a guide for addressing health disparities · in terms of reducing health disparities or inequality...

ADDRESSING HEALTH DISPARITIES

A G U I D E F O R

This guide was designed to serve as a foundational tool to address health disparities and help focus health improvement activities for the Central New York region. The guide was produced by JSI Research & Training Institute, Inc. in collaboration with, and funded by the Central New York Population Health Improvement Program (CNY PHIP) at HealtheConnections. CNY PHIP is a program supported by the New York State Department of Health that aims to be a regional resource for convening stakeholders and establishing neutral forums for identifying, sharing, disseminating and helping implement best practices and strategies to promote population health and reduce health disparities.

HealtheConnections is a not-for-profit corporation that supports the meaningful use of health information exchange and technology adoption, and the use of community health data and best practices, to enable Central New York stakeholders to transform and improve patient care, improve the health of populations and lower health care costs. For more information please visit: www.healtheconnections.org.

CONTENTS

SECTION I: ABOUT THIS GUIDE 7

SECTION II: DEFINING HEALTH DISPARITIES, HEALTH INEQUALITY, HEALTH EQUITY, AND DETERMINANTS OF HEALTH 9

SECTION III: GETTING THERE FROM HERE: A ROADMAP FOR REDUCING HEALTH DISPARITIES 11

FIGURE 1. STAKEHOLDER CATEGORIZATION 12

TABLE 1: STAKEHOLDER ENGAGEMENT DEFINITIONS 12

TABLE 2: PASSIVE AND ACTIVE CONSUMER ENGAGEMENT ACTIVITIES 13

FIGURE 2: SOCIAL ECOLOGICAL MODEL 14

FIGURE 3: EBP DECISION-MAKING AND INFLUENCING FACTORS 17

FIGURE 4: HEALTH DISPARITIES PLANNING CYCLE 19

APPENDIX: RESOURCES AND TOOLS 20

STAKEHOLDERS ANALYSIS MATRIX 23

STAKEHOLDERS ENGAGEMENT PLAN 25

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SECTION I: ABOUT THIS GUIDE

Everyone benefits when people are fully able to contribute to commu-nities and lead happy, productive lives. Health equity work focuses on improving health by addressing the root causes of health disparities, which often includes improving physical environments, raising social and educational attainment, and other health-influencing factors. This requires community mobilization, scientific data to inform efforts, and collaboration with a multitude of like-minded stakeholders. Whether community disparities are based on race, rural versus urban location, educational status, or income, there are universal approaches that can help reduce disparities.

Best Practice Begins with Best Process

Prevention and health equity work is rooted in common processes. Stan-dardized planning processes help identify disparities, target populations, specific context, and how to tailor interventions accordingly. Our road map to health equity begins with an assumption that this process IS best practice, and offers a template for engaging in health equity work.

9A Guide for: Addressing Health Disparities

SECTION II: DEFINING HEALTH DISPARITIES, HEALTH INEQUALITY, HEALTH EQUITY, AND DETERMINANTS OF HEALTH

How we discuss and communicate differences in health is very important, yet the more sensitive we are to the language and culture of health, the more hesitant we may be about choosing words that best express what we mean to convey. Health dis-parities, inequality, equity, and determinants are common terms used in the work to improve health status. The following working definitions for these terms establish a foundation for using this guide and working in this area.

Health disparities and health inequality are used inter-changeably to describe significant and avoidable differences in health between populations. Differences may be measured in a number of ways; those which are most familiar include disease incidence, mortality, and life expectancy.1 Racial health disparities are perhaps most widely familiar because they are among the most significant disparities in the United States. HealtheConnec-tion’s work is grounded in the communities that we serve and extends to social and economic population qualities including geography, income, education, age, and other factors.2

Health equity describes the lack of significant differences in health between populations. As such, efforts are often described in terms of reducing health disparities or inequality and increasing health equity.3

Determinants of health are a range of personal, social, eco-nomic, and environmental factors that influence health status. An understanding of determinants of health is important when examining differences in population health. For example, we expect differences in rates of arthritis between younger and older populations; as the body ages it is more susceptible to disease. We should not expect variations in arthritis rates between higher and lower income adults, yet lower income populations are disproportionately represented among those with arthritis.

Scientists have defined five primary determinants of health of a population. According to the Centers for Disease Control and Prevention these include:

» Biology and genetics, including a person’s sex and age.

» Individual behavior, including alcohol, tobacco, and drug use, and eating habits.

» Social environment and the influence of discrimination, income, and gender.

» The physical environment in which a person works and lives, including the influence of the built environment.

