CDC and States: Partnering to Achieve Health Equity

1. CDC and States: Partnering to Achieve Health Equity Michael L. Sells, MSPH, CHES Behavioral Scientist Program Development and Evaluation Branch Division of Nutrition, Physical Activity & Obesity Centers for Disease Control and Prevention The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention

2. Objectives of the Presentation • Overview of Key Terms • CDC’s priorities for achieving health equity and eliminating health disparities • Health disparities-focused strategies across the behavioral target areas • Example approaches from the states

3. Key Terms • Justice • Health Equity • Health Disparities • Socioeconomic Factors • Social Determinants of Health

4. Justice in Public Health • Justice defined: • The fair disbursement of common advantages and the sharing of common burdens. • Two Aspects of Justice • Health Improvement for the population • Fair treatment of the disadvantaged Source: Gostin, L. & Powers, M. (2006) What Does Social Justice Require for the Public’s Health? Public Health Ethics and Policy Imperatives. Health Affairs, 25:4

5. Factors that Affect Health Smallest Impact Largest Impact Examples Eat healthy, be physically active Counseling & Education Rx for high blood pressure, high cholesterol, diabetes Clinical Interventions Immunizations, brief intervention, cessation treatment, colonoscopy Long-lasting Protective Interventions Long-lasting Protective Interventions Fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax Changing the Context to make individuals’ default decisions healthy Changing the Context to make individuals’ default decisions healthy Poverty, education, housing, inequality Socioeconomic Factors a Socioeconomic Factors

6. CDC’s Health Protection Goals Healthy People in Every Stage of LifeAll people, and especially those at greater risk of health disparities, will achieve their optimal lifespan with the best possible quality of health in every stage of life. Healthy People in Healthy PlacesThe places where people live, work, learn, and play will protect and promote their health and safety, especially those people at greater risk of health disparities. Source: www.cdc.gov/osi/goals/ Health Disparities Identified as a Strategic Priority by the Division of Nutrition Physical Activity & Obesity

7. DNPAO’s Health Equity Initiative& Work Group • Mission: • To achieve health equity in physical activity, nutrition, and healthy weight across the United States and abroad through the elimination of health disparities. • Goal: • to achieve health equity by developing and sustaining the capacity and resources of DNPAO to reduce and eventually eliminate disparities in nutrition, physical activity and obesity among different segments of the population in collaboration with the NCCDPHP, as well as internal and external partners.

8. Geographic Location Gender Race/Ethnicity Education Income Age Disability Risk Factors in Health Disparities

9. The DNPAO Health Equity Strategy • Four Phases (infrastructure, planning, execution and evaluation) • Infrastructure and Planning Phases • Logic Model • Strategic Plan • Focus Areas • Objectives

10. Convergence Model of Health Disparities PA F&V SSB ED TV BF Target Behaviors: Developed by: Michael Sells, MSPH, CHES

11. Convergence Model of Health Disparities PA F&V SSB ED TV BF Target Behaviors: RF RF RF RF RF RF RF RF RF RF RF RF RF RF RF RF RF RF Health Disp. Risk Factors: Developed by: Michael Sells, MSPH, CHES

12. Convergence Model of Health Disparities PA F&V SSB ED TV BF Target Behaviors: RF RF RF RF RF RF RF RF RF RF RF RF RF RF RF RF RF RF Health Disp. Risk Factors: Education Income Race Macro Level Health Disparities: Developed by: Michael Sells, MSPH, CHES

13. Establish staff capacity and/or infrastructure Inventory of existing activities Identify the disparities with data Strategic planning Prioritize activities Baseline data for evaluation Final strategic plan Implement activities Source: CDC’s Division of Nutrition Physical Activity and Obesity Operationalizing Health Equity at CDC

14. Examples of approaches and opportunities in DNPAO • Health Impact Assessments • Facilitation of the Navajo Nation Worksite Breastfeeding Law • Dietary Quality and Breastfeeding Expert Panels • Evaluability Assessments • Food desert information recently submitted to H.H.S. that informed the White House Initiative • COCOMO Measures

15. Examples of Approaches and Opportunities in DNPAO (Cont.) • Health Disparities-focused Strategies based on the top three strategies across the six Behavioral Target Areas • Expert Panel, Curriculum and Toolkit • Publish, Partnerships & Technical Assistance • Policy approach-The zoning regulation in Los Angeles that resulted in a moratorium on fast food restaurants.

