35.2 Leading Initiatives to Transform Health Systems to Reduce Health Inequities

Community-Based Participatory Research

Community-based participatory research (CBPR) involves collaborative research partnerships among community members, researchers, and public health practitioners. This approach ensures that communities are actively involved in the research process, from identifying research questions to interpreting and disseminating findings. CBPR helps to address community priorities, build trust, and promote sustainable interventions (Agency for Healthcare Research and Quality [AHRQ], 2020).

At the core of CBPR lies collaboration, highlighting the significance of partnerships between researchers and community members. This approach recognizes communities’ immense knowledge and expertise regarding their health concerns. CPBR highly values community engagement and empowerment, involving community partners in all phases of the research process. Community members are active participants, co-researchers, and co-implementers of interventions. The ultimate goal of CBPR is to empower communities to take charge of the research process and use the findings to advocate for change and enhance their health outcomes (AHRQ, 2020).

CBPR is committed to producing actionable outcomes that lead to positive change in the community. It aims to translate research findings into interventions and policies that address community health concerns. CBPR considers sustainability, ensuring that research efforts have a lasting impact and support long-term improvements in community health (AHRQ, 2020).

In conducting community-based participatory research, ethical considerations are given the utmost importance, such as respecting community autonomy, cultural sensitivity, and informed consent and protecting human subjects. Adherence to ethical guidelines and protocols ensures the welfare and rights of all participants.

The research process has been extensively utilized in public health, health care, and social sciences to tackle health inequities, advance community health outcomes, and promote health equity. CBPR aims to create culturally appropriate, contextually relevant knowledge and significantly impact communities’ health and well-being by involving community members as active partners (AHRQ, 2020).

Health in All Policies

Health in All Policies (HiAP) seeks to incorporate health considerations into policymaking across various sectors and government agencies. As described in Engagement in the Policy Development Process, HiAP is “a collaborative approach that integrates and articulates health considerations into policymaking across sectors to improve the health of all communities and people” (CDC, 2016a). It recognizes that health outcomes are influenced by various social, economic, and environmental factors extending beyond the health care sector. HiAP aims to ensure that health is considered and integrated into decision-making processes and policies at all levels of government.

HiAP emphasizes addressing health inequities and the underlying SDOH, given that health disparities often stem from unequal access to resources, opportunities, and power. HiAP strongly encourages collaboration among various sectors, including health care, education, transportation, housing, environment, and agriculture. This approach recognizes that addressing SDOH requires a comprehensive, coordinated effort. When these sectors work together, they can align policies, strategies, and actions to promote health and well-being. HiAP aims to address the social, economic, and environmental factors contributing to health inequities and achieve equitable health outcomes for all populations. HiAP stresses integrating health impact assessments, epidemiological data, and research findings into policy development processes, as evidence and data are crucial to informing policymaking (CDC, 2016b).

Collaboration between community and public health nurses and professionals from various sectors and government agencies is crucial for promoting HiAP. By engaging in intersectoral partnerships, community and public health nurses can work with policymakers, community organizations, schools, transportation departments, and housing authorities, and other concerned parties to advocate for policies that address social determinants of health. Community and public health nurses can provide expertise on health promotion, disease prevention, and community needs to inform policy discussions. They can also support the implementation of health impact assessments (HIAs), which evaluate the potential health effects of proposed policies, plans, and projects across different sectors. Nurses can contribute their understanding of local health needs, data, and community perspectives to ensure that HIAs are comprehensive and reflect the specific community context. Additionally, they can collect and analyze data on health outcomes, SDOH, and the impact of policies on population health to provide evidence for the effectiveness of HiAP interventions. HIA and HiAP are policy tools that include health considerations in decision-making processes across sectors such as transportation, education, criminal justice, and equity (Rogerson et al., 2020). By sharing this evidence with partners, the community, and public health, nurses can advocate for evidence-based policy changes that promote healthier communities.

Public health nurse Josh can use the data analysis he performed to identify areas within his community to be the focus of intervention. For example, the data revealed a high prevalence of obesity and related chronic conditions, and Josh has identified significant health disparities and inequities, with limited health care, education, and healthy food options characterizing the community. Josh’s examination of interventions attempted in the past reveals that traditional approaches to improving health have not been sufficient and decides to adopt the HiAP framework to address the underlying social determinants of health.

Josh works with the local government and initiates a HiAP team to promote cross-sector collaboration involving representatives from various health, transportation, housing, education, and urban planning departments. Regular meetings and working groups facilitate communication, collaboration, and information sharing. This collaboration ensures that health considerations are integrated into policy discussions across sectors. The HiAP team collects and analyzes a wide range of data related to health outcomes, social determinants of health, and existing policies.

The HiAP team identifies critical health indicators, disparities, and areas where policy interventions can significantly impact health equity. This data-driven approach provides the necessary evidence to guide policy development and implementation. The HiAP team reviews existing policies and identifies opportunities for alignment with health goals. They identify policies that have the potential to impact health determinants, such as transportation infrastructure, affordable housing, access to parks and recreation, and healthy food options. The team works with relevant departments to integrate health considerations into policy development, ensuring that decisions prioritize health equity.

