health disparities

need one page for each individual questions

Question 1:

how can you leverage intersectoral and multisectoral approaches to health policy to drive positive change in healthcare. Discuss enablers and barriers.

Question 2:

do a summary and reaction using the article attached

need apa references

Transformational Community
Engagement to Advance Health Equity
Prepared by Health Equity Solutions
A grantee of the Robert Wood Johnson Foundation
January 2023
Within government, policy and programmatic changes are often made without engaging the people they will affect
or the people currently experiencing the challenges of existing policies and programs. By comparison, software
developers rely on end-user testing to refine their products and marketing and communications professionals leverage
focus groups to identify effective messaging strategies. Inequities in COVID-19 mortality, morbidity, and vaccine
distribution have underlined the historical legacies and contemporary realities of distrust of government and the failures
of our health and social services systems to meet the needs of people of color. Community engagement is one of the
ways states are attempting to establish and maintain trust and improve the accessibility and quality of services.1 Such
efforts can improve communication, lead to more effective and efficient programs, and result in ongoing collaboration
with people who have experienced state-run systems and services.2, 3
Community Engagement and Equity
Community engagement is central to addressing the systemic inequities and structural discrimination entrenched in
our health and social services systems. By fostering trust and mutual respect, exposing unforeseen or unintended
barriers to health, and improving program efficacy by responding to the experiences of the people impacted by
programs and policies, community engagement can promote equity. However, community engagement by nature is
not a guaranteed tactic to advance equity. To actualize its full potential, community engagement must be designed
with equity as its leading principle through engagement of diverse communities and accounting for power imbalances
facing minoritized communities. Without intentionally and meaningfully engaging the communities directly impacted by
state programs and policies, changes to programs and policies are likely to exacerbate or maintain existing inequities.
Community engagement that moves beyond “checking a box” recognizes the importance of community voice and the
valuable insights and knowledge people can offer. Each person is, at minimum, an expert on their own experience and
efforts to engage people of diverse identities can help programs mitigate inequities by leveraging lived experience to
design and adjust interventions, communication, and programming.
Defining Community Engagement
Community engagement has a variety of definitions and interpretations and a range of functions. Further, design and
implementation vary widely both between and within states.4 State agency approaches can range from a dedicated
community engagement division with internal organizational capacity to conduct community engagement to
contracting with community-based organizations to support engagement efforts or a hybrid model combining both.
Community partners are often helpful in addressing issues of trust with communities that have a history of distrust
and/or negative interaction with government entities and health systems.
Key Terms:
Community engagement: 5, 6, 7, 8, 9 Collaborative processes between organizations/institutions and communities impacted by their
policies, programs, or practices to influence decisions and actions through the mutually beneficial and bidirectional exchange of
resources, expertise, and information.
Outreach: Activities and processes related to raising awareness, disseminating information, or training external partners to connect
their constituents or members with a service, program, or information (e.g., Medicaid enrollment services). Outreach is more
one-sided, with a goal of conveying clear messages across diverse populations. Effective outreach is a part of strategic
communication. Both communication and outreach can be improved when paired with engagement to align with community needs,
priorities, and preferences.
1
Figure 1: Meaningful Community Engagement
Understanding Community Engagement
To illustrate the range of community engagement options, consider community engagement approaches operating
on two axes (as illustrated in Figure 1): impact and power. Impact describes the degree to which engagement results
in change that centers the needs of those impacted by the program or policy. This can range from non-existent (in
which there is no community engagement) to transactional (engagements centering the needs of the agency and often
focused on a specific idea or product at a single point in time) to transformational (ongoing and bidirectional efforts
that result in equity-focused change). Power indicates the scope of influence communities have in the engagement
process, decision-making, and outcomes and is often shaped by how communities are engaged. Power ranges
from nonexistent (in which communities are not engaged) to acknowledging community power through a one-sided
relationship (such as seeking input on a project that is nearly complete and unlikely to change) to collaboration and cocreation in which communities have a strong role in identifying the policies and programs to be addressed, designing
solutions, and evaluating implementation.