» The presence or absence of health services including financial or physical access to health care.4

1http://www.raconline.org/topics/rural-health-disparities2http://www.csun.edu/~hchsc006/Minority%20Health.ppt3http://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities4http://www.cdc.gov/socialdeterminants/Definitions.html


SECTION III: GETTING THERE FROM HERE: A ROADMAP FOR REDUCING HEALTH DISPARITIES

This section provides a step-by-step approach to engaging in health equity-focused work and moves readers from establishing relationships with stakeholders through planning, implementa-tion, and evaluation of this work. While the information in this section is presented in a linear fashion, your own process may go back and forth between steps. For example, Step 1 describes an approach to developing a stakeholder engagement plan. As your planning process unfolds and you understand more about the pop-ulation and necessary approaches to reducing health disparities, you may consider engaging additional stakeholders. Determining whether you are partnering with the right people and organiza-tions is ongoing.

Step 1: Create a stakeholder engagement plan

Stakeholder engagement is central to the planning process and may take many forms. At each step outlined in this guide, ask these questions:

• Have you engaged stakeholders who will provide input, support, and capacity for implementation of your program?

• Are you finding stakeholders who are suited to the roles in your program development?

Stakeholders may be categorized in five ways as described in Figure 1 and defined in Table 1.

Spotlight on consumer engagement:

• Be prepared to discuss and explain issues. Consumers don’t use the same professional jargon or have access to the same information. As you review data and formulate a preliminary problem statement, focus on accessible language.

• Develop a value statement about why collaborative work with consumers is central to success.

• Convene a meeting to talk about the issue and why their participation is valued. Explain time commitment and what they will need to arrange to participate (schedule, initial trainings, childcare).

• Outline the responsibilities and expectations of consumers.

• Develop measures of success and seek unanimous consumer agreement on the priorities and projects.

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Use this information to develop a stakeholder engagement matrix to document the engagement approach. A sample matrix is in-cluded in the appendix. Create a list of potential stakeholders and note the following considerations.

Define stakeholder category: Each stakeholder should be re-viewed to determine their role. Stakeholders may change cate-gories over time. Remember, it is important to include consumers and consumer advocacy stakeholders.

Describe the engagement purpose: Define the purpose of engaging the stakeholder, e.g., to influence stakeholder activity; to influence others; for information; to promote participation in evaluation planning; to promote participation in evaluation data collection. The engagement purpose may change over time. Stakeholders do not have unlimited time and may be wary about new collaborations so be sure to involve them in ways that are meaningful, suited to them, and respectful of their time.

TABLE 1: STAKEHOLDER ENGAGEMENT DEFINITIONS

PartnershipAccountability and responsibility is characterized by two way engagement, joint learning, decision making, and actions.

Participation Part of the “team,” engaged in completing tasks or responsibility for a particular area/activity.

ConsultationInvolved but not responsible or necessarily able to influence change outside consultation boundaries. Limited two-way engagement: ask questions, stakeholders answer.

Push Communications One-way engagement. Broadcast information to all or particular stakeholder groups.

Pull Communications One-way engagement. Make information available, stakeholder chooses whether to use it.

FIGURE 1. STAKEHOLDER CATEGORIZATION

Participation

Consultation

Push Communications

Pull Communications

High InfluenceHigh Interest

High InfluenceLow Interest

Low InfluenceHigh Interest

Low InfluenceLow Interest

Grea

ter e

ffort

fewer

stak

ehold

ers

Less

effo

rtmor

e sta

keho

lders

Partnership


TABLE 2: PASSIVE AND ACTIVE CONSUMER ENGAGEMENT ACTIVITIES

Less-Active Engagement Moderate Engagement High Engagement

Flyers Information sessions Strategic planning meetings

Email blast/listserv Discussion forums Grassroots organizing

Newsletter Presentations to stakeholders Workshops

Social media Conference presentations Joint review of findings

PPT templates/canned presentationsInquiry regarding population needs (focus

groups)Product and message development chal-

lenges/contests

Print communications Stakeholder reaction meeting Collaborative planning

Fact sheets Implement survey or poll Collaborative research

This is important because it is easier to involve stakeholders at the outset than it is to reengage them if they leave. At the same time, stakeholder roles can evolve or shift over time, so initial roles may not be binding.

Select an engagement activity: The table above provides exam-ples of active and passive stakeholder engagement activities.

Step 2: Develop organizational capacity for health equity work

The National Standards for Culturally and Linguistically Appropri-ate Services (CLAS) in Health and Health Care were developed to give organizations a set of standard skills and approaches to advance health equity and eliminate health disparities. The CLAS Principle Standard is to “provide effective, equitable, understand-able, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languag-es, health literacy, and other communication needs.”5 This section summarizes key components of the extensive training resources

available to help organizations implement CLAS standards.

