STARFIELD II

HEALTH EQUITY SUMMIT

PRIMARY CARE’S ROLE IN ACHIEVING HEALTH EQUITY

A guidebook to the HEALTH EQUITY CURRICULAR

TOOLKIT Ofalltheformsofinequality,injusticeinhealthcareisthemostshockingandinhumane.

MartinLutherKingJr.Chicago,1966

Eachtimeamanstandsupforanideal,oractstoimprovethelotofothers,orstrikesoutagainstinjustice,hesendsforthatinyrippleofhope,andcrossingeachotherfromamilliondifferentcentersofenergyanddaring,thoseripplesbuildacurrentthatcansweepdownthemightiestwallsofoppressionandresistance.

RobertF.KennedySouthAfrica,1966

Copyright©2018BoardofRegentsoftheUniversityofWisconsinSystem

UniversityofWisconsinSchoolofMedicineandPublicHealthThisworkislicensedundertheCreativeCommonsAttribution-NonCommercial4.0InternationalLicense.

Toviewacopyofthislicense,visithttp://creativecommons.org/licenses/by-nc/4.0/

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CONTRIBUTORS JenniferEdgoose,MD,MPH(lead)HealthEquityTeam,FamilyMedicineforAmerica’sHealthParkwayLeawood,KSOfficeofCommunityHealthDepartmentofFamilyMedicineandCommunityHealthUniversityofWisconsinSchoolofMedicineandPublicHealthMadison,WISarahDavis,JD,MPA(co-lead)CenterforPatientPartnershipsUniversityofWisconsinSchoolofLawMadison,WIKarinaAtwell,MD,MPHDepartmentofFamilyMedicineandCommunityHealthUniversityofWisconsinSchoolofMedicineandPublicHealthMadison,WISonaliSangeetaBalajee,MSSonaliConsultingPortland,ORAndrewBazemore,MD,MPHRobertGrahamCenterforPolicyStudiesWashington,DCArleneS.Bierman,MD,MSCenterforEvidenceandPracticeImprovementAgencyforHealthcareResearchandQualityRockville,MD

JordanL.Brown,MS,BSDukeUniversitySchoolofMedicineDurham,NCJoedreckaBrown-Speights,MD,FAAFPDepartmentofFamilyMedicineandRuralHealthFloridaStateUniversityCollegeofMedicineTallahassee,FLBrigitM.Carter,PhD,MSN,BSNAcceleratedBachelorofScienceinNursingProgramDukeUniversitySchoolofNursingDurham,NCFrederickChen,MD,MPHDepartmentofFamilyMedicineUniversityofWashingtonSchoolofMedicineSeattle,WATiffanyLynnCovas,MD,MPHDepartmentofCommunityandFamilyMedicineDukeUniversitySchoolofMedicineDurham,NCAnneDerouin,DNP,APRN,CPNP,FAANPPediatricNursePractitioner-PrimaryCareProgramDukeUniversitySchoolofNursingDurham,NCBrianFrank,MDDepartmentofFamilyMedicineOregonHealth&ScienceUniversityPortland,OR

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LauraGottlieb,MD,MPHDepartmentofFamilyandCommunityMedicineandSocialInterventionsResearchandEvaluationNetwork(SIREN),CenterforHealthandCommunityUniversityofCaliforniaSanFrancisco,CARonyaGreen,MDMethodistFamilyMedicineResidencyProgramMethodistHealthSystemDallas,TXBrigitHatch,MD,MPHDepartmentofFamilyMedicineOregonHealth&ScienceUniversityPortland,ORCraigHostetler,MHAOregonPrimaryCareAssociationPortland,ORPatrickHuffer,MDMarquetteFamilyMedicineResidencyUPHealthSystemMarquette,MIMichaelKidd,AM,MBBS,MD,FAHMSWorldOrganizationofFamilyDoctors(WONCA)DepartmentofFamilyandCommunityMedicineUniversityofTorontoToronto,ON,Canada

KjerstiKnox,MDFamilyMedicineAuroraHealthCareUniversityofWisconsinSchoolofMedicineandPublicHealthMilwaukee,WIVivianaMartinez-Bianchi,MD,FAAFPHealthEquityTeam,FamilyMedicineforAmerica'sHealthParkwayLeawood,KSDepartmentofCommunityandFamilyMedicineDukeUniversitySchoolofMedicineDurham,NCJamesLloydMichener,MDDepartmentofCommunityandFamilyMedicineDukeUniversitySchoolofMedicineDukeUniversitySchoolofNursingDurham,NCBaileyMurph,MPHOfficeofCommunityHealthDepartmentofFamilyMedicineandCommunityHealthUniversityofWisconsinSchoolofMedicineandPublicHealthMadison,WITannerNissly,DODepartmentofFamilyMedicineandCommunityHealthUniversityofMinnesotaMinneapolis,MN

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ElizabethPaddock,MDFamilyMedicineResidencyofWesternMontanaUniversityofMontanaMissoula,MTNancyPandhi,MD,MPH,PhDDepartmentofFamilyMedicineandCommunityHealthUniversityofWisconsinSchoolofMedicineandPublicHealthMadison,WIBrianPark,MD,MPHFamilyMedicineResidencyProgramPreventiveMedicineOregonHealth&ScienceUniversityPortland,ORRobertPhillips,MD,MSPHResearchandPolicyAmericanBoardofFamilyMedicineLexington,KYBonzoReddick,MD,MPH,FAAFPDiversityandInclusionFamilyMedicineMercerUniversitySchoolofMedicineSavannah,GADeniseRodgers,MDInterprofessionalProgramsFamilyMedicineandCommunityHealthRutgersUrbanHealthandWellnessInstituteRutgersRobertWoodJohnsonMedicalSchoolNewBrunswick,NJ

MichaelRodriguez,MD,MPHDepartmentofFamilyMedicineDavidGeffenSchoolofMedicineatUCLAUCLAFieldingSchoolofPublicHealthUCLABlumCenteronPovertyandHealthinLatinAmericaLosAngeles,CASomnathSaha,MD,MPHDivisionofGeneralInternalMedicineandGeriatricsPublicHealth&PreventiveMedicineOregonHealth&ScienceUniversitySchoolofMedicineVAPortlandHealthCareSystemPortland,ORElizabethSteinerHayward,MDStateSenatorDistrict17,NWPortland/BeavertonSalem,ORWilliamSchwab,MDDepartmentofFamilyMedicineandCommunityHealthUniversityofWisconsinSchoolofMedicineandPublicHealthMadison,WIMansiShah,MDFamilyMedicineResidencyProgramDepartmentofCommunityandFamilyMedicineDukeUniversitySchoolofMedicineDurham,NCLucasStone,BSOregonHealth&ScienceSchoolofMedicineOregonHealth&ScienceUniversityPortland,OR

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JaneA.Weida,MD,MSDepartmentofFamilyMedicineCollegeofCommunityHealthSciencesUniversityofAlabamaTuscaloosa,AL

AndreaWestby,MDDepartmentofFamilyMedicineandCommunityHealthUniversityofMinnesotaMinneapolis,MNDavidWilliams,PhD,MPH(keynote)DepartmentofSocialandBehavioralSciencesHarvardSchoolofPublicHealthDepartmentofAfricanandAfricanAmericanStudiesDepartmentofSociologyHarvardUniversityCambridge,MA

Funding:Thisprojectreceivedfinancialsupportfrom FamilyMedicineforAmerica’sHealth(FMAHealth)

Acknowledgements:SpecialthankstomembersoftheHealthEquityTacticTeamofFMAHealthandtheFMAHealthBoardfortheirsteadfastsupportandguidance;totheAmericanAcademyofFamilyPhysicians(AAFP)CenterforDiversityandHealthEquityforhousingandmaintainingourtoolkitandtheAAFPNationalResearchNetworkforevaluatingit;toCFARespeciallyChristianCarmanandAshleighReevesfortheirtechnicalsupport;andLauraCruzandMattFlemingattheUniversityofWisconsinDepartmentofFamilyMedicineandCommunityHealthfortheireditorialandmediasupport.

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TABLE OF CONTENTS

CONTRIBUTORS 1INTRODUCTION 7OVERARCHING GOALS 7A CALL TO ACTION 8AUDIENCE 10LEARNING MODULES 10

CATEGORIES, FRAMING, AND ORGANIZATION 10SOCIO-ECOLOGICAL FRAMING 12SOCIAL ACCOUNTABILITY AND AN EQUITY LENS 13MODULE ORGANIZATION 14ESSENTIAL THOUGHTS ABOUT USING THE TOOLKIT 15For the facilitator 15For the learner 20DEFINITIONS 21HEALTH EQUITY RESOURCES 41 INTERPROFESSIONAL TEACHING/FACILITATION RESOURCES 45 APPENDIX A: EQUITY AND EMPOWERMENT LENS ASSESSMENT WORKSHEET 47APPENDIX B: MODULE TITLES 53

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_____________________

UseofthisGuidebook

AguidebooktotheHEALTHEQUITYCURRICULARTOOLKITbyStarfieldSummitIIHealthEquityattendees,availableatXXX,islicensedunderaCreativeCommonsAttribution-NonCommercial-ShareAlike4.0InternationalLicense.Thistoolkitexistsforthebenefitofthehealthcareandmedicaleducationcommunities.Thesematerialsareavailablefreeofchargeandcanbeusedwithoutpermission.Ifyoudecidetousethesematerials,weaskthatyoupleaseusethefollowingcitations:

CitationfortheGuidebook:

EdgooseJ,DavisS.et.al.AGuidebooktotheHealthEquityCurricularToolkit.ParkwayLeawood,KS:HealthEquityTeamforFamilyMedicineforAmerica’sHealth;2018.URL.AccessedDate.

Suggestedcitationforeachmodule:

Authorlastnamefirstinitial,et.al.ifmorethansixauthors.ModuleTitle.In:EdgooseJ.(ed)HealthEquityCurricularToolkit.ParkwayLeawood,KS:HealthEquityTeamforFamilyMedicineforAmerica’sHealth;2018.URL.AccessedDate.

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INTRODUCTION

ThisStarfieldSummit,heldinPortland,OregonfromApril22-25,2017,broughttogetheradiverseanddynamicgroupofpeoplewithinterestindecreasinghealthdisparitiesandachievinghealthequityandsocialaccountability.

Thoughtleaders,primarycarecliniciansrepresentingnumerousorganizations,publichealthexperts,educators,researchers,trainees,advocates,policyexperts,socialserviceorganizations,patients,andcommunitymemberscametogethertocreateablueprintfortheroleofhealthprofessionalschools,primarycare,andfamilymedicineinachievinghealthequity.

ThistoolkitwasinspiredbythepresentationsanddiscussionsattheSummitandisintendedtofacilitateongoingconversationstoimproveequitableoutcomeswithinourcommunities,locallyandnationally.Itsgoalistofacilitateexplorationofsomeofthemostpressingquestionsofourtimeasweconfrontpersistenthealthinequities.

Wecreatedashortvideocalled“OrientationtotheHealthEquityCurricularToolkit”thatmayalsohelpacquaintyoutothisresource:https://youtu.be/xPo3FXaYiio.

OVERARCHING GOALS

ItisoverfiftyyearssinceMartinLutherKingJr.said,“Ofalltheformsofinequality,injusticeinhealthcareisthemostshockingandinhumane”andyetwecontinuetoliveinalandofvasthealthdisparitiesoftendeterminedbytheneighborhoodandhomesweliveinorthecolorofourskin.

Healthisafundamentalhumanright.In1946,theConstitutionoftheWorldHealthOrganization(WHO)firstarticulatedtherighttoenjoythehighestattainablestandardofphysicalandmentalhealth.Thepreambledefinedhealthas“astateofcompletephysical,mentalandsocialwell-beingandnotmerelytheabsenceofdiseaseorinfirmity”and,moreover,that“theenjoymentofthehighestattainablestandardofhealthisoneofthefundamentalrightsofeveryhumanbeingwithoutdistinctionofrace,religion,politicalbelief,economicorsocialcondition.”1

1 PreambletotheConstitutionoftheWorldHealthOrganizationasadoptedbytheInternationalHealthConference,NewYork,19-22June,

1946;signedon22July1946bytherepresentativesof61States(OfficialRecordsoftheWorldHealthOrganization,no.2,p.100)andentered

intoforceon7April1948..

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Wehopethistoolkitwillspurconversationandlearningthroughacollectionofmodulesfocusingoncriticaltopicsaroundhealthdisparitiesandhealthequity.Ultimately,ourgoalistoenableusersofthistoolkittoacquireknowledge,skillsandtoolstopromoteandcollaboratetowardequitableoutcomes.Weproposeaframeworkofsocialaccountabilityandwillexplorethisindepthinourintroductorymodulewhichwillbecriticalfoundationalworkbeforepursuingallsubsequentmodules.Wealsouseaconsistentsocio-ecologicalframingandequitylenstoreinforcethevalueofthesetoolsinprofessionalpractice.