Transformational community engagement shares power with community and is built on trust, transparency, and mutual
accountability. At its best, this means prioritizing shared power with communities by ensuring participants can engage
in a safe and robust manner and have a measurable influence on engagement priorities that then lead to sustained
change. All forms of community engagement have the potential to address inequities and promote efficacy, but
initiatives that fall in the lower left corner of Figure 1—transactional with little power sharing—can exacerbate distrust
and frustration among participants.
Understanding Impact in Community Engagement
Impact is a continuum, not a dichotomy. Actions along the continuum between transactional and transformational can
occur when engagement is completed at a single point in time with a narrow scope, if that engagement meets one or
more of the following criteria: 1) expectations regarding the duration and level of influence are clear to participants; 2)
change, particularly high impact change, can or does result from the engagement; and 3) participants are informed
about how their input was or was not incorporated and why. To avoid increasing mistrust, states should strive for
transformational engagement and seek feedback about participants’ experience of all engagement efforts.
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Transactional Community Engagement: These efforts engage communities through commentary on near-final
products or narrow questions and are often characterized by single interactions. This frequently results in superficial
changes to a policy or program, changes that exacerbate inequities or fail to meet community needs, or no change
at all. While transactional engagement requires fewer resources, it also runs the risk of reinforcing a perception by
participants that the state is “checking the box,” results in minimal learning for the state and fatigue among community
partners and advocates, and devalues the feedback obtained. Examples: A single point in time survey, focus group, or
interview.
Transformational Community Engagement: These efforts form sustainable relationships, operate with
transparency, and result in changes to policies and/or practices. Features of this type of engagement include, but are
not limited to, participants learning how their input was or was not incorporated and why. This is the best standard of
engagement and requires time, organizational commitment, resources, and readiness. Examples: Robust consumer
advisory boards, partnerships with grassroots and community-based organizations, or hiring agency staff with lived
experience to build ongoing relationships.
Transactional Engagement:
• Checking a box
• Narrow engagement
• Seeking input on near-final product
• Results in superficial or technical change only
• Challenges: may lead to community fatigue, lack of trust
Transformational Engagement:
•
Sustainable relationships
•
Transparency and “feedback loop”
•
Results in cultural or structural change
•
Challenges: resource intensive, requires institutional commitment and readiness
Understanding Power in Community Engagement
Like impact, power is a continuum. Addressing power begins with intentional processes of recognizing community
participation via financial and/or in-kind compensation.10 Such recognition can include a range of options to both
acknowledge participants’ time and input and address logistical barriers to participation such as: providing food,
transportation, child care, or lodging; offering gift cards; and providing certificates at the completion of a term of
service, public recognition, and opportunities for participants to tell and celebrate their stories.
Practical Considerations for Sharing Power
Shifting power to the community can be done in a variety of ways. In addition to sharing decision-making power
with the community, increasing access to the decision-making process is key. In addition to the decision-making
power that states hold, access to the information and knowledge that informs those decisions is another element of
power. Program enrollees or users do not necessarily know or understand the complexities of program design, legal
requirements, state and federal regulations, or the jargon being used. Developing the capacity of members to have
discussions about complex issues by sharing information specifically developed for the community and orienting
participants to new or technical concepts enables each community member to fully participate. This can be as simple
as sharing slides in advance of meetings and offering to answer questions or as involved as one-on-one support and
may vary based on the level of intricacy of the issue under consideration.
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Physical, cultural, linguistic, and logistic access define the inclusivity of engagement efforts and who has a place
at the table to shift power. To fully engage, community members need spaces that suit their physical and linguistic
abilities, at a time and place they can access, with accommodations for work schedules and dependent care, as well
as for physical travel or virtual access. Financial and non-financial compensation for participation can improve access
for some communities (see State Examples of Medicaid Community Engagement Strategies: Two Case Studies for
detailed examples. Working with community-based organizations (CBOs that know and serve the communities being
engaged is an effective strategy for increasing access. For example, CBOs can aid in recruitment and facilitation if
they are trusted, local entities. An important aspect of inclusivity is ensuring each engagement is structured so that all
participants are comfortable participating. These structures will vary based on whether other stakeholders (such as
payers, providers, and advocates) are included and the needs of the community members being engaged.
