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Date Last Updated: December 3 rd , 2020 1 Equity in Public Health Practice Resources
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Equity in Public Health Practice Resources

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Source Notes

Fraser Health. (2018). Community Planning Tool: Applying a Health Equity Lens to Program Planning. Surrey (BC): Fraser Health. https://www.fraserhealth.ca/-/media/Project/FraserHealth/FraserHealth/Health-Topics/20180322_Community_Planning_Tool_Online.pdf

This tool was intended for program planning teams at community agencies designing public health programs. While not specific to I-NGOs, this tool provides practical steps that are likely applicable to global health programs as well. This tool was designed to complement standard program planning processes by providing simple guiding questions for each stage of planning which will help teams apply a health equity lens to their work. The document consists of:

• Seven steps which identify opportunities to address equity throughout the project lifecycle

• Seven guides in the appendix which provide practical resources for applying the seven steps.

Steps: STEP 1 Assess Inequities & Define Scope - the first step to creating your desired change is to gain a better understanding of this health issue, including how it affects population groups differently. STEP 2 Identify & Assemble Partnership - In this stage of program planning, you will identify and engage the stakeholders who might partner with you in pursuit of a shared goal or agenda. STEP 3 Assess Community Capacity & Engage Community - In this stage of program planning, you will engage with the broader community to learn about existing strengths or assets, established relationships, and readiness to take action on the issue you have identified. You will also develop a shared language and common understanding among partners and community members as to how social factors influence health. STEP 4 Select Approach to Change & Plan for Action - In this stage of program planning, you will use the evidence you have gathered to select your approach to change, develop your action plan, and create a framework for monitoring and evaluation. STEP 5 Implement & Monitor - In this stage of program planning you will be implementing your action plan and monitoring your implementation process.

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STEP 6 Assess Your Progress - In this stage of program planning you will be reviewing your progress to reach conclusions about the effectiveness of your program. STEP 7 Maintain Momentum - In this final stage of program planning, you will focus on maintaining your momentum. This requires some flexibility as the community will change over time.

Hogan V, Rowley DL, White SB, Faustin Y. Dimensionality and R4P: A Health Equity Framework for Research Planning and Evaluation in African American Populations. Matern Child Health J. 2018 Feb;22(2):147-153. doi: 10.1007/s10995-017-2411-z. PMID: 29392541.

This article introduces a framework (R4P) for creating equity that requires understanding all dimensions of contributors to inequities and that requires engaging with communities. The framework was created to help US public health organizations integrate multiple theoretical perspectives into a framework of action to eliminate health inequities experienced by African Americans. R4P requires organizations to address removal of racism, repair of past exposures that continue to have an impact, remediate current exposures, restructure of policies, and provide services that address cultural and economic needs. The five components of R4P are:

1) Remove: Identify Structures, attitudes, beliefs, practices or experiences specific to “Race/ethnicity”, low SES or gender that confer disadvantage to these populations

2) Repair: Assess experiences, attitudes, behaviors, and beliefs of disparity populations about the institution that have roots in the past, and may have bearing on willingness of or ability to engage with institution

3) Remediate: Assess needs for protection of individuals in disparity populations against existing insults, protections that need to be in place until the insult can be structurally removed

4) Restructure: Assess structures in the organization that maintain systematic exclusion of disparity populations; or provide advantage/ privilege to others at the exclusion of disparity populations (Sources of “insults”; structures that continue to create risk for some populations)

5) Provide: Focus on HOW services of the organization are IMPLEMENTED from a qualitative standpoint. Culturally, and economically feasible delivery of services, that accommodates all gender roles and responsibilities, along

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with providing the required resources and environmental supports, so that it is the easiest option for people to choose and take advantage of to achieve equity

The Association of State and Territorial Health Officials (ASTHO). (2018). Foundational Practices for Health Equity: A Learning and Action Tool for Public Health Organizations. https://www.astho.org/Health-Equity/Documents/Foundational-Practices-for-Health-Equity/

This tool was created to assist public health organizations by: 1) identifying a set of seven foundational practices to advance health equity within their organization and with partners; 2) Identify and document the organization’s current capabilities and practices in the area of health equity and determine areas for development and action; 3) Track improvements and changes in capabilities and practices; and 4) Transform public health practices to advance health equity. The target audience for this tool was public health organizations based in the US. However, many of these foundational practices are likely applicable to global health programs. Foundational Practices:

I. Expand the understanding of health in words and action II. Assess and influence the policy context III. Lead with an equity focus IV. Use data to advance health equity V. Advance health equity through continuous learning VI. Support successful partnerships and strengthen community capacity VII. Assure strategic and targeted use of resources

Minkler M, Rubin V, and Wallerstein N. Community-Based Participatory Research for Health: A Strategy for Building Healthy Communities and Promoting Health through Policy Change. A Report to The California Endowment https://www.policylink.org/sites/default/files/CBPR.pdf

This report describes the methods for Community-based Participatory Research (CBPR). This approach emphasizes researchers joining with the community as full and equal partners in all phases of the research process. There are nine guiding principles of CBPR (p11). They all have the overarching commitment to equity and power-sharing in the process of research and action. They also provides “eight promising CBPR Practices….relevant for having an impact on the policy or systems level, and better addressing the social determinants of health” (p17). This report is more geared towards policy action but describes the general concepts and principles of CBPR quickly and efficiently. This approach is described in more detail in a book titled “Critical issues in developing and following community-based participatory research principles” by Israel et al. (2003).

