The Water Surrounding the Iceberg: Cultural Racism and Health Inequities

Policy Points

• Cultural racism—or the widespread values that privilege and protect Whiteness and White social and economic power—permeates all levels of society, uplifts other dimensions of racism, and contributes to health inequities.
• Overt forms of racism, such as racial hate crimes, represent only the “tip of the iceberg,” whereas structural and institutional racism represent its base. This paper advances cultural racism as the “water surrounding the iceberg,” allowing it to float while obscuring its base.
• Considering the fundamental role of cultural racism is needed to advance health equity.

     

Potentially More Out of Reach: Public Reporting Exacerbates Inequities in Home Health Access

Policy Points

• Public reporting is associated with both mitigating and exacerbating inequities in high-quality home health agency use for marginalized groups.
• Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does.
• Targeted federal, state, and local interventions should focus on raising awareness about the five-star quality ratings among marginalized populations for whom inequities have been exacerbated.

     

Evidence on Scaling in Health and Social Care: An Umbrella Review

Policy Points

• More rigorous methodologies and systematic approaches should be encouraged in the science of scaling. This will help researchers better determine the effectiveness of scaling, guide stakeholders in the scaling process, and ultimately increase the impacts of health innovations.
• The practice and the science of scaling need to expand worldwide to address complex health conditions such as noncommunicable and chronic diseases.

• Although most of the scaling experiences described in the literature are occurring in the Global South, most of the authors publishing on it are based in the Global North. As the science of scaling spreads across the world with the aim of reducing health inequities, it is also essential to address the power imbalance in how we do scaling research globally.

     

A Population Health Impact Pyramid for Health Care

Policy Points

• To meaningfully impact population health and health equity, health care organizations must take a multipronged approach that ranges from education to advocacy, recognizing that more impactful efforts are often more complex or resource intensive.
• Given that population health is advanced in communities and not doctors’ offices, health care organizations must use their advocacy voices in service of population health policy, not just health care policy.
• Foundational to all population health and health equity efforts are authentic community partnerships and a commitment to demonstrating health care organizations are worthy of their communities’ trust.

     

Conceptualizing the Mechanisms of Social Determinants of Health: A Heuristic Framework to Inform Future Directions for Mitigation

Policy Points

• A large body of scientific work examines the mechanisms through which social determinants of health (SDOH) shape health inequities. However, the nuances described in the literature are infrequently reflected in the applied frameworks that inform health policy and programming.
• We synthesize extant SDOH research into a heuristic framework that provides policymakers, practitioners, and researchers with a customizable template for conceptualizing and operationalizing key mechanisms that represent intervention opportunities for mitigating the impact of harmful SDOH.
• In light of scarce existing SDOH mitigation strategies, the framework addresses an important research-to-practice translation gap and missed opportunity for advancing health equity.

     

Abortion Policy in the United States: The New Legal Landscape and Its Threats to Health and Socioeconomic Well-Being

Policy Points

• The historic 2022 Supreme Court Dobbs v Jackson Women's Health Organization decision has created a new public policy landscape in the United States that will restrict access to legal and safe abortion for a significant proportion of the population.
• Policies restricting access to abortion bring with them significant threats and harms to health by delaying or denying essential evidence-based medical care and increasing the risks for adverse maternal and infant outcomes, including death.
• Restrictive abortion policies will increase the number of children born into and living in poverty, increase the number of families experiencing serious financial instability and hardship, increase racial inequities in socioeconomic security, and put significant additional pressure on under-resourced social welfare systems.

     

The Black-White Disparity in Preterm Birth: Race or Racism?

Policy Points

• Racism is an upstream determinant of health that influences health through many midstream and downstream factors. This Perspective traces multiple plausible causal pathways from racism to preterm birth.
• Although the article focuses on the Black-White disparity in preterm birth, a key population health indicator, it has implications for many other health outcomes.
• It is erroneous to assume by default that underlying biological differences explain racial disparities in health. Appropriate science-based policies are needed to address racial disparities in health; this will require addressing racism.

     

Politics and the Public Health Workforce: Lessons Suggested from a Five-State Study

Policy Points

• The United States public health system relies on an inadequate and inefficient mix of federal, state, and local funding.
• Various state-based initiatives suggest that a promising path to bipartisan support for increased public health funding is to gain the support of local elected officials by providing state (and federal) funding directly to local health departments, albeit with performance strings attached.
• Even with more funding, we will not solve the nation's public health workforce crisis until we make public health a more attractive career path with fewer bureaucratic barriers to entry.

     

Making Communities More Visible: Equity-Centered Data to Achieve Health Equity

Policy Points

• Despite decades of research exposing health disparities between populations and communities in the US, health equity goals remain largely unfulfilled. We argue these failures call for applying an equity lens in the way we approach data systems, from collection and analysis to interpretation and distribution. Hence, health equity requires data equity.
• There is notable federal interest in policy changes and federal investments to improve health equity. With this, we outline the opportunities to align these health equity goals with data equity by improving the way communities are engaged and how population data are collected, analyzed, interpreted, made accessible, and distributed.
• Policy priority areas for data equity include increasing the use of disaggregated data, increasing the use of currently underused federal data, building capacity for equity assessments, developing partnerships between government and community, and increasing data accountability to the public.

