Achieving Health Equity through Science, Policy, and Partnerships

Introduction

I am delighted to write the Foreword for this timely supplement to Ethnicity & Disease. The work of the Transdisciplinary Collaborative Center for Health Disparities Research at Morehouse School of Medicine exemplifies the mission and scope of the journal, which includes understanding and addressing social and racial/ethnic factors related to health care access and outcomes. This supplement moves the field forward in its collective efforts toward disparity reduction and health equity, with a focus on health policy. The articles in this special issue have a common theme – health equity advancement and potential targets for policy interventions to eliminate disparities.

Health Equity

Health equity is the aspirational goal of optimal health for all.1 Reducing health disparities is necessary to achieve and maintain health equity, and requires community-centered, multi-sector, transdisciplinary initiatives developed to address the specific needs of affected groups and are mindful of policy implications at the outset. The persistence of heath care inequities manifests itself in societal burdens that are costly to all of us. Strategies to address health disparities can occur at many levels, including the individual, family, community, and population levels – and each play a role in improving population health. For instance, individual-level approaches often represent the core of strategies subsequently scaled to reach whole populations. However, policy-level interventions are perhaps the most effective and expeditious at eliminating health disparities.2 A recent article by Polite et al2 provides compelling exemplars of the role of policies in both the etiology and reduction of disparities in cancer. As noted in the article, effective policies included key elements, such as medical-community partnerships, sustained investments in evidence-based early detection, and high-quality patient navigation from prevention to survivorship. The articles in this special issue of Ethnicity & Disease provide models of health disparities research that value diversity and inclusion, collaboration, partnerships beyond the halls of academic institutions, and the generation of science-informed policies to promote equity.

Overview of Special Issue

The Transdisciplinary Collaborative Center for Health Disparities Research was founded by Dr. David Satcher, who was also the 16th Surgeon General of the United States. A visionary ahead of his time, Dr. Satcher made affirmative commitments to equity-focused health policy research grounded in academic-community partnerships that value the contributions of all stakeholders. The center recognizes that innovative strategies are needed to improve population health (ie, taking care of the needs of the “whole”), while filling the “holes” (ie, eliminating the undue burden of negative health outcomes among underserved or never-served populations).3 Dawes4 offers a concise historical account of how federal policies have influenced health inequities and how contemporary national initiatives have specified health equity goals.

This special collection is an extension of the original vision of the center and highlights the thought-provoking transdisciplinary research it supports. The topics covered underscore the breadth and depth of health inequities across populations, including adults with developmental disabilities,5-6 persons living with chronic illnesses,6 racial/minority youth with mental health concerns,7 and transgender medical patients.8 The articles encourage readers to consider the multilevel changes required to achieve the desired goal of optimal health for all, such as cultural competence training for health care providers,9 health policy training,10-11 the use of consumer health informatics applications for disease self care,12 stakeholder education13 and organizational engagement.14 In addition to research dissemination, this supplement is designed to serve as: 1) a resource to researchers seeking to advance the science of health equity; 2) an educational resource for those working in community-based and/or grassroots settings; and 3) a transdisciplinary document demonstrating the importance of keeping the policy implications of health research in the foreground, from project conceptualization through the interpretation and dissemination of findings.

The articles in this issue describe the application of an overarching health equity framework to address complex societal determinants of health disparities, and to inform policy. This includes efforts toward the development, implementation, and evaluation of policies grounded in rigorous scientific methods, and the inclusion of diverse stakeholders.15 Important in this discussion, is the role of “health-in-all” policies to promote health equity, and the adaption of existing models to evaluate multilevel (ie, downstream, midstream, and upstream) policy interventions using a health equity lens.16 Taken together, the Transdisciplinary Collaborative Center for Health Disparities Research embodies an innovative approach, T^x ™, which moves research from translational to transformational,17 and seeks to shorten the timeline to adoption and implementation in clinical and/or community settings. The center also recognizes the need to assess impact, by conducting participatory evaluations using research logic models, and evaluations of both processes and outcomes.18

Articles in this issue describe multi-level training efforts to advance health equity. McGregor et al9 applied theoretical approaches and an integrated care model to train behavioral health care providers in cultural competence to improve health equity. This has important and testable policy implications. For instance, behavioral health care organizations could implement a policy to deliver annual cultural competence training, and evaluate patient, provider, and organizational change outcomes. Graduate and professional training in policy within the context of health equity is also critical to prepare current and future professionals to create institutional change. Survey data from the Satcher Health Leadership Institute’s post-doctoral health policy fellowship suggest positive effects on learner outcomes, career opportunities,9 and resultant knowledge matched to the needs of professional environments.10 This highlights the need to institutionalize high-quality mentoring programs to increase the pipeline of future researchers and professionals trained in health policy and health equity.9

Articles in this collection also focus on understudied populations for which health policies are needed deeply to advance health equity. These studies exemplify challenges associated with intersectionality, or the extra-disadvantage experienced by individuals with multiple “minority” social positions.19 Importantly, this work yielded feasible and actionable policy areas with the potential to address the health care needs of populations at high risk for morbidity, discrimination, and marginalization, including transgender patients,8 adults with developmental disabilities,5 HIV+ adults with intellectual and/or developmental disabilities,6 and medically underserved Korean American women.20 Two articles focus on health equity promotion for children. Butler and Rodgers7 highlight racial/ethnic disparities in child mental health and provide a nice roadmap for developing and disseminating a policy brief on equity in services for all children. One of the key points in their process was attention to message framing within the policy. Based on their formative research, they recommended a disparities-neutral vs disparities-explicit approach. Reese et al21 provide a cogent description of a diverse coalition of organizational partners pursuing equity in child health and early education through a peer-led parenting program. Their discussion of implementation facilitators and challenges in the real-world can guide others developing similar initiatives, with attention to capacity-building, program evaluation needs and parameters, and sustainability.

Charting a Path Forward for Health Equity and Collaborative Health Policy Research

I congratulate the Transdisciplinary Collaborative Center for Health Disparities Research at Morehouse School of Medicine for their ambitious work. The Center is dedicated to a challenge rather than to a single topic or set of topics. This challenge is to conduct community-engaged research to inform health policies that result in health equity. To actualize this goal, diversity of partnerships, mutually beneficial collaborations, and innovative strategies are needed to translate findings into communities, and ultimately transform health for all. It also requires a metacognitive understanding of processes and potential outcomes of such efforts. Robust empirical findings are necessary, but not sufficient, to ensure transformative evidence-based policies that lead to measurable change. As guidelines, standards of care, and policies are crafted using the best available science, we must also consider additional factors such as effective dissemination and implementation methods, longitudinal surveillance of disparities and policy amendments over time as needs change, and ongoing evaluation to assess and avoid unintended consequences.