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Book: Israel B, Eng E, Schulz A, and Parker E. Methods for Community-Based Participatory Research for Health. Second Edition. San Francisco: Jossey-Bass; 2013. pp. 8-16.

Google Link

Nine guiding principles of CBPR:

1. Recognize, distinguish, and respect the community as a unique and vital partner in the research process

2. Listen to, learn from, and identify what each partner brings to the process – build on strengths and find solutions to challenges

3. Enable fairness and equality at each step of the research process 4. Ensure all partners learn, grow, and share throughout the process 5. Work towards a balance between research and action so that all partners

benefit → “translation step – what we learn from research that is applied to service provision”

6. Know local and relevant health problems— learn about and respect the community’s history and wide-ranging factors that impact their health and well-being.

7. Build flexibility, feedback, and compromise into the process 8. Share findings and lessons learned with all partners in meaningful ways to

meet all partners’ goals 9. Commit to the problem, process, and evolving relationships 10. Disagreements should be anticipated and are healthy

Seven broad core components in conducting CBPR:

1. Forming a CBPR partnership 2. Assessing community strengths and dynamics 3. Identifying priority health concerns and research questions 4. Designing and conducting etiologic intervention and/or policy research 5. Feeding back and interpreting research findings 6. Disseminating and translating research findings 7. Maintaining, sustaining, and evaluating CBPR partnerships

Centers for Disease Control and Prevention – Division of Community Health. A Practitioner’s Guide for Advancing

This guide provides various documents for incorporating health equity into foundational skills of public health. It provides lessons learned and practices from the field. This resource is meant to help local health departments incorporate the

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Health Equity: Community Strategies for Preventing Chronic Disease. Atlanta, GA: US Department of Health and Human Services; 2013. https://www.cdc.gov/nccdphp/dnpao/state-local-programs/health-equity-guide/index.htm

concept of health equity into core components of public health practice such as organizational capacity, partnerships, community engagement, identifying health inequities, and evaluation. The first major section of the resource “Incorporating Health Equity into Foundational Skills of Public Health” provides guidance for incorporating health equity into seven foundational skills of public health. Seven guides for incorporating health equity into public health practice:

1. Building organizational capacity 2. Engaging community members 3. Developing partnerships and coalitions 4. Identifying and analyzing health inequities 5. Selecting, designing, and implementing strategies 6. Making the case for health equity 7. Addressing health equity in evaluation efforts

Alcaraz, K. I., Sly, J., Ashing, K., Fleisher, L., Gil-Rivas, V., Ford, S., Yi, J. C., Lu, Q., Meade, C. D., Menon, U., & Gwede, C. K. (2017). The ConNECT Framework: a model for advancing behavioral medicine science and practice to foster health equity. Journal of behavioral medicine, 40(1), 23–38. https://doi.org/10.1007/s10865-016-9780-4

This article introduces the ConNECT Framework as a model to link the sciences of behavioral medicine and health equity. ConNECT seeks to allow for better planning and integration of health equity in the processes of research and care delivery, rather than reinforcing the prevailing mindset of measuring health equity solely for surveillance. Two additional pillars of the ConNECT Framework include leveraging ever-growing communication technologies (to reduce digital divide) and specialized training in health equity essential for dissemination and advancement of clinical and public health practice and policy. ConNECT comprises five broad and synergistic health equity-focused principles:

1. Integrating CONtext: appreciate situational and interactive influences on health

2. Fostering a Norm of Inclusion: consistently engage and examine diverse groups

3. Ensuring Equitable Diffusion of Innovations: facilitate real-world benefit for all

4. Harnessing Communication Technology: optimize e-communication for wide reach

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5. Prioritizing Specialized Training: integrate education, training, and mentoring

Brooks, D, Douglas, M, Aggarwal, N, Prabhakaran, S, Holden, K, Mack, D. Developing a framework for integrating health equity into the learning health system. Learn Health Sys. 2017; 1:e10029. https://doi.org/10.1002/lrh2.10029

This paper introduces a practical framework (PETAL framework) for integrating health equity into US learning health systems, and to demonstrate how this framework applies using two case studies. The authors developed a practical framework that is grounded in community partnership and incorporates supportive technology, social determinants of health, and sustainability. The authors envision this framework to be applicable to any level of a health system, from the individual clinician to programs spanning single organizations to multi-institutional systems. Overarching Elements of the PETAL framework:

1. Social Determinants of Health 2. Sustainability 3. Technology

Core Components of the PETAL framework: 1. Prioritize health equity: Health equity cannot simply exist as a concept; it

must be embedded into the core mission and supported through purposeful, tangible, and measurable actions.