Ourgoalisnottoprovideanswersbuttostimulatediscussionandhopefullyagroup-informedcollaborationthatwillleadtoideas,morequestions,andmaybesomeanswers.WeremindyouthatAlbertEinsteinsaid,“IfIhadanhourtosolveaproblemI’dspend55minutesthinkingabouttheproblemand5minutesthinkingaboutsolutions.”

A CALL TO ACTION

History

Theresponsibilityofhealthcaretopartnerwithcommunitiesandinvestinastrongcivicinfrastructuretoimprovehealthandhealthequityhaslongbeenunderstood.Thefounderofsocialmedicine,RudolfVirchow,declaredin1849,“Forifmedicineisreallytoaccomplishitsgreattask,itmustinterveneinpoliticalandsociallife.”Familymedicinewas,infact,foundedontheunderstandingthathealthandillnessoccurlargelyoutsideoftheexamroomanditspractitionersarecalledto“acceptresponsibilityforthepatient’stotalhealthcarewithinthecontextofenvironment,includingthecommunityandthefamilyorcomparablesocialunit.”2

PresentReality

Unfortunately,duetoawidearrayoffactors,modernhealthcarehasremainedlargelyfocusedoncuringillnessforindividualpatients,ratherthanpreventingdiseasewithcommunities.Andyetthereisgrowingconsensusthatthatapproachisnotworking.TheUnitedStateshasfailedtoachievetheQuadrupleAimofimprovingpopulationhealth,enhancingpatientexperiences,reducinghealthcarecosts,andimprovingprovidersatisfaction.3Inaddition,poorhealthoutcomesinequitablyburdencommunitiesofcolor,andotherminorityandvulnerablepopulations.

2 WillardWR.Meetingthechallengeoffamilypractice:ThereportoftheAdHocCommitteeonEducationforFamilyPracticeoftheCouncilon

MedicalEducation.Chicago,IL:CouncilonMedicalEducation,AmericanMedicalAssociation;1966.

3BodenheimerT,SinskyC.Fromtripletoquadrupleaim:careofthepatientrequirescareoftheprovider.AnnFamMed.2014Nov

1;12(6):573-6.

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ACalltoAction

Inlightofthesepersistentdisparities,primarycareandpublichealthexpertshavecalledfortheneedtoaddresshuman-madesocialdeterminantsofequity—suchasracism,sexism,ageism,ableism,homo-andtrans-phobia—thatinequitablydistributepower,andthesocialandbiologicaldeterminantsofhealthalongwithsocialdeterminantsofhealth.4,5Forexample,medianhouseholdincome(awidelyrecognizedsocialdeterminantofhealththatimpactshealthoutcomesandmortality)issignificantlyinfluencedbyrace/ethnicityasasocialdeterminantofequity,withblackhouseholdsearning$0.59forevery$1.00earnedbywhitehouseholdsnationally.6

Thereisgrowingrecognitionoftheneedtoreturntothefoundationalprinciplesofsocialmedicineandfamilymedicinetomoreeffectivelyadvancehealthequity.Wemustmovebeyondhealthsystem-basedinterventionsthatmerelyaddressindividual-by-individualmedicalandsocialissuesthroughadirectservicemodelandembracemulti-sectoralcommunitypartnershipsthatcanmoreholisticallytransformcommunitiesandsociopoliticalstructures.Evidencedirectshealthcareprofessionalstomoveoutintothecommunitytoaddresstheserootcausesofhealthandinequities—andtodosoinpartnership.Examplesinclude:primarycare-publichealthintegration,resident/patient/clientengagement,communityhealthimprovementplans,multi-sectoralpartnerships.Physicians,inparticular,shouldbemindfulandstrategicintheprivilegedandthus,powerful,positiontheyhold.Theyshouldrecognizetheyneednot(andperhapsshouldnot)leadtheseeffortsbutadvocatethroughtheirmedically-orientedlensandthroughthestoriestheyhavebeenentrustedwithbytheirpatientsandcommunitiestoengagepolicy-makerstowardchange.Communities—definedgeographicallyorbyrace/ethnicity—offersignificantexpertisein,andlivedexperiencewith,health-harmingfactors.Listeningtocommunitiesbuildstrustandenhancesadvocacyefforts.Partnershipsvaluingeveryone’sexpertiseandassetshavethepotentialtonotonlyimprovehealthandreducedisparities,buttoenhancecommunitycapacityforsustainedsocialchange.7

4JonesCP,JonesCY,PerryGS,BarclayG,JonesCA..Addressingthesocialdeterminantsofchildren'shealth:acliffanalogy..JHealthCarePoor

Underserved.2009:20(4),1-12.

5GivensM,KindigD,TranInzeoP,FaustV.Power:TheMostFundamentalCauseofHealthInequity?HealthAffairswebsite..

https://www.healthaffairs.org/do/10.1377/hblog20180129.731387/full/.AccessedJuly26,2018.

6KrausMW,RuckerJM,RichesonJA.Americansmisperceiveracialeconomicequality.ProceedingsoftheNationalAcademyofSciences.

2017;114(39):10324-10331.

7 Geiger HJ, ThefirstcommunityhealthcenterinMississippi:Communitiesempoweringthemselves.AmJPublicHealth.2016;106(10):1738-

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AUDIENCE

Whilewehopethistoolkitwillfeelaccessibletoallpeopleengagedintryingtoimproveprimarycareandhealthoutcomesforall,ourtargetaudienceis:

● clinicalandpublichealthlearners● primarycarefacultywhowouldlikeanopportunitytofurtherexplorethisareathat

oftenwasnotintentionallyandadequatelyprioritizedinpastmedicalschoolandresidencycurricula.

Wehopetostretchthinkingoffacilitators,whoarelikelyeducatorsthemselves,aswellastheirlearnersandstrivetowardcreative,collaborativesolutions.

Eachmodulespecificallydescribesthe“appropriateaudience”forthatmodule.

● Alllearners:Theselearnersmayincludemedicalandotherinterprofessionalstudents(e.g.nursingandpublichealthstudents),primarycareresidents,andfacultyandfellows.

● Advancedlearners:Thesemodulesaremoreappropriateforprimarycareresidents,facultyandfellows,andpossiblymoreadvancedmedicalandotherhealthprofessionalstudentswhohavecompletedseveralotherhealthequitymodules.

● FacultyandFellows:Onemoduleisspecificallyforfacultyandfellowsandiscalled“ImprovingPatientOutcomesbyEnhancingStudentUnderstandingofSocialDeterminantsofHealthandanActionLearningApproachtoTeachingtheSocialDeterminantsofHealth.”

ThistoolkitwasoriginallyconceivedbyfamilyphysicianswhoaremembersoftheHealthEquityTeamforFamilyMedicineforAmerica’sHealthwhichiswhythistoolkitisfamilymedicine-centric.Membersofthisteam,however,recognizethatcollaboratingwithandlearningfrompeoplebeyondourdisciplineisessentialtoachievinghealthequityand,infact,havepartneredwithotherinterprofessionalcolleaguesindesigningtheStarfieldHealthEquitySummitandincreatingthistoolkit.Wehopethistoolkitwillfindabroadaudiencenotonlywithinbutalsobeyondfamilymedicine.

LEARNING MODULES CATEGORIES, FRAMING, AND ORGANIZATION

Wewillprovideaprerequisitetwo-partintroductorymodule.First,participantswillhaveanopportunitytolistentoanddiscussDr.DavidWilliam’skeynoteaddressillustratingthegravity

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oftheproblem,potentialdrivers,andinspirationalmodelsthatofferapathwaytochange.Followingthiswillbeadeepdiveintotheconceptualframeworkofsocialaccountabilityandthepotentialforapplicationofanequitylensthatisfurtherdescribedbelow.

Aftercompletingtheprerequisitemodule,youwillhaveanopportunitytoexploreavarietyoftopicsaroundhealthequity.Wehavegroupedthesecriticaltopicssothattheyfallwithinthreelargercategories:(1)SocialDeterminantsofHealthinPrimaryCare;(2)VulnerablePopulations;and(3)EconomicsandPolicy.Eachcategoryoffersavaluablelenswithwhichtoquestionandlearn.ThesecategoriesorganizedourexplorationattheStarfieldSummitandthereforethemodulesweofferhere.

SOCIALDETERMINANTSOFHEALTHINPRIMARYCAREAswestriveforhealthequity,whatsocialandeconomicfactorsmustbeaddressed?Socialdeterminantsofhealth(SDoH)arethose“conditionsintheplaceswherepeoplelive,learn,work,andplay[that]affectawiderangeofhealthrisksandoutcomes.”8Thesearenowrecognizedtobetheprimarydriversofhealthoutcomesacrossthelifespan,eclipsingbothqualityofcareandaccesstocare.Here,weexaminehowsuchexperiencesshape:

● howpeopleperceivetheirhealthandinterfacewiththehealthcaresystem;● howscreeningforSDoHcouldenhanceourunderstandingofourpatients’and

communities’health;and● howprimarycareneedstofurtherdevelopandresearchevidence-basedpracticesand

innovationstolinkhowthis“upstreamist”vantageshouldshapeboththepracticeandeducationoftheprimarycareworkforce.

VULNERABLEPOPULATIONSAsweexaminehealthdisparities,wholiesonthewrongsideoftheequation?“Vulnerabilityinvolvesseveralinterrelateddimensions:individualcapacitiesandactions;theavailabilityorlackofintimateandinstrumentalsupport;andneighborhoodandcommunityresourcesthatmayfacilitateorhinderpersonalcopingandinterpersonalrelationships.”9Suchadefinitionbringsusclosertoanunderstandingofhealthinequities:“whendisparitiesarestronglyandsystematicallyassociatedwithcertainsocialgroupcharacteristicssuchaslevelofwealthoreducation,whetheronelivesinacityorruralarea.”10Weexploredisparitiesthroughthelensofdifferentpopulationslivinginenvironmentsthatpromotevulnerabilityandaddafurtherlayerofcomplexityasweintroducethetopicof“intersectionality.”Foreaseofwritingweshall

8SocialDeterminantsofHealth.HealthyPeople.govwebsite.https://www.healthypeople.gov/2020/topics-objectives/topic/social-

determinants-of-healthAccessedSeptember18,2018.

9MechanicD,TannerJ.Vulnerablepeople,groups,andpopulations:Societalview.HealthAff(Millwood).2007;26;1220-1230.

10 WirthME,DelamonicaE,SacksE,BalkD,StoreygardA,MinujinA.MonitoringHealthEquityintheMDGs:APracticalGuide.NewYork,NY:

CIESINandUNICEF;2006.

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usetheterm“vulnerablepopulations”inthistoolkitbutwanttoexplicitlystatethatwemeanpopulationslivinginenvironmentsthatpromotevulnerability.ECONOMICSANDPOLICYAswestriveforlastingchange,whatsystemicfactorsmustchange?Combatinghealthinequitiesrequireschangesininstitutionalpowerandlegalstructures.Possiblesolutionscanbebetterunderstoodbylookingatglobaleffortsandothercreativereforms.Forexample,OntariofoundsizableinequitiesdrivenbySDoHinasettingofuniversalhealthcare.TheUnitedKingdomandNewZealandofferpotentialmodelsdemonstratingpaymentadjustmentsbasedonecologicSDoHindicators.TheAffordableCareActhasopenedthewaytoexploringSDoHaspartofitsmovetowardvalue-basedcare.CapturingcommunityvitalsigndataandpersonalSDoHdatahasenormouspotentialtobegintheprocessoflevelingtheplayingfieldforpatientsandpopulations.

SOCIO-ECOLOGICAL FRAMING

Wesuggestconsideringasocio-ecologicalmodelfornavigatingeachmoduleandofferthefollowingthatextendsfromamicrotoamacrosystemlevel:11

11SocialandBehavioralChangeCommunication(SBCC)andGender.TheHealthCommunicationCapacityCollaborative.GenderandSBCC

ImplementationKitswebsite.https://sbccimplementationkits.org/gender/sbcc-gender-models-and-frameworks/AccessedNovember19,2017.

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Wehavealsoincludedasubheaderforeachmodulenamed“RelatedModules”thatdirectsyoutomodulesyoumaywishtoexplorenext.