Professional development. Staff should receive training and technical assistance to help them perform to the best of their ability. Important professional development areas include cultural competency, understanding the impact of social determinants of health, and how to conduct work using a health equity lens. Orga-nizations can tailor professional development offerings to reflect the communities with which they work.

Organizational mission. All prevention-focused entities should have an organizational mission statement reflecting the impor-tance of health disparities or health equity in their work.

Relationships with communities. Ongoing strong relationships with communities, stakeholders, and consumers are key for un-derstanding and creating solutions to health disparities. Relation-ships may be institutionalized by community representation on the board of directors, advisory groups, and staff.

5https://www.thinkculturalhealth.hhs.gov/pdfs/NationalCLASStandardsFactSheet.pdf

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Step 3: Understand frameworks for prevention

The prevention spectrum

Understanding where along the prevention spectrum a dispar-ity exists will help organizations identify the most effective approaches and partnerships. The spectrum is described as including primary, secondary and tertiary prevention.

Primary Prevention: Widespread actions aimed at reducing the average risk in the whole population or reduction of particular exposures among identified higher risk groups or individuals. This may include addressing individual behaviors such as tobacco use, diet and physical activity, or environmental issues such as water and air quality.

Secondary Prevention: Preventing progression to disease (from wellness to illness) through early detection and intervention. This may include colon, breast, or cervical cancer screenings or manag-ing hypertension and weight loss.

Tertiary Prevention: Reducing consequences of established disease through effective patient management to reduce the prog-ress or complications of disease. This may include management of hemoglobin A1c among individuals with diabetes, medication management, or diet and physical activity.6

During your strategic planning process determine where along the prevention spectrum interventions should be applied and which strategies and evidence-based practices will mitigate the disparity.

The Social Ecological Model

The social ecological model provides an approach to understand-ing the “spheres of influence” that affect health and helps orga-nizations determine strategies and partnerships for their interven-tions. Later in this guide you will be prompted to characterize the influences of health disparities as defined in the model.

Individual-level interventions include classes, workshops, vouch-ers, and coaching to increase knowledge, attitude, behavior or belief.

Spotlight: Addressing Community Factors

Shape Up Somerville is a city-wide campaign to increase daily physical activity and healthy eating through programming, physical infrastructure improvements, and policies. The campaign targets all segments of the community, including schools, city government, civic organizations, community groups, businesses, and people who live, work, and play in Somerville, MA. The initiative includes interventions in school food service, curriculum, after-school programming, and Safe Routes to School. Shape Up Somerville also conducts community outreach, encourages walkability and the exten-sion of community paths, and promotes farmers markets and community/school gardens. Dedicated health department staff have engaged the community through a taskforce of more than 25 people.

6National Public Health Partnership (2006). The Language of Prevention. Melbourne: NPHP

Public Policy

Community (cultural values, norms)

Organizational (environment, ethos)

Int

erpersonal (social network)

Individual(knowledge,

attitude skills)

FIGURE 2: SOCIAL ECOLOGICAL MODEL


Interpersonal-level interventions involve people who can influence attitudes, behaviors, or beliefs of a target population. They may be clergy, medical professionals, family members, or peers and serve as role models, counselors, coaches, and educators.

Institutional-level interventions include patient reminders in primary care practice electronic health records, worksite wellness programs, and soliciting patient input for quality improvement.

Community-level interventions include public awareness cam-paigns and collaborative approaches to promote screenings.

Public-policy-level interventions include insurance provision, low-ered copays, and urban planning to reduce “food deserts.” Step 4: Use data to identify health disparities

Data are critical for identifying, understanding, and reducing health disparities. Health disparity assessment helps us under-stand the population experiencing the disparity and the context in which it exists. The following questions can guide the process of inquiry:7

What do the data say? Select an area of interest such as popula-tion or geographic location and assemble the health data. If you already have a specific interest in a health issue, population, or region, you can further focus your data inquiry.

Are there disparities within the area of interest? Significant differences in health data among different populations or regions indicate the presence of a disparity. Disparities are often found among racial and ethnic minorities, rural and low-income popula-tions, and individuals with low educational attainment. Examine the extent of the disparity and the difference between the best and the worst health status. Look for additional data about the population. Next, summarize the data and write a preliminary statement e.g., “As compared to urban populations in our region, rural populations have a 25 percent higher skin cancer death rate.”

Are there social determinants of health that contribute to the disparity? Seek additional data about the population in question and its context. Based upon further inquiry, what more can you say about the issue? Building on the example statement above,

you might now say that “Compared to our region’s urban counter-parts, rural populations experience higher skin cancer death rates. This population generally has lower primary care utilization and preventive screening rates. The agricultural industry represents the largest employment category for this population, which may indicate a workforce with high sun exposure.”

