Introduction—Knowledge Translation and Urban Health Equity: Advancing the Agenda

In 2011, an interdisciplinary symposium was organized in Toronto, Canada to investigate prevailing models of health policy change in the knowledge translation literature and to assess the applicability of these models for equity-focused urban health research. The papers resulting from the symposium have been published together, in the Journal of Urban Health, along with this introductory essay. This essay describes how the different papers grapple in different ways with how to understand and to bridge the gaps between urban health research and action. The breadth of perspectives reflected in the papers (e.g., social epidemiology, public health, political science, sociology, critical labor studies, and educational psychology) shed much light on core tensions in the relationship between KT and health equity. The first tension is whether the content of evidence or the context of decision making is the strong determinate of research impact in relation to health equity policy. The second tension is whether relationships between health equity researchers and decision makers are best viewed in terms of collaboration or of conflict. The third concerns the role that power plays in evidence-based policy making, when the issues at stake are not only empirical but also normative.     

Loops and Building Blocks: a Knowledge co-Production Framework for Equitable Urban Health

This paper sets out a structured process for the co-production of knowledge between researchers and societal partners and illustrates its application in an urban health equity project in Accra, Ghana. The main insight of this approach is that research and knowledge co-production is always partial, both in the sense of being incomplete, as well as being circumscribed by the interests of participating researchers and societal partners. A second insight is that project-bound societal engagement takes place in a broader context of public and policy debate. The approach to co-production described here is formed of three recursive processes: co-designing, co-analysing, and co-creating knowledge. These ‘co-production loops’ are themselves iterative, each representing a stage of knowledge production. Each loop is operationalized through a series of research and engagement practices, which we call building blocks. Building blocks are activities and interaction-based methods aimed at bringing together a range of participants involved in joint knowledge production. In practice, recursive iterations within loops may be limited due of constraints on time, resources, or attention. We suggest that co-production loops and building blocks are deployed flexibly.     

Peer Reviewed: Building Multisectoral Partnerships for Population Health and Health Equity

Poor performance in achieving population health goals is well-noted — approximately 10% of public health measures tracked are met. Less well-understood is how to create conditions that produce these goals. This article examines some of the factors that contribute to this poor performance, such as lack of shared responsibility for outcomes, lack of cooperation and collaboration, and limited understanding of what works. It also considers challenges to engaging stakeholders at multiple ecologic levels in building collaborative partnerships for population health. Grounded in the Institute of Medicine framework for collaborative public health action, it outlines 12 key processes for effecting change and improvement, such as analyzing information, establishing a vision and mission, using strategic and action plans, developing effective leadership, documenting progress and using feedback, and making outcomes matter. The article concludes with recommendations for strengthening collaborative partnerships for population health and health equity.     

Adopting a “Compound” Exposome Approach in Environmental Aging Biomarker Research: A Call to Action for Advancing Racial Health Equity

Background: In June 2020, the National Academies of Sciences, Engineering, and Medicine hosted a virtual workshop focused on integrating the science of aging and environmental health research. The concurrent COVID-19 pandemic and national attention on racism exposed shortcomings in the environmental research field’s conceptualization and methodological use of race, which have subsequently hindered the ability of research to address racial health disparities. By the workshop’s conclusion, the authors deduced that the utility of environmental aging biomarkers—aging biomarkers shown to be specifically influenced by environmental exposures—would be greatly diminished if these biomarkers are developed absent of considerations of broader societal factors—like structural racism—that impinge on racial health equity.Objectives: The authors reached a post-workshop consensus recommendation: To advance racial health equity, a “compound” exposome approach should be widely adopted in environmental aging biomarker research. We present this recommendation here.Discussion: The authors believe that without explicit considerations of racial health equity, people in most need of the benefits afforded by a better understanding of the relationships between exposures and aging will be the least likely to receive them because biomarkers may not encompass cumulative impacts from their unique social and environmental stressors. Employing an exposome approach that allows for more comprehensive exposure–disease pathway characterization across broad domains, including the social exposome and neighborhood factors, is the first step. Exposome-centered study designs must then be supported with efforts aimed at increasing the recruitment and retention of racially diverse study populations and researchers and further “compounded” with strategies directed at improving the use and interpretation of race throughout the publication and dissemination process. This compound exposome approach maximizes the ability of our science to identify environmental aging biomarkers that explicate racial disparities in health and best positions the environmental research community to contribute to the elimination of racial health disparities. https://doi.org/10.1289/EHP8392     