SOCIAL ACCOUNTABILITY AND AN EQUITY LENS

Whilethereismuchtoconsidertounderstandthecurrentlandscapeofhealthinequitiesandhowtochallengethestatusquo,wethinkitwouldbehelpfulforusersofthistoolkittohaveanunderstandingofconceptsofsocialaccountabilityearlyintheprocess.Socialaccountability—whereordinarycitizensandcivilsocietyorganizationsparticipateinexactingaccountability—isapromisingframetoassureprogresstoequitableoutcomes.Inhealthcare,socialaccountabilityprioritizesthehealthconcernsofthepeopleandcommunitiesserved,withanimplicitgoalofhealthequityand,infact,compelsanequitylens.Tofacilitateyourapplicationofmaterialsineachmoduletoyourprofessionalpractice,wewillposereflectivequestionsbasedupontheEquityandEmpowermentLens’5Ps—Purpose,People,Place,Process,Power.12Thiswillbefurtherreviewedintheprerequisitemodule.Briefly,theEquityandEmpowermentLens“isatransformativequalityimprovementtoolusedtoimproveplanning,decision-making,andresourceallocationleadingtomore...equitablepoliciesandprograms.Atitscore,itisasetofprinciples,reflectivequestions,andprocessesthatfocusesattheindividual,institutional,andsystemiclevelsby:

● deconstructingwhatisnotworkingaround[health]equity; ● reconstructingandsupportingwhatisworking; ● shiftingthewaywemakedecisionsandthinkaboutthiswork;and ● healingandtransformingourstructures,ourenvironments,andourselves.”13

Itwasdesignedwitharacialjusticefocustoachieveracialequity;weareadaptingittoapplybroadlytohealthequity,whichisinclusiveofracialjustice.TofurtherassistwithuseoftheEquityandEmpowermentLens,wehavedevelopedanEquityandEmpowermentLensAssessmentWorksheet(seeAppendixA)andasupplementalvideocalled“ApplicationoftheEquityandEmpowermentLensforFacilitatorsandLearners”https://youtu.be/1hsl6lQjXnU. 12WhatistheEquityandEmpowermentLens?MultnomahCountywebsite.https://multco.us/diversity-equity/equity-and-empowerment-

lensAccessedSeptember18,2018.

13WhatistheEquityandEmpowermentLens?Availableat:https://multco.us/diversity-equity/equity-and-empowerment-lens

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MODULE ORGANIZATION

Eachmodulecontainsthefollowingelements:

● Learningobjectives

● Briefbackground/context

● “Ignite”video(eachabout6-12minutes*)ledbyanexpertinthefieldandtheaccompanyingslides

● Aseriesofproposedquestionsforthefacilitatorforgroupdiscussion

● Aninvitationtoproposeanactionableresponsetothediscussionwithanopportunitytoapplyanequitylens

● Linkstomaterialinanannotatedbibliographyformoreindepthreadingandmoreadvanceddiscussion

● AlistofhighlevelhealthequityresourcesareincludedattheendoftheGuidebooktoconsiderwhenexploringquestionsinthemodules

● Alistofwordsandconceptsusedinthemodulethataredefinedattheendofthisguidebookattheendofthistoolkittoencouragecommonlanguageandbaseunderstandingforfacilitatorsandlearners

*Theprerequisiteintroductorymoduleisalargertwo-partmodulewithabout90minutesofvideomaterial.

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ESSENTIAL THOUGHTS ABOUT USING THE TOOLKIT

Afifteen-minutevideocalled“FacilitatingConversationsaboutInequity,Oppression,andPrivilege”wascreatedtosupportfacilitators:https://youtu.be/aE9s-sGt0js.

FOR THE FACILITATOR

Werecognizethatfewofuswillbetrueexpertsinthisfieldbutbelieveyourknowledgeofyourlearnersandyourdesiretobetterteachissuesaroundpopulationandcommunityhealthisacriticalstartingplace.

Thetoolkitismeanttoprovideyouwitheasy-toaccessresourcesandapotentialguideforteaching.Pleasefeelfreetoadaptandfurtherdevelopyourownlearningobjectivesandaspirations—thecreativecommonslicenseandacademicfreedomencourageit!

Beingabletoteachaboutcomplextopicssuchasracismandsexismisanimportantcomponenttoteachingaboutwaystomovetheconversationtowardhealthequity.Althoughoneofourmodulesbeginstoaddressthis,werecognizethatthisisaparticularlycomplicatedareathatisworthyofalongitudinalcoursetoassurewepursueajourneytowardculturalhumilityandself-reflection.Whilebeyondthescopeofthetoolkit,wewillprovideotherresourcesinourannotatedbibliography.

Belowarefacilitatorinstructionsfromthe“Toolkitforteachingaboutracisminthecontextofpersistenthealthandhealthcaredisparities”thatyoumayfindusefulbeforeteachingareasthatmaybepersonallytriggering.14

BEFORETHELEARNINGSESSION:

Takesometimetoself-reflect.

● Whatarecomments,situations,andfeelingsthattriggeryou?Howwillyouhandleitiftheycomeupduringthesessionthatyouareleading?

● Whatisyourstyleofcommunicationandinteraction?Areyouanextrovert/introvert,silent/verbalprocessor,confrontational/avoidant,orcerebral/emotive?Areyoustrictorflexiblewithagendatiming?Itisimportanttoknowyourstylesothatyoucanfacilitateintentionally.

● Whatareyouhopingtoaccomplishduringthesession?Thiswillhelpyouplaneffectiveactivitiestoaccomplishthedesiredgoal.Asessionwiththegoalofwinningbuy-inforcurriculumdevelopmentwilllookverydifferentthanattemptingtocreateamore

14AdaptedfromEdgooseJetal.Toolkitforteachingaboutracisminthecontextofpersistenthealthandhealthcaredisparities.Draft

manuscriptpendingsubmission.

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engageddiscussionabouttheimpactsofracismwithstudents.Thiswillalsohelppreventyoufromprojectingyourowngoalsontothediscussionineffectively.

● Considertheimpactofyourownidentity.Whatmightfacilitatorsfromadvantagedgroups(e.g.male,white)needtobesensitiveof?Whatmightfacilitatorsfromdisadvantagedgroups(e.g.women,PeopleofColor[POC])needtobesensitiveof?)

DURINGTHELEARNINGSESSION

GuidelinesforGroupDiscussionSettinggroundrulesexplicitlyandintentionallyatthebeginningofagroupexperiencecanbeahelpfulandaffirmingexercise.Itmaybevaluabletosharetheseguidelineswithyourgroupbyprintingthisoutforeachparticipantorhangingitonawall.Askifeveryonecanabidebytheserulesandiftheywouldofferanyadditionalonesforyourparticulargroup.

● Whatyousharewithinthecontextoftheconversationisconfidential,honored,andrespected.

● Use“I”statements—avoidspeakingforanotherorforanentiregroup.● Avoidcritiquingothers’experiences;focusonyourownexperiences.● Behonest,willingtoshare,andvulnerable.● Usethe“StepUp,StepBack”approach.Ifyoutendtobequieteringroups,challenge

yourselftoshare.Ifyoutendtoshare,makesurethereisspaceforotherstoshare.● Listenwithcuriosityandthewillingnesstolearnandchange;resistthedesireto

interrupt.● Suspendjudgment.Beopentothewisdomineachperson’sstory.● Bebraveandleanintodiscomfort.● Addressdifferencesintentionally.● Acceptnon-closure.● Reflectupontheemotionsthatyouarefeelingandwhatmightbecausingthem.

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GeneralDo’sandDon’tsofFacilitating

● Dolistenattentively ● Dobeawareofyouremotional

resilience ● Dopracticeempathy ● Doguideconversationbacktofocus ● Dorefertostoriesthatpeoplehave

shared(inalargegroupsetting) ● Dobepreparedthateveryonemay

notagreewithyourpointofview ● Doexploreemotionsinadditionto

content

● Don’ttakeanythingpersonally ● Don’tteach/preach ● Don’tcutpeopleoff ● Don’tmakeanyoneaspokesperson ● Don’tmonopolizetheconversation ● Don’tallowintolerantspeech ● Don’trescueorreassurewhite

people ● Don’tturntodisadvantagedgroups

suchaspeopleofcolorasexperts ● Don’tignoreconflict/tensi

ThingstoRememberIfThingsGetTense

● Takeadeepbreathandcheckyourpulse—remindyourself:tensionisgood,thismeanspeoplearebeinghonestandit’slikelyanopportunitytoexploresomethingsignificant

● Don’tpanic● Callthetensionoutandnameit—tryingtodiffuseitwithoutdirectlyaddressing

frequentlymakesthingsworse,causesalossoftrust/engagement,andcanbedismissive

● Takeabreakfromthecontentoftheconversationtoexploretheemotionsthatarebeingfelt

● Returntothegroupdiscussionnormstoguidetheconversationbacktoengagingratherthanattacking

● Helppeopleclarifywhattheyaresayingandthinkingwithgenuinecuriosity● Slowdowntheconversationandtakethingsstep-by-step

Themostimportantthingtorememberisthatyourbehaviorisjustasinstructiveasanycontentyouprovide.Youaremodelingthepatience,compassion,curiosity,andcouragethatyouwouldlikeyourparticipantstopractice.

● Useyourownmistakesasatransparentlearningsession.Apologizeandrecognizewhywhatyousaidordidwaspainfulorignorant.Openlydiscussthemistakeyoumadeandwhatbiasesrevealinyourownself.Modelthatit’soktomakemistakes;what’smostimportantiswhatwedoafterwards.

● Bepresent.Don’tjustplanwhatyou’regoingtosaynext.Youareallowedtothinkaftersomeonespeaks,anditmodelsthoughtfulbehaviorforotherstoemulate.

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GuidanceforGroupswithInterprofessionalLearners

Manyoftheguidelinesweofferforfacilitatorsaboveareaptlyappliedtointerprofessionalgroups.However,sincehavinggroupsmadeupofdifferentdisciplinescanaddadditionalcomplexitytowhatmightalreadybetendertopicsformanyparticipants,weofferafewadditionalthoughtsandresources.Beawareofthefollowingpotentialfacilitationchallengeswhenworkingwithinterprofessionalgroups,andconsiderthesesuggestionstoaddressthem:

FacilitationChallenges15 PotentialRemedies

Uniqueprofessionallearningrequirementsthatmayinfluenceconversations

Beinquisitive—askstudentstoexplaintheirdisciplinaryperspectiveonatopicifyouhaveahunchthisisatplay.

Generalizations/stereotypesthatstudentsmayhaveaboutdifferentprofessionals

Calltheseoutasyouwouldanystereotypes;invitestudentstoexplainwhythegeneralizationisinaccurate.

Applicabilityofcaseexamplestoallstudents

Modifycaseexamplestobemoreinclusiveofdiverseprofessions.Ideallydothisbeforetheclasssession,butifnecessarydosoonthefly.

Useofjargonbystudents Askstudentstoexplaintermstheyuse.Modelingthisbehaviorencouragesfuture/youngprofessionalstodothisinothercontexts.

AdditionalresourcesforteachinginterprofessionalgroupsareincludedattheendoftheGuidebook.

15IPEFacilitationTrainingToolkit.Section2.CommonFacilitationChallenges.Section4.Materials:FacilitationPocketGuide.CenterforHealth

SciencesInterprofessionalEducationUniversityofWashingtonwebsite.https://collaborate.uw.edu/ipe-teaching-resources/ip-curriculum-

educators/ipe-facilitation-training-toolkit/AccessedSeptember18,2018.

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AGuidetoCreatingSupplementalQuestions

Whilewewelcomeyoutouseourincludedquestions,weencourageyoutosupplementthesewithyourown.Herearesomeexamplesofthetypesofquestionsfacilitatorsmightpose:16

Interest-gettingquestions.Example:"Howdoyouthinkcolleagueswouldreactifyougotinvolvedinadvocacyeffortsregardingincreasingtheprimarycareworkforce?"

Diagnosingandcheckingquestions.Example:"HowwouldtheprinciplesofCommunityBasedParticipatoryResearch(CBPR)behelpfulinthissituation?"

Recallofspecificfactsorinformationquestions.Example:"WhatdoyouinterpretheauthorsofHealthCareAdvocacyassayingabouttheroleoflobbyinginlegislativeadvocacy?"

Structureandredirectlearningquestions.Example:"Nowthatwehavediscussedtheadvantagesof,andlimitationstoutilizingpatientanecdotesinlegislativeadvocacy,whocandothesamefortheuseofdata/evidence?"

Allowexpressionofaffectquestions.Example:"Howdidyoufeelaboutthecontroversyaroundphysicianadvocacy?"

Encouragehigherlevelthoughtprocessesquestions.Example:"Consideringwhatyouhaveread,andwhatwasdiscussedinthepoststhispastweek,canyousummarizealltheadvantagestoengagingpatientsinqualityimprovementeffortsinorganizations?"

16DavisS.Advocatingforpopulations:Partneringtoimprovecommunityhealth.DiscussionForumFacilitatorsGuide.2014.CenterforPatient

Partnerships.Madison,WI.Onfilewiththeauthor.

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FOR THE LEARNER

Youractiveparticipationiscritical.Sharingofyourexperienceswillbeasimportantasconveyingyourunderstanding.Asthistopicisoftenliterallyadiscussionaboutthe“haves”and“have-nots”itwilloftenbeacomplexdiscussionofpowerandprivilege.Ifyoutendtobeaquietparticipant,weencourageyoutoexerciseyourvoice.Ifyoutendtobeavocalparticipant,pauseandthinkhowyourcontributionscanhelpenableotherstocontributeorperhapssimplylistentothethoughtsofothers.