Step 5: Engage partners, stakeholders, and consumers

Key partners, consumers, and organizations (“stakeholders”) can provide important insight for finding solutions to health disparities and are critical resources for successful interventions. While their involvement in all steps is encouraged, it is critical for Step 5 when the data have been reviewed and exhausted.

Understanding the root causes and then taking action to reduce disparities cannot be done in isolation because it may result in duplication of efforts or misalignment between the intervention and the population’s actual needs. The following activities will help you move from understanding the data to development of an intervention.

Convene a meeting. Invite stakeholders to discuss the issue and how to respond to it. As the organizer, you must act as a neutral facilitator and assure shared ownership of the meeting and its outcomes. If you are expected to represent your organization’s interests, it may be impossible to remain neutral. In this case,

7http://communityscience.com/knowledge4equity/DataMakesADifference.pdf

Important social determinants data to consider:

Education: Educational attainment, graduation rates, dropout rates, post-secondary enrollment.

Employment: Unemployment rates, underemployment rates, type of employment.

Access to health care: Screening rates, primary care utilization rates, immunization rates, distribution of health care providers, insurance status.

Built environment: Access to supermarkets and phar-macies, well- lit streets, recreational opportunities.

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ask a third party to facilitate the meeting. Be sure to circulate an agenda in advance and allow participants to add agenda items that are relevant to the focus of the meeting. It can be difficult to get consumer participation, so consider their schedules and needs when planning the timing and format of the meeting. Be sure to provide refreshments (or a meal, depending on the hour and length of the meeting) and offer childcare.

Explore what you know and what you do not know. Review the data you have gathered to date and ask participants if they agree with your summary statement about the disparity and data de-scriptors of the population. Discuss what you do not know about the health issue and the population experiencing the disparity. The group may know of additional data, or opportunities to collect new data, both quantitative and qualitative.8

Explore root causes of the health disparity. Understanding the root of health disparities helps identify the factors that can decrease the disparity. The “5 Whys” is a common approach for conducting a root cause analysis. The process is called the 5 Whys because it usually takes between 3 and 5 ‘whys’ to reach a root cause.

The root cause analysis process may indicate the need for addi-tional stakeholder involvement or additional data collection. Do not be discouraged if your root cause analysis hits an obstacle. Ask the meeting attendants to think about how you can better understand the issue and plan the next meeting.

Honor each stakeholder’s interest. The value of engaging con-sumers and diverse stakeholders is that each has a perspective based on his/her understanding of the issue and the population. Each stakeholder will have an idea of how s/he can contribute to mitigating the root causes. For example, cities and towns may be more effective at designing zoning policies to promote access to retail and grocery stores. Rural development staff may be inter-ested in agricultural worker education, and consumers may be interested in the role of schools and social service organizations. The idea is to explore individual and common approaches and coordinate efforts to leverage the maximum benefit.9

Characterize the issues. Describe the issue as you now under-stand it, including the data and the root causes. Consider where on the prevention spectrum these issues reside and how they would be described in the context of the social ecological model.

A“5 Whys” example

Problem statement: Rural adults have higher skin cancer mortality rates.

Why #1: Why do they have higher skin cancer mortality rates? Because they do not get screened as recommended.

Why #2: Why do they not get screened as recommended? Because they have low utilization of primary care services.

Root cause #1 = Low utilization of primary care services.

Why #3: Why do they have low utilization of primary care? Because there is a shortage of primary care provider and practices are not accepting new patients.

Root cause #2 = Primary care provider shortage.

In this example, only three whys were needed, but it indicates that to fully understand the root cause, you need input from stakeholders who are knowledgeable about the issue and the population. The example also illustrates that there may be more than one root cause for each issue.

8http://www.cdc.gov/nccdphp/dch/pdfs/health-equity-guide/health-equity-guide-sect-1-4.pdf9http://www.cdc.gov/nccdphp/dch/pdfs/health-equity-guide/health-equity-guide-sect-1-3.pdf


10http://www.cdc.gov/pcd/issues/2012/11_0324.htm

FIGURE 3: EBP DECISION-MAKING AND INFLUENCING FACTORS10

Best available research evidence

Decision-making

Population characteristics,

needs, values, and preferences

Reso

urces

, inclu

ding

practi

tione

r exp

ertise

Environment and organizational context

Revisit organizational capacity and team. Before you consider evidence-based approaches to mitigate the identified health disparity and its causes, think about how you have characterized the issue and consider if additional organizational capacity or stakeholders are needed.