     

The Role of Primary Care in Improving Population Health

Policy Points

• Systems based on primary care have better population health, health equity, and health care quality, and lower health care expenditure.
• Primary care can be a boundary-spanning force to integrate and personalize the many factors from which population health emerges.
• Equitably advancing population health requires understanding and supporting the complexly interacting mechanisms by which primary care influences health, equity, and health costs.

     

Population Health Science: Fulfilling the Mission of Public Health

Policy Points

• The historical mission of public health is to ensure the conditions in which people can be healthy, and yet the field of public health has been distracted from this mission by an excessive reliance on randomized‐control trials, a lack of formal theoretical models, and a fear of politics.
• The field of population health science has emerged to rigorously address all of these constraints. It deserves ongoing and formal institutional support.

The united states is failing in population health. life expectancy in the United States is falling for the first time since reliable mortality records have been available, and health equity has been on a downward trend for decades. ¹ Why is the United States, among the richest countries in the world, failing to protect the health of its residents? A dysfunctional medical system that pays for sickness rather than wellness is certainly part of the problem, but so is confusion about the role of public health in the United States.     

The Perils of Medicalization for Population Health and Health Equity

Policy Points

• Medicalization is a historical process by which personal, behavioral, and social issues are increasingly viewed through a biomedical lens and “diagnosed and treated” as individual pathologies and problems by medical authorities.
• Medicalization in the United States has led to a conflation of “health” and “health care” and a confusion between individual social needs versus the social, political, and economic determinants of health.
• The essential and important work of population health science, public health practice, and health policy writ large is being thwarted by a medicalized view of health and an overemphasis on personal health services and the health care delivery system as the major focal point for addressing societal health issues and health inequality.
• Increased recognition of the negative consequences of a medicalized view of health is essential, with a focus on education and training of clinicians and health care managers, journalists, and policymakers.

     

Public Health Emergency Preparedness After COVID-19

Policy Points

• The critical task of preparedness is inseparable from the regular work of advancing population health and health equity.

     

Fifty Years of Trust Research in Health Care: A Synthetic Review

Policy Points

• First, policymakers can create conditions that will facilitate public trust in health care organizations by making creating and enforcing health policies that make exploitative behavior costly.
• Second, policymakers can bolster the trustworthiness of health care markets and organizations by using their regulatory authority to address and mitigate harm from conflicts-of-interest and regulatory capture.
• Third, policymakers and government agencies can further safeguard the public's trust by being transparent and effective about their role in the provision of health services to the public.

     

US State Policy Contexts and Population Health

Policy Points

• This Perspective connects the dots between the polarization in US states’ policy contexts and the divergence in population health across states.
• Key interlocking forces that fueled this polarization are the political investments of wealthy individuals and organizations and the nationalization of US political parties.
• Key policy priorities for the next decade include ensuring all Americans have opportunities for economic security, deterring behaviors that kill or injure hundreds of thousands of Americans each year, and protecting voting rights and democratic functioning.

     

Child Poverty and Health: The Role of Income Support Policies

Policy Points

• Child poverty is associated with both short- and long-term health and well-being, and income support policies can be used to improve child health.
• This article reviews the types of income support policies used in the United States and the evidence of the effectiveness of these policies in improving child health, highlighting areas for future research and policy considerations specific to income support policies.

     

Disease Surveillance and Achieving Synergy In Public Health Quality Improvement

Objective

To examine disease surveillance in the context of a new national framework for public health quality and to solicit input from practitioners, researchers, and other stakeholders to identify potential metrics, pivotal research questions, and actions for achieving synergy between surveillance practice and public health quality.

Introduction

National efforts to improve quality in public health are closely tied to advancing capabilities in disease surveillance. Measures of public health quality provide data to demonstrate how public health programs, services, policies, and research achieve desired health outcomes and impact population health. They also reveal opportunities for innovations and improvements. Similar quality improvement efforts in the health care system are beginning to bear fruit. There has been a need, however, for a framework for assessing public health quality that provides a standard, yet is flexible and relevant to agencies at all levels.The U.S. Health and Human Services (HHS) Office of the Assistant Secretary for Health, working with stakeholders, recently developed and released a Consensus Statement on Quality in the Public Health System that introduces a novel evaluation framework. They identified nine aims that are fundamental to public health quality improvement efforts and six cross-cutting priority areas for improvement, including population health metrics and information technology; workforce development; and evidence-based practices (1).Applying the HHS framework to surveillance expands measures for surveillance quality beyond typical variables (e.g., data quality and analytic capabilities) to desired characteristics of a quality public health system. The question becomes: How can disease surveillance help public health services to be more population centered, equitable, proactive, health-promoting, risk-reducing, vigilant, transparent, effective, and efficient—the desired features of a quality public health system?Any agency with a public health mission, or even a partial public health mission (e.g., tax-exempt hospitals), can use these measures to develop strategies that improve both the quality of the surveillance enterprise and public health systems, overall. At this time, input from stakeholders is needed to identify valid and feasible ways to measure how surveillance systems and practices advance public health quality. What exists now and where are the gaps?