2. Engage the community: It is impossible to address and eliminate the health inequities of populations without engaging the very people affected: the community.

3. Target health disparities: The intervention must be evidence-based, driven by the data, and targeted to address disparities. Data collection may include both qualitative and quantitative methods.

4. Act on the data: Once the data are gathered and analyzed, strategies and interventions can be developed to address specific barriers to health equity.

5. Learn and improve: The final component of the PETAL framework is to learn from the challenges and successes of the interventions and to improve health disparities.

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O’Neill Institute for National and Global Health Law Georgetown University Law Center. (2019). Health Equity Programs of Action: An Implementation Framework. https://oneill.law.georgetown.edu/media/HEPA-Guide-1.pdf

“This guide was conceptualized, developed, and drafted by Eric A. Friedman at the O’Neill Institute for National and Global Health Law at the Georgetown University Law Center, with the support of Institute colleagues Drew Aiken, Matthew Kavanagh, and John Stephens” (p3). This guide is meant to serve as a resource for national policy leaders and public health servants interested in creating national prioritized efforts (health equity programs of action) to end health inequities. This guide will expand on these seven principles and how countries or local jurisdictions could implement them through national health plans. The health equity programs of action would be developed based on the seven principles listed below (p6). This document is beneficial for PATH’s efforts since it was created with an international audience in mind and provides guidance for the practical application of universal principles in national health systems. Health equity programs of action would be based on the following principles:

1. Empowering participation and inclusive leadership, with people from marginalized and disadvantaged populations part of the leadership of all processes related to these programs of action

2. Maximum health equity, addressing all health issues and structural determinants of health inequities;

3. Health systems and beyond, covering the health sector and the full array of social, environmental, economic, and political determinants of health, including through intersectoral actions;

4. Every population counts, systematically and comprehensively addressing each population experiencing health inequities;

5. Actions, targets, and timelines, with specific actions linked to timelines for carrying them out, along with measurable targets;

6. Comprehensive accountability, encompassing but extending well beyond monitoring and evaluation to also include establishing or strengthening a comprehensive suite of health accountability mechanisms, and;

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7. Sustained high-level political commitment, necessary for ensuring sufficient resources and intersectoral action and coordination, as well as for successful implementation.

World Health Organization. 2016. The Innov8 approach for reviewing national health programmes to leave no one behind. https://www.who.int/life-course/partners/innov8/innov8-resources/en/

The Innov8 technical handbook is a user-friendly resource as part of the Innov8 approach for reviewing national health programs to leave no one behind. It gives detailed guidance and exercise sheets for each of the 8 steps of analysis that comprise the review process and includes background readings, country examples and analytical activities. WHO encourages the adaptation of exercises and activities to best match the national and programmatic context, and align with ongoing national programmatic review and planning processes. The 8 steps of analysis are as follows:

1. Complete the diagnostic checklist. 2. Understand the program theory. 3. Identify who is being left out by the program 4. Identify the barriers and facilitating factors that subpopulations experience. 5. Identify mechanisms generating health inequities. 6. Consider intersectoral action and social participation as central elements. 7. Produce a redesign proposal to act on the review findings. 8. Strengthen monitoring and evaluation.

Massachusetts Health Policy Commission. (2020). Health Equity Framework. https://www.mass.gov/doc/presentation-hpc-health-equity-framework/download

This file is a presentation by the Massachusetts Healthy Policy Commission I stumbled across during my literature searches. The presentation includes background on equity, a visual depicting how structural Inequities negatively impacts health outcomes, MHPC’s commitment to health equity, five principles for incorporating health equity, four core strategies to advance health equity, a guide to applying an equity lens in project life cycles (Initiation, planning, implementation, and close-out), and next steps. This presentation is very similar to what PATH would likely do to promote the equity in programming framework. Principles for incorporating health equity:

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1. The HPC acknowledges the pervasiveness of health inequities – and the systemic racism that underlies them – and that eliminating inequities is integral to achieving the HPC's mission of better health and better care at a lower cost for all residents of the Commonwealth.

2. The HPC will embed health equity concepts in all aspects of our work and will apply all four of its core strategies to the goal of advancing health equity in the Commonwealth: research and report, convene, watchdog, and partner.

3. The HPC’s work will be informed and guided by those with lived experience of inequities.

4. The HPC will educate itself about the impact of systemic racism and will promote diversity, equity, and inclusion in our workplace in order to more fully cultivate the culture of anti-racism within our agency.

5. Advancing health equity in the Commonwealth is a shared responsibility. The HPC will actively seek opportunities to align, partner, and support other state agencies, the health care system, and organizations working for health equity on these goals.