Step 6: Use evidence-based practices and design a health equity approach

There are two sets of steps to the implementation of an appro-priate and effective evidence-based practice (EBP). Selection of an EBP should be informed by the data and input gathered in previous steps. To the extent possible, the EBP should mirror the population characteristics, community context, and the organi-

zational capability. Once an EBP is selected, stakeholders should review and modify it according to the community in which it will be implemented. These steps are described further in this section.

Step 1:

EBPs are critical to the implementation of interventions because they give organizations a template for successful programs. The increasingly large body of EBPs makes it difficult to identify the practice best suited to your population’s needs. The Centers for Disease Control and Prevention outlines influencing factors, defined below, to guide the decision-making process for select-ing an intervention. Figure 3 illustrates the intersection of these factors.

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Best available research evidence: The best way to evaluate EBPs is to turn to credible sources. Organizations such as the CDC and the Robert Wood Johnson Foundation have extensive resourc-es that have already been reviewed for credibility.

Population characteristics, needs, values, and preferences: Consider how the EBP would resonate with the population of focus and if the EBP would need to be adapted for this population.

Resources, including practitioner expertise: If implementing partners don’t have the skills, relationship with the target popu-lation, or the financial resources for a particular EBP, it will fail. Consider a cost/benefit analysis to determine which EBP would be most effective with available resources.

Environment and organizational context: Awareness of co-occurring initiatives, events, and the overall environment in which the EBP will be implemented will help you avoid barriers and delays.

Step 2:

EBPs are based on interventions with specific populations, health issues, and context. You should examine the EBP and consider adaptations to make it relevant to your population’s context. The second set of steps for using an EBP outlines a simplified ap-proach to tailoring.11

Convene stakeholders: Include relevant organizations, members of the target population, and academic partners.

Gather information: If you do not have enough information to suggest adaptations, identify additional information sources and their availability.

Synthesis: Analyze the EBP using the information available and ask stakeholders to identify elements that will need to be adapt-ed. Consider culture and language, literacy and learning channels, community context, challenges, and sustainability.

Adapt components: Make changes to the EBP to suit the community.

Review capacity: Make sure that you have the capacity to implement the suggested EBP modifications and have included the right mix of partners.

Evaluate: Create evaluation measures that monitor whether the adaptations will create the same results as the EBP in its original form. Because outcome measures are difficult and often long term, consider using process measures.

Implement: Launch the EBP.

11Nápoles AM, Santoyo-Olsson J, Stewart AL. Methods for Translating Evidence-Based Behavioral Interventions for Health-Disparity Communities. Prev Chronic Dis 2013;10:130133. DOI: http://dx.doi.org/10.5888/pcd10.130133.

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Use data to identify the health issue and disparity

Describe the issue and population

Review and describe social determinants of health

Use the social ecological model to characterize the issues

Identify where on the prevention spectrum the issue occurs

Convene stakehold-ers and conduct root cause analysis

Assure the right part-ners, sources, skills, and overall capacity to implement an intervention

Choose an evidence-based intervention best suited for the population and issue

Adapt the evidence-based intervention according to population and local context (then evaluate).

FIGURE 4: HEALTH DISPARITIES PLANNING CYCLE

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APPENDIX: RESOURCES AND TOOLSSocial

Ecological Model

Construct

Program Description Citation/for more information

IndividualInstitutional

Stanford Diabetes Self-ManagementThe Diabetes Self-Management workshop is given 2½ hours once a week for six weeks, in community settings such as churches, community centers, libraries, and hospitals. People with type 2 diabetes attend the workshop in groups of 12-16. Workshops are facilitated from a highly detailed manual by two trained leaders, one or both of whom are peers (i.e., have diabetes themselves). Subjects covered include: 1) techniques to deal with the symptoms of diabetes, fatigue, pain, hyper/hypoglycemia, stress, and emotional problems such as depression, anger, fear, and frustration; 2) appropriate exercise for maintaining and improving strength and endurance; 3) healthy eating 4) appropriate use of medication; and 5) working more effectively with health care providers. Participants make weekly action plans, share experience, and help each other solve problems with creating and carrying out their self-management program. Physicians, diabetes educators, dietitians, and other health professionals both at Stanford and in the community have reviewed all materials in the workshop.

http://patienteducation.stanford.edu/programs/diabeteseng.html

IndividualInterpersonalInstitutional

The Reach Out and Read program partners with doctors, nurse practitioners, and other medical professionals to incorporate literacy support into regular well-child visits. From the 6-month checkup through age five, medical providers give children developmentally appropriate books and give parents guid-ance and encouragement on reading with their children. The program focuses on children in low-income communities .