Exploringthequestionsposedinmanyofthemoduleswillinvariablybemostfruitfulwhenconsideredcollectivelyandnotindividually.Ifyoufindthatyoudonotunderstandoragreewithanotherparticipant,getcuriousandaskthemtoexplainwhy.Bevulnerableandhumble—sharethatyouwouldwelcomeadditionalinformationtoguideyourlearning.

Doyoufindthatyoutalkmorewhenyouareuncomfortable?Considerthesetips:Resisttheurgeandleanintolistening.Writedownyourthoughtsinsteadofsayingthemoutloud.

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DEFINITIONS

Asset-BasedCommunityDevelopment:Asset-basedcommunitydevelopmentmethodologyisusedtopromotethesustainabledevelopmentofcommunitiesbasedontheirstrengthsandpotentials.Theassessmenttoolisusedtoassesstheresources,skillsandexperienceavailablewithinagivencommunity.Theassessmentinformationisusedtoorganizethecommunity,andbuildsontheskillsofthelocalresidents,thepoweroflocalassociations,andthesupportivefunctionsoflocalinstitutions.AsylumSeeker:Seerefugee.Community:Agroupofpeoplewhohavecommoncharacteristics;communitiescanbedefinedbylocation,race,ethnicity,age,occupation,interestinparticularproblemsoroutcomes,orothercommonbonds.Individualswithasharedaffinity,andperhapsgeography,whoorganizearoundanissue,withcollectivediscussion,decisionmaking,andaction.

● TurnockBJ.PublicHealth:WhatitIsandHowItWorks.,MA:JonesandBartlettLearning,LLC;2016.

● LabonteR.Healthpromotion:Fromconceptstostrategies.HealthcManageForum.1988;1(3):24-30.

CommunityandEducationBasedFramework:Communityandeducationbasedframeworksembracenewwaysoflearningandpreparefacultythroughcommunityandcollaborativepartnerships.Fitzgeraldetal(2012)describethisframeworkas:Embracingengagementasanaspectoflearninganddiscoverythatenhancessocietyandhighereducation.Communityengagementisanunderstandingthatnotallknowledgeandexpertiseresidesintheacademyandthatbothexpertiseandgreatlearningopportunitiesinteachingandscholarshipalsoresideinnonacademicsettings.

● FitzgeraldH,BrunsK,SonkaS,FurcoA,SwansonL.Thecentralityofengagementinhighereducation.JHighEducOutreachEngagem.2012;16(3):7-27.

CommunityAssessment:ThePublicHealthAccreditationboarddefinescommunityhealthassessmentasasystematicexaminationofthehealthstatusindicatorsforagivenpopulationusedtoidentifykeyproblemsandassetsinacommunity.

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CommunityDriven:Communitydriven,asdefinedbytheWorldBankGroup,givesthecontrolofdecisionsandresourcestocommunitygroups.Thecommunityistreatedasassetsandpartnersinthedevelopmentprocess,buildingontheirinstitutionsandresources.CommunityEngagement:Theprocessofworkingcollaborativelywithandthroughgroupsofpeopleaffiliatedbygeographicproximity,specialinterest,orsimilarsituationstoaddressissuesaffectingthewell-beingofthosepeople.Ingeneral,goalsofcommunityengagementaretobuildtrust,enlistnewresourcesandallies,createbettercommunication,andimproveoverallhealthoutcomesassuccessfulprojectsevolveintolastingcollaborations.

● PrinciplesofCommunityEngagement.2nded.CentersforDiseaseControlandPrevention(CDC).https://www.atsdr.cdc.gov/communityengagement/pdf/PCE_Report_508_FINAL.pdf.AccessedonSeptember15,2018.

CommunityHealth:Aperspectiveonpublichealththatassumescommunitytobeanessentialdeterminantofhealthandtheindispensableingredientforeffectivepublichealthpractice.Ittakesintoaccountthetangibleandintangiblecharacteristicsofthecommunity–itsformalandinformalnetworksandsupportsystems,itsnormsandculturalnuances,anditsinstitutions,politics,andbeliefsystems.

● KindigDA.Understandingpopulationhealthterminology.MilbankQ2007;85(1):139-161.

CommunityHealthCenter(CHC):-AlsoknownasFederallyQualifiedHealthCenter(FQHC);aprimarycareclinicwithamissiontoservelow-incomeandunderservedcommunities.

● WallaceSP,YoungM,RodríguezMA,etal.Communityhealthcentersplayacriticalroleincaringfortheremaininguninsuredintheaffordablecareactera.https://blumcenter.ucla.edu/files/view/policydocs/FQHC_PB-oct2016.pdf.PolicyBriefUCLACentHealthPolicyRes.PublishedOctober2016.(PB2016-7):1-8.AccessedJune9,2018.

CommunityVitalSigns:Incorporatinggeocodedsocialdeterminantsintoelectronicrecordstopromotepatientandpopulationhealth.JAmMedInformAssoc.2016Mar;23(2):407-412.CommunityHealthImprovementPlan(HIP):Along-term,systematicefforttoaddresshealthproblemsonthebasisoftheresultsofassessmentactivitiesandthecommunityhealthimprovementprocess.Thisplanisusedbyhealthandothergovernmentaleducationandhumanserviceagencies,incollaborationwithcommunitypartners,tosetprioritiesand

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coordinateandtargetresources.AHIPiscriticalfordevelopingpoliciesanddefiningactionstotargeteffortsthatpromotehealth.Itshoulddefinethevisionforthehealthofthecommunityinclusivelyandshouldbedoneinatimelyway.Thisdefinitionofcommunityhealthimprovementplanalsoreferstoatribal,stateorterritorialcommunityhealthimprovementplan.

● CommunityHealthAssessments&HealthImprovementPlans.CenterforDiseaseControlandPrevention.https://www.cdc.gov/stltpublichealth/cha/plan.html.AccessedSeptember27,2018.

CommunityHealthNeedsAssessment:Aprocessthatusesquantitativeandqualitativemethodstosystematicallycollectandanalyzedatatounderstandhealthwithinaspecificcommunity.Anidealassessmentincludesinformationonriskfactors,qualityoflife,mortality,morbidity,communityassets,forcesofchange,socialdeterminantsofhealthandhealthinequity,andinformationonhowwellthepublichealthsystemprovidesessentialservices.Communityhealthassessmentdataareintendedtoinformcommunitydecisionmaking,theprioritizationofhealthproblems,andthedevelopment,implementation,andevaluationofcommunityhealthimprovementplans.

● DefinitionsofCommunityHealthAssessments(CHA)andCommunityHealthImprovementPlans(CHIPs).NationalAssociationofCityandCountyHealthOfficials(NACCHO).http://archived.naccho.org/topics/infrastructure/community-health-assessment-and-improvement-planning/upload/Definitions.pdf.AccessedonJune9,2018.

CommunityHealthNeedsAssessment(CHNA)–InternalRevenueService(IRS):ACHNAisrequiredundertheIRSCodebythePatientProtectionandAffordableCareAct(ACA).TheIRSrequireshospitalorganizationstodocumentcompliancewithCHNArequirementsforeachoftheirfacilitiesinawrittenreportthatincludes:

− Adescriptionofthecommunityserved − Adescriptionoftheprocessandmethodsusedtoconducttheassessment − Adescriptionofmethodsusedtoincludeinputfrompeoplerepresentingthebroad

interestsofthecommunityserved − AprioritizeddescriptionofallcommunityhealthneedsidentifiedintheCHNA,aswellas

adescriptionoftheprocessandcriteriausedinprioritizingsuchneeds − Adescriptionofexistinghealthcarefacilitiesandotherresourcesinthecommunity

availabletomeettheneedsidentifiedintheCHNA.https://www.irs.gov/pub/irs-drop/n-11-52.pdf

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CommunityHealthWorker(CHW):Afrontlinepublichealthworkerwhoisatrustedmemberofand/orhasanunusuallycloseunderstandingofthecommunityserved.ThistrustingrelationshipenablestheCHWtoserveasaliaison/link/intermediarybetweenhealth/socialservicesandthecommunitytofacilitateaccesstoservicesandimprovethequalityandculturalcompetenceofservicedelivery. ACHWalsobuildsindividualandcommunitycapacitybyincreasinghealthknowledgeandself-sufficiencythrougharangeofactivitiessuchasoutreach,communityeducation,informalcounseling,socialsupport,andadvocacy.

● CommunityHealthWorkers.AmericanPublicHealthAssociation.https://www.apha.org/apha-communities/member-sections/community-health-workers.AccessedSeptember27,2018.

CulturalCompetence:Theintegrationandtransformationofknowledgeaboutindividualsandgroupsofpeopleintospecificstandards,policies,practices,andattitudesusedinappropriateculturalsettingstoincreasethequalityofservices;therebyproducingbetteroutcomes.

● DavisK.ExploringtheIntersectionBetweenCulturalCompetencyandManagedBehavioralHealthCarePolicy:ImplicationsforStateandCountyMentalHealthAgencies.Alexandria,VA:NationalTechnicalAssistanceCenterforStateMentalHealthPlanning;1997.

DeprivationIndex:Usesdatarepresentingaspectsofmaterialandsocialdeprivationfromcensusesorfromadministrativedatasets.Suchindicesaredesignedtomeasuresocioeconomicvariationacrosscommunities,assesscommunityneeds,informresearch,adjustclinicalfunding,allocatecommunityresources,anddeterminepolicyimpact.

● PhillipsRL,LiawW,CramptonP,etal.HowOtherCountriesUseDeprivationIndices—AndWhytheUnitedStatesDesperatelyNeedsOne.HealthAff.2016;35(11):1991-1998.

DevelopmentalDisabilities:Agroupofconditionsduetoanimpairmentinphysical,learning,language,orbehaviorareas.Theseconditionsbeginduringthedevelopmentalperiod,mayimpactday-to-dayfunctioning,andusuallylastthroughoutaperson’slifetime.(CDC)Disability:Aphysicalormentalimpairmentthatsubstantiallylimitsoneormoremajorlifeactivity(referstolifelongoracquiredconditions).

● AmericanswithDisabilitiesActof1990,Asamended.https://www.ada.gov/pubs/adastatute08.htm#12102.AccessedSeptember15,2018.

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DownstreamDeterminantsofPublicHealth(Downstream):Maybeseenastheoutcomesofupstreamfactorsandvariables.Insomerespects,downstreamdeterminantsaremoreeasilymitigatedorpreventedbytheindividual,suchasachangeineatinghabitsorreducingriskofinjuryonthejob.Electronichealthrecord(EHR):Asystematizedcollectionofpatienthealthinformationthatisstoredelectronically.EquityLens:Atransformativequalityimprovementtoolusedtoimproveplanning,decision-making,andresourceallocationleadingtomoreequitablepoliciesandprograms.GeocodedData:Theprocessofjoiningafactordatapointtogetherwithadescriptionofitslocation—suchasapairofcoordinates,anaddress,oranameofaplace—suchthatitcanbelocalizedtoasinglepointorgeographicallydefinedarea(e.g.censusblock,zipcode,county,state)ontheearth'ssurface,allowingittobeusedformappingorspatialanalysis.GlobalHealth:Healthproblems,issues,andconcernsthattranscendnationalboundaries,maybeinfluencedbyencountersorexperiencesinothercountries,andarebestaddressedbycooperativeeffortsandsolutions.

● StarfieldB.Globalhealth,equity,andprimarycare.JAmBoardFamMed.2007;20(6):511-513.

Health:Astateofcompletephysical,mental,andsocialwell-beingandnotjusttheabsenceofsicknessorfrailty(CDC).

● PreambletotheConstitutionoftheWorldHealthOrganizationasadoptedbytheInternationalHealthConference,N.Y.,19-22June1946;signedon22July1946bytherepresentativesof61States(OfficialRecordsoftheWorldHealthOrganization,no.2,p.100)andenteredintoforceon7April1948.

HealthDisparities:Apreventableexcessmorbidityandmortalitythatimpactsagroupofpeople.Itis“aparticulartypeofhealthdifferencethatiscloselylinkedwithsocial,economic,and/orenvironmentaldisadvantage.Healthdisparitiesadverselyaffectgroupsofpeoplewhohavesystematicallyexperiencedgreaterobstaclestohealthbasedontheirracialorethnicgroup;religion;socioeconomicstatus;gender;age;mentalhealth;cognitive,sensory,orphysicaldisability;sexualorientationorgenderidentity;geographiclocation;orothercharacteristicshistoricallylinkedtodiscriminationorexclusion.”

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● NationalPartnershipforActiontoEndHealthDisparities.U.S.DepartmentofHealthandHumanServiceswebsite.http://www.minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1&lvlid=34.AccessedonJune9,2018.

HealthCareDisparities:“racialorethnicdifferencesinthequalityofhealthcarethatarenotduetoaccess-relatedfactorsorclinicalneeds,preferences,andappropriatenessofintervention.”

● Smedley,BD,StithAY,NelsonAR,eds.UnequalTreatment:ConfrontingRacialandEthnicDisparitiesinHealthCare.InstituteofMedicine.CommitteeonUnderstandingandEliminatingRacialandEthnicDisparitiesinHealthCare,BoardonHealthPolicy,InstituteofMedicine.Washington,DC:NationalAcademyPress;2003.

HealthDisparityPopulations:Asignificantdisparityintheoverallrateofdiseaseincidence,prevalence,morbidity,mortalityorsurvivalratesinthepopulationascomparedtothehealthstatusofthegeneralpopulation(NationalInstituteonMinorityHealthandHealthDisparities)

HealthEquity:Theabsenceofsystematicdisparitiesinhealth(orinthemajorsocialdeterminantsofhealth)betweengroupswithdifferentlevelsofunderlyingsocialadvantage/disadvantage—thatiswealth,power,orprestige.Equityisanethicalprinciple;italsoisconsonantwithandcloselyrelatedtohumanrightsprinciples.

● BravemanP,GruskinS.Definingequityinhealth.JournalofEpidemiolCommunityHealth.2003;57:254-258.

Health/PatientExperiences:“encompassestherangeofinteractionsthatpatientshavewiththehealthcaresystem,includingtheircarefromhealthplans,andfromdoctors,nurses,andstaffinhospitals,physicianpractices,andotherhealthcarefacilities.Asanintegralcomponentofhealthcarequality,patientexperienceincludesseveralaspectsofhealthcaredeliverythatpatientsvaluehighlywhentheyseekandreceivecare,suchasgettingtimelyappointments,easyaccesstoinformation,andgoodcommunicationwithhealthcareproviders.Understandingpatientexperienceisakeystepinmovingtowardpatient-centeredcare.Bylookingatvariousaspectsofpatientexperience,onecanassesstheextenttowhichpatientsarereceivingcarethatisrespectfulofandresponsivetoindividualpatientpreferences,needsandvalues.Evaluatingpatientexperiencealongwithothercomponentssuchaseffectivenessandsafetyofcareisessentialtoprovidingacompletepictureofhealthcarequality.”

● WhatIsPatientExperience?AgencyforHealthcareResearchandQualitywebsite..http://www.ahrq.gov/cahps/about-cahps/patient-experience/index.html.AccessedJune9,2018.

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“patient[s]tell[ing]thestoryofwhathashappenedtothemintheirownway,focusingontheissuesthatareimportanttothem.”

● ZieblandS,CoulterA,CalabreseJ,LocockL,eds.UnderstandingandUsingHealthExperiences.ImprovingPatientCare.Oxford,UK:OxfordUniversityPress;2013.

HealthExperiencesResearch:Researchthataimstofindoutwhatisimportanttoparticipants,includingwhatmeaningstheyattachtohealthandillnessandhowtheybehaveasaresult.Itshedslightonhowpeopleunderstand,explainandadapttotheirchanginghealth.

● DefinitionadaptedfromZieblandS,CoulterA,CalabreseJ,LocockL,eds.UnderstandingandUsingHealthExperiences.ImprovingPatientCare.Zieblandetal(Eds).Oxford,UK:OxfordUniversityPress;2013.

HealthInequality:Differences,variations,anddisparitiesinthehealthachievementsofindividualsandgroupsofpeople.

● KawachiI.Aglossaryforhealthinequalities.JEpidemiolandCommunityHealth.2002;56(9):647.

HealthInequity:Adifferenceordisparityinhealthoutcomesthatissystematic,avoidable,andunjust.

● BravemanPA.Monitoringequityinhealthandhealthcare:Aconceptualframework.JHealthPopulNutr.2003;21(3):181.

● Whitehead,M.Theconceptsandprinciplesofequityandhealth.HealthPromotInt.1991.6(3):217.

HealthProfessionalShortageAreas(HPSAs):Designationsthatindicatehealthcareprovidershortagesinprimarycare,dentalhealth,ormentalhealth.Shortagesmaybegeographic-,population-(e.g.,lowincome,migrantfarmworkers),orfacility-based(e.g.,correctionalfacility,mentalhealthfacility,Indianhealthfacility).

● HealthProfessionalShortageAreas(HPSAs).HealthResourcesandServicesAdministrationwebsite.https://bhw.hrsa.gov/shortage-designation/hpsas.AccessedJune9,2018.

Hispanic:TheU.S.OfficeofManagementandBudget(OMB)requiresfederalagenciestouseaminimumoftwoethnicitiesincollectingandreportingdata:HispanicorLatinoandNotHispanicorLatino.OMBdefines"HispanicorLatino"asapersonofCuban,Mexican,PuertoRican,SouthorCentralAmerican,orotherSpanishcultureororiginregardlessofrace.(seeLatino/Latina/Latinx)

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● HispanicOrigin.UnitedStatesCensusBureauwebsite.https://www.census.gov/topics/population/hispanic-origin/about.html.AccessedMay12,2018.

Immigrant:Anyforeignnationalwhoentersacountryforpurposesofpermanentresettlement.

● MartinezO,WuE,SandfortT,et.al.Evaluatingtheimpactofimmigrationpoliciesonhealthstatusamongundocumentedimmigrants:Asystematicreview.JImmigrMinorHealth.2015Jun;17(3):947-70.

ImplicitBias:seeunconsciousbias.IndividualLevelSocialDeterminants:Socialdeterminantsthatpresentasbarrierstostudentsuccesswhichcanincludebutarenotlimitedtoinadequatefinancialsupport,lackofemotionalandmoralsupport,asenseofisolationandloneliness,discrimination,lackofadvisingandacademicsuccess,lackofmentorsandrolemodels,littlesenseofprofessionalsocialization,limitedcomputeraccessandtechnologycompetencyanddeficiencyofculturalcompetence.IntellectualDisabilities:Disabilitiescharacterizedbysignificantlimitationsbothinintellectualfunctioning(reasoning,learning,problemsolving)andinadaptivebehavior,whichcoversarangeofeverydaysocialandpracticalskills.Thesedisabilitiesoriginatebeforetheageof18.

● AmericanAssociationonIntellectualandDevelopmentalDisabilities(AAIDD).http://aaidd.org/intellectual-disability/definition.AccessedSeptember15,2018.

Intersectionality:Aframeworkthatconsidersdifferentsourcesofsocialinequality(e.g.,race,gender,socialclass)collectively,ratherthaninisolation,asdeterminantsthatshapethedegreeofadvantageordisadvantageexperiencedbyagivenperson,community,orpopulation.Latino/Latina/Latinx:While“Latino”and“Hispanic”aretwotermssometimesusedinterchangeably,"Hispanic"isanarrowertermthatonlyreferstopersonsofSpanish-speakingoriginorancestry,while"Latino"ismorefrequentlyusedtorefergenerallytoanyoneofLatinAmericanoriginorancestry,includingBrazilians.TheUnitedStatesCensusBureau,however,uses“Hispanic”and“Latino”interchangeably.“Latino”referstechnicallytomalesand“Latina”tofemalesso“Latinx”(firstusedin2004)hasbeengrowinginpopularityasthegenderneutraltermoftenusedinlieuofLatinoorLatina(referencingLatinAmericanculturalorracialidentity)

● HispanicOrigin.UnitedStatesCensusBureauwebsite.https://www.census.gov/topics/population/hispanic-origin/about.html.AccessedMay12,2018.

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● Hispanic-Latinonamingdispute.Wikipediawebsite.https://en.wikipedia.org/wiki/Hispanic%E2%80%93Latino_naming_dispute.AccessedMay12,2018.

● Latinx.Wikipediawebsite.https://en.wikipedia.org/wiki/Latinx.AccessedMay12,2018. LearningHealthcareSystem:Asysteminwhich,“science,informatics,incentives,andculturearealignedforcontinuousimprovementandinnovation,withbestpracticesseamlesslyembeddedinthedeliveryprocessandnewknowledgecapturedasanintegralby-productofthedeliveryexperience.”

● InstituteofMedicine(IOM).2007.TheLearningHealthcareSystem:WorkshopSummary.Washington,DC:TheNationalAcademiesPress.

MedicallyUnderservedPopulations:Specificsub-groupsofpeoplelivinginadefinedgeographicareawithashortageofprimarycarehealthservices.Thesegroupsmayfaceeconomic,cultural,orlinguisticbarrierstohealthcare.

● MedicallyUnderservedAreasandPopulations(MUA/Ps).HealthResourcesandServicesAdministrationwebsite.https://bhw.hrsa.gov/shortage-designation/muap.AccessedSeptember26,2018.

Microaggressions:Brief,everydayexchangesthatsenddenigratingmessagestocertainindividualsbecauseoftheirgroupmembership.

● SueDW,CapodilupoC,TorinoGC,etal.Racialmicroaggressionsineverydaylife:Implicationsforclinicalpractice.AmPsychol.2007;62(4):271-286.

Minority:“Anygroupofpeoplewho,becauseoftheirphysicalorculturalcharacteristics,aresingledoutfromtheothersinthesocietyinwhichtheylivefordifferentialandunequaltreatment,andwhothereforeregardthemselvesasobjectsofcollectivediscrimination.”

● WirthL.Theproblemsofminoritygroups.InTheScienceofManinTheWorldCrisis.RalphLinton,ed.NewYork:ColumbiaUniversityPress.

Oppression:Thesystemicandpervasivenatureofsocialinequalitywoventhroughoutsocialinstitutionsaswellasembeddedwithinindividualconsciousness.Oppressionfusesinstitutionalandsystemicdiscrimination,personalbias,bigotryandsocialprejudiceinacomplexwebofrelationshipsandstructuresthatsaturatemostaspectsoflifeinoursociety.

● AdamsM,BellLA,GriffinP,eds.TeachingforDiversityandSocialJustice:ASourcebook.NewYork,NY:Routledge;2016.

PatientandFamilyEngagement:Patients,families,theirrepresentatives,andhealthprofessionalsworkinginactivepartnershipatvariouslevelsacrossthehealthcaresystem—

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directcare,organizationaldesignandgovernance,andpolicymakingtoimprovehealthandhealthcare

● CarmanKristinL,DardessP,MaurerM,etal.Patientandfamilyengagement:Aframeworkforunderstandingtheelementsanddevelopinginterventionsandpolicies.HealthAffairs.2013;32(2)223-31.https://www.healthaffairs.org/doi/10.1377/hlthaff.2012.1133.AccessedSeptember26,2018.

● PCORIdefinesEngagementinResearchas“themeaningfulinvolvementofpatients,caregivers,clinicians,andotherhealthcarestakeholdersthroughouttheresearchprocess—fromtopicselectionthroughdesignandconductofresearchtodisseminationofresults.”PCORI“believe[s]thatsuchengagementcaninfluenceresearchtobemorepatientcentered,useful,andtrustworthyandultimatelyleadtogreateruseanduptakeofresearchresultsbythepatientandbroaderhealthcarecommunity.”

● WhatWeMeanbyEngagement.Patient-CenteredOutcomesResearchwebsite.https://www.pcori.org/engagement/what-we-mean-engagement.AccessedJune9,2018.

Patient/HealthExperiences:seeHealth/PatientExperiences.Patient-Centered:Providingcarethatisrespectfulof,andresponsiveto,individualpatientpreferences,needsandvalues,andensuringthatpatientvaluesguideallclinicaldecisions.

● InstituteofMedicine.CrossingtheQualityChasm:ANewHealthSystemforthe21stCentury.Washington,DC:NationalAcademyPress;2001.

Patient-CenteredOutcomes/PatientReportedOutcomes(PROs):PROsaredefinedbytheFood&DrugAdministration(FDA)andNationalQualityForum(NQF)as“…areportthatcomesdirectlyfromthepatient(i.e.,studysubject)aboutthestatusofapatient’shealthconditionwithoutamendmentorinterpretationofthepatient’sresponsebyaclinicianoranyoneelse.”‘Outcome’inreflectsavarietyofinformationreporteddirectlybythepatient,includinghealth-relatedqualityoflife,functionalstatus,symptoms,andtreatmentadherence.PROsaredistinctfromotherpatientoutcomessuchasphysiologicalmeasures(e.g.,hemoglobinA1c),clinician-reportedmeasures(e.g.,globalimpressions),andcaregiver-reportedmeasures.Patient-centeredoutcomesresearch(PCOR)stressestheimportanceofresearch“informedbytheperspectives,interestsandvaluesofpatients”throughouttheresearchprocess,therebyincorporatingPROs.

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● SnyderCF,JensenRE,SegalJB,WuAW.Patient-reportedoutcomes(PROs):Puttingthepatientperspectiveinpatient-centeredoutcomesresearch.MedCare.2013;51(8Suppl3):S73-S79.(CitingFDA,NQF,andPCORI)

PatientNavigator:apersonwhoprovidesindividualizedassistancetohelpapatientovercomehealthcaresystembarriersandfacilitatetimelyaccesstoqualitymedicalandpsychosocialcare.

● Natale-PereiraA,EnardK,NevarezL,JonesL.Theroleofpatientnavigatorsineliminatinghealthdisparities.Cancer.2011;117(15Suppl):3543-3552.

Place-basedInitiative:Establishinginclusiveparticipatorycommunity-basedstrategyasthebasisforaction,planningandimplementation.

● Dankwa-MullanI,Perez-StableE.Addressinghealthdisparitiesisaplace-basedissue.AmJofPublicHealth.2016;106(4):637-639.

PopulationHealth:

1. Aconceptualframeworkforthinkingaboutwhysomepopulationsarehealthierthanothers,aswellasthepolicydevelopment,researchagenda,andresourceallocationthatflowfromit.

2. Thehealthoutcomesofagroupofindividuals,includingthedistributionofsuchoutcomeswithinthegroup.

3. Thehealthofapopulationasmeasuredbyhealthstatusindicatorsandasinfluencedbysocial,economic,andphysicalenvironments;personalhealthpractices;individualcapacityandcopingskills;humanbiology;earlychildhooddevelopment;andhealthservices.

● KindigDA.Understandingpopulationhealthterminology.MilbankQ2007;85(1):139-161.

Poverty:- AbsolutePoverty:Aconditioncharacterizedbyseveredeprivationofbasichuman

needs,includingfood,safedrinkingwater,sanitationfacilities,health,shelter,educationandinformation.Itdependsnotonlyonincomebutalsoonaccesstoservices.

- RelativePoverty:One’sstatuswithregardtotheeconomicconditionofothermembersofthesociety:peoplearepooriftheyfallbelowprevailingstandardsoflivinginagivensocietalcontext.

- IncomePoverty:aformofrelativepoverty;whenanindividual’sorfamily'sincomefailstomeetafederallyestablishedthresholdthatdiffersacrosscountries.

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- ExtremePoverty:Individual/familyincomelessthantheinternationalstandardof$1/day.

○ Poverty.Paris:UnitedNationsEducational,ScientificandCulturalOrganizationwebsite.http://www.unesco.org/new/en/social-and-human-sciences/themes/international-migration/glossary/poverty/.AccessedJune9,2018.

Power:Insocialscienceandpolitics,poweristheabilitytoinfluenceoroutrightcontrolthebehaviorofpeople.Theterm“authority”isoftenusedforpowerperceivedaslegitimatebythesocialstructure.Powercanbeseenasevilorunjust,buttheexerciseofpowerisacceptedasendemictohumansassocialbeings.Adiscussionofattendingtopowerasadeterminantisemerginginhealthequityscholarship.Seealso“Resources”and“StructuralInequality.”

● LuthansF,LuthansBC,LuthansKW.OrganizationalBehavior:AnEvidenceBasedApproach,13thEd.2015.

● GivensM,KindigD,TranInzeo,P,FaustV.Power:Themostfundamentalcauseofhealthinequity?HealthAffairsBlog.https://www.healthaffairs.org/do/10.1377/hblog20180129.731387/full/.AccessedMay15,2018.

PrimaryCare:Primarycareisfirst-contact,continuous,comprehensive,andcoordinatedcareprovidedtopopulationsundifferentiatedbygender,disease,ororgansystem.

● StarfieldB.Isprimarycareessential?Lancet.1994;344(8930):1129-1133.Privilege:Privilegeoperatesonpersonal,interpersonal,cultural,andinstitutionallevelsandgivesadvantages,favors,andbenefitstomembersofdominantgroupsattheexpenseofmembersoftargetgroups.IntheUnitedStates,privilegeisgrantedtopeoplewhohavemembershipinoneormoreofthesesocialidentitygroups:

● Whitepeople;● Able-bodiedpeople;● Heterosexuals;● Males;

● Christians;● Middleorowningclasspeople;● Middle-agedpeople;● English-speakingpeople.

Privilegeischaracteristicallyinvisibletopeoplewhohaveit.Peopleindominantgroupsoftenbelievethattheyhaveearnedtheprivilegesthattheyenjoyorthateveryonecouldhaveaccesstotheseprivilegesifonlytheyworkedtoearnthem.Infact,privilegesareunearnedandtheyaregrantedtopeopleinthedominantgroupswhethertheywantthoseprivilegesornotandregardlessoftheirstatedintent.

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Unliketargetsofoppression,peopleindominantgroupsarefrequentlyunawarethattheyaremembersofthedominantgroupduetotheprivilegeofbeingabletoseethemselvesaspersonsratherthanstereotypes.

● MorrisonM.Seminarpresented:DoingOurOwnWork:ASeminarforAnti-RacistWhiteWomen;2003;LeavenCenter;Lyons,MI.

PublicHealth:

1. Activitiesthatasocietyundertakestoassuretheconditionsinwhichpeoplecanbehealthy.Theseincludeorganizedcommunityeffortstoprevent,identify,andcounterthreatstothehealthofthepublic.

○ KindigDA.Understandingpopulationhealthterminology.MilbankQ2007;85(1):139-161.

2. Whatweasasocietydocollectivelytoassuretheconditionsinwhichpeoplecanbehealthy.

○ InstituteofMedicine.TheFutureofPublicHealth.Washington,DC:NationalAcademyPress;1998.

3. Thescienceandartofpreventingdisease,prolonginglifeandpromotinghealththroughtheorganizedeffortsandinformedchoicesofsociety,organizations,publicandprivate,communitiesandindividuals.

○ WinslowCEA.Theuntilledfieldsofpublichealth.Science.1920;2:183–91.QualityImprovement:“thecombinedandunceasingeffortsofeveryone—healthcareprofessionals,patientsandtheirfamilies,researchers,payers,plannersandeducators—tomakethechangesthatwillleadtobetterpatientoutcomes(health),bettersystemperformance(care)andbetterprofessionaldevelopment.”Alsoreferredtoas“ContinuousImprovement.”

● BataldenPB,DavidoffF.Whatis“qualityimprovement”andhowcanittransformhealthcare?Quality&SafetyinHealthCare.2007;16(1):2-3.

● SeealsoLearningHealthcareSystemQualityImprovement:Theattainmentorprocessofattaininganewlevelofperformanceorquality.

● QualityimprovementMeSHdescriptordata2018.U.S.NationalLibraryofMedicinewebpage..https://meshb.nlm.nih.gov/record/ui?ui=D058996.AccessedAugust29,2018.

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Race:Asocialconstructcreatedtodividepeopleinordertopreventthemajorityofpeoplefromrisingupagainstthosewithwealthandpower.Ithasbeenwovenintotheveryfabricofoursociety.Whileitisnotabiologicalreality,ithasaveryrealandprofoundsocialrealityandimpactonthelivesofpeopleofcolor.

● AdelmanL.Raceandgenestudies:Whatdifferencesmakeadifference?Race—ThePowerofanIllusion.PBSwebsite.http://www.pbs.org/race/000_About/002_04-background-01-02.htm.AccessedSeptember15,2018.

Racism:Asystemofstructuringopportunityandassigningvaluebasedonthesocialinterpretationofhowonelooks(“race”).Itunfairlydisadvantagessomeindividualsandcommunities,unfairlyadvantagesotherindividualsandcommunities,andsapsthestrengthofthewholesocietythroughthewasteofhumanresources.

● JonesCP.Confrontinginstitutionalizedracism.Phylon2003;50(1-2):7-22.Refugee/AsylumSeeker:anypersonwhoentersacountrytoavoidpersecution.

● MartinezO,WuE,SandfortT.etal.Evaluatingtheimpactofimmigrationpoliciesonhealthstatusamongundocumentedimmigrants:Asystematicreview.JImmigrMinorHealth.2015;17(3):947-70.

Relational:Thewayinwhichpeopleandcommunitiesareconnected.Forexample,powerisarelationalconceptthatcanonlybeunderstoodintermsofinteractionsbetweenindividualsandgroups.

● OxfordEnglishDictionaries.OxfordUniversityPress.

“Representative”Input:“representingthebroadestpossiblerangeofhealthexperiences.”● OurMethods.healthexperienceusa.orgwebsite.http://healthexperiencesusa.org/our-

methods/AccessedonJune9,2018.Resources:“Wedefineresourcesbroadlytoincludemoney,knowledge,power,prestige,andthekindsofinterpersonalresourcesembodiedintheconceptsofsocialsupportandsocialnetwork.”

● LinkBG,PhelanJ.Socialconditionsasfundamentalcausesofdisease.JHealthSocBehav1995Jan1:80-94.

RiskAdjustment:Astatisticalprocessthattakesintoaccounttheunderlyinghealthstatusandhealthspendingoftheenrolleesinaninsuranceplanwhenlookingattheirhealthcareoutcomesorhealthcarecosts.Forhealthequity,itis“SocialRiskFactors”thatareadjustedfor.

● HealthCare.govwebsite.https://www.healthcare.gov/glossary/risk-adjustment/.AccessedJune9,2018.

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● JoyntKE,DeLewN,SheingoldSH,ConwayPH,GoodrichK,EpsteinAM.Shouldmedicarevalue-basedpurchasingtakesocialriskintoaccount?NewEnglJMed.2017;376(6):510-3.

Rural:

1. Anythingthatisnoturban(i.e.population<2,500)(USCensusBureau)2. Non-metropolitancounties(coreareapopulation<50,000)(OfficeofManagementand

Budget)3. Combinedefinitions1and2withruralurbancommutingarea(RUCA)codes(ameasure

ofcommutingtimeanddistance,developedbytheUniversityofWashington)(HRSAOfficeofRuralHealthPolicy)

● DefiningRuralPopulation.HealthResourcesandServiceAdministrationwebsite.https://www.hrsa.gov/rural-health/about-us/definition/index.html.AccessedJune9,2018.

ServiceLearning:Astructuredlearningexperiencethatcombinescommunityservicewithpreparationandreflection.Studentsengagedinservicelearningprovidecommunityserviceinresponsetocommunity-identifiedconcernsandlearnaboutthecontextinwhichserviceisprovided,theconnectionbetweentheirserviceandtheiracademiccoursework,andtheirroleascitizens.

Sexism:Prejudiceordiscriminationbasedonaperson'ssexorgender."Sexismisthefoundationonwhichalltyrannyisbuilt.Everysocialformofhierarchyandabuseismodeledonmale-over-femaledomination."--AndreaDworkin

SocialAccountability:“anapproachtowardsbuildingaccountabilitythatreliesoncivicengagement,i.e.,inwhichitisordinarycitizensand/orcivilsocietyorganizationswhoparticipatedirectlyorindirectlyinexactingaccountability.”

● AckermanJM.Socialaccountabilityinthepublicsector:Aconceptualdiscussion.SocialDevelopmentPapers.WorldBank.http://siteresources.worldbank.org/WBI/Resources/Social_Accountability_in_the_Public_Sector_with_cover.pdf.Published2005.AccessedSeptember11,2018.

SocialAccountabilityinHealthCare:Socialaccountabilityinhealthcareprioritizesthehealthconcernsofthepeopleandcommunitiesserved,withanimplicitgoalofhealthequity.Itis“theobligation[ofphysiciansandmedicalinstitutions]todirecttheireducation,researchandservicetowardaddressingthepriorityhealthconcernsofthecommunity,region,and/ornationtheyhaveamandatetoserve.”

● BoelenC,HeckJE.Definingandmeasuringsocialaccountabilityinmedicalschools.WorldHealthOrganization.DivisionofDevelopmentandHumanResourcesforHealth.

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http://apps.who.int/iris/bitstream/handle/10665/59441/WHO_HRH_95.7.pdf?sequence=1&isAllowed=y.Published1995.AccessedSeptember11,2018.

SocialDeterminantsofEquity(SDoE):Human-madesocialdeterminants—suchasracism,sexism,ageism,ableism,homo-andtrans-phobia—thatinequitablydistributepower,andcreateinequitiesinthesocialandbiologicaldeterminantsofhealth.AddressingSDoEisnecessarytoachievesocialjusticeandeliminatehealthdisparities,whereasaddressingSDoHtargetshealthoutcomes.AddressingSDoErequires:

● monitoringforinequitiesinexposuresandopportunities,aswellasfordisparitiesinoutcomes;

● examinationofstructures,policies,practices,norms,andvalues;and● interventiononsocietalstructuresandattentiontosystemsofpower.

○ JonesCP,JonesCY.,Perry,G.S.,Barclay,G,.,JJones,C.A.Addressingthesocialdeterminantsofchildren'shealth:Acliffanalogy.JournalofHealthCareforthePoorandUnderserved.2009:20(4)1-12.JonesC.PresentationatCDC.https://minorityhealth.hhs.gov/Assets/pdf/Checked/1/CamaraJones.pdf.AccessedMay16,2018.

SocialDeterminantsofHealth(SDoH):“conditionsintheenvironmentsinwhichpeopleareborn,live,learn,work,play,worship,andagethataffectawiderangeofhealth,functioning,andquality-of-lifeoutcomesandrisks.”

● SocialDeterminantsofHealth.HealthyPeople.govwebsite.https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health.AccessedJune9,2018.

SocialRiskFactors:Factorssuchaslowsocioeconomicposition(asindicated,forexample,byincomeoreducationallevel),minorityraceorethnicbackground,lowerdegreeofacculturation,minoritysexualorientationorgenderidentity,limitedsocialrelationships,andlivingaloneorinadeprivedneighborhoodthatnegativelyinfluencehealthoutcomes.

● BuntinMB,AyanianJZ.SocialriskfactorsandequityinMedicarepayment.NewEnglJMed.2017;376(6):507-10.

SocioeconomicStatus(SES):Thesocialstandingorclassofanindividualorgroup.Itisoftenmeasuredasacombinationofeducation,incomeandoccupation.

● AmericanPsychologicalAssociationwebsite.http://www.apa.org/topics/socioeconomic-status/.AccessedSeptember11,2018.

StereotypeThreat:Theexperienceofanxietyinasituationinwhichapersonhasthepotentialtoconfirmanegativestereotypeabouthisorhersocialgroup.

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● InzlichtM.Stereotypethreat:theory,process,andapplication.NewYork,NY.:OxfordUniversityPress;2012.

StructuralCompetency:Improvingunderstandingofhowsocialconditions,historicalcontext,andpracticallogisticsunderminethecapacitiesofpatientstoaccesshealthcare,adheretotreatment,andmodifylifestylessuccessfully.Theabilityforhealthprofessionalstorecognizeandrespondwithself-reflexivehumilityandcommunityengagementtothewaysnegativehealthoutcomesandlifestylepracticesareshapedbylargersocio-economic,cultural,political,andeconomicforces.

● BourgoisP,HolmesSM,SueK,QuesadaJ.Structuralvulnerability:operationalizingtheconcepttoaddresshealthdisparitiesinclinicalcare.AcadMed. 2017;92(3):299-307.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5233668/.AccessedMay17,2018.

● HolmesS.FreshFruit,BrokenBodies:MigrantFarmworkersintheUnitedStates.Berkeley,Calif:UniversityofCaliforniaPress;2013

StructuralInequality:Biasthatisbuiltintothestructureoforganizations,institutions,governments,orsocialnetwork.

● Structuralinequality.Wikipedia.https://en.wikipedia.org/wiki/Structural_inequality.Published[November3,2011].Updated[July27,2018].Accessed[September12,2018].

Thereisa“growingawarenessthatsocialjusticemustbeunderstoodasastructuralphenomenonencompassingacomplexinterplayofeconomic,racial,gender,andpoliticaldimensions….contestingstructuralinequalityisacentralthemeinthemanysocialmovementstoday.”

● RahmanKS.Structuralinequalityandthelaw,partII.LawandPoliticalEconomy.Availableathttps://lpeblog.org/2018/03/05/structural-inequality-and-the-law-part-ii/.Adaptedfrom,RahmanKS.Constructingandcontestingstructuralinjustice.CriticalAnalysisofLaw.2018;5(1).https://cal.library.utoronto.ca/index.php/cal/article/view/29507/21992.AccessedSeptember12,2018.

StructuralViolence:Onewayofdescribingsocialarrangementsthatputindividualsandpopulationsinharm’sway…Thearrangementsarestructuralbecausetheyareembeddedinthepoliticalandeconomicorganizationofoursocialworld;theyareviolentbecausetheycauseinjurytopeople.

● BourgoisP,HolmesSM,SueK,QuesadaJ.Structuralvulnerability:operationalizingtheconcepttoaddresshealthdisparitiesinclinicalcare.AcadMed. 2017;92(3):299-307.

● QuesadaJ,HartL,BourgoisP.StructuralvulnerabilityandthehealthofLatinomigrantlaborers.MedAnthropol.2011;30(4):339–362.

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StructuralVulnerability:Anindividual'sorapopulationgroups'conditionofbeingatriskfornegativehealthoutcomesthroughtheirinterfacewithsocioeconomic,politicalandcultural/normativehierarchies.Patientsarestructurallyvulnerablewhentheirlocationintheirsociety'smultipleoverlappingandmutuallyreinforcingpowerhierarchies(e.g.,socioeconomic,racial,cultural)andinstitutionalandpolicy-levelstatuses(e.g.,immigrationstatus,laborforceparticipation)constraintheirabilitytoaccesshealthcareandpursuehealthylifestyles.

● BourgoisP,HolmesSM,SueK,QuesadaJ.Structuralvulnerability:Operationalizingtheconcepttoaddresshealthdisparitiesinclinicalcare.AcadMed. 2017;92(3):299-307.

TransactionalMetric:Anobjective,oftennumeric,outcomethatcanbequantitativelymeasured(e.g.,thenumberofsurveysdistributedandthenumberofsurveyscompleted).Transactionaldatadoesnotprovidemuchinsightintothequalityofthedatafieldstheyaretracking.TransformationalMetric:Ametricthatdemonstratesbehavioralchangeandisfundamentallyrelationallydriven.Ithighlightsnotonlyoutputsbutoutcomes.Trauma-informedApproach:“Aprogram,organization,orsystemthatistrauma-informed:

1. Realizesthewidespreadimpactoftraumaandunderstandspotentialpathsforrecovery;

2. Recognizesthesignsandsymptomsoftraumainclients,families,staff,andothersinvolvedwiththesystem;

3. Respondsbyfullyintegratingknowledgeabouttraumaintopolicies,procedures,andpractices;and

4. Seekstoactivelyresistre-traumatization." ● Trauma-InformedApproachandTrauma-SpecificInterventions.SubstanceAbuseand

MentalHealthServicesAdministrationwebsite.https://www.samhsa.gov/nctic/trauma-interventions.AccessedJune9,2018.

Unconscious(Implicit)Bias:Theattitudesorstereotypesthataffectourunderstanding,actions,anddecisionsinanunconsciousmanner.Thesebiases,whichencompassbothfavorableandunfavorableassessments,areactivatedinvoluntarilyandwithoutanindividual’sawarenessorintentionalcontrol.Residingdeepinthesubconscious,thesebiasesaredifferentfromknownbiasesthatindividualsmaychoosetoconcealforthepurposesofsocialand/orpoliticalcorrectness.Rather,implicitbiasesarenotaccessiblethroughintrospection.

● Implicitbiasesarepervasive.Everyonepossessesthem,evenpeoplewithavowedcommitmentstoimpartialitysuchasjudges.

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● Implicitandexplicit(conscious)biasesarerelatedbutdistinctmentalconstructs.Theyarenotmutuallyexclusiveandmayevenreinforceeachother.

● Theimplicitassociationsweholddonotnecessarilyalignwithourdeclaredbeliefsorevenreflectstanceswewouldexplicitlyendorse.

● Wegenerallytendtoholdimplicitbiasesthatfavorourowningroup,thoughresearchhasshownthatwecanstillholdimplicitbiasesagainstouringroup.

● Implicitbiasesaremalleable.Ourbrainsareincrediblycomplex,andtheimplicitassociationsthatwehaveformedcanbegraduallyunlearnedthroughavarietyofdebiasingtechniques.

○ UnderstandingImplicitBias.TheOhioStateUniversityKirwanInstitutefortheStudyofRaceandEthnicitywebsite.http://kirwaninstitute.osu.edu/research/understanding-implicit-bias/.AccessedJune9,2018.

UndocumentedImmigrant:Anyforeignnationalwhohas(1)legallyenteredthenationstateorterritorybutremainedinthecountryaftertheirvisa/permitexpired;(2)receivedanegativedecisionontheirrefugee/asyleeapplicationbutremainedinthecountry;(3)experiencedchangesintheirsocioeconomicpositionandcouldnotrenewresidencepermitbutremainedinthecountry;(4)usedfraudulentdocumentationtoenterthecountryorterritory;or(5)unlawfullyenteredthecountryorterritory,includingthosewhoweresmuggled.

● MartinezO,WuE,SandfortT,DodgeB,Carballo-DieguezA,PintoR,et.al..Evaluatingtheimpactofimmigrationpoliciesonhealthstatusamongundocumentedimmigrants:Asystematicreview.JImmigrMinorHealth.2015;17(3):947-70.

UpstreamDeterminantsofPublicHealth(Upstream):Overarchingfactorsthatarelargelyoutsideofthecontroloftheindividualandwhichhavesignificanttrickledowneffectsonother,moreproximal,determinantsofpublichealth.Muchthesamewaythatpollutionupstreamofariverwillhavelastingandfarreachingeffectsonthosepopulationsdownstream,despitethesepopulationshavinglittletonocontroloverthispollution.Urban:UrbanareasincludeUrbanizedAreas,whichcontain>50,000people,andUrbanClusters,whichcontainbetween2,500and50,000people.

● DefiningRuralPopulation.HealthResources&ServicesAdministrationwebsite.https://www.hrsa.gov/rural-health/about-us/definition/index.html.AccessedJune9,2018.

Value-BasedPrograms/Payments/ReimbursementModels:Value-basedprogramsrewardhealthcareproviderswithincentivepaymentsforthequalityofcare.Theyarepartofalargerqualitystrategytoreformhowhealthcareisdeliveredandpaidfor.Theyaimtomovetowardpayingprovidersbasedonthequality,ratherthanthequantityofcaretheygivepatients.

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● WhataretheValue-BasedPrograms?CMS.govwebsite.https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html.AccessedJune9,2018.

Vulnerability:“Vulnerabilityinvolvesseveralinterrelateddimensions:individualcapacitiesandactions;theavailabilityorlackofintimateandinstrumentalsupport;andneighborhoodandcommunityresourcesthatmayfacilitateorhinderpersonalcopingandinterpersonalrelationships.”

● MechanicD,TannerJ.Vulnerablepeople,groups,andpopulations:Societalview.HealthAff(Millwood).2007;26;1220-1230.

VulnerablePopulations:Groupsofpersonswhoserangeofoptionsisseverelylimited,whoarefrequentlysubjectedtocoercionintheirdecisionmaking,orwhomaybecompromisedintheirabilitytogiveinformedconsent.

● VulnerablePopulationsMeSHDescriptorData2018.NationalLibraryofMedicinewebsite.https://meshb.nlm.nih.gov/record/ui?ui=D035862.AccessedSeptember17,2018.

Weathering(biologicalweathering):“namely,thatthehealthofAfrican-Americanwomen[andmen]maybegintodeteriorateinearlyadulthoodasaphysicalconsequenceofcumulativesocioeconomicdisadvantage.”

● GeronimusAT.TheweatheringhypothesisandthehealthofAfrican-Americanwomenandinfants:Evidenceandspeculations.EthnDis.1992;2(3):207-221.

WONCA(WorldOrganizationofFamilyDoctors):WONCAwasfoundedasacollaborationofmultipleinternationalprimarycareorganizationsin1972.ThemissionofWONCAistoimprovequalityoflifeofpeoplearoundtheworld.WONCArepresentsandactsasanadvocateforitsconstituentmembersataninternationallevelwhereitinteractswithworldbodiessuchastheWorldHealthOrganization(WHO),withwhomithasofficialrelationsasanon-governmentalorganizationandisengagedinanumberofcollaborativeprojects.

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HEALTHEQUITYRESOURCESDATABASESCentersforDiseaseControlandPreventionTheCommunityGuidehttps://www.thecommunityguide.org/

● TheGuidetoCommunityPreventiveServices(TheCommunityGuide)isacollectionofevidence-basedfindingsoftheCommunityPreventiveServicesTaskForce(CPSTF)-organizedbyover20publichealthtopics,includinghealthequity.Thesefindingssupportinterventionstoimprovehealthandpreventdiseaseatthemacroandmesolevels.Resourcesanswerwhathasworkedforothers,costconsiderations,andhighlightevidencegaps.Theyalsoprovideactionabletoolstoguidecommunity-engagedwork.

CommunityHealthRankingshttp://www.countyhealthrankings.org

● TheannualrankingsfromtheRobertWoodJohnsonFoundationprovideasnapshotatthecounty-levelofhowhealthisinfluencedbywherewelive,learn,workandplay.Rankingcommunitiesonhealthoutcomesandhealthfactors,includingsocialdeterminantsofhealth,theyprovideastartingpointforchangeincommunities.

● Thewebsitealsoprovidesextensiveresources,includingStateHealthGapReportsthathighlighthealthdisparitiesandanActionCenterwithtoolsforeachstageoftheprocesstomakecommunitieshealthier.

○ StateHealthGapReports:http://www.countyhealthrankings.org/health-gaps○ ActionCenter:http://www.countyhealthrankings.org/roadmaps/action-center

PracticalPlaybookhttps://www.practicalplaybook.org

● ThePracticalPlaybookstrivestoadvancecollaborationamongpublichealth,primarycare,andotherstoimprovepopulationhealth.Withinthiswebsitearepracticalimplementationtools,guidance,andresourcesincludingsuccessstoriestoinspireandencourageexpansionofsuchwork.

UnnaturalCauseshttp://www.unnaturalcauses.org/

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● Thisseven-partacclaimeddocumentaryseriesbroadcastbyPBSisnowusedbythousandsoforganizationstotackletherootcausesofouralarmingsocio-economicandracialinequitiesinhealth.