Core strategies to advance health equity:

1. Research and Report (Investigate, analyze, and report trends and insights) 2. Watchdog (Monitor and intervene when necessary to assure market

performance) 3. Partner (Engage with individuals, groups, and organizations to achieve

mutual goals) 4. Convene ( Bring together stakeholder community to influence their actions

on a topic or problem Steps to guide the HPC’s work in applying an equity lens:

i. Step 1: Initiation (How are different populations affected by the status quo?; What sources did the research/data that informed this issue area rely on?)

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ii. Step 2: Planning (Whose voices are at the table, and whose are not and how can we include them?)

iii. Step 3: Implementation (Have differences correlated with social, economic, and/or environmental conditions been observed?)

iv. Step 4: Closeout (Were there unintended or inequitable effects? If so, how could the course of this work be corrected?)

Plamondon, K. M., & Bisung, E. (2019). The CCGHR Principles for Global Health Research: Centering equity in research, knowledge translation, and practice. Social Science & Medicine, 239, 112530. https://www.sciencedirect.com/science/article/pii/S0277953619305246?via%3Dihub

The CCGHR Principles for Global Health Research are standards for how Canadians engage in global health research. They can serve as a broadly relevant framework to guide how to integrate equity considerations into everyday research, knowledge translation, and practice activities. Comprised of six principles, they are an aspirational and reflective frame that can elevate equity as a central procedural goal and outcome. CCGHR Principles for Global Health Research:

1. Authentic Partnering - This principle aligns with evidence and current thought about the need for attention to issues of power, resources, needs, and norms within research relationships

2. Inclusion - Including people in a process led by systems of privilege implies a capacity and willingness to examine and mitigate power imbalances that are deeply rooted in sociopolitical histories of colonization, class, race, and wealth.

3. Shared Benefits - Sharing benefits invites teams to identify and create a more equitable distribution of benefits, with careful attention to reciprocity for all partners—including, for example, the consideration of data ownership, training and capacity building, joint publication and presentations, and access to post-study products and services

4. Commitment to the future - Threats to the future of the planet, considered in the context of this principle, require the GHR community to mobilize efforts around solutions-based research, knowledge translation, and fostering informed public dialogue about why, what, and how equity can support a better future.

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5. Responsiveness to the causes of health inequities - Shifting our gaze to structural and social determinants of health, and to the causes of causes of inequities, this principle is about being actively wakeful to causes of inequities and making choices that move closer to disrupting them.

6. Humility - this principle is about adopting an attitude of learning rather than knowing.

U.S. Agency for International Development (USAID). (2016). Collaborating, Learning, and Adapting (CLA) Framework and Maturity Tool. https://usaidlearninglab.org/sites/default/files/resource/files/cla_maturity_matrix_overview_final.pdf

This a major initiative that USAID uses to advance equity. It is a set of practices that helps USAID improve their development effectiveness through strategic collaboration and coordination. The Collaborating, Learning and Adapting (CLA) Framework and Maturity Tool provides a clear picture of what systematic, intentional, and resourced integration of CLA can look like throughout the Program Cycle. The tool is founded by a CLA framework which “stresses the holistic and integrated nature of the various components of CLA to reinforce the principle that CLA is not a separate workstream—it should be integrated into existing processes to strengthen the discipline of development and improve aid effectiveness.” Integrating collaborating, learning, and adapting throughout the Program Cycle can help development practitioners think through:

v. Collaborating: Are we collaborating with the right partners at the right time to promote synergy over stove-piping?

vi. Learning: Are we asking the most important questions and finding answers that are relevant to decision making?

vii. Adapting: Are we using the information that we gather through collaboration and learning activities to make better decisions and make adjustments as necessary?

viii. Enabling Conditions: Are we working in an organizational environment that supports our collaborating, learning, and adapting efforts?

While this framework is mostly related to community partnerships, the layout and presentation of the documents may be useful for PATH’s final equity deliverables.

Braveman P, Arkin E, Orleans T, Proctor D, and Plough A. What Is Health Equity? And What Difference Does a Definition Make?

This brief discusses the meaning of health equity and the implications for action within the Robert Wood Johnson Foundation’s (RWJF) Culture of Health Action Framework.