The HiAP team establishes mechanisms to assess the impact of policies on health outcomes and health equity. They track vital indicators, collect data, and evaluate the effects of policy changes on various population groups. This evaluation process helps to identify successes, challenges, and areas for improvement. The findings are shared with policymakers and community partners to inform future decision-making processes.

The local government actively engages with the community throughout the HiAP process. They conduct community consultations, focus groups, and public hearings to ensure that community members’ voices are heard and their health needs are considered in policy development.

Community feedback and perspectives are integrated into policy decisions to ensure relevance and responsiveness to local needs. Through the implementation of HiAP, the city government has witnessed several positive outcomes and impacts. Policies and interventions are designed and implemented with health equity in mind, resulting in improved access to health care services, increased availability of healthy food options, enhanced public transportation systems, and revitalized neighborhoods. Health disparities begin to narrow, and community members report improved health outcomes and a sense of well-being.

Community Health Workers

As introduced in Implementation and Evaluation Considerations, community health workers (CHWs) are essential public health workers who serve as a critical link between communities, health care systems, and state health departments. CHWs are trusted liaisons between the health care system and its communities. They provide culturally appropriate education, outreach, and support to individuals and families, particularly those facing health care difficulties. They significantly enhance health literacy, facilitate care coordination, and promote preventive health behaviors (CDC, 2022).

For example, CHWs conduct community outreach activities to connect individuals with health care resources and services. They may assist community members in navigating the health care system, scheduling appointments, completing paperwork, accessing insurance coverage, and understanding their rights and responsibilities. CHWs provide emotional support, encourage self-advocacy, and help individuals overcome barriers to health care access (CDC, 2022).

As collaborators with health care providers and other community organizations, the CHW facilitates care coordination for individuals with complex health needs. They help individuals understand their treatment plans, adhere to medications, and navigate the health care system. CHWs also make referrals to resources, such as social services, mental health providers, substance misuse treatment programs, and support groups (CDC, 2022).

CHWs serve as advocates for the health needs of their communities. They raise awareness of health disparities, promote policy changes to address social determinants of health, and engage in community organizing activities. CHWs empower community members to participate in decision-making that actively affects their health and well-being (CDC, 2022).

Community and public health nurses frequently collaborate with CHWs, offering training, supervision, and assistance. This partnership enables public health agencies to utilize CHWs’ cultural proficiency, valuable insights, and strong community ties to develop targeted interventions, enhance health care accessibility, and tackle health disparities effectively. When these groups work together, public health efforts can have a broader reach and more significant impact, ensuring that interventions are tailored to meet the specific needs of the communities they serve.

Some states require certification or training for CHWs, which may be implemented by the Department of Health, Department of Public Health, Department of Human Services, board of nursing, or third-party entities. Certification is often necessary for reimbursement, and some CHWs view it as a tool for career advancement, while others may not see it as necessary for their role or community connection (Rural Health Information Hub, 2023).

Public health nurses like Josh recognizes CHWs as a critical link between communities, health care systems, and state health departments. Josh advocates for funding to support hiring a CHW to serve the county. Josh and CHW Tawana conduct a comprehensive needs assessment to identify the health needs and concerns of the community. They engage community members through surveys, interviews, and focus groups to understand their specific challenges, cultural beliefs, and preferences. Based on the findings, Josh and Tawana developed a joint plan that aligns with the community’s priorities and addresses the identified health issues.

They collaborate to design and deliver health education programs tailored to the community’s needs. They also develop culturally sensitive materials and workshops on chronic disease prevention, healthy lifestyle choices, and disease management. The CHW is vital in bridging cultural and language barriers, ensuring the information is accessible and relatable to community members.

Josh and Tawana work together to reach out to community members, particularly those who are underserved or face barriers to health care access. They conduct home visits, organize community health fairs, and partner with local organizations and faith-based groups. Their combined efforts raise awareness about available health care resources, facilitate access to services, and empower community members to take control of their health. Josh leverages his clinical expertise to develop care plans, provide health assessments, and offer specialized services. Meanwhile, Tawana serves as a trusted advocate, assisting with appointment scheduling and medication management and connecting individuals to social services. Together, they ensure continuity of care and support for individuals throughout their health journey.

Josh and Tawana regularly evaluate the effectiveness of their collaborative efforts. They track key indicators, such as health care utilization rates, client satisfaction, and health outcomes. By analyzing the data, they identify areas of improvement, make necessary adjustments to their interventions, and measure the impact of their work on community health. The collaborative work of Josh and Tawana yields several positive outcomes and impacts in the community. Through their joint efforts, they increase health literacy and empower individuals to make informed decisions about their health. The collaborative approach also strengthens community engagement, fosters trust, and promotes cultural competence in health care delivery. As a result, community members experience improved health outcomes, reduced health disparities, and a sense of empowerment and ownership over their well-being.