Minimal Power Sharing: Community-informed engagement11 ignores differences in power. Addressing power
dynamics is seen as beyond the engagement’s scope of purpose. The focus is on imparting information about policies
or programs that are already planned or in place or extracting information to inform policy changes prioritized by
the institution without community input. Institutions are the sole sources of information and knowledge. Community
outreach is another term that can be used for this type of engagement. The goal is to keep communities informed
and/or encourage specific actions. Examples: presentations, brochures, educational materials, media, public
relations events.
Some Power Sharing: Community-involved engagement12 recognizes power dynamics without fully addressing
them. The agency works with communities and trusted messengers to align the needs of the community with the
engagement efforts and collect feedback. Community knowledge and expertise is recognized. There is a degree of
exchange of ideas between some communities, particularly those who are deemed “easy to reach,” and the agency.
Community members are offered limited channels through which they can influence decision-making and prioritysetting. These efforts often focus on a narrow aspect of a program or policy that has little flexibility to adopt significant
input. Such efforts often seek input from community members, providers, and policymakers at once and may or
may not include a mechanism for communicating how input was incorporated. Examples: Community focus groups,
surveys, advisory councils or workgroups which include community members alongside healthcare providers and/or
other stakeholders; town halls; public comment periods; public hearings.
Maximal Power Sharing: Community-driven engagement13 intentionally acknowledges traditional power dynamics
by enacting processes to neutralize or subvert power imbalances. Community voices are recognized, treated as
experts, and lead the agenda. Community members collaborate with the agency to form ideas and prioritize issues.
Agencies provide infrastructure, financial support, and a commitment from leadership to support inclusive engagement
and partnerships with diverse communities. The engagement’s design, priorities, implementation, ownership, and
accountability are shared between the agency and community members through collaborative participation and
ongoing relational partnership. Such efforts often address imbalances in knowledge by ensuring meetings are
conducted in plain language and participants are offered support or background information in advance. Examples:
Community-based participatory research and budgeting, democratic processes, robust consumer advisory boards, and
building consensus.
Benchmarking Community Engagement Efforts: Planning and Evaluation
Reflecting on current community engagement initiatives and infrastructure is the first step in moving towards
transformational community engagement. To do this, state agencies must identify where their organization’s existing
community engagement efforts fall in the context of health equity. Figure 1 offers a simple visual to locate where efforts
fall along the axes of community engagement. Assessment of current practices allows states to determine their goals
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for community engagement and the strategies and concrete tactics needed to achieve these goals. Once a benchmark
is established, the next step is evaluating agency resources and setting goals to advance equitable community
engagement.
The National Academy of Medicine (NAM developed a conceptual model to assess community engagement in the
context of health equity and systems transformation (see Figure 2.14 The model defines core principles necessary
to produce meaningful engagement and four outcome areas to evaluate if and how efforts are moving the needle
on health equity. NAM plans to release additional resources to accompany the model, including assessment
instrument summaries.15
Figure 2: A Dynamic Relationship: Achieving Health Equity and Systems
Transformation through Meaningful Community Engagement
Strategies and Tactics for Community Engagement
The following list of strategies and tactics offers options for states to consider when working to advance towards
transformational community engagement and achieve their community engagement goals. These recommendations
are organized according to the four outcome domains of NAM’s conceptual model (see Figure 2 to aid states in
operationalizing this framework and evaluating community engagement efforts. The strategies are broad considerations
or approaches for achieving each domain, while the tactics are concrete action steps for carrying out the strategies and
achieving the goals of each domain.
For more specific, detailed examples of how states are currently operationalizing community engagement practices,
see State Examples of Medicaid Community Engagement Strategies: Two Case Studies, which highlights Medicaid
community engagement initiatives in Virginia and Colorado.
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Strengthened Partnerships + Alliances
Health Equity Strategies
• Consider composition of external stakeholder councils:
councils or subcommittees comprised exclusively of
individuals with lived experience vs. spaces that include
providers, advocates, and other stakeholders.
• Invest in inclusive structures to enable participation of
diverse members in engagement initiatives (e.g., holding
engagement opportunities outside of standard business
hours; in-person vs. hybrid formats; determining the
accessibility of engagements based on location, physical
ability, technology and WIFI availability, literacy, preferred
language, etc.).
• Build multiple channels for member recruitment
beyond written applications and passive solicitation
of applications.
• Build leadership and professional development
opportunities into community engagement activities.
• Offer financial/non-financial16 supports and benefits to
participants and community-based organizations that
reflect and meet their needs.