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Princeton, NJ: Robert Wood Johnson Foundation, 2017. https://buildhealthyplaces.org/content/uploads/2017/05/health_equity_brief_041217.pdf

The brief presents nine principles as fundamental to guide action to achieve health equity: 1. Achieving health equity requires societal action to remove obstacles to health and increase opportunities to be healthy for everyone, focusing particularly on those who face the greatest social obstacles and have worse health. It also requires engaging excluded or marginalized groups in identifying and addressing their health equity goals. 2. Policy, systems, and environmental improvements have great potential to prevent and reduce health inequities, but only if they explicitly focus on health equity and are well designed and implemented. 3. Opportunities to be healthy depend on the living and working conditions and other resources that enable people to be as healthy as possible. 4. Pursuing health equity entails striving to improve everyone’s health while focusing particularly on those with worse health and fewer resources to improve their health. Equity is not the same as equality; those with the greatest needs and least resources require more, not equal, effort and resources to equalize opportunities. 5. Approaches to achieving health equity should build on and optimize the existing strengths and assets of excluded or marginalized groups. 6. Piecemeal approaches targeting one factor at a time are rarely successful in a sustained way. Approaches are needed that both increase opportunities and reduce obstacles. Successful approaches should address multiple factors, including improving socioeconomic resources and building community capacity to address obstacles to health equity. 7. Achieving health equity requires identifying and addressing not only overt discrimination but also unconscious and implicit bias and the discriminatory effects— intended and unintended—of structures and policies created by historical injustices, even when conscious intent to discriminate is no longer clearly present.

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8. Measurement is not a luxury; it is crucial to document inequities and disparities and to motivate and inform efforts to eliminate them. Without measurement, there is no accountability for the effects of policies or programs. 9. The pursuit of equity is never finished. It requires constant, systematic, and devoted effort. A sustained commitment to improving health for all—and particularly for those most in need—must be a deeply held value throughout society.

Save the Children Federation and Oxfam America. (2016). The Power of Ownership: Transforming US Foreign Assistance (Local Engagement Assessment Framework). file:///Users/gabrielamarmolejos/Downloads/PowerOfOwnership_FullReport_FINAL_161111_Web.pdf

This research report was written by a joint team of Oxfam America and Save the Children staff, led by Tariq Sayed Ahmad at Oxfam America and Andrew Wainer at Save the Children. The Power of Ownership analyzes examples of innovative development practice and provides recommendations for how the next administration can increase the local ownership of US foreign assistance. The project features a new analytical tool, the Local Engagement Assessment Framework (LEAF), which was designed to systematically measure and evaluate country ownership. The Local Engagement Assessment Framework (LEAF) captures local engagement by assessing who among the host country government, civil society, and the private sector engaged with US-supported projects, how that engagement empowered local stakeholders, and during what parts of the project cycle the engagement took place. The LEAF is organized around three main dimensions of donor policy and practice, and when the information is graphically displayed, the LEAF depicts a tree (p22):

• What: The phases of a project cycle when local stakeholders can exercise influence. The visual tree findings from this element are displayed in the trunk.

• Who: The local stakeholders who are engaged in each of these project elements. In the tree, this element is depicted on the left-side of the trunk.

• How: The quality of the local stakeholder engagement in the project. This element is displayed on the right-side of the trunk.

Taken together, these three dimensions provide an analytical framework to examine how much power and authority local stakeholders exercised over a

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particular aspect of a project and who among the local stakeholders carried the most influence.

Addressing Health Equity in Public Health Practice: Frameworks, Promising Strategies, and Measurement Considerations Leandris C. Liburd, Jeffrey E. Hall, Jonetta J. Mpofu, Sheree Marshall Williams, Karen Bouye, and Ana Penman-Aguilar Annual Review of Public Health 2020 41:1, 417-432

This literature review describes the context of health equity and options for integrating equity into public health practice. The article discusses specific ways to address equity in core public health functions, provide examples of relevant frameworks and promising strategies, and discuss conceptual and measurement issues relevant to assessing progress in moving toward health equity. Challenges and opportunities and their implications for future directions are identified. The article also identifies three health equity frameworks: R4P, ConNECT and the CDC OMHHE Framework.

Draft CDC Health Equity Framework for Action --unable to find final version of CDC OMHHE Framework. I suspect the final version was taken down under this administration as this publication states the following: “ The views and recommendations in this report do not represent the official position of the Centers for Disease Control and Prevention.” The Association of State and Territorial Health Officials (ASTHO). (2016). Recommendations for strengthening the capacity of public health departments to advance health equity and operationalize the CDC health equity framework. https://www.astho.org/April-2016-Meeting-Report-Report-from-the-National-Leadership-Academy-on-Health-Equity/

This report captures key takeaways from both the plenary panel sessions and breakout sessions where nationally recognized experts convened to provide feedback to the CDC Draft Health Equity Framework as well as provide recommendations to the CDC and other national partners about how health equity activities at the local, state, tribal and national levels can be supported and operationalized. The framework is meant to provide operating principles on data measurement, program implementation, policy initiatives, and organizational infrastructure for US state and local health departments.

Signal L, Martin J, Cram F and Robson B. 2008. The Health Equity Assessment Tool: A User's

The Health Equity Assessment Tool (HEAT) was published by the government of New Zealand to ensure health programs and policies promote health equity. The

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Guide. Wellington: Ministry of Health. https://www.health.govt.nz/publication/health-equity-assessment-tool-users-guide

intended audience for this tool is fairly broad, they state “HEAT is designed for use by people in the health sector. It is most frequently used by people making funding, planning and policy decisions” (p7). The tool consists of ten questions which are discussed in-depth throughout the guide. The guide also provides various resources and suggestions for how each question could be answered during program planning.