16. Healthy Food Retail: State partnerships should have diverse representation including community representatives, grocery store owners, agricultural players, distributors, and other nontraditional partners to give insight into kind of store and products needed to ensure successful and sustainable store change. Business associations, Hispanic coalitions, and other community organizations and advocates may be much more connected to communities to add appropriate context to plans to change retail environment t han state partners. (ex. Using girl scouts to take pictures of sidewalks to show city council) Menu Labeling/Nutrition Standards: Addressing healthy food access in general may be more pertinent to address disparities in communities before menu labeling because increasing access to healthy foods and increasing choices is important not just labeling what is unhealthy Sugar Sweetened Beverages: Beware of unintended consequences (promote diet soda and 100% juice by taxing SSB). We need to come to a consens us about how we feel about all artificially sweetened beverages including diet drinks; need to have consistent policy/definition/standard; consistent messaging ‘Choose only water?’ water is the cheapest from disparities perspective; no matter what the stra tegy is; but all (government and private) need to be on the same page Reducing Dietary Quality Disparities Expert Panel Priority Recommendations

17. Breastfeeding Expert Panel Priority Recommendations • Panel Session I – Community • Improve health promotion efforts targeting African Americans • Panel Session II – Medical Care • Encourage hospitals to provide an alternative to formula bags • Panel Session III – Employment • Provide employers with breastfeeding-friendly policies and have CDC and state govts. set stds. /models, etc. • Panel Session IV – Infrastructure • Develop a website on African American Breastfeeding, associated with social marketing campaign

18. Examples of Health Disparity Focused Strategies by Target Area • Breastfeeding • Maternity care practices • Peer Support • Educating mothers • Media and social marketing • Physical Activity • Enhanced physical education in schools • Social support interventions in community settings

19. Examples of Health Disparity Focused Strategies by Target Area • Sugar Sweetened Beverages • Ensure ready access to safe drinking water of acceptable quality • Limit access to sugar sweetened beverages • Fruits and Vegetables • Include or expand Farm-to-Where-You-Are Programs • Increase access to fruits and vegetables in emergency food programs

20. Examples of Health Disparity Focused Strategies by Target Area • Energy Density • Promote menu labeling • Improve geographic accessibility of supermarkets in underserved areas • Television Viewing • Develop and implement curricula to reduce TV/screen time

21. Examples from States • North Carolina - Community Gardens • Montana – Trail adaptation for older adults • Georgia – Accessibility and teaching behavioral skills in partnership with WIC • Indiana – funding local minority coalitions • New York – Partnering with diabetes program to work with American Indian populations

22. State Programs Health Disparities Inventory

23. Criteria for identifying Health Disparities-focused Strategies • The strategy targets specific populations that are disproportionately impacted by obesity, poor nutrition, or lack of adequate physical activity as identified through one or more of the following risk factors: low income, racial/ethnic minority group(s); persons with less than or equal to high school diploma; gender; rural or urban geographic locations; and persons with disabilities. • The strategy is either evidence-based or practice-based if it (1) has been successfully evaluated or (2) has been piloted in the populations experiencing the risk factor(s) physical activity.

24. Potential Strategies and Interventions for States • Farm to fork • Urban Agriculture • Seed funding • Active + passive policies • Health marketing (old + new approaches) • Equity in built environments • Multi-disciplinary collaborations • Training of lay health workers

25. Consider these factors as we seek to become more culturally competent • Respect • It is a process • Different beliefs • Learn about other cultures • Work with other groups • Genuine desire Source: Smith, R. Ethnicity & Culture (2008)

26. Considerations • Policy strategies • Passive: require no action on the part of the at-risk individuals • Active: require cooperation from the at-risk individuals Source: Gielen & Girasek (2001). Integrating Perspectives on the Prevention of Unintentional Injuries. Integrating Behavioral with Social Sciences • Behavioral change • Assets-based approach • Culturally & linguistically appropriate standards • Multi-level or Ecological approach • Resilience Research

27. In Conclusion A rising tide will not lift all boats if some boats have holes in them. Let’s work together to achieve health equity and patch up the holes by addressing health disparities and social determinants of health.

28. Thank You Michael L. Sells, MSPH, CHES Email: znp1@cdc.gov Phone: (770)488-5465