Multilevel Factors Impacting Substance Use Treatment Access, Engagement, and Racial Equity Among Opioid Overdose Survivors in Boston, MA.

BACKGROUND: There are well-documented racial/ethnic inequities in drug-related overdoses and access to evidence-based opioid use services nationally and in Boston, MA. OBJECTIVE: To qualitatively explore the drivers of racial/ethnic inequities in access to opioid use disorder treatment and services in Boston. DESIGN: Semi-structured qualitative interviews. PARTICIPANTS: Using purposive sampling, researchers recruited 59 opioid overdose survivors in Boston who self-identified as Black, Hispanic or Latino/a/x, and/or White. APPROACH: Interviewers administered a socio-demographic and drug use survey, and used a semi-structured interview guide to explore experiences with and perspectives on substance use treatment and services. KEY RESULTS: Participants' racial/ethnic identities were distributed across three subgroups: non-Hispanic Black (n = 18; 31%), non-Hispanic White (n = 18; 31%), and Latino/a/x (n = 23; 39%). Qualitative analysis identified multiple themes that were organized into four social-ecological levels after analysis. At the individual level, some participants emphasized the importance of personal responsibility and individual motivation in determining access to services. Participants expressed a range of perspectives about using medication for opioid use disorder treatment; Black and Latino/a/x participants were more likely than White participants to have critical perspectives. At the interpersonal level, experiences of bias, stigma, and racism from staff in healthcare and treatment settings were common. At the program/process level, participants described challenges connecting to services following overdose and barriers within specific programs, with Black and Latino/a/x participants experiencing particular gaps. At the systems level, the limited availability of housing, employment, and mental health care negatively impacted treatment access and engagement. CONCLUSION: A racism lens was used during data interpretation to apply the themes at a broader population level. Through this lens, the identified barriers can be understood to have a disproportionate impact on people of color. Findings call for programmatic and policy solutions that address racism, break down stigma, and ensure equitable access to evidence-based services and social supports.

Current Practices in Operationalizing and Addressing Racial Equity in the Provision of Type 1 Diabetes Care: Insights from the Type 1 Diabetes Exchange Quality Improvement Collaborative Health Equity Advancement Lab.

OBJECTIVE: Medical racism contributes to adverse health outcomes. Type 1 Diabetes Exchange Quality Improvement Collaborative (T1DX-QI) is a large population-based cohort engaged in data sharing and quality improvement to drive system changes in T1D care. The annual T1DX-QI survey included questions to evaluate racial equity in diabetes care and practices to promote equity. METHODS: The annual T1DX-QI survey was administered to participating clinics in fall 2022 and had a 93% response rate. There were 50 responses (pediatric: 66% and adult: 34%). Questions, in part, evaluated clinical resources and racial equity. Response data were aggregated, summarized, and stratified by pediatric/adult institutions. RESULTS: Only 21% pediatric and 35% adult institutions felt that all their team members can articulate how medical racism contributes to adverse diabetes outcomes. Pediatric institutions reported more strategies to address medical racism than adult (3.6 vs 3.1). Organizational strategies to decrease racial discrimination included employee trainings, equity offices/committees, patient resources, and hiring practices. Patient resources included interpreter services, transportation, insurance navigation, and housing and food assistance. Hiring practices included changing prior protocols, hiring from the community, and diversifying workforces. Most institutions have offered antiracism training in the last year (pediatric: 85% and adult: 72%) and annually (pediatric: 64% and adult: 56%). Pediatric teams felt that their antiracism training was effective more often (pediatric: 60% and adult: 45%) and more commonly, they were provided resources (pediatric: 67% and adult: 47%) to help address inequities. CONCLUSION: Despite increased antiracism training, insufficient institutional support and perceived subeffective training still represent obstacles, especially in adult institutions. Sharing effective strategies to address medical racism will help institutions take steps to mitigate inequities.

The Association of Racial and Ethnic Concordance in Primary Care with Patient Satisfaction and Experience of Care.

BACKGROUND: The lack of racial and ethnic concordance between patients and their physicians may contribute to American health disparities. OBJECTIVE: To examine the level of racial and ethnic concordance for patients and primary care clinicians and its association with measures of patient experience. DESIGN: Multivariate cross-sectional analysis of nationally representative data. PARTICIPANTS: Adults 18 to 64 in the 2019 Medical Expenditure Panel Survey who had at least one medical visit in the past year. MAIN MEASURES: Key independent variables include having a racially/ethnically concordant primary care clinician, lacking a usual source of care, and having a usual source that is a place rather than a person. Outcomes include overall satisfaction with health care, number of medical visits, having enough time in care, ease of understanding the clinician, and receiving respect. KEY RESULTS: The comparison between the actual level of concordance with an expected distribution if all patients had the same probability of having a clinician of a given race or type indicates that Black, Latino, and Asian patients are three or more times as likely to have a concordant clinician than expected, suggesting a strong preference for clinicians of the same race or ethnicity. Racial or ethnic concordance has a modest positive association with overall health care satisfaction and respect but is not significantly associated with the number of medical visits or other outcomes. Poor health status, being uninsured, and lacking a usual source of care are more strongly associated with patient experience. DISCUSSION: Efforts to increase the diversity of the primary care workforce could increase racial/ethnic concordance but may have only modest effects on patients' experience of care. Policies like lowering the number of uninsured or increasing those with a usual source of care may be more salient in improving experience of care.