http://www.countyhealthrankings.org/policies/reach-out-and-read


Policy

Farmers’ Market Nutrition Programs (FMNP) are part of both the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the Senior Nutrition Program. These programs provide fresh, unprepared, locally grown fruits and vegetables to participating women, children, and seniors. The federal FMNP benefit ranges from $10 to $30 per year; states may supplement this amount.

http://www.countyhealthrankings.org/policies/wic-and-senior-farmers-market-nutrition-programs

IndividualPolicy

Promoting Health Equity through Education Programs and Policies: Out-of-School-Time Academic ProgramsOut-of-school-time academic programs are provided outside regular school hours to students in grades K-12 who are either low-achieving or at risk of low achievement. Out-of-school-time academic programs are offered during the school year—usually after school hours—or during summer recess. These programs must include an academic component, which can range from minimal academic content, such as supervised time for students to complete their homework or receive homework assistance, to more intensive tutoring or remedial classes focused on specific subjects, such as reading or math. Pro-grams also may include sports and recreation, snacks, or counseling. Attendance is most often voluntary, though students may be required to participate under certain circumstances (e.g., to avoid retention in current grade).

http://wwwn.cdc.gov/CHIdatabase/items/promoting-health-equity-through-education-programs-and-policies-out-of-school-time-academic-programs

IndividualCommunity

Community Referral Liaisons Help Patients Reduce Risky Health Behaviors, Leading to Improvements in Health StatusThe Community Health Educator Referral Liaisons project helped patients reduce risky health behaviors (e.g., drinking, smoking, physical inactivity) by linking them with community resources, offering counseling and encouragement over the telephone, and providing feedback to referring physicians. Originally implemented between February 2006 and July 2007, the program included four liaisons who worked with 15 primary care practices in three Michigan communities, referring patients to community preventive health services and offering counseling and encouragement to help patients achieve their health-related goals. The program resulted in improvements in body mass index and self-reported health status, with these gains being largely the result of reductions in risky health behaviors.

https://innovations.ahrq.gov/profiles/community-referral-liaisons-help-patients-reduce-risky-health-behaviors-leading

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Nurses Provide Free Health and Safety Screenings on Farms, Leading to Better Eating Habits and Cholesterol Levels and High Atten-dance at Follow-up AppointmentsThe Rural Health Initiative (a nonprofit agency) sends registered nurses with farming backgrounds to farms in three Wisconsin counties to provide free preventive health and occupational safety screenings to farmers and their adult family members and employees. The nurses take a medical history, perform routine screenings, and provide health education and counseling on relevant issues. They also tour the farm to identify safety issues, providing farmers with a list of potential hazards that should be addressed. They typically return several weeks later to review test results and, if necessary, make referrals for appropriate follow-up care. The program has enhanced access to routine medical care and safety screenings, improved eating habits and high-density lipoprotein levels, and generated high attendance at follow-up appointments and high levels of satisfaction. Many participating farmers report making safety improvements in response to issues identified by the nurses.

https://innovations.ahrq.gov/profiles/nurses-provide-free-health-and-safety-screenings-farms-leading-better-eating-habits-and

Policy

Increase green space/parksRails to trails programs, brownfield redevelopment, community gardens, and park enhancements are examples of programs that increase access to green space. Such efforts can be applied to green space accessible by foot, bike, and other types of transportation, and are frequently implemented in low-income neighborhoods.

http://www.countyhealthrankings.org/policies/increase-green-spaceparks

Institutional

Rural Practice Redesigns Care Processes to Allow Multidisciplinary Teams to Leverage Electronic Health Record, Leading to Better Screening of Medically UnderservedThe Kodiak Area Native Association, a practice based in Kodiak, Alaska, redesigned its care processes in conjunction with adoption of a new electronic health record system, with the goal of improving the quality of care provided to Alaska Natives living in Kodiak and the island’s six remote villages. The redesigned process features multidisciplinary care teams that use the electronic health record (along with other modes of communication and in-formation sharing as necessary) to facilitate the provision of appropriate care. Team members, who include providers at a central clinic and community health aides working in the villages, use the electronic health record to document care in real time and share information. They also take advantage of various system functions to promote the provision of preventive care, including clinical reminders, a population health management tool, and patient registries.

https://innovations.ahrq.gov/profiles/rural-practice-redesigns-care-processes-allow-multidisciplinary-teams-leverage-electronic