Methods

Improving public health by applying quality measures to disease surveillance will require innovation and collaboration among stakeholders. This roundtable will begin a community dialogue to spark this process. The first goal will be to achieve a common focus by defining the nine quality aims identified in the HHS Consensus Statement. Attendees will draw from their experience to discuss how surveillance practice advances the public health aims and improves public health. We will also identify key research questions needed to provide evidence to inform decision-making.

Results

The roundtable will discuss how the current state of surveillance practice addresses each of the aims described in the Consensus Statement to create a snapshot of how surveillance contributes to public health quality and begin to articulate practical measures for assessing quality improvements. Sample questions to catalyze discussion include:

• —How is surveillance used to identify and address health disparities and, thereby, make public health more equitable? What are the data sources? Are there targets? How can research and evaluation help to enhance this surveillance capability and direct action?
• —How do we identify and address factors that inhibit quality improvement in surveillance? What are the gaps in knowledge, skills, systems, and resources?
• —Where can standardization play a positive role in the evaluation of quality in public health surveillance?
• —How can we leverage resources by aligning national, state, and local goals? —What are the key research questions and the quality improvement projects that can be implemented using recognized models for improvement?
• —How can syndromic surveillance, specifically, advance the priority aims?

The roundtable will conclude with a list of next steps to develop metrics that resonate with the business practices of public health at all levels.     

US State Polarization,Policymaking Power,and Population Health

Policy Points

• Explanations for the troubling trend in US life expectancy since the 1980s should be grounded in the dynamic changes in policies and political landscapes. Efforts to reverse this trend and put US life expectancy on par with other high‐income countries must address those factors.
• Of prime importance are the shifts in the balance of policymaking power in the United States, the polarization of state policy contexts, and the forces behind those changes.

The troubling trend in us life expectancy and the widening disparities in life expectancy across the United States have deep roots. This article posits that both trends are grounded in the dynamic changes in the policy and political landscapes since the 1980s. It first briefly describes the trends and the importance of excavating their structural roots. It then builds the case that changes in state policies and politics, as well as the forces behind those changes, are key explanations for both trends.     

Mixed Signals in Child and Adolescent Mental Health and Well-Being Indicators in the United States: A Call for Improvements to Population Health Monitoring

Policy Points

• Social indicators of young peoples’ conditions and circumstances, such as high school graduation, food insecurity, and smoking, are improving even as subjective indicators of mental health and well-being have been worsening. This divergence suggests policies targeting the social indicators may not have improved overall mental health and well-being.
• There are several plausible reasons for this seeming contradiction. Available data suggest the culpability of one or several common exposures poorly captured by existing social indicators.
• Resolving this disconnect requires significant investments in population-level data systems to support a more holistic, child-centric, and up-to-date understanding of young people's lives.

     

Systems Thinking as a Framework for Analyzing Commercial Determinants of Health

Policy Points:

• Worldwide, more than 70% of all deaths are attributable to noncommunicable diseases (NCDs), nearly half of which are premature and apply to individuals of working age. Although such deaths are largely preventable, effective solutions continue to elude the public health community.
• One reason is the considerable influence of the “commercial determinants of health”: NCDs are the product of a system that includes powerful corporate actors, who are often involved in public health policymaking.
• This article shows how a complex systems perspective may be used to analyze the commercial determinants of NCDs, and it explains how this can help with (1) conceptualizing the problem of NCDs and (2) developing effective policy interventions.

Context

The high burden of noncommunicable diseases (NCDs) is politically salient and eminently preventable. However, effective solutions largely continue to elude the public health community. Two pressing issues heighten this challenge: the first is the public health community's narrow approach to addressing NCDs, and the second is the involvement of corporate actors in policymaking. While NCDs are often conceptualized in terms of individual‐level risk factors, we argue that they should be reframed as products of a complex system. This article explores the value of a systems approach to understanding NCDs as an emergent property of a complex system, with a focus on commercial actors.

Methods

Drawing on Donella Meadows's systems thinking framework, this article examines how a systems perspective may be used to analyze the commercial determinants of NCDs and, specifically, how unhealthy commodity industries influence public health policy.

Findings

Unhealthy commodity industries actively design and shape the NCD policy system, intervene at different levels of the system to gain agency over policy and politics, and legitimize their presence in public health policy decisions.

Conclusions

It should be possible to apply the principles of systems thinking to other complex public health issues, not just NCDs. Such an approach should be tested and refined for other complex public health challenges.