Leveraging individual power to improve racial equity in academia.

Academia in the United States continues to grapple with its longstanding history of racial discrimination and its active perpetuation of racial disparities. To this end, universities and academic societies must grow in ways that reduce racial minoritization and foster racial equity. What are the effective and long-lasting approaches we as academics should prioritize to promote racial equity in our academic communities? To address this, the authors held a diversity, equity, and inclusion (DEI) panel during the Society for Behavioral Neuroendocrinology 2022 annual meeting, and in the following commentary synthesize the panelists' recommendations for fostering racial equity in the US academic community.

Addressing anti-black racism in an academic preterm birth initiative: perspectives from a mixed methods case study.

BACKGROUND: Growing recognition of racism perpetuated within academic institutions has given rise to anti-racism efforts in these settings. In June 2020, the university-based California Preterm Birth Initiative (PTBi) committed to an Anti-Racism Action Plan outlining an approach to address anti-Blackness. This case study assessed perspectives on PTBi's anti-racism efforts to support continued growth toward racial equity within the initiative. METHODS: This mixed methods case study included an online survey with multiple choice and open-ended survey items (n = 27) and key informant interviews (n = 8) of leadership, faculty, staff, and trainees working within the initiative. Survey and interview questions focused on perspectives about individual and organizational anti-racism competencies, perceived areas of initiative success, and opportunities for improvement. Qualitative interview and survey data were coded and organized into common themes within assessment domains. RESULTS: Most survey respondents reported they felt competent in all the assessed anti-racism skills, including foundational knowledge and responding to workplace racism. They also felt confident in PTBi's commitment to address anti-Blackness. Fewer respondents were clear on strategic plans, resources allocated, and how the anti-racism agenda was being implemented. Suggestions from both data sources included further operationalizing and communicating commitments, integrating an anti-racism lens across all activities, ensuring accountability including staffing and funding consistent with anti-racist approaches, persistence in hiring Black faculty, providing professional development and support for Black staff, and addressing unintentional interpersonal harms to Black individuals. CONCLUSIONS: This case study contributes key lessons which move beyond individual-level and theoretical approaches towards transparency and accountability in academic institutions aiming to address anti-Black racism. Even with PTBi's strong commitment and efforts towards racial equity, these case study findings illustrate that actions must have sustained support by the broader institution and include leadership commitment, capacity-building via ongoing coaching and training, broad incorporation of anti-racism practices and procedures, continuous learning, and ongoing accountability for both short- and longer-term sustainable impact.

Black mothers' birthing experiences: in search of birthing justice.

OBJECTIVES: Previous studies have suggested that often, Black mothers' birthing experiences are not what they expected because of how they were treated by healthcare providers during labor and birth. Our goal in this study was to ask Black mothers who had recently given birth about the quality of their birthing experiences as well as their level of respect from, trust in, and satisfaction with their maternity healthcare providers. DESIGN: This study gathered data from Black mothers (N = 209) who had given birth within the past two years, using a cross-sectional online survey measuring several variables about the birthing experience including types of healthcare provider communication, provider respect for the mother, trust, birth satisfaction, and emotional responses to birth. RESULTS: Provider-centered communication, although preferred by some mothers, was associated with lower birth satisfaction and stronger negative emotions whereas positive birth satisfaction was linked to patient-centered communication which resulted in positive emotions. While most mothers reported overall satisfaction with their birth experience, nearly half reported experiencing some degree of disrespect from their healthcare providers during labor and birth. Moreover, trust and respect mediated the relationship for patient-centered communication with positive emotion and birth satisfaction. Over one-third of participants gave birth with a certified nurse midwife attending. There were no differences in perception of being respected or the quality of birth given the professional identity of the provider as an Obstetrician/Gynecologist or as a midwife. The advice suggested by Black mothers for their healthcare providers was instructive in identifying ways those providers could better serve their patients during birth. CONCLUSION: This study showed that there is still additional work that needs to be done for racial equity and respect during birth. Practical implications for addressing health inequities are discussed.

Federal Direction + Local Implementation as a Strategy for Improving Infant Health: The Founding and Evolution of the Infant Welfare Society of Evanston.