Accelerating and Strengthening Native American Health Research Through a Collaborative NIH Initiative

This paper is intended to provide an overview of the considerations that informed the development of a National Institutes of Health funding opportunity to promote health and prevent disease in Native Americans, including American Indian, Alaska Native, and Native Hawaiian communities. NIH Institute staff thoughtfully considered epidemiologic research findings and feedback from constituents regarding the need for more published research overall and stronger prevention efforts to address persistent health concerns affecting many Native communities. This led to the publication of four funding announcements supported by multiple NIH Institutes and one NIH Office. Through the efforts of researchers, tribal leaders, community collaborators, and NIH leadership and staff, a growing body of knowledge regarding culturally informed approaches to supporting health in Native Americans is emerging. This article describes how staff who developed the funding opportunities envisioned a process to support high impact science through ensuring methodological rigor, responsiveness to prevention needs, and respect for community heritage, values, and history with non-Native peoples. In addition, this article highlights the growth of the researchers and collaborators within a community of scientists expanding the knowledge base further by sharing their research resources, instruments, and strategies for engaging in scientific inquiry that meets the needs of Native communities and those of funding organizations.

     

Linking Research to Global Health Equity: The Contribution of Product Development Partnerships to Access to Medicines and Research Capacity Building

Certain product development partnerships (PDPs) recognize that to promote the reduction of global health disparities they must create access to their products and strengthen research capacity in developing countries.We evaluated the contribution of 3 PDPs—Medicines for Malaria Venture, Drugs for Neglected Diseases Initiative, and Institute for One World Health—according to Frost and Reich’s access framework. We also evaluated PDPs’ capacity building in low- and middle-income countries at the individual, institutional, and system levels.We found that these PDPs advance public health by ensuring their products’ registration, distribution, and adoption into national treatment policies in disease-endemic countries. Nonetheless, ensuring broad, equitable access for these populations—high distribution coverage; affordability, particularly for the poor; and adoption at provider and end-user levels—remains a challenge.PRODUCT DEVELOPMENT partnerships (PDPs) are not-for-profit organizations that build partnerships between the public, philanthropic, academic, and private sectors to drive the development of new products for underserved markets and thereby improve health in low- and middle-income countries (LMICs). The PDP mission differs from that of the pharmaceutical industry, whose main objective is to maximize profits for shareholders by creating interventions for lucrative markets. Key features of the PDP model are a public health objective, use of the portfolio management approach, focus on a neglected disease target, and development of technical interventions (vaccines, drugs, or diagnostics). Yet PDPs vary on several parameters, including their core choice of disease and product targets, scope or breadth of activities (basic research, clinical research, access activities, capacity building), financial model, and operations model.1The World Health Organization recognizes that PDPs can contribute to the reduction of global health disparities.2 This idea has been reiterated by high-income country governments and influential organizations such as the United States’ Institute of Medicine, which identified the PDP platform as “one of the most promising approaches” to combat health disparities between and within countries.3^(p30),4 Accordingly, high-income country aid agencies, such as the US Agency for International Development and the United Kingdom’s Department for International Development, and philanthropic organizations have increasingly supported the PDP platform.5 Of the more than 60 existing drug projects for neglected diseases, three quarters are being performed by PDPs.6Despite their capacity to generate much-needed interventions for neglected diseases, PDPs are not without their critics. It has been suggested that the paradigm perpetuates research disparities and power inequities between high-income countries and LMICs. Financial control and decision-making power within PDPs rest with first-world head offices and senior staff primarily from the United States and Europe.7 We recently contended that because the majority of PDPs’ investment in research infrastructure and personnel goes to high-income countries, their ability to promote global health equity may be impaired.8For PDPs to improve the health of LMIC populations, it has been argued that they must not only develop new products for diseases identified as a priority by these countries but also, at a minimum, help to create access to their products and make meaningful efforts to strengthen research capacity.9,10 PDPs have expertise in the conduct of clinical research, making them an appropriate vehicle for capacity building in that area. PDPs can thus promote LMICs’ ability to one day conduct their own research to develop products for neglected diseases and to improve their health systems.Some