OnlineCollectionofHealthEquityResourceshttp://www.unnaturalcauses.org/resources.php

● Thisdatabasecontainshundredsofarticles,websites,videoclips,charts,datasets,interviews,transcripts,andeducationalandoutreachmaterials.Itissearchablebytopic,thedocumentaryepisodetopics,type,andkeyword.

REPORTSandPROCEEDINGSBachrachD.,PfisterH.,WallisK.,andLipsonM.AddressingPatients'SocialNeeds:AnEmergingBusinessCaseforProviderInvestment.TheCommonwealthFundwebsite.May29,2014.http://www.commonwealthfund.org/publications/fund-reports/2014/may/addressing-patients-social-needsAccessedSeptember17,2018.

● Thisreportoutlineshowgrowingnumbersofcliniciansareconcludingthatinvestingininterventionsaddressingtheirpatients’socialneedsmakesgoodbusinesssense.Asmorelow-incomepeoplegainhealthcarecoverage,evidenceonwhichinterventionsaremostcost-effectiveinaddressingtheirsocialneedsandimprovingtheirhealthwillgrow,andvalue-basedreimbursementwillbecomestandardacrosspayers.

NationalAcademiesofSciences,Engineering,andMedicine.Communitiesinaction:Pathwaystohealthequity.2017.Washington,DC:TheNationalAcademiesPress.doi:10.17226/24624.https://doi.org/10.17226/24624.

● Thisreport“seekstodelineatethecausesofandthesolutionstohealthinequitiesintheUnitedStates.Thisreportfocusesonwhatcommunitiescandotopromotehealthequity,whatactionsareneededbythemanyandvariedstakeholdersthatarepartofcommunitiesorsupportthem,aswellastherootcausesandstructuralbarriersthatneedtobeovercome.”

NationalAcademiesofSciences,Engineering,andMedicine.Exploringequityinmultisectorcommunityhealthpartnerships:Proceedingsofaworkshop.2017.Washington,DC:TheNationalAcademiesPress.http://nationalacademies.org/hmd/reports/2017/exploring-equity-in-multisector-community-health-partnerships-proceedings.aspx

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● Thisreport—summarizingaworkshophostedbytheRoundtableonPopulationHealthImprovementoftheNationalAcademiesofSciences,EngineeringandMedicine—exploreshowavarietyofsuccessfulcommunity-basedorganizationscreatedandmaintainedinnovativeandsustainableapproachestomultisectorcommunityhealthpartnerships.

InstituteofMedicine.Spread,scale,andsustainabilityinpopulationhealth:Workshopsummary.2015.Washington,DC:TheNationalAcademiesPress.https://www.nap.edu/catalog/21708/spread-scale-and-sustainability-in-population-health-workshop-summary

● ThisreportsummarizesaworkshopconvenedbytheInstituteofMedicine'sRoundtableonPopulationHealthImprovementtodiscussthespread,scale,andsustainabilityofpractices,models,andinterventionsforimprovinghealthinavarietyofinter-organizationalandgeographicalcontexts.Itexploreshowusersmeasurewhethertheirstrategiesofspreadandscalehavebeeneffectiveanddiscusseshowtoincreasethefocusonspreadandscaleinpopulationhealth.

UsingDatatoImpactCommunityHealthandDriveAction.PracticalPlaybookwebsite.https://www.practicalplaybook.org/resources/using-data-impact-community-health-and-drive-action.AccessedSeptember17,2018.

● Thisreportfromthe2017PracticalPlaybookNationalMeeting“ImprovingPopulationHealth:CollaborativeStrategiesThatWork”identifiesproblemsmostlikelytooccurinpartnershipsbetweenpublichealthandprimarycare,andofferspractical,actionablestrategiestosharedataacrosssectors.

EffectiveStrategiestoBuildMomentumandRealignPopulationHealthProgramsinaChangingHealthcareLandscape.PracticalPlaybookwebsite.https://www.practicalplaybook.org/resources/effective-strategies-build-momentum-and-realign-population-health-programs-changing-healthcareAccessedSeptember17,2018.

● Thisreportfromthe2017PracticalPlaybookNationalMeeting“ImprovingPopulationHealth:CollaborativeStrategiesThatWork”sharesspecific,workablestepsforaddressingthesocialdeterminantsofhealthandprovenbestpracticesforworkingacrosssectorseffectively

DemonstratingValueinPopulationHealthProjects.PracticalPlaybookwebsite.

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https://www.practicalplaybook.org/resources/demonstrating-value-population-health-projectsAccessedSeptember17,2018.

● Thisreportfromthe2017PracticalPlaybookNationalMeeting“ImprovingPopulationHealth:CollaborativeStrategiesThatWork”identifiesstrategiestohelpcross-sectorcollaborationsdefinevaluetoallpartnersandensuretheirongoingsupport.

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INTERPROFESSIONALTEACHING/FACILITATIONRESOURCES

TRAININGSIPEFacilitationTrainingToolkit.CenterforHealthSciencesInterprofessionalEducationUniversityofWashingtonwebsite.https://collaborate.uw.edu/ipe-teaching-resources/ip-curriculum-educators/ipe-facilitation-training-toolkit/AccessedSeptember17,2018.

● This toolkit is designed for educators interested in learning to facilitate student Interprofessional Education (IPE) and/or train other educators to facilitate IPE. It contains free-source activities and methods to actively engage educators in learning and applying various instructional methods to teach IPE competencies. All materials for each activity are available for download and use. The purpose is to help facilitators understand common facilitation challenges in interprofessional learning groups and to help facilitators identify situations in which particular/effective facilitation strategies could be employed.

ARTICLESCrowJ.,SmithL.Usingco-teachingasameansoffacilitatinginterprofessionalcollaborationinhealthandsocialcare.JInterprofCare.2003;17(1):45-55.http://informahealthcare.com/doi/pdf/10.1080/1356182021000044139.

● Foragroupofinterprofessionalstudents,thisarticlehighlightstheprocessofusingco-teaching(byfacilitatorswithdifferentprofessional/academicbackgrounds)torolemodelsharedlearningandcollaborativeworkingwithintheclassroomandhighlighttheimportanceofcarefullyplanningco-teachinginteraction,includingtheuseofhumor,tension,differentknowledgebasesandstylesofdebate.Thedeliberateuseoftheinteractionsmadepossiblebyco-teachingenabledtheauthorstocreateanactivelearningenvironmentthatfacilitatedtheteachingofcollaboration.Theydiscusstheconsiderablepotentialofusingco-teachingtorolemodelcollaborativeworkingformultidisciplinarystudentgroups.

DiProsperoL.,Bhimji-HewittS.Learningisinthefacilitation:Facultyperspectiveswithfacilitatedteachingandlearning-recommendationsfrominformaldiscussions.JAlliedHealth.2011;40(4):e61–65.

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● Thisarticlerecommendsusingfacilitatorguideswithspecificdebriefinstructionsforthegivenobjectivesinordertoencourageeffectivelearningdialogueamongallparticipants,formalizedfacilitatortraining,anddebriefstrategiesinordertoattaintheskillstobetterguidestudentlearning.

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APPENDIX A: EQUITY AND EMPOWERMENT LENS ASSESSMENT WORKSHEET

EquityandEmpowermentLensAssessmentWorksheet

WhatisthePurpose?/DefineOutcomes

1. Circlewhichareathisintervention/practice/policywillprimarilyimpact:

a. Clinicalhealthmetric(e.g.hemoglobinA1c)b. Accesstoservicesc. Socialdeterminantofhealth(e.g.education,housing)d. Other

2. Whatareyouoryourteamtryingtoimprove?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

3. Whodoesthisintendtoserve?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

4. Whatdataorevidenceguidesthisintervention/practice/policy/etc.(Consideralldemographicdata;maps;qualitativeexperience,etc.)?

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___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

5. Whatisthedatatellingyouaboutinequitiesexperiencedinthecommunity?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

6. Doesthedatatakeintoaccountcommunityprioritiesandculturally-specificfeedback?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

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ConnectiontoPeople

7. Who,inthecommunityandinyourorganization,willbemostaffectedbyandconcernedwiththisintervention/practice/policy?Considerpositiveandnegativeimpactstothephysical,mental,spiritualandcontextualhealthofgroupsincludingforpotentialtrauma/re-trauma;andtothedistributionofresources.Haveyousoughttheirinput?

Demographics(groupaffected–

bespecificandconsiderstaff)

DifferentialimpactsPositive–benefit

DifferentialimpactsNegative–burden

Structuralcausesforbenefitsandburdens*

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*Thinkdeep(e.g.challengeyourselftoconsidernotmerely“lackoffunding”butwhyistherelackoffunding?)

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ConnectiontoPlace

8. Doesthisintervention/practice/policyaccountforapersonorgroup’semotionalorphysicalsafety?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

9. Doesthisintervention/practice/policyaffecttheenvironmentorarethereissuesofenvironmentaljusticetoconsider?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

10. Howareresourcesandinvestmentsdistributedgeographically?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

ConnectiontoProcessandPower

11. Whatbarriersdoyouandyourteamencounterinmakingchangesrelatedtoequityandracialjustice?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

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12. Howdoesyourorganizationengagethecommunityinplanning,decision-makingandevaluation?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

a. Whatpolicies,processesandsocialrelationshipsintentionallyincludecommunitiesaffectedbyinequities?_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

b. Whatpolicies,processesandsocialrelationshipscontributetotheexclusionofcommunitiesmostaffectedbyinequities?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

c. Whatactionsorstrategiescouldbuildinclusion?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

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13. Howdoestheintervention/practice/policybuildcommunitycapacityandpowerincommunitiesmostaffectedbyinequities?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

References:TheEquityandEmpowermentLensWorksheetisadaptedfromEquityandEmpowermentLens2012.MultnomahCountyOfficeofDiversityandEquity.https://multco.us/file/31833/downloadAccessedNovember13,2018.Fivepossiblekeyquestions:● PURPOSE:Whatistheproblemyouaretryingtosolve?Describeyourproposed

intervention. ● PEOPLE:Whichpatientsarepositivelyandnegativelyaffectedbythisintervention? ● PLACE:Howdoesthisinterventionaccountforpatients’emotionalandphysicalsafety

andtheirneedtobeproductiveandfeelvalued? ● PROCESS:Howarewemeaningfullyincludingandexcludingpatientsintheprocess? ● POWER:Howcouldwebetterintegratevoicesandprioritiesofallstakeholders?

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APPENDIX B: MODULE TITLES

INTRODUCTORYMODULE

● Part1:MakingAmericaHealthierforAll:WhatEachofUsCanDo o DavidWilliams,PhD,MPH

● Part2:ShiftingtheParadigmTowardSocialAccountability o SonaliSangeetaBalajee,MS,JenniferEdgoose,MD,MPH,JoedreckaBrown-

Speights,MD,andBonzoReddick,MD,MPH,FAAFP

SOCIALDETERMINANTSOFHEALTH● IdentifyingandAddressingPatients'SocialandEconomicNeedsintheContextofClinical

Care o LauraGottlieb,MD,MPH

● CommunitiesWorkingTogethertoImproveHealthandReduceDisparities

o J.LloydMichener,MD CommunityHealthImprovementPlansandPatient-CenteredPrimaryCareHomesasToolstoAddressHealthDisparities

o ElizabethSteinerHayward,MD

● ImprovingPatientOutcomesbyEnhancingStudentUnderstandingofSocialDeterminantsofHealth

o BrigitCarter,PhD,RN,CCRN AnActionLearningApproachtoTeachingtheSocialDeterminantsofHealth

o VivianaMartinez-Bianchi,MD,FAAFP

● Understandinghealthexperiencesandvaluestoaddresssocialdeterminantsofhealth o NancyPandhi,MD,PhD,MPHandSarahDavis,JD,MPA

VULNERABLEPOPULATIONS

● WhyRuralMatters o FrederickChen,MD,MPH

● Racism,Sexism,andUnconsciousBias

o DeniseRodgers,MD,FAAFP,FAAFP

● ImmigrantPopulationsinaNationofChangingPolicy o MichaelRodriguez,MD,MPH

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● Intersectionality—TheInterconnectednessofClass,Gender,RaceandotherTypesofVulnerability

o SomnathSaha,MD,MPH

● PeoplewithDisabilities(DevelopmentalandIntellectual) o WilliamSchwab,MD

ECONOMICSANDPOLICY

● InternationalEffortstoReduceHealthDisparities o MichaelKidd,AM,MBBS,MD,FAHMS

● HowSocialandEnvironmentalDeterminantsCanBeUsedtoPayDifferentlyforHealth

Care o RobertPhillips,MD,MSPH

ACAOpenedtheDoorforPaymentReformandPracticeTransformationtoAddressSocialDeterminantsofHealth,NowWhat?

o CraigHostetler,MHA

● CommunityVitalSigns:AchievingEquitythroughPrimaryCareMeansCheckingMorethanBloodPressure

o AndrewBazemore,MD,MPH

● AccesstoPrimaryCareisNotEnough:AHealthEquityRoadMap o Bierman,MD,MS