Increase Health Equity Research Articles

Don’t ignore the tipping point: A framework to fuel diversity, equity, and inclusion efforts in health-care sciences

In the United States, social determinants of health have resulted in inequities in health care, particularly for communities affected by systemic forms of racism and oppression. Health-care professionals are essential in assisting participation in the health-care system. Building a more diverse health-care workforce can expand access to care, improve the quality of care, and increase health equity. However, many health-care professions have struggled to effectively recruit and retain individuals from diverse backgrounds. In the field of occupational therapy, leaders in diversity, equity, and inclusion worked together to establish a framework with nationwide initiatives to effectively recruit and retain a workforce that is more representative of the communities, in which health-care professionals serve. The initiatives and framework outlined below can be replicated to advance efforts to increase diversity and create systems that address justice, equity, and inclusion.

Association of Chain Restaurant Advertising Spending With Obesity in US Adults

Restaurants spend billions of dollars on marketing. However, little is known about the association between restaurant marketing and obesity risk in adults. To examine associations between changes in per capita county-level restaurant advertising spending over time and changes in objectively measured body mass index (BMI) for adult patients. This cohort study used regression models with county fixed effects to examine associations between changes in per capita county-level (370 counties across 44 states) restaurant advertising spending over time with changes in objectively measured body mass index (BMI) for US adult patients from 2013 to 2016. Different media types and restaurant types were analyzed together and separately. The cohort was derived from deidentified patient data obtained from athenahealth. The final analytic sample included 5 987 213 patients, and the analysis was conducted from March 2018 to November 2019. Per capita county-level chain restaurant advertising spending. Individual-level mean BMI during the quarter. The included individuals were generally older (37.1% older than 60 years), female (56.8%), and commercially insured (53.5%). For the full population of 29 285 920 person-quarters, there was no association between changes in all restaurant advertising per capita (all media types, all restaurants) and changes in BMI. However, restaurant advertising spending was positively associated with weight gain for patients in low-income counties but not in high-income counties. A $1 increase in quarterly advertising per capita across all media and restaurant types was associated with a 0.053-unit increase in BMI (95% CI, 0.001-0.102) for patients in low-income counties, corresponding to a 0.12% decrease in BMI at the 10th percentile of changes in county advertising spending vs a 0.12% increase in BMI at the 90th percentile. The results of this study suggest that restaurant advertising is associated with modest weight gain among adult patients in low-income counties. To date, there has been no public policy action or private sector action to limit adult exposure to unhealthy restaurant advertising. Efforts to decrease restaurant advertising in low-income communities should be intensified and rigorously evaluated to understand their potential for increasing health equity.

Dietary guidelines made useful in migrant networks

Abstract Globally, many deaths and DALY:s are attributed to unhealthy diets. Short education, low income and migration are risk factors. Healthy food cost more and is less available while unhealthy food is cheaper and heavily advertised. Health guides (HG) speak Swedish and at least one more language and have networks among migrants. Their work draw on the Right to health framework - availability, accessibility, acceptability and quality for all (AAAQ). HG transfer viewpoints from their groups to health care and contribute to culturally accessible and acceptable information and support. Public Health Unit of a local hospital initiated a project with the aim to develop a method to make information about healthy food accessible for a wider range of people. How to make food based dietary guidelines useful for recent migrants? How to avoid that official guidelines, when transferred by laymen, become distorted by personal experiences rather than being enriched by them? Systematic collection of viewpoints from inhabitants, helped of HG, implied that “shop walks” have potential to increase health equity. During a shop walk the guide shows healthy alternatives and transfers knowledge on different options. The intervention was developed during 2019. The first shop walks were conducted in February 2020. Dietary guidelines were made useful by a process including cooperation between HG, nutritionally skilled staff and the communication department. A detailed manuscript and a participant folder were developed together with a mandatory education including theory and practice. 14 HG speaking six languages were included. During the first three weeks six shop walks were conducted. Qualitative evaluation implies that shop walks are functional arenas for strengthening AAAQ. By structured shop walks HG can contribute to making dietary guidelines relevant for recent migrants. AAAQ is supported by participation of stakeholders in the population in collaboration with professional expertise. Key messages If food based dietary guidelines are to be made useful outside the majority population, methods that allow those most concerned to participate in planning, execution and evaluation should be used. Availability, accessibility, acceptability and quality - The Right to health framework – should be used when developing public health interventions that aim at health equity.