PDPs appear to have recognized this and have expanded their scope to include access and capacity building. The access strategy of the Drugs for Neglected Diseases Initiative (DNDi) aims to facilitate a consistent and affordable treatment supply of DNDi products to LMICs; this entails ensuring rapid regulatory approval, making agreements with manufacturing partners, forecasting, ensuring supply to LMICs, and updating in-country treatment guidelines. Its strategy involves eventually shifting access activities for products to in-country champions.11 The access approach of the Medicines for Malaria Venture (MMV) is similar but involves an element—expanding reach—that could extend its role further than DNDi’s. Expanding reach means working with partners to achieve availability not just at the country level but also at the clinic level (point of use) and to ensure uptake by patients. Unlike DNDi, MMV’s strategy does not discuss an endpoint of involvement.12 In 2010, DNDi and MMV spent € 2.9 million (10.6% of total expenditure) and US $4.78 million (8.6% of total expenditure) on access and delivery, respectively.13,14 The Institute for One World Health (OWH) is undertaking access activities as well, although it does not have a formal access strategy. Both MMV and DNDi are involved in building research capacity in LMICs, but OWH is not. Even so, different objectives underlie DNDi and MMV’s research capacity–strengthening efforts. MMV sees capacity building as necessary for its performance of high-quality clinical trials; DNDi aims to contribute to the development of sustainable health research systems in LMICs.12,13Although MMV, DNDi, and OWH have expanded their scope to access and capacity building, some funders and even PDP board members have questioned the appropriateness and effectiveness of PDPs’ role in these areas, suggesting that they should focus solely on product development.15,16 Because most PDP products have only recently been launched, little investigation has been conducted into PDP achievements beyond product development to indicate whether such claims have substance. So far, PDPs have been evaluated against their success in financing and developing new vaccines and drugs, with their recent product approvals highlighted.5,6 Aside from acknowledging that listing these products on the World Health Organization’s Essential Medicine List does not amount to access,17 PDPs’ contribution to product accessibility or to research capacity strengthening in LMICs has undergone limited assessment.We examined the progress MMV, DNDi, and OWH have made in creating access to 8 of their recently launched products (Coartem Dispersible, Eurartesim, Pyramax, artesunate–amodiaquine [ASAQ], and artesunate–mefloquine [ASMQ] for malaria; nifurtimox–eflornithine combination therapy [NECT] for human African trypanosomiasis [HAT]; and paromomycin and sodium stibogluconate–paromomycin combination therapy for leishmaniasis). We selected these PDPs as the focus of our assessment because they are the first PDPs to have brought products to market.18 Relying on information derived from publicly available sources, we used the access framework developed by Frost and Reich to evaluate the 8 products for availability, affordability, and adoption.9 We assessed DNDi''s and MMV''s approaches to research capacity strengthening in LMICs for individual, institutional, and system achievements. This accords with a growing consensus that research capacity building at the country level requires strategies to be directed at these 3 distinct but complementary levels.10,19 We also compared PDPs’ access activities to those of the pharmaceutical industry to determine whether the 2 types of drug development organizations’ differing missions affected their access approaches.Because we only selected drug development PDPs for analysis, our conclusions may not reflect the approaches and achievements of vaccine development PDPs. Herman and Oudin argue that public health systems in LMICs are an adequate means of vaccine distribution to target populations.16 For certain vaccine PDPs, the GAVI Alliance also provides a centralized financing mechanism. As a result, access planning processes for new vaccines are potentially less complex and may require vaccine PDPs to take on fewer activities than do drug development PDPs.     

Translating Life Course Theory to Clinical Practice to Address Health Disparities

Life Course Theory (LCT) is a framework that explains health and disease across populations and over time and in a powerful way, conceptualizes health and health disparities to guide improvements. It suggests a need to change priorities and paradigms in our healthcare delivery system. In “Rethinking Maternal and Child Health: The Life Course Model as an Organizing Framework,” Fine and Kotelchuck identify three areas of rethinking that have relevance to clinical care: (1) recognition of context and the “whole-person, whole-family, whole-community systems approach;” (2) longitudinal approach with “greater emphasis on early (“upstream”) determinants of health”; and (3) need for integration and “developing integrated, multi-sector service systems that become lifelong “pipelines” for healthy development”. This paper discusses promising clinical practice innovations in these three areas: addressing social influences on health in clinical practice, longitudinal and vertical integration of clinical services and horizontal integration with community services and resources. In addition, barriers and facilitators to implementation are reviewed.