Afsana K, Habte D, Hatfield J, Murphy J, Neufeld V: Partnership assessment toolkit. 2009, Ottawa, ON: Canadian coalition for global health research (CCGHR); https://www.ccghr.ca/wp-content/uploads/2013/05/PAT_web_e.pdf

This toolkit is meant to address the persistent problems facing health research partnerships and to insist that a new approach to partnerships is an integral part of research ethics. The following tool is intended for use by members of the donor community, administrators of academic institutions and research institutes, junior and senior researchers, students and all other parties involved in research partnerships. It helps users to identify and evaluate several partnership phases: Inception, Implementation, Dissemination and Wrapping-Up. It is adaptable and can be used for small projects or planning large trans-disciplinary programs of research.

Pauly, B., Shahram, S. Z., van Roode, T., Strosher, H.W., & MacDonald, M. (2018). Reorienting Health Systems Towards Health Equity: The Systems Health Equity Lens (SHEL). Victoria, BC: The Equity Lens in Public Health (ELPH) Research Project. https://www.uvic.ca/research/projects/elph/assets/docs/kte-resource-6---systems-health-equity-lens.pdf

The Systems Health Equity Lens (SHEL) was developed as part of the Equity Lens in Public Health (ELPH) program to reorient health systems towards health equity. It is founded on public health values of social justice, to support health equity action across health systems. The SHEL is designed to inform health system planning and actions using a socio-ecological model to shift the health system towards health equity as a value, priority and set of actions across all levels. The SHEL has a dual focus on: 1) understanding and recognizing the root causes of health inequities; and 2) strengthening actions that promote health equity.

Public Health Institute (CA4Health). (2018). Guiding Principles for Health Equity and Social Justice. https://www.phi.org/thought-leadership/guiding-principles-for-health-equity-and-social-justice/

PHI’s CA4Health has been exploring how their program office and members can collectively embody their commitment to health equity. Following the PolicyLink Equity Summit in April 2018, members of the CA4Health delegation collaborated to craft a set of intentions related to equity that will keep the energy and lessons alive for the network. The first outcome from these discussions is CA4Health’s Guiding Principles for Health Equity and Justice. These principles express their commitment

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to equity and will inform how they assess what policies and/or actions CA4Health will support. The Principles include:

• People power • A right to health for all • Acknowledging systems and history of inequity • Leveraging privilege for impact • Centering community voices and community narratives • Intersectional movement building • Moving to action • Inclusion and accessibility

Center for Disease Control and Prevention (CDC). (June 2011). Principles of community engagement. Second edition. https://www.atsdr.cdc.gov/communityengagement/pdf/PCE_Report_508_FINAL.pdf

Chapter 2 describes the nine principles of community engagement what is needed to put them into action will help readers to form effective partnerships (p43-53). The principles are organized in three sections: items to consider prior to beginning engagement, what is necessary for engagement to occur, and what to consider for engagement to be successful. The principles are as follows:

1. Be clear about the purposes or goals of the engagement effort and the populations and/or communities you want to engage.

2. Become knowledgeable about the community’s culture, economic conditions, social networks, political and power structures, norms and values, demographic trends, history, and experience with efforts by outside groups to engage it in various programs. Learn about the community’s perceptions of those initiating the engagement activities

3. Go to the community, establish relationships, build trust, work with the formal and informal leadership, and seek commitment from community organizations and leaders to create processes for mobilizing the community

4. Remember and accept that collective self-determination is the responsibility and right of all people in a community. No external entity

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should assume it can bestow on a community the power to act in its own self-interest.

5. Partnering with the community is necessary to create change and improve health.

6. All aspects of community engagement must recognize and respect the diversity of the community. Awareness of the various cultures of a community and other factors affecting diversity must be paramount in planning, designing, and implementing approaches to engaging a community

7. Community engagement can only be sustained by identifying and mobilizing community assets and strengths and by developing the community’s capacity and resources to make decisions and take action.

8. Organizations that wish to engage a community as well as individuals seeking to effect change must be prepared to release control of actions or interventions to the community and be flexible enough to meet its changing needs.

9. Community collaboration requires long-term commitment by the engaging organization and its partners

Rubin V, Ngo D, Ross Á, Butler D, and Balaram N. Counting a Diverse Nation: Disaggregating Data on Race and Ethnicity to Advance a Culture of Health. Robert Wood Johnson Foundation & PolicyLink, 2018. https://www.policylink.org/sites/default/files/Counting_a_Diverse_Nation_08_15_18.pdf

This report analyzes the key focus areas in data disaggregation to advance a culture of health and recommends changes and improvements to the conduct of research and data collection and to the government and corporate policies that define priorities and allocate resources. Opportunities abound to improve how disaggregated data about race and ethnicity are created, understood, and managed. The findings and recommendations are grouped into two broad areas: • Methods for collecting and analyzing data about race and ethnicity at more

detailed levels in the US • Government policies that can enable and enhance data disaggregation in the

US Public Health England. 2020. Health Equity Assessment Tool (HEAT).