Using Land Policy to Improve Population Health

We examine whether zoning can increase health equity and population health by assessing a new zoning ordinance in the City of Baltimore that forced 76 liquor stores in residential areas to relocate, close, or convert to an approved use. To do so, we undertake a baseline assessment of neighborhoods with affected liquor stores, and predict the potential impact of the zoning change by estimating the impact of previous closures and openings of liquor stores on neighborhood crime in Baltimore using a spatial Poisson random trend fixed effects model. We find that affected stores are concentrated in high poverty, majority black neighborhoods with high vacancy rates, and that liquor store closings are associated with a statistically significant reduction in violent crime on the block group in question with no negative spillover affects onto the nearby block groups.

Using Zoning as a Public Health Tool to Reduce Alcohol Outlet Oversaturation, Promote Compliance, and Guide Future Enforcement: a Preliminary Analysis of Transform Baltimore.

Alcohol outlet oversaturation often exacerbates negative public health outcomes. Recently, Baltimore City passed an extensive zoning rewrite ("TransForm Baltimore") that sought to give local government and residents a tool to reduce alcohol outlet oversaturation through land use regulation. The present investigation evaluated the outlet and neighborhood characteristics of stores impacted by two components of TransForm Baltimore: (1) a requirement that taverns licensed for on-premise consumption in addition to off-premise, carryout sales generate at least 50% of their business from on-premise sales, and (2) a requirement to close, repurpose, or relocate all package stores (i.e., off-premise alcohol outlets) that have been operating as "non-conforming" in residential zones since 1971. Research assistants visited every off-premise alcohol outlet in the city (n = 685) to complete an observational assessment. Approximately 77% (n = 530) of these off-premise alcohol outlets were open, including 292 taverns and 238 package stores. t tests and chi-square tests were used to compare neighborhood characteristics (neighborhood disadvantage, median household income, and racial segregation) of sham taverns (i.e., taverns with less than 50% space dedicated for on-premise sales that were primarily operating as a package store) and non-conforming package stores. Of the 292 taverns accessible during the study, the remainder were chronically closed (n = 130); 24 (8.2%) were deemed sham taverns. Sham taverns were more likely to be located in communities with more economic disadvantage and lower median household income (t test; p < 0.05). Compared to taverns, a lower proportion of sham taverns had visible dance floor space, patrons drinking, and menus available (chi-square test; p < 0.001). There were 80 residentially zoned, non-conforming alcohol outlets. These non-conforming alcohol outlets were disproportionately distributed in predominately poor and African American communities (t test; p < 0.05). As compared to conforming alcohol outlets, more non-conforming alcohol outlets sold sex paraphernalia and healthy foods (chi-square test; p < 0.05). With active enforcement, TransForm Baltimore offers the opportunity for local government and residents to improve public health and increase health equity in vulnerable and marginalized neighborhoods.

Network-Based Delivery and Sustainment of Evidence-Based Prevention in Community-Clinical Partnerships Addressing Health Equity: A Qualitative Exploration.

Background: Increased delivery of evidence-based preventive services can improve population health and increase health equity. Community-clinical partnerships offer particular promise, but delivery and sustainment of preventive services through these systems face several challenges related to service integration and collaboration. We used a social network analysis perspective to explore (a) the range of contributions made by community-clinical partnership network members to support the delivery of evidence-based preventive services and (b) important influences on the ability of these partnerships to sustain service delivery.Methods: Data come from an implementation evaluation of the Prevention and Wellness Trust Fund initiative, which supported nine Massachusetts communities to coordinate delivery of evidence-based prevention and address inequities in hypertension, pediatric asthma, falls among older adults, or tobacco use. In 2016, we conducted semi-structured interviews with (a) leadership teams representing nine community-level partnerships and (b) practitioners from four high-implementation partnerships (n = 23). We managed data using NVivo11 and utilized a framework analysis approach.Results: Key network contributions for delivery of evidence-based preventive services included creating referrals, delivering services, providing links to community members, and administration and leadership. Less emphasized contributions included wraparound services, technical assistance, and venue provision. Implementers from high-implementation partnerships also highlighted contributions such as program adaptation, creating buy-in, and sharing information to improve service delivery. Expected drivers of program sustainability included the ability to develop a business case, ongoing network facilitation, technology support, continued integrated action, and sufficient staffing to maintain programming.Conclusion: The study highlights the need to take a long-term, infrastructure-focused approach when designing community-clinical partnerships. Strategic partnership composition, including identifying sources of necessary network contributions, in conjunction with efforts from the outset to link systems, align effort, and build a long-term funding structure can support the required coordinated action around preventive services needed to improve health equity.

