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

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

Key Terms Justice Health Equity Health Disparities Socioeconomic Factors Social Determinants of Health

Justice in Public Health Justice defined: – The fair disbursement of common advantages and the sharing of common burdens. Two Aspects of Justice 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

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

CDC’s Health Protection Goals Healthy People in Every Stage of LifeHealthy People in Every Stage of Life All 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 PlacesHealthy People in Healthy Places The 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: Health Disparities Identified as a Strategic Priority by the Division of Nutrition Physical Activity & Obesity

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.

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

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

Convergence Model of Health Disparities PAF&V EDSSBTVBF Target Behaviors: Developed by: Michael Sells, MSPH, CHES

Convergence Model of Health Disparities PAF&V EDSSBTVBF Target Behaviors: Health Disp. Risk Factors: RF Developed by: Michael Sells, MSPH, CHES

Convergence Model of Health Disparities PAF&V EDSSBTVBF Target Behaviors: Health Disp. Risk Factors: RF Macro Level Health Disparities: EducationIncomeRace Developed by: Michael Sells, MSPH, CHES

Operationalizing Health Equity at CDC 1.Establish staff capacity and/or infrastructure 2.Inventory of existing activities 3.Identify the disparities with data 4.Strategic planning 5.Prioritize activities 6.Baseline data for evaluation 7.Final strategic plan 8.Implement activities Source: CDC’s Division of Nutrition Physical Activity and Obesity

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

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.

Reducing Dietary Quality Disparities Expert Panel Priority Recommendations 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 than 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 labelingbecause 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 consensus 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 strategy is; but all (government and private) need to be on the same page

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

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

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

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

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

State Programs Health Disparities Inventory

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.

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

Consider these factors as we seek to become more culturally competent 1.Respect 2.It is a process 3.Different beliefs 4.Learn about other cultures 5.Work with other groups 6.Genuine desire Source: Smith, R. Ethnicity & Culture (2008)

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

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.

Thank You Michael L. Sells, MSPH, CHES Phone: (770)