The HEAT is a tool consisting of a series of questions and prompts, which are designed to help program teams systematically assess health inequalities related to their work program and identify what they can do to help reduce inequalities.

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https://www.gov.uk/government/publications/health-equity-assessment-tool-heat

HEAT has similarities to other health equity assessment tools (notably the HEAT tool by the government of New Zealand), but is unique in providing a lightweight yet still systematic framework for assessing and driving action on health inequalities. It was mostly intended to be used at the domestic level in England. Does not discuss community engagement, only measurement of inequalities. The tool has 4 stages: 1. Prepare. What health inequalities (HI) exist in relation to your work? 2. Assess. How might your work affect HI (positively or negatively)? How might

your work address the needs of different groups that share protected characteristics?

3. Refine and apply. What are the next steps? 4. Review. How will you monitor and evaluate the effect of your work? Consider

lessons learned Community Engagement IMPACT Practice Model. 2018. The Colorado Health Foundation. https://www.coloradohealth.org/reports/community-engagement-impact-practice-model

o Community Engagement IMPACT Practice Model o Ten Community Engagement Guiding Principles to guide how program

staff conduct themselves and carry out work in communities. o The IMPACT (Intelligence, Manage, Prospect, Act, Cultivate, Trust)

practice model is a multi-stage approach to support communities across Colorado in improving health and addressing health equity. Program staff are expected to utilize the model, which includes “key functions” (including activities and behaviors expected of each function) to guide their continuum of engagement with communities. The model’s approach is not linear and includes two continuous stages in achieving success as program staff. Activities may be revisited emergently, but some stages naturally require others to be completed before proceeding.

Community engagement: improving health and wellbeing and reducing health inequalities. 2016. National Institute for Health and Care Excellence (a non-

This guideline covers community engagement approaches to reduce health inequalities, ensure health and wellbeing initiatives are effective. The guideline complements work by Public Health England on community engagement

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departmental public body of the Department of Health in England). https://www.nice.org.uk/guidance/ng44/chapter/Recommendations#overarching-principles-of-good-practice

approaches for health and wellbeing. These guidelines were intended to be used for domestic organizations in England. Recommendations: 1.1 Overarching principles of good practice

i. Ensure local communities, community and voluntary sector organizations and statutory services work together to plan, design, develop, deliver and evaluate health and wellbeing initiatives (see sections 1.2 and 1.3).

ii. Recognize that building relationships, trust, commitment, leadership and capacity across local communities and statutory organizations needs time

iii. Support and promote sustainable community engagement by encouraging local communities to get involved in all stages of a health and wellbeing initiative.

iv. Ensure decision-making groups include members of the local community who reflect the diversity of that community. Encourage individual members to share the views of their wider networks and others in the community. Groups should adhere to the key principles outlined in this section.

v. Feedback the results of engagement to the local communities concerned, as well as other partners. This could be communicated in a range of ways, for example, via the local newspaper or community website, via community groups or via public events in community venues or other widely accessible places.

1.2 Developing collaborations and partnerships to meet local needs and priorities 1.3 Involving people in peer and lay roles to represent local needs and priorities 1.4 Local approach to making community engagement an integral part of health and wellbeing initiatives 1.5 Making it as easy as possible for people to get involved

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Group Health Foundation (n.d.) Equity Agreements.

According to their website, “ We offer our appreciation to the Tribal and Urban Leadership Advisory Committee of the American Indian Health Commission for Washington State for sharing this articulation of The Seven Generation Principle.” To ensure equity is a fundamental part of their “organizational DNA”, they have focused considerable energy on learning and talking about how they integrate equity into everything they do. The agreements listed on their website acknowledge those areas where they have shared understanding and collective agreement. As their work gets more complex, they will return to these agreements to ground their efforts. They intend to revise and expand these agreements over time. See the agreements here: https://grouphealthfoundation.org/about-ghf/our-equity-agreements/ Additionally, this document shows their Approach to Building Relationships with Communities: https://grouphealthfoundation.org/wp-content/uploads/2020/03/GHF_factsheets_relationships_Mar2020.pdf https://grouphealthfoundation.org/wp-content/uploads/2020/02/GHF_approach_info-learning-eval_Feb2020.pdf

Child Trends. August 2019. How to Embed a Racial and Ethnic Equity Perspective in Research: Practical Guidance for the Research Process. https://www.childtrends.org/publications/a-guide-to-incorporating-a-racial-and-ethnic-equity-perspective-throughout-the-research-process

This paper offers five guiding principles to help researchers apply this lens to the stages of the research process detailed in this resource. “While there is no “one-size-fits-all” approach to incorporating a racial and ethnic equity perspective into research, these guiding principles can help researchers better identify where inequities exist, their structural cause, and the environments and conditions that perpetuate those inequities. These guiding principles encourage researchers to examine their own biases, make a commitment to dig deeper into their data, recognize how the research process impacts communities, engage with those communities as research partners, and guard against the implicit or explicit assumption that white is the default experience of the world.” Five guiding principles: 1. Examine their own backgrounds and biases.