• Embrace codesigned or community participatory vs.
prescriptive approaches to establishing community
engagement vision, strategic plan, and meeting
agendas. Example: California’s Department of Public
Health.17
Health Equity Tactics
• Conduct a strengths, weaknesses,
opportunities, threats (SWOT) analysis to evaluate
the agency’s community/consumer relationships and
elevate which communities are missing from existing
engagements.
• Conduct a “What’s in it for Me” analysis18 to identify
the benefits and value of engagement for community
members, advocates, and other external stakeholders
the agency intends to engage.
• Determine available levels of support (financial/
non-financial) the agency can provide to trusted
messengers and community-based organizations and
continue to reevaluate periodically; for example:
contracting with community-based organizations to
support engagement; providing honoraria for efforts
supporting recruitment or co-hosting events; assess
the potential risk of losing eligibility for services when
compensating community members.
• Clearly communicate financial support and agency
investment in community engagement infrastructure
(e.g., member advisory councils) via a dedicated
budget for engagement initiatives and transparent
goals for engagement.
Expanded Knowledge
Health Equity Strategies
Health Equity Tactics
• Build multiple channels vs. “one-size-fits-all”
strategies for engaging diverse participants and
populations with specific needs (e.g. cultural,
linguistic, technical, etc.).
• Adopt agency-wide standards for community
engagement, community feedback loops, and
community-ready information (Example: Louisiana
Department of Health, Phase I21).
• Develop culturally centered and linguistically responsive
approaches to the creation, dissemination, and delivery
of information.19
• Establish an agency community engagement plan
that is reviewed annually and community-informed
at a minimum, ideally community-driven (Example:
Louisiana Department of Health, Phase II22).
• Recognize communities as experts on their own
needs and acknowledge learning is bi-directional;
leverage learnings to shift practices.
• Review tangible deliverables and outputs of engagement
for transferability/generalizability to other programs (e.g.
leveraging lessons on messaging expanded Medicaid
• Include knowledge building as a function of all
engagement initiatives and adequately prepare
members for participation in councils or other
engagement conversations.
eligibility to other government programs20).
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Improved Health + Healthcare Programs + Policies
Health Equity Strategies
• Elevate community-defined problems and develop
cooperatively defined metrics of success to evaluate
engagement initiatives.
• Identify sustainable resources for long-term change,
such as dedicated staff, budgeting, and sustainable
partnerships.
• Advance alignment between health and social service
programs.
• Engage in ongoing evaluation/impact assessment to
ensure engagement is meeting members’ needs and
resulting in sustained organizational change.
Health Equity Tactics
• Require all agency staff to participate in cultural humility
training.
• Hire staff with lived experience or contract with
community-based organizations to organize and
conduct engagement activities.
• Publicly create, update, and disseminate a community
feedback tracker (Example: Virginia Department of
Medical Assistance Services23).
• Create a standard, yet flexible, process to co-define
problems and barriers, identify areas for change, and
define associated metrics to track the intended and
unintended impact of engagement efforts.
•Embed health equity/racial and ethnic impact
assessments in engagement planning, design, and
implementation activities (Example: PEW Charitable
Trusts24).
Thriving Communities
Health Equity Strategies
•Embrace getting perspective not taking perspective25
by engaging in targeted conversations rather than
simply trying to understand enrollees’ points of view
without their direct input.
• Share power and resources with communities
vs. simply acknowledging community power and
expertise.26
• Collect accessible, high-quality, complete
demographic data.
• Sustain improved conditions within communities
beyond the time and reach of community engagement
initiatives.
Health Equity Tactics
• Collect demographic data and report trends in
utilization, process, and outcomes for specific
populations of community members (consider race,
ethnicity, geography, disability status, sexual orientation,
gender identity, and health needs/diagnoses).
• Regularly seek community input on engagement
processes through formal (e.g. advisory boards) and
informal channels.
• Assess community engagement efforts by determining
what success looks like from both organizational
and community perspectives (See endnote for sample
reflection questions27).
• Ensure community engagement results in change
and communicate measurable, timebound goals
to participants (e.g. invest in processes resulting in
robust feedback loops28).
• Build and sustain trust over time with participants and
the wider community through consistent, bi-directional
communication and ongoing relationships with
community-based and grassroots organizations.