While the role of the US federal government in improving Maternal and Child Health (MCH) is often seen as a history of opportunities and tensions between the federal bureaucracy and state implementation, less is known about how federal governmental policies to improve MCH have been implemented at the local level, and the nature of the dynamic between local implementation and federal adoption of locally generated strategies. By describing the emergence of the Infant Welfare Society of Evanston in the first part of the 20th century and describing its evolution until 1971, we showcase the forces that shaped the emergence of an MCH institution at the local level in the early part of the history of MCH in the US.  This article highlights the interaction of a progressive maternalistic frame and the growth of local public health infrastructure as fundamental to the basis of action to address infant health during this period. However, this history also highlights the complex relationship of institutions dominated by White women and their relationship to the populations served in the development of the field of MCH and elucidates the need for more explicit attention to understanding the role of Black social institutions in the development of the field of MCH.

The history of Maternal and Child Health (MCH) in the US is often seen through the lens of federal-state relations; however, less is known about how federal governmental policies to improve MCH have been implemented at the local level, and the nature of the dynamic between local implementation and federal adoption of locally generated strategies. To address this gap in our historical knowledge, we tell the story of the Infant Welfare Society of Evanston (IWSE), a community-based organization, whose activities to address infant health beginning in the second decade of the 20th century directly parallel and in some circumstances influenced federal MCH efforts. Examining this history enables us to also explore issues of racial equity in the development of the field of MCH in the US.

Racial and Ethnic Representation in Preventive Intervention Research: a Methodological Study.

Individuals who are Asian or Asian American, Black or African American, Native American or American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and Hispanic or Latino (i.e., presently considered racial ethnic minoritized groups in the USA) lacked equal access to resources for mitigating risk during COVID-19, which highlighted public health disparities and exacerbated inequities rooted in structural racism that have contributed to many injustices, such as failing public school systems and unsafe neighborhoods. Minoritized groups are also vulnerable to climate change wherein the most severe harms disproportionately fall upon underserved communities. While systemic changes are needed to address these pervasive syndemic conditions, immediate efforts involve examining strategies to promote equitable health and well-being-which served as the impetus for this study. We conducted a descriptive analysis on the prevalence of culturally tailored interventions and reporting of sample characteristics among 885 programs with evaluations published from 2010 to 2021 and recorded in the Blueprints for Healthy Youth Development registry. Inferential analyses also examined (1) reporting time trends and (2) the relationship between study quality (i.e., strong methods, beneficial effects) and culturally tailored programs and racial ethnic enrollment. Two percent of programs were developed for Black or African American youth, and 4% targeted Hispanic or Latino populations. For the 77% of studies that reported race, most enrollees were White (35%) followed by Black or African American (28%), and 31% collapsed across race or categorized race with ethnicity. In the 64% of studies that reported ethnicity, 32% of enrollees were Hispanic or Latino. Reporting has not improved, and there was no relationship between high-quality studies and programs developed for racial ethnic youth, or samples with high proportions of racial ethnic enrollees. Research gaps on racial ethnic groups call for clear reporting and better representation to reduce disparities and improve the utility of interventions.

Race matters in addressing homelessness: A scoping review and call for critical research.

Structural racism contributes to homelessness in the United States, as evidenced by the stark racial disparities in who experiences it. This paper reviews research at the intersections of race and homelessness to advance efforts to understand and address racial inequities. Part 1 offers a synthesis of homelessness research from the 1980s to 2015, where several scholars examined the role of race and racism despite mainstream efforts to present the issue as race-neutral. Part 2 presents the results of a systematic scoping review of research at the intersections of race and homelessness from 2016 to 2021. The 90 articles included demonstrate a growing, multidisciplinary body of literature that documents how needs and trajectories of people experiencing homelessness differ by race, examines how the racialized structuring of society contributes to homelessness risk, and explores how programs, policies, and grassroots action can address inequities. In addition to charting findings and implications, included studies are appraised against research principles developed by Critical Race Theory scholars, mapping the potential of existing research on race and homelessness to challenge racism.

Striving for safety, impact, and equity: A critical consideration of AJCP publications on formal youth mentoring programs.

In this virtual special issue (VSI) we curate and reflect upon 22 articles on formal youth mentoring previously published in the American Journal of Community Psychology (AJCP). First, we provide historical context and highlight AJCP's 2002 special issue on mentoring, which played an important role in establishing youth mentoring as a vibrant area of research. Next, we review and discuss findings from subsequent AJCP studies in three interrelated lines of inquiry: (1) the importance of facilitating high-quality mentoring relationships; (2) associations among youth's presenting needs, relationship quality, and outcomes; and (3) program practices leading to stronger, more impactful relationships. Throughout, we highlight and expand upon critical commentary from AJCP contributors, calling on the field to move away from paternalistic models that overly localize risk with youth and families without interrogating structural oppression. Our recommendations include: (1) centering critical consciousness, racial equity, and social justice in program curricula and mentor trainings; (2) respectfully engaging grassroots programs developed for and by communities of color that are underrepresented in research; (3) making meaningful efforts to recruit mentors from marginalized communities and removing barriers to their participation; and (4) examining youth's racial, ethnic, and other areas of identity development processes during mentoring.