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2. Make a commitment to dig deeper into the data. 3. Recognize that the research process itself has an impact on communities, and

researchers have a role in ensuring research benefits communities. 4. Engage communities as partners in research. 5. Guard against the implied or explicit assumption that white is the normative,

standard, or default position. W.K. Kellogg Foundation. August 2020. Reflecting on the past to transform the future: lessons leader from grant making in promoting health equity and responding to crisis. https://www.wkkf.org/resource-directory/resources/2020/08/reflecting-on-the-past-to-transform-the-future--lessons-learned-from-grantmaking-in-promoting-health

Given their longtime work with communities, experiences in emergency grant-making and partnership with researchers and advocates to address health and social inequities, this report offer the following framework and lessons from their grant making experiences. They offer ten lessons from community voices for timely practice & policy. This article is mostly about equity in grant-making (from a donor perspective).

World Health Organization. 2013. Handbook on health inequality monitoring: with a special focus on low- and middle-income countries. https://www.rockefellerfoundation.org/report/health-inequality-monitoring-with-a-special-focus-on-low-and-middle-income-countries/

The World Health Organization developed the Handbook on health inequality monitoring: with a special focus on low- and middle-income countries to provide an overview for health inequality monitoring within low- and middle-income countries, and act as a resource for those involved in spearheading, improving or sustaining monitoring systems. The handbook was principally designed to be used by technical staff of ministries of health to build capacity for health inequality monitoring in World Health Organization Member States.

Maternal and Child Survival Program and United States Agency for International Development (USAID). September 2016. Maternal and Child Survival Program Equity Toolkit A Practical Guide to Addressing Equity in Reproductive, Maternal, Newborn, and Child Health Programs.

This guide was developed to give those who design and implement community-oriented health programs a systematic approach to programming that incorporates identifying and addressing health inequities and measuring equity improvements. This guide is aimed at professionals working in reproductive, maternal, newborn, and child health (RMNCH) programs, especially those that are part of country programs of the Maternal and Child Survival Program (MCSP), funded by the U.S. Agency for International Development (USAID). The toolkit is a set of considerations, worksheets, and available resources that can help program

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https://www.mcsprogram.org/wp-content/uploads/2016/09/MCSP-Updated-Equity-Toolkit.pdf

implementers apply the MCSP six-step process for incorporating equity into project design and implementation. The checklist is comprised of the following six steps: 1. Understand the equity issues in the project area:

a. Identify inequities in health outcomes and the magnitude of the differences, and b. Understand underlying issues and barriers.

2. Identify the disadvantaged group or priority inequities on which to focus. 3. Decide what is in the project’s manageable interest to change. 4. Define equity goals, objectives, and a project-specific definition of equity. 5. Determine equity strategies and activities. 6. Develop an equity-focused monitoring and evaluation (M&E) system.

About the Grand Bargain. May 2016. Inter-Agency Standing Committee (IASC). https://interagencystandingcommittee.org/about-the-grand-bargain

As part of the preparations for the World Humanitarian Summit (WHS) in 2016, the High-Level Panel on Humanitarian Financing sought solutions to close the humanitarian financing gap. Initially thought as a deal between the five biggest donors and the six largest UN Agencies, the Grand Bargain now includes 63 (25 Member States, 11 UN Agencies, 5 inter-governmental organizations and Red Cross/Red Crescent Movements and 22 NGOs) which represent around 84% of all donor humanitarian contributions donated in 2019 and 69% of aid received by agencies. The Signatories are working across eight workstreams to implement the commitments: 1. Greater Transparency (Co-convenors: The Netherlands, World Bank) 2. More support and funding tools to local and national responders (Co-convenors: IFRC, Switzerland)

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3. Increase the use and coordination of cash-based programming (Co-convenors: UK, WFP) 4. Reduce Duplication and Management costs with periodic functional reviews (Co-convenors: Japan, UNHCR) 5. Improve Joint and Impartial Needs Assessments (Co-convenors: ECHO, OCHA) 6. A Participation Revolution: include people receiving aid in making the decisions which affect their lives (Co-convenors: USA, SCHR) 7. & 8. Increase collaborative humanitarian multi-year planning and funding & Reduce the earmarking of donor contributions (Co-convenors: Canada, Sweden, UNICEF, ICRC, OCHA, NRC) 9. Harmonize and simplify reporting requirements (Co-convenors: Germany, ICVA)


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