InstitutionalIndividual

Institutional

Pharmacists Support Employees and Physicians in Managing Chronic Conditions, Leading to Better Care and Disease Control, Lower Costs, and Higher ProductivityUsing a model known as medication therapy management, which is often sponsored by employers, a program manager assigns participants to care managers (typically pharmacists) to provide ongoing chronic care management support to employees/covered dependents and their physicians. The goal is to improve care processes and patient self-management skills related to diabetes, asthma, cardiovascular risk factors, and/or depression. Spon-soring employers create financial incentives for participation, typically through lower or waived copayments for drugs and supplies and/or reductions in the employee share of the premium. Care managers meet regularly with individual enrollees to support their self-management and contact their physi-cian as needed to suggest treatment changes. Originally pioneered in Asheville, NC, for city employees (and hence known as the Asheville Project) and now implemented by employers throughout the nation, the program has improved adherence to recommended care and self-management behaviors, leading to better disease control, lower costs, higher productivity, and a significant return on investment.

https://innovations.ahrq.gov/profiles/pharmacists-support-employees-and-physicians-managing-chronic-conditions-leading-better

IndividualInstitutionalCommunity

Statewide Collaborative Combines Social Marketing and Sector-Specific Support to Produce Positive Behavior Changes, Halt Increase in Childhood ObesityLet’s Go! is a multilevel, multisector initiative in Maine that promotes physical activity and healthy eating to increase the proportion of children at a healthy weight. The program, which began as a demonstration project in greater Portland and now operates throughout Maine, consists of complemen-tary interventions in six sectors (schools, after-school programs, primary care practices, child care centers, work sites, communities). Key components include a consistent message and associated social marketing campaign to encourage healthy eating and regular physical activity; national, state, and local advocacy efforts; and toolkits, resources, and other support to help each sector adopt policies and strategies to promote healthier behaviors in children. The overall program has raised public awareness of desired behaviors and encouraged Maine youth to adopt these behaviors, which in turn has helped to halt the increase in childhood overweight/obesity in Maine. Specific program components have encouraged primary care providers, schools, and child care providers to do more to support youth in adopting healthier lifestyles.

https://innovations.ahrq.gov/profiles/statewide-collaborative-combines-social-marketing-and-sector-specific-support-produce

Social Ecological Model Construct Program Description Citation/for more information

Institutional

Project ASSERT (Alcohol and Substance Abuse Services, Education, and Referral to Treatment) is a screening, brief intervention, and referral to treat-ment model designed for use in health clinics or emergency departments (EDs). Project ASSERT targets three groups:1. Out-of-treatment adults who are visiting a walk-in health clinic for routine medical care and have a positive screening result for cocaine and/or

opiate use. Project ASSERT aims to reduce or eliminate their cocaine and/or opiate use through interaction with peer educators (substance abuse outreach workers who are in recovery themselves for cocaine and/or opiate use and/or are licensed alcohol and drug counselors).

2. Adolescents and young adults who are visiting a pediatric ED for acute care and have a positive screening result for marijuana use. Project ASSERT aims to reduce or eliminate their marijuana use through interaction with peer educators (adults who are under the age of 25 and, often, college educated).

3. Adults who are visiting an ED for acute care and have a positive screening result for high-risk and/or dependent alcohol use. Project ASSERT aims to motivate patients to reduce or eliminate their unhealthy use through collaboration with ED staff members (physicians, nurses, nurse practi-tioners, social workers, or emergency medical technicians).

http://nrepp.samhsa.gov/ViewIntervention.aspx?id=222

Individual

ModerateDrinking.com and Moderation Management are complementary online interventions designed for nondependent, heavy-drinking adults who want to reduce the number of days on which they drink, their peak alcohol use on days they drink, and their alcohol-related problems. Moder-ateDrinking.com (MD) is a Web-based behavioral self-control skills training program, and Moderation Management (MM) is an online support group network.The MD Web site guides participants in setting, reaching, and maintaining drinking reduction goals by providing both personalized feedback on self-reported drinking behavior and online training in behavioral self-control skills. The skills training modules address motivation and self-confidence, identifying and managing drinking triggers, developing alternatives, problem solving, dealing with drinking lapses and relapses, considering alcohol abstinence, and mood self-monitoring. Although the MD Web site recommends that users access the online training modules sequentially, participants may choose to use only the training modules that meet their needs. Each participant starts the program by making a 30-day commitment to either total alcohol abstinence or a moderation target. At the start of each subsequent login to the online program, the participant enters information on his or her drinking since the previous visit and receives a detailed feedback report on progress toward the established drinking goal.