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Support for this brief was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily
reflect the views of the Foundation.
ABOUT THE ROBERT WOOD JOHNSON FOUNDATION
The Robert Wood Johnson Foundation (RWJF) is committed to improving health and health equity in the United States. In
partnership with others, we are working to develop a Culture of Health rooted in equity that provides every individual with a
fair and just opportunity to thrive, no matter who they are, where they live, or how much money they have.
Health is more than an absence of disease. It is a state of physical, mental, and emotional wellbeing. It reflects what takes
place in our communities, where we live and work, where our children learn and play, and where we gather to worship. That is
why RWJF focuses on identifying, illuminating, and addressing the barriers to health caused by structural racism and other
forms of discrimination, including sexism, ableism, and prejudice based on sexual orientation.
We lean on evidence to advance health equity. We cultivate leaders who work individually and collectively across sectors to
address health equity. We promote policies, practices, and systems-change to dismantle the structural barriers to wellbeing
created by racism. And we work to amplify voices to shift national conversations and attitudes about health and health equity.
Through our efforts, and the efforts of others, we will continue to strive toward a Culture of Health that benefits all. It is our
legacy, it is our calling, and it is our honor.
For more information, visit www.rwjf.org.
ABOUT STATE HEALTH AND VALUE STRATEGIES—PRINCETON UNIVERSITY SCHOOL OF PUBLIC AND
INTERNATIONAL AFFAIRS
State Health and Value Strategies (SHVS) assists states in their efforts to transform health and healthcare by providing
targeted technical assistance to state officials and agencies. The program is a grantee of the Robert Wood Johnson
Foundation, led by staff at Princeton University’s School of Public and International Affairs. The program connects states with
experts and peers to undertake healthcare transformation initiatives. By engaging state officials, the program provides lessons
learned, highlights successful strategies, and brings together states with experts in the field. Learn more at www.shvs.org.
ABOUT HEALTH EQUITY SOLUTIONS
This document was prepared by Tekisha Dwan Everette, Dashni Sathasivam, and Karen Siegel. Health Equity Solutions
(HES) promotes policies, programs, and practices that result in equitable health care access, delivery, and outcomes for all
people regardless of race or income. HES works with State Health and Value Strategies (SHVS) to guide the program’s
health
equity work generally while also providing targeted technical assistance to states. HES is based in Hartford, Connecticut and
focuses its work outside of the support it provides to SHVS on achieving health equity in Connecticut.
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E NDN O TES
1. Loewenson, R., Colvin, C. J., Szabzon, F., Das, S., Khanna, R., Coelho, V. S. P., … & Nolan, E. Beyond command and control: a rapid review of
meaningful community-engaged responses to COVID-19. Global Public Health. 2002. 16(8-9), 1439-1453.
2. Apenteng, B. A., Kimsey, L., Opoku, S. T., Owens, C., Peden, A. H., & Mase, W. A. Addressing the Social Needs of Medicaid Enrollees Through
Managed Care: Lessons and Promising Practices from the Field. Population Health Management. 2002. 25(1), 119-125.
3. Center for Consumer Engagement in Health Innovation. An exploration of Consumer Advisory Councils Within Medicare Medicaid Plans to Participate in
the Financial Alignment Initiative. https://www.healthinnovation.org/resources/publications/ an exploration-of-consumer-advisory-councils-within
medicaremedicaid-plans.
4. Zhu, J. M., Rowland, R., Gunn, R., Gollust, S., & Grande, D. T. Engaging Consumers in Medicaid Program Design: Strategies from the States. The
Milbank quarterly. 2021. 99(1), 99–125. https://doi.org/10.1111/1468-0009.12492
5. Bassler, A. et al. Center for Rural Pennsylvania. 2008. Developing Effective Citizen Engagement: A How-to Guide for Community Leaders.
6. Carnegie Foundation for the Advancement of Teaching. Palo Alto: Carnegie Foundation for the Advancement of Teaching. 2006.
Community engagement classification.
7. Israel, B. A., Parker, E. A., Rowe, Z., Salvatore, A., Minkler, M., López, J., Butz, A., Mosley, A., Coates, L., Lambert, G., Potito, P. A., Brenner, B.,
Rivera, M., Romero, H., Thompson, B., Coronado, G., & Halstead, S. 2005.