Putting the system in systemic racism: A systems thinking approach to advancing equity.

Generations of scholars and activists have argued that racial inequities emerge not only because of racist ideologies but also from a hierarchical system of racial oppression. This theoretical tradition has highlighted numerous ways in which systemic racism manifests itself, from racist policies to differential access to material conditions and power. However, given that by definition systemic racism is focused on systems, theories of systemic racism would be more comprehensive and actionable by drawing on scholarship related to systems thinking. Systems thinking is a conceptual orientation that aims to understand how different types of systems function over time. This paper builds on the work of previous scholars to propose a systems thinking approach to understand and strategically disrupt racist systems. We provide a typology of system characteristics (organized into the categories of paradigms, structures, elements, and feedback loops) that together can be used to help understand the operation of systemic racism in different system contexts. The paper also provides an approach to identify and strategically target multiple system leverage points to simultaneously disrupt the status quo of racial inequity and promote the emergence of conditions enabling racial equity. This systems thinking approach can be used to guide learning and action within an ongoing process of antiracist praxis.

Using Collective Impact to Develop a Community-Led Initiative for Improving Black Infant Mortality.

The United States has one of the highest infant mortality rates among developed countries. When stratified by race, disparities are more evident: Black infant mortality rates are 2.5 times higher than non-Hispanic white infants. Structural, systemic racism is a contributing cause for these racial disparities. Multisector collaborations focused on a common agenda, often referred to as collective impact, have been used for infant mortality reduction interventions. In addition, community-based participatory approaches have been applied to incorporate those with lived experience related to adverse pregnancy outcomes. This article critically describes the transition of an infant mortality collective impact initiative from being led by a multisector organizational group to being community led over a 5-year period, 2015-2020. A 34-member community leaders group was developed and determined four priorities and corresponding strategies for the initiative. Findings show that community participatory approaches are a way to address racial equity for public health initiatives.

Group vs traditional prenatal care for improving racial equity in preterm birth and low birthweight: the Centering and Racial Disparities randomized clinical trial study.

BACKGROUND: The United States has persistently high rates of preterm birth and low birthweight and is characterized by significant racial disparities in these rates. Innovative group prenatal care models, such as CenteringPregnancy, have been proposed as a potential approach to improve the rates of preterm birth and low birthweight and to reduce disparities in these pregnancy outcomes. OBJECTIVE: This study aimed to test whether participation in group prenatal care would reduce the rates of preterm birth and low birthweight compared with individual prenatal care and whether group prenatal care would reduce the racial disparity in these rates between Black and White patients. STUDY DESIGN: This was a randomized controlled trial among medically low-risk pregnant patients at a single study site. Eligible patients were stratified by self-identified race and ethnicity and randomly allocated 1:1 between group and individual prenatal care. The primary outcomes were preterm birth at <37 weeks of gestation and low birthweight of <2500 g. The primary analysis was performed according to the intent-to-treat principle. The secondary analyses were performed according to the as-treated principle using modified intent-to-treat and per-compliance approaches. The analysis of effect modification by race and ethnicity was planned. RESULTS: A total of 2350 participants were enrolled, with 1176 assigned to group prenatal care and 1174 assigned to individual prenatal care. The study population included 952 Black (40.5%), 502 Hispanic (21.4%), 863 White (36.8%), and 31 "other races or ethnicity" (1.3%) participants. Group prenatal care did not reduce the rate of preterm birth (10.4% vs 8.7%; odds ratio, 1.22; 95% confidence interval, 0.92-1.63; P=.17) or low birthweight (9.6% vs 8.9%; odds ratio, 1.08; 95% confidence interval, 0.80-1.45; P=.62) compared with individual prenatal care. In subgroup analysis, greater attendance in prenatal care was associated with lower rates of preterm birth and low birthweight. This effect was most noticeable for the rates of low birthweight for Black participants in group care: intent to treat (51/409 [12.5%]), modified intent to treat (36/313 [11.5%]), and per compliance (20/240 [8.3%]). Although the rates of low birthweight were significantly higher for Black participants than White participants seen in individual care (adjusted odds ratio, 2.00; 95% confidence interval, 1.14-3.50), the difference was not significant for Black participants in group care compared with their White counterparts (adjusted odds ratio, 1.58; 95% confidence interval, 0.74-3.34). CONCLUSION: There was no difference in the overall rates of preterm birth or low birthweight between group and individual prenatal care. With increased participation in group prenatal care, lower rates of preterm birth and low birthweight for Black participants were observed. The role of group care models in reducing racