual staff member, individual awareness of SDH and training on SDH, collaboration across the programs, leadership support and comfort in this space, collaboration with external partners, community capacity building, program orientation to community needs, and staff cultural diversity
Ingham County Health Department 41	Health Equity Practice Evaluation	Aim: not available Audience: public health departments	Not included	A matrix with a series of 11 questions with a continuum of possible responses	Themes: support equity as a human right, leadership, multidisciplinary coordination, workforce development and education, working and collaborating with communities, communications strategy, health promotion, building alliances and coalitions, public policy development and analysis, advocacy, and monitoring and surveillance
Inzeo et al (2019) 42	Advancing Coalition Health Equity Capacity Using a Three-Dimensional Framework	Aim: build and assess coalition health equity capacity Audience: coalitions	The degree to which organizations understand, have the skills, orient themselves toward, and implement strategies to advance health equity	Qualitative framework	Three dimensions of health equity capacity: conceptual foundations, collective action and impact, and civic orientation
Noe et al (2014) 43	Providing Culturally Competent Services for American Indian and Alaska Native Veterans to Reduce Health Care Disparities	Aim: assess and determine organizational characteristics that predict the provision of culturally competent services for American Indian/Alaska Native veterans Audience: those serving veterans	Not included	Adapted version of the ORCA	ORCA high-level themes focus on need (staff need, program need), leadership (support, practices, performance measures, opinion leaders), resources (staffing, training, offices, equipment, general), and organizational climate (mission, change pressure, autonomy, cohesion, communication)
Stamatakis et al (2020) 44	Development of a Measurement Tool to Assess Local Public Health Implementation Climate and Capacity for Equity-Oriented Practice: Application to Obesity Prevention in a Local Public Health System	Aim: develop a theory-based snapshot measurement tool that captures LHD organizational characteristics that align with implementation of equity-oriented practice and assess progress in building these structures and functions Audience: LHDs	Not included	An online questionnaire that draws from the Consolidated Framework for Implementation Research and the BARHII domains, as well as measurement items from the National Association of County and City Health Officials’ roadmap for chronic disease prevention, to develop a measure of equity-oriented implementation climate and practice	Four domains of implementation climate: relative priority, tension for change, compatibility, and organizational incentives/rewards Four practice areas: assessment and planning, monitoring and analysis, leadership support, and obesity prevention practice
Tagai et al (2018) 45	Assessing Capacity of Faith-Based Organizations for Health Promotion Activities	Aim: assess capacity for health promotion activities to improve the health of medically underserved communities and reduce health disparities Audience: faith-based organizations	Survey/assessment	A survey/assessment that is entitled the Faith-Based Organization Capacity Inventory	Across 3 categories: staffing and space (membership, building leadership, and staffing), health promotion experience (health ministry–specific activities), and external collaboration (collaborative partnerships, investment in research, and technical assistance)
University of Wisconsin Population Health Institute 46	Organizational Health Equity Checklist	Aim: support organizational improvement in advancing health equity Audience: any health organization	Not included	A checklist based on the Association of State and Territorial Health Officials’ Foundational Practices for Health Equity	The checklist aligns with the foundational practices. Question areas include understanding of health and health equity, organizational policy context, equity leadership within the organization, use of data, relevant workforce training and quality improvement, cross-sectoral and community partnerships and capacity building, and strategic use of resources.

Abbreviations: BARHII, Bay Area Regional Health Inequities Initiative; LHD, local health department; OCA, organizational health equity capacity assessment; ORCA, Organizational Readiness to Change Assessment; SDH, social determinants of health.

Table 2.

OCA implementation information to inform use by public health organizations, as identified through a scoping review, January–February 2022

First author (year)	Article title	Location	Capacity findings/results	Resources required	Other implementation information
Annie E. Casey Foundation (2006) 30	Race Matters: Organizational Self-Assessment	Rice County, Minnesota	Rice County Public Health staff “utilized the assessment to discuss how current policies and practices facilitated or hindered the advancement of health equity. The assessment process helped identify opportunities to advance health equity. One result was the development of a departmental health equity policy to guide for how the department advances health equity.”	A state grant was available to support the internal assessment and other next steps. An external facilitator was used. Rice County Public Health collaborated with SDH staff to develop and tailor this assessment.	Individuals can complete the Race Matters tool, choosing their own unit of analysis—a whole organization or a unit within an organization. Rice County also used the BARHII in its adaptation.
Balajee (2012) 31	Equity and Empowerment Lens: First Version	Multnomah County, Oregon	Not described	Self-assessment only	Considerations for implementation of the equity and empowerment lens as an individual or organization, including how to create space for the process. A team of key voices is recommended.
BARHII (2010) 32	Local Health Department Organizational Self-Assessment for Addressing Health Inequities: Toolkit and Guide to Implementation	Harris County, Texas; Maricopa County, Arizona; Rice County, Minnesota; Hennepin County, Minnesota	Harris County: used a modified toolkit to assess staff willingness to embrace new concepts and health equity priority areas. Used the framework to develop a health equity framework to guide programming. Maricopa County: administered a subset of BARHII questions; 82% of agency staff (n = 496) participated in the survey. Responses provided a baseline assessment of staff perceptions of the agency’s health equity focus (eg, the right amount, too much, not enough)	Appendix V includes estimates for time and materials budgeted for implementation, depending on the components selected for use. This analysis focuses on the staff survey to allow for comparability with other OCAs. The survey is the most resource intensive with leadership and staff time required to organize, manage, and take the survey, plus time to analyze the data (and potential for consultant).	Leadership must be engaged. The organization should have clarity about why this assessment is needed. The process requires sufficient staff capacity, someone who can facilitate the process (partner or consultant), and financial or technology resources available. Should clearly communicate to staff about how the results will be used, consider key timing, and communicate next steps. The ideal team makeup is also described.
Bloss et al (2018) 33	Health Equity and Social Justice in Public Health—A Dialogue-Based Assessment Tool	Michigan	Summarized results provide an organizational overview, strengths, gaps, and action items.	Not described	The tool is meant to be completed through individual reflection, followed by group dialogue to discuss answers. Health administrators, staff, partners, and other relevant individuals and organizations should all complete the tool.
Centers for Disease Control and Prevention (2013) 34	A Practitioner’s Guide for Advancing Health Equity: Community Strategies for Preventing Chronic Disease. Chapter: Building Organizational Capacity to Advance Health Equity	Not applicable	Not described	Not described	Not described
Cohen et al (2013) 35	A Conceptual Framework of Organizational Capacity for Public Health Equity Action	Local and regional programs in 7 Canadian provinces	Not described	Not described	Not described
Cohen et al (2018) 36	Indicators to Guide Health Equity Work in Local Public Health Agencies: A Locally Driven Collaborative Project in Ontario	Ontario	Use of the indicators served as a “prompt for future planning,” “helped participants to think about doing things differently,” and improved internal communication within some agencies.	Time to source data, human resources	Barriers: poor data quality, time needed to source data, and limited human resources to engage (were lacking in smaller local public health agencies). Facilitators: when existing strategic plans explicitly addressed health equity, it was easier to align this work and find associated data. Having strong leadership also helped, as did having strong community relationships.
Region V Collaborative Improvement and Innovation Network on Infant Mortality (2016) 37	Foundational Practices for Health Equity: A Learning and Action Tool for State Health Departments	Not applicable	Not described	Should be completed by a team of individuals with substantial knowledge of the organization’s structures and functions	Not described
Curry-Stevens and Reyes (2014) 38	Protocol for Culturally Responsive Organizations	Not applicable	Not described	Time, leadership commitment, and a team to implement. An implementation process is required.	Not described
De Marco et al (2011) 39	Assessing the Readiness of Black Churches to Engage in Health Disparities Research	North Carolina	Found a range of readiness to engage, but overall readiness was high. Proximal factors, including pastor leadership and presence of a health-related budget, did appear to play a role in church readiness, whereas other church characteristics did not.	Church leadership involvement is required, as is skill in data analysis.	Some churches felt the researchers were using too much time to collect data without enough corresponding technical assistance.
Hennepin County Public Health Department (2019) 40	Public Health Department Health Equity Assessment	Minneapolis, Minnesota	Hennepin County used survey results to identify opportunities for improvement. The county followed the initial assessment with a shorter follow-up survey 1 year later.	The initial survey takes most people 15-20 minutes to complete; the follow-up survey takes 5-10 minutes to complete.	Not described
Ingham County Health Department 41	Health Equity Practice Evaluation	Ingham County Health Department, Michigan	Not described	Not described	Not described
Inzeo et al (2019) 42	Advancing Coalition Health Equity Capacity Using a Three-Dimensional Framework	Wisconsin	Capacity rankings are displayed on a capacity spectrum. Across all dimensions, the cohort of coalitions had strong SDH understanding, whereas there was least understanding in areas requiring strategies to address imbalances in power and, thus, to target structural determinants.	Qualitative research skills and related time and financial resources	Limitations include that it is difficult to assess growth via descriptive data analysis. Applying this approach requires qualitative research/coding capacity. The framework did provide a way of assessing and supporting health equity capacity growth.
Noe et al (2014) 43	Providing Culturally Competent Services for American Indian and Alaska Native Veterans to Reduce Health Care Disparities	Western region, US Department of Veterans Affairs	The 27 facilities assessed scored highly on all measures. The authors anticipated that higher scores would be associated with greater likelihood of staff perceiving that their facilities met the needs of AI/AN veterans. In general, findings did not support hypothesis; higher scores on the ORCA were not associated with greater implementation of programs and practices for AI/AN veterans. However, some substantial considerations for improvement concerning needs, leadership, and communication were identified; identifying facilities with these characteristics may also support success of new native-specific programs.	Ability to administer the survey and conduct a regression analysis	Not included
Stamatakis et al (2020) 44	Development of a Measurement Tool to Assess Local Public Health Implementation Climate and Capacity for Equity-Oriented Practice: Application to Obesity Prevention in a Local Public Health System	Missouri LHDs	Identifies structures and processes that may be leverage points for implementation strategies to improve equity-oriented approaches in LHDs. Where implementation climate index is higher, there is a higher likelihood of engagement in assessment and planning of activities geared toward health equity. During implementation, “measures of equity-oriented implementation climate indicated areas of variability with respect to strengths and gaps across LHDs.” LHD barriers to this work were conflicting priorities and lack of external support. Findings also show the importance of additional training in a number of areas.	Not described	This is a theory-based snapshot tool for organizations that do not have the capacity, readiness, or support for a more in-depth, comprehensive review (eg, BARHII).
Tagai et al (2018) 45	Assessing Capacity of Faith-Based Organizations for Health Promotion Activities	Prince George’s County and Baltimore City, Maryland	FBO-CI may be used as part of research or as a self-directed internal assessment of a faith-based organization’s capacity. Additional refinement is needed from testing the tool further. Descriptive church profiles with highest, median, and lowest FBO-CI scores were examined to “illustrate the application of the FBO-CI to 3 churches of variable capacity.” The FBO-CI framework was found to be promising.	The interviews required considerable time and resources to complete.	The survey was paper-and-pencil. Some participants had difficulty responding to some items as a self-assessment, so the research team determined that an interview format “would yield higher quality and more timely data collection.” The survey was then distributed to the church with follow-up interviews so that it had time to collect the data. Most churches completed the interview format, while only 5 of the 34 recruited churches completed the self-administered format.
University of Wisconsin Population Health Institute 46	Organizational Health Equity Checklist	Not applicable	Not described	Not described	Not described

Abbreviations: AI/AN, American Indian/Alaska Native; BARHII, Bay Area Regional Health Inequities Initiative; FBO-CI, Faith-Based Organization Capacity Inventory; LHD, local health department; OCA, organizational health equity capacity assessment; ORCA, Organizational Readiness to Change Assessment; SDH, social determinants of health.

Discussion

We found little consistency in how organizational health equity capacity is defined or assessed. As public health organizations seek to strengthen efforts to reduce health inequities, we sought to fill a key gap in the literature by identifying and characterizing the tools that have been developed to assess or review capacity for organizational health equity. The 17 OCAs that we included can help public health organizations improve their capacity to develop, implement, and sustain equity-focused work. The OCAs all described a similar purpose, with common aims of assessing readiness or capacity for organizational health equity. Most aimed to provide considerations or strategies to increase organizational health equity capacity or readiness and can be used repeatedly to monitor progress.

Many OCAs lack specific definitions of organizational health equity capacity. Where specified, organizational health equity capacity is variably defined to include equity-oriented organizational characteristics, practices, programs, and policies; key competencies; and foundational practices. Some tools do not include definitions, making it challenging for potential OCA implementers to quickly assess whether the approach to organizational health equity capacity in a given tool is appropriate for their organization.

We found that OCAs published in the peer-reviewed literature were more challenging to find than OCAs published in the gray or practitioner literature, because they were not commonly linked on practice-oriented websites and were found only through a targeted search in Embase or PubMed. However, these peer-reviewed OCAs often included useful data on capacity findings or results. For example, the Health Equity and Social Justice Dialogue-Based Assessment Tool summarized results to provide an overview, strengths, gaps, and action items. ³³ The LHD Implementation Climate and Capacity questionnaire, when implemented with 115 LHD practitioners in Missouri, identified barriers to health equity capacity development, including conflicting organizational priorities, a lack of external support for health equity work, and the importance of additional training in several areas. ⁴⁴

Some but not all of the peer-reviewed tools included implementation information (eg, barriers to and/or facilitators of OCA implementation). Cohen et al field-tested indicators to assess and guide the health equity work of public health agencies among 4 local public health agencies in Ontario (a mix of urban and rural). ³⁶ This pilot illuminated barriers to using the indicators, such as poor data quality, time requirements, and human resource requirements, as well as facilitators, such as strong leadership, community relationships, and existing strategic plans that address health equity. The authors of the Three-Dimensional Framework to Advance Coalition Health Equity Capacity noted that qualitative research and thematic coding capacity are needed for implementation. ⁴² The Faith-Based Organization Capacity Inventory framework was implemented with church congregations in Prince George’s County and Baltimore City, Maryland; although it was envisioned as a self-assessment, participants had difficulties responding, so an interview format was recommended instead. ⁴⁵ In general, we found minimal descriptions of resources required.

Many LHDs—including but not limited to Harris County, Texas; Maricopa County, Arizona; Hennepin County, Minnesota; and Rice County, Minnesota—have adapted the Bay Area Regional Health Inequities Initiative’s LHD Organizational Self-assessment Toolkit for their own use. ³² (Rice County also incorporated the Race Matters Organizational Assessment. ³⁰ ) These LHDs reported the utility of conducting these self-assessments but did not document their implementation process or results. The original Bay Area Regional Health Inequities Initiative toolkit includes a section on planning for implementation, describing leadership, communication, staff capacity, and resource requirements. ³²

We could not identify capacity assessment results or implementation information for the following OCAs: the Health Department Self-Assessment Questions, ⁴¹ the Equity and Empowerment Lens, ³¹ the Protocol for Culturally Responsive Organizations, ³⁸ the Learning and Action Tool for Public Health Organizations, ³⁷ the Centers for Disease Control and Prevention’s Building Organizational Capacity to Advance Health Equity self-assessment module, ³⁴ and the Organizational Health Equity Checklist. ⁴⁶

Our research did not find sufficient evidence to explore the types of domains or measures most widely used or most applicable in different contexts. For example, 1 study identified the internal organizational health equity capacity factors that are likely important in the context of serving urban African American neighborhoods—leadership, institutional commitment, trust, credibility, and interorganizational networks. ⁴⁷ Such findings could influence OCA selection. Contextual information should be included in OCA publications, if possible.

We did not restrict the type of OCA structures or formats that we included in the review, because we aimed to describe the full breadth of OCAs available. We found OCA structures ranging from a qualitative framework to individual surveys and reflections to a full toolkit with multiple components. Regardless of where an organization is in its health equity journey, an OCA is likely well suited. Yet, it was challenging to locate some OCAs, in part because the language used to describe this work varied widely. The most commonly used title was “assessment,” but OCAs were also described as a tool, protocol, conceptual framework, instrument, questionnaire, or inventory. Using consistent language would enable OCAs to be more easily found, compared, selected, and used.

Our scoping review had several limitations. First, publication bias is inherent in peer-reviewed databases, which we hope was minimized by searching the gray literature. Second, we searched as extensively as possible for gray-literature articles, reports, and case studies available online, but we may have missed some examples, including but not limited to those in languages other than English or those found only in additional databases. Finally, the field of health equity practice is changing rapidly, and our results are current only through March 2022.

Public Health Implications

Our review aims to bring the role of OCAs to the forefront of equity-oriented public health practice. OCAs provide a valuable starting point to understand an organization’s health equity readiness and capacity. Our characterizations of the identified OCAs are intended to assist public health organizations in selecting an OCA to assess, guide, and/or monitor their internal organizational health equity capacity. This review also provides a useful summary of the state of the art for anyone considering developing similar tools or frameworks. We recommend that future publications and case studies include data related to OCA implementation, including capacity findings, implementation lessons learned, and resources required, where possible. This information is necessary to inform OCA uptake and implementation.