8. Israel, Barbara A., et al. Community-Based Participatory Research: Lessons Learned from the Centers for Children’s Environmental Health and Disease
Prevention Research. Environmental Health Perspectives. Oct. 2005. pp. 1463–1471, www.ncbi.nlm.nih.gov/pmc/articles/PMC1281296/, 10.1289/
ehp.7675.
9. Holland, B., & Ramaley, J. Creating a Supportive Environment For Community-University Engagement: Conceptual Framework. HERDSA. 2008.
Creating a Supportive Environment for Community- University Engagement: Conceptual Frameworks | herdsa.org.au
10. While several states offer financial compensation for participation in community engagement, we note that this can be complex both because of state
administrative requirements and concerns about slight increases in income impacting enrollees’ eligibility status. For more on this topic, see State
Examples of Medicaid Community Engagement Strategies: Two Case Studies.
11. Gonzalez, Rosa. The Spectrum of Community Engagement to Ownership. Facilitating Power. 2019. https://movementstrategy.org/resources/
the spectrum-of-community-engagement-to-ownership/.
12. Ibid
13. Ibid
14. Assessing Meaningful Community Engagement: A Conceptual Model to Advance Health Equity through Transformed Systems for Health.
NAM Perspectives. Commentary, National Academy of Medicine. 2022. https://doi.org/10.31478/202202c.
15. Ibid
16. When offering financial support it is crucial to ensure that the level of support does not increase participants’ income to an extent that makes
them ineligible for programs/services. A more detailed discussion is included in State Examples of Medicaid Community Engagement Strategies: Two
Case Studies.
17. California Department of Public Health. 2021. Engaging Communities for Greater Equity and Environmental Justice (ca.gov)
18. Madera, J. M. What’s in It for Me? Perspective Taking as an Intervention for Improving Attitudes Toward Diversity Management.
Cornell Hospitality Quarterly. 2008, 59(2), 100–111. https://doi.org/10.1177/1938965517730319
19. Cultural and Linguistic Competence Policy Assessment. National Center for Cultural Competence, Georgetown University Center for Child and Human
Development. 2006. https://nccc.georgetown.edu/documents/CLCPA.pdf
20. Cordoba, M. Effective Messaging About the Medi-Cal Expansion to Older Adults. California Health Care Foundation. 2002.
https://www.chcf.org/publication effective-messaging-medi-cal-expansion-older-adults/
21. Louisiana Department of Health. Health Equity Plan Phase I. 2002. https://ldh.la.gov/assets/cphe/Equity_Framework.pdf
22. Louisiana Department of Health. Health Equity Roadmap, Phase 2: Nothing About Us Without Us. 2002.
https://ldh.la.gov/assets/cphe/resources/Health-Equity-Roadmap-Phase2.pdf
23. Virginia Department of Medical Assistance Services. Virginia Medicaid Member Advisory Committee Annual Report. 2002.
https://www.dmas.virginia.gov/media/2566/2019-mac-report.pdf
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E N D N O TES
24. Pew Charitable Trusts. Do Health Impact Assessments Help Promote Equity Over the Long Term? 2002. https://www.pewtrusts.org/en/
researchandanalysis/reports/2020/11/do-health-impact-assessments-help-promote-equity-over-the-long-term – :~:text=The key findings are%
3A,health equity and public decisions
25. Eyal, T., Steffel, M., & Epley, N. Perspective mistaking: Accurately Understanding the Mind of Another Requires Getting Perspective, Not Taking Perspective.
Journal of Personality and Social Psychology. 114(4), 547.
26. Bataille, J. and Hodes, C. Advancing Health Equity in Oregon: Building a Foundation. 2002. https://www.shvs.org/oregon-health-authority-health-equitycase
study/
27. Gonzalez, Rosa. The Spectrum of Community Engagement to Ownership Facilitating Power. 2019. https://movementstrategy.org/resources/the-spectrum
-of-community-engagement-to-ownership/
28. Jackson, K. T., Burgess, S., Toms, F., & Cuthbertson, E. L. Community engagement: Using feedback loops to empower residents and influence
systemic change in culturally diverse communities. Global Journal of Community Psychology Practice. 2018. 9(2), 1-21.
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