http://nrepp.samhsa.gov/ViewIntervention.aspx?id=212


Policy

TThe ABC Grow Healthy Initiative, designed to promote healthy eating and physical activity in the child care setting, is an emerging intervention.The South Carolina Department of Health and Environmental Control partnered with the South Carolina Department of Social Services to develop and enhance nutrition and physical activity-related standards for incorporation into the existing statewide ABC Child Care Quality Rating and Improvement System (ABC Quality).The integration of new nutrition and physical activity standards into the ABC Quality system for child care centers was an administrative policy change. The policy seeks to create change in behaviors and health status via organizational policy changes as well as changes in staff practices.The components of the ABC Grow Healthy administrative policy are:• ABC Grow Healthy Best Practices: Nutrition Standards• ABC Grow Healthy Best Practices: Physical Activity Standards

http://centertrt.org/?p=intervention&id=1194

IndividualPolicy

The Texas Mother-Friendly Worksite Program (MFWP) is designed to bestow official recognition upon worksites that adhere to the program’s criteria for being “Mother-Friendly,” including having a written and communicated policy that provides space for breast milk expression in the worksite, flexible work schedules for breastfeeding mothers, and access to hygienic breast milk storage options (refrigerator or cooler). Additional recognition is given for worksites with more comprehensive lactation support programs. The MFWP encourages organizational policy and practice changes to develop worksite cultures that help employees who choose to breastfeed meet their personal breastfeeding goals. This is a practice-tested intervention.

http://centertrt.org/?p=intervention&id=1182

IndividualInstitutionalCommunity

Moving to Opportunity is a 10-year research demonstration of the U.S. Department of Housing and Urban Development that combines tenant-based rental assistance with housing counseling to help very low-income families move from poverty-stricken urban areas to low-poverty neighborhoods to better understand the effects of residential location on employment, income, education, and well-being. Using a randomized controlled trial, 4,498 women living with children in public housing were assigned from 1994-1998 (baseline) to one of three groups: 1) low-poverty voucher (move to a neigh-borhood that is less poor) with counseling on moving (n=1,788); 2) traditional voucher without counseling on moving (n=1,312) (comparison intervention); and 3) no new assistance (n=1,398) (control). From 2008-2010, data were collected on health outcomes (height, weight, and level of glycated hemoglo-bin) as part of long-term follow-up. The opportunity to move from a neighborhood with a high level of poverty to one with a lower level of poverty was associated with modest but potentially important reductions in the prevalence of extreme obesity and diabetes.

http://portal.hud.gov/hudportal/HUD?src=/programdescription/mto

Sample Stakeholder Engagement Assessment Tool and Plan http://www.cpc.unc.edu/measure/publications/ms-11-46-e

Social Ecological Model Construct Program Description Citation/for more information

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Name of stakeholder organization, group, or individualNational, regional, or local?

Stakeholder descriptionPrimary purpose, affiliation, funding

Potential role in the issue or activityVested interested in the activity

Level of knowledge of the issueSpecific areas of expertise

Level of commitmentSupport of oppose the activi-ty, to what extent, and why?

Available resourcesStaff, volunteers, money, technology, information, influence

Constraints Limitations: need funds to participate, lack of personnel, political or other barriers.

Non-government sector

Other civil society target audience

International Donors

STAKEHOLDERS ANALYSIS MATRIX1 Program issue:

Proposed Activity:

Date:

1Adapted from Brinkerhoff, D. and B. Crosby, Managing Policy Reform: Concepts and Tools for Decision-makers in Developing and transitions Countries, Kumarian Press, CT 2002 and POLICY, Networking for Policy Change: and Advocacy Training Manual, 1999.

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Name of stakeholder organization, group, or individualNational, regional, or local?

Stakeholder descriptionPrimary purpose, affiliation, funding

Potential role in the issue or activityVested interested in the activity

Level of knowledge of the issueSpecific areas of expertise

Level of commitmentSupport of oppose the activi-ty, to what extent, and why?

Available resourcesStaff, volunteers, money, technology, information, influence

Constraints Limitations: need funds to participate, lack of personnel, political or other barriers.

Non-government sector

Other civil society target audience

International Donors

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STAKEHOLDERS ENGAGEMENT PLAN2 Program issue:

Proposed Activity:

Date:

Stakeholder organization, group, or individual Potential role in the activity Engagement strategy How will you engage this stakeholder in the activity?

Follow-up StrategyPlans for feedback or continued involvement

Government Sector

Political Sector

Commercial Sector

2Adapted from Brinkerhoff, D. and B. Crosby, Managing Policy Reform: Concepts and Tools for Decision-makers in Developing and transitions Countries, Kumarian Press, CT 2002 and POLICY, Networking for Policy Change: and Advocacy Training Manual, 1999

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Stakeholder organization, group, or individual Potential role in the activity Engagement strategy How will you engage this stakeholder in the activity?

Follow-up StrategyPlans for feedback or continued involvement

Government Sector

Political Sector

Commercial Sector

a guide for addressing health disparities · in terms of reducing health disparities or inequality...

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