The Evolving Role of Public Health in Medical Education.

Medical education in the twentieth century was largely influenced by the Flexner Report, with significant proportions of instruction dedicated to the molecular underpinnings of the pathologic pathways and minimal mention of the socio-ecological determinants of health. When examining the predominant diseases of the twenty first century landscape, widening health disparities, and significant changes in the United States healthcare system, it is imperative to view wellness and sickness in a broader public health context rather than a singular focus of the biomedical model. While undergraduate opportunities to study public health are on the rise in the United States, there is a parallel urgency for medical curricula to recognize the importance of the complex interrelated socio-ecological root causes of health, well-being, and illness. In order to reduce the risk of non-communicable diseases and increase health equity, it is necessary for medical education to integrate core public health knowledge and competencies. Contemporary health challenges require a public health approach, in addition to clinical skills, for physicians to provide equitable care. The COVID-19 pandemic further underscores the necessity to mitigate the effects of socio-ecological determinants of health. Seven key recommendations are presented from a training to practice timeline emphasizing the important linkages between medical education, socio-ecological influences on health, and public health. As the health challenges in society and communities shift, so too must training of future physicians. There is a need and an opportunity for medicine and public health to address the shared health challenges of our global society.

4244 A Community Partnered Research Approach to Promote Health Equity in Diverse Families

OBJECTIVES/GOALS: Youth and Families Determined to Succeed (YFDS), a non-profit organization in Hennepin County, MN, provides programs to address health disparities and increase health equity in diverse families. The objective of this capacity building community engaged research study was to identify factors and opportunities to expand YFDS. METHODS/STUDY POPULATION: A community partnered participatory research framework using 3 community engaged (CE) studies was conducted. This structured research process involves a facilitated discussion with a presentation on YFDS programming and a guided discussion with YFDS stakeholders. The theoretical foundation included constructs from the Model of Improvement and Health Belief Model. A trained qualitative research team led the discussion, took detailed notes, and used traditional content analysis to thematically code the notes (n = 29 pages). The studios were not audio recorded for confidentiality. Preliminary findings were presented to YFDS leadership with plans to present the results to YFDS stakeholders and families. RESULTS/ANTICIPATED RESULTS: A total of 16 YFDS past and current members participated in the studios. The average age was 42.5 years with 69% female and 75% black participants. The main themes were YFDS programming, outreach, and partnership. Participants mentioned YFDS youth “gained confidence”, found an additional family, and suggested ways to increase outreach and partnerships. Participants suggested YFDS increase their social media presence, create multicultural programing, partner with faith based organizations and schools, and determine new ways to evaluate health, social, and athletic gains. DISCUSSION/SIGNIFICANCE OF IMPACT: YFDS has positively impacted the lives of their families. With the use of CE studios, we have the opportunity to hear the voices of the members impacted that is necessary for capacity building community engaged research. We were able to find factors that made YFDS successful and suggestions to better improve and to increase positive wellness gains.

Cultural safety in hospitals: validating an empirical measurement tool to capture the Aboriginal patient experience.

Objective The aim of the present study was to develop a scale to measure cultural safety in hospitals from an Aboriginal patient perspective. Methods The Cultural Safety Survey was designed to measure five key characteristics of cultural safety that contribute to positive hospital experiences among Aboriginal hospital patients. Investigators developed a range of different methods to assess the validity and reliability of the scale using a sample of 316 participants who had attended a New South Wales hospital in the past 12 months. Targeted recruitment was conducted at two hospital sites. Opportunistic recruitment took place through a local health district, discharge follow-up service and online via social media. Results The Cultural Safety Survey Scale was a robust measurement tool that demonstrated a high level of content and construct validity. Conclusion The Cultural Safety Survey Scale could be a useful tool for measuring cultural safety in hospitals from the Aboriginal patient perspective. What is known about the topic? There are increasing calls by governments around the world for health institutions to enhance the cultural safety of their services as one way of removing access barriers and increasing health equity. However, currently there are no critical indicators or systematic methods of measuring cultural safety from the patient perspective. What does this paper add? The cultural safety scale, an Australian first, presents the first empirically validated tool that measures cultural safety from the Aboriginal patient perspective. What are the implications for practitioners? This measurement model will allow hospitals to measure the cultural safety of their services and ascertain whether current efforts aimed to improve cultural safety are resulting in Aboriginal patients reporting more culturally safe experiences. Over time it is hoped that the tool will be used to benchmark performance and eventually be adopted as a performance measure for hospitals across New South Wales.

Educational differences in the prevalence of behavioural risk factors in Germany and the EU - Results from the European Health Interview Survey (EHIS) 2.

This article examines educational differences in the prevalence of behavioural risk factors among adults and compares the results for Germany with the average from the European Union (EU). Data were derived from the second wave of the European Health Interview Survey, which took place between 2013 and 2015 (EHIS 2). Analyses were conducted using a regression-based calculation of relative and absolute educational differences in the prevalence of behavioural risk factors, based on self-reported data from women and men aged between 25 and 69 (n=217,215). Current smoking, obesity, physical activity lasting less than 150 minutes per week, heavy episodic drinking and non-daily fruit or vegetable intake are more prevalent among people with a low education level than those with a high education level. This applies to Germany as well as the EU average. Overall, the relative educational differences identified for these risk factors place Germany in the mid-range compared to the EU average. However, relative educational differences in current smoking and heavy episodic drinking are more manifest among women in Germany than the EU average, with the same applying to low physical activity among men. In contrast, relative educational differences in non-daily fruit or vegetable intake are less pronounced among women and men in Germany than the average across the EU. Increased efforts are needed in various policy fields to improve the structural conditions underlying health behaviour, particularly for socially disadvantaged groups, and increase health equity.

A digitalized methodology to strengthen health equity: control, influence and participation

Abstract Problem Angered Hospital is situated in the northeast of Gothenburg, Sweden, serving municipalities with high prevalence of ill health. Dedicated to increase health equity, the hospital has established a Public Health Unit (PHU) to support residents to healthier lives. PHU found that lack of transparency concerning strategies, reflections and results hindered knowledge-exchange between public health practitioners. Also, information from the execution of public health interventions and programs needed to be more accessible for policy-makers and researchers. Description PHU developed a digitalized methodology for systematic steering. It draws on control, influence and participation, using Social Cognitive Theory to plan for strategies. The evaluation build on norm-critical reflections of structured reports. Themes include: How to improve efforts on the structural level? What measures do we plan for and conduct to enhance participation from residents? Quantitative goals were set. Results 222 activity reports were launched and discussed by team members, leading to professional development. Strategies to support self-efficacy were used throughout. The strategy “reciprocal determinism” was planned for more than used, due to giving floor to participants to raise their issues. Methods that draw on transparency, sound evidence and continous collaboration allow for residents to rethink their lifestyle and strive for change. Issues for future development included the importance og giving time for trust and shared values to emerge. Quantitive goals were reached. Lessons Quality assurance of public health work enables formative and summative evaluation, increases potential to close the health gap, provides policy-makers with valuable knowledge and opens for research. Trust and shared values are vital at all levels. The methodology allows for organizations to develop their health literacy in order to include and give voice to people in underserved areas. Key messages Public health units aiming at health equity should use tailored evidence based methods, including norm-critical reflections. Digitalizing a methodological instrument increases accessability and transparency which enables common knowledge development.

Health Equilibrium Methodology (HEM), a digital tool in public health work for health equity

Abstract HEM draws on theories for health behavior and power relations. The methodology contains a structured documentation for formative and summative purposes. Strive for a high level of participation, control and influence from individuals and community members is a foundation pillar. Systematic use of theories allows for answering the fundamental question “in what way do we anticipate the planned intervention to contribute to closing the health gap?” Social Cognitive Theory (SCT) considers social and physical environment. HEM currently involve several SCT determinants in planning and evaluation; self- efficacy, observational learning, facilitating, expectations of outcome, reciprocal determination. The qualitative procedure is described below. Numeric data are also collected. Step one (before action, e.g. a dialogue-meeting): Consider which determinant(s) may be affected by the planned action, and by what mechanisms. Step two: Carry out the action. Step three: Describe what happened, based on input from the participants and the anticipated determinants and mechanisms. Step four: Systematic self-critical review based on common grounds for discrimination. Examples: Was it difficult to engage or include participants because of language, gender, function variation, national background or other factor? In retrospect, can you identify stereotypes in the examples you used? Did anybody else at the event act to maintain prejudice or exclusion? Step five: consider implications for methodological development. Step six: Formative collective evaluation based on reflections from step four and implications from step five. Stakeholders using HEM gather regularly for workshops based on their HEM-reports, aiming at developing tools for increasing health equity. HEM is implemented in public health work of Angered Hospital and the Dental Public Health, Region Västra Götaland, and is used by 20 different stakeholders. A web-application has been developed to facilitate documentation and spread.

Workshop: Digital quality assurance of equitable public health interventions: why, how and examples

Abstract Objectives are to highlight knowledge and experiences of follow-up and evaluation of public health interventions with a focus on health equity. A digital instrument for planning, documentation and quality assurance, used in several Swedish settings, will be presented. Health inequity emerges from structural issues. Public health interventions generally widen the health gap which is maintained and enforced by mechanisms on many levels in the societies. Interventions that aim to counteract health inequity need to take this into account and broaden the perspective to include not only life style habits but also discrimination, stigmatization, control, influence and power. Critical reflection is necessary to prevent interventions from consolidating current positions of power and to assure that communities and individuals - can influence goal-setting and measures taken. The Swedish Commission for Equity in Health highlighted the importance of methodological development and knowledge-based efforts including better follow-up, evaluation, research and dialogue. Mediators between measures taken and effects need to be clarified. Health promotion needs to be evaluated systematically with a focus on how interventions function in relation to the task of closing the gap. However, interventions are often merged into other activities and the impact of a continuously changing society cannot be controlled for. Use of evidence-based methods including influence from participants are fundamental, as is critical reflection. Documented by a digital instrument, measures taken and reflected upon can form a database for continuous summative and formative evaluation, aiming at developing methods for effective public health work. Added value Presenting and discussing a digital instrument for planning, documentation and quality assurance will increase the potential for public health efforts to close the health gap. We use it for formative and summative evaluation. For 2018, 222 activity reports were launched and discussed by team members, leading to professional development. Issues for future development included the importance of giving time for shared values to consolidate and trust to emerge. Quantitive goals were reached. Coherence Presentation 1 will clarify why control, power and influence must be taken into consideration in interventions that aim at counteracting health inequity. Presentation 2 will describe the instrument and how it draws on theories of health and critical reflection. Presentation 3 will tell the story of an example from a Swedish dental public health care setting where the instrument has been used and point at strengths and areas for development. Format Presentation 15 minutes each. Followed by short discussions (5 minutes) in the audience who will then be asked to present short inputs on post-it notes that will be collected by the organizers. During the last 30 minutes there will be a general discussion using the post-it notes as starting point. Key messages A digital instrument for planning, documentation and quality assurance, with focus on health equity, will increase the positive impact of public health efforts. Public health interventions that use the instrument will be better equipped to increase health equity.

Improving chronic illness self-management with the Apsáalooke Nation: Development of the Báa nnilah program

RationaleSince 1996, members of the Apsáalooke (Crow) Nation and faculty and students at Montana State University have worked in a successful community-based participatory research (CBPR) partnership, leading to increased trust and improvements in health awareness, knowledge, and behaviors. As major barriers to health and healthy behaviors have caused inequities in morbidity and mortality rates for multiple chronic diseases among the Apsáalooke people, community members chose to focus the next phase of research on improving chronic illness management. ObjectiveExisting chronic illness self-management programs include aspects inconsonant with Apsáalooke culture and neglect local factors seen as vital to community members managing their health conditions. The aim of this study was to use CBPR methods grounded in Apsáalooke cultural values to develop an intervention for improving chronic illness self-management. MethodCommunity members shared stories about what it is like to manage their chronic illness, including facilitators and barriers to chronic illness management. A culturally consonant data analysis method was used to develop a locally-based conceptual framework for understanding chronic illness management and an intervention grounded in the local culture. ResultsComponents of the intervention approach and intervention content are detailed and similarities and differences from other chronic illness management programs are described. ConclusionsOur collaborative process and product may be helpful for other communities interested in using story data to develop research projects, deepen their understanding of health, and increase health equity.

Federal Weatherization and Health Education Team up: Process Evaluation of a New Strategy to Improve Health Equity for People With Asthma and Chronic Obstructive Pulmonary Disease.

Unhealthy housing is a major cause of respiratory health inequity. In-home health education improves health equity for low-income and minority populations with asthma and chronic obstructive pulmonary disease. Yet, outcomes of educational interventions are limited by poor housing conditions. Federal weatherization programs represent a promising source of funding for home repairs. Innovative legislation in Washington State integrates the 2 interventions as "Weatherization Plus Health," offering environmental health education in partnership with the Weatherization Assistance Program for low-income families with respiratory disease. This practice brief describes process evaluation results of a Weatherization Plus Health program in Pierce County, Washington. Evaluation data were gathered via interviews with service providers and ethnographic observation. Workers report that the combined intervention expanded their understanding of their practice, skills, and feelings of efficacy in meeting client needs. Integrating federally funded home weatherization with health education shows promise for building public health system capacity and increasing health equity.

An Exploration of Patient Navigation and Community Health Worker Activities Across National Comprehensive Cancer Control Programs.

Purpose: Health disparities persist across the cancer care continuum. Patient navigator (PN) and community health worker (CHW) interventions are designed to increase health equity. National Comprehensive Cancer Control Program (NCCCP) awardees develop and implement plans to coordinate cancer prevention and control activities, including supporting PN and CHW interventions. This content analysis examined NCCCP action plans to assess the extent to which jurisdictions report engaging in PN and/or CHW activities.Methods: We abstracted PN and CHW content from NCCCP action plans and coded content according to specific areas of PN and/or CHW intervention (e.g., screening, survivorship, and cancer type), used descriptive statistics to characterize overall results, and calculated chi-squares to determine whether programs engaged PNs and CHWs differently.Results: Eighty-two percent (n=53) of 65 NCCCP action plans had content related to PN and/or CHW activities, with more PN language (83%) than CHW (58%). These action plans described engaging PNs and CHWs in activities across the cancer continuum, but particularly for screening (60%) and survivorship (55%). Eighty-one percent of these plans described activities related to workforce development, such as training and standardizing roles and competencies. Programs engaged CHWs more often than PNs for outreach and in community settings.Conclusion: The majority of NCCCP awardees reported engaging in PN and/or CHW activities. Understanding how NCCCP awardees engage PNs and CHWs, including awardees' needs for workforce development in this area, can help Centers for Disease Control and Prevention provide more focused technical assistance as programs increase engagement of PNs and CHWs to improve health equity.

FAmily-CEntered (FACE) Advance Care Planning Among African-American and Non-African-American Adults Living With HIV in Washington, DC: A Randomized Controlled Trial to Increase Documentation and Health Equity

ContextNo prospective studies address disease-specific advance care planning (ACP) for adults living with HIV/AIDS. ObjectiveTo examine the efficacy of FAmily-CEntered (FACE) ACP in increasing ACP and advance directive documentation in the medical record. MethodsLongitudinal, two-arm, randomized controlled trial with intent-to-treat design recruited from five hospital-based outpatient HIV clinics in Washington, DC. Adults living with HIV and their surrogate decision-makers (N = 233 dyads) were randomized to either an intensive facilitated two-session FACE ACP (Next Steps: Respecting Choices goals of care conversation and Five Wishes advance directive) or healthy living control (conversations about developmental/relationship history and nutrition). ResultsPatients (n = 223) mean age: 51 years, 56% male, 86% African-American. One hundred ninety-nine dyads participated in the intervention. At baseline, only 13% of patients had an advance directive. Three months after intervention, this increased to 59% for the FACE ACP group versus 17% in the control group (P < 0.0001). Controlling for race, the odds of having an advance directive in the medical record in the FACE ACP group was approximately seven times greater than controls (adjusted odds ratio = 6.58, 95% CI: 3.21–13.51, P < 0.0001). Among African-Americans randomized to FACE, 58% had completed/documented advance directives versus 20% of controls (P < 0.0001). ConclusionsThe FACE ACP intervention significantly improved ACP completion and advance directive documentation in the medical record among both African-American and non-African-American adults living with HIV in Washington, DC, providing health equity in ACP, which can inform best practices.

Navigating Intersectional Approaches, Methods, and Interdisciplinarity to Health Equity in LGBTQ+ Communities

The broad spectrum of health services and wellness surrounding lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities operates within multiple layers of social inequities. Research using intersectionality features numerous research methods purposed specifically for clarity toward increasing health equity. Generated in the scope of various research methods (e.g., quantitative, qualitative, mixed-methods), utilizing intersectionality illustrates potential to explore complex phenomena and outcomes within LGBTQ+ communities. As intersectionality thrives on interdisciplinarity, this article focuses on three overarching purposes: (a) accentuate health equity and social justice across an interdisciplinary scope for LGBTQ+ communities, (b) highlight formative principles grounded in intersectionality, and (c) supplement recommendations for research targeting health equity.

The trade-off between equity and efficiency in population health gain: Making it real

Two fundamental goals of health systems are to maximise overall population health gain (referred to as efficiency) and to minimise unfair health inequalities (equity). Often there is a trade-off in maximising efficiency vis a vis equity and the relative weight given to one goal over the other is acknowledged to be essentially a value judgement. Health systems necessarily make those value judgements but in making them would benefit from relevant and accurate opportunity cost information. Unfortunately the development of practical tools to measure equity-efficiency trade-offs has lagged theoretical advances in this area. We address this gap by presenting a practical technique to reveal opportunity costs of equity (and efficiency) gains in decentralised population-based health systems, applying stochastic data envelopment analysis to ethnic-specific life expectancy (LE) changes for 20 New Zealand (NZ) District Health Boards for the inter-census period 2006–2013, thereby deriving a notional health frontier from 10,000 Monte Carlo simulations. Four different ways to increase health equity emerge. These show that a trade-off between equity and efficiency does not always exist. In particular, improving both productive efficiency and allocative efficiency (up to its maximum) can also yield gains in equity through reductions in LE inequalities. However, in NZ's case, the opportunity cost (in sacrificed European life-years) of achieving gains in equity beyond the point of maximum productive and allocative efficiency is relatively high, even for quite small reductions in the LE gap between Māori and European populations. This high opportunity cost may explain why, despite governments' strong rhetorical commitment to equity, NZ's health gains have not strayed far from the path of maximising allocative efficiency. Nevertheless, this opportunity cost could be reduced significantly by measures which shift the health frontier outward, highlighting the importance of technical and organisational innovation as potential drivers of greater equity in health outcomes.

Community-Engaged Research as an Approach to Expedite Advances in HIV Prevention, Care, and Treatment: A Call to Action.

Throughout the world, we continue to face profound challenges to reducing the impact of the HIV epidemic. Community-engaged research has emerged as an approach to increase our understanding of HIV and reduce health disparities, increase health equity, and promote community and population health. Our partnership has conducted more than 25 community-engaged research studies in the U.S. and Guatemala, and members have identified nine themes to facilitate community-engaged research and expedite advances in HIV prevention, care, and treatment. These themes include the inclusion of multisectoral partners, trust building and maintenance, the alignment of partner priorities, a can-do attitude, capacity and desire to move beyond service and conduct research, flexibility, power sharing, empowerment, an assets orientation, the shared and timely use of findings, and a stepwise approach. To reduce HIV disparities, community-engaged research is as critical now as ever, and we desperately need to reinvigorate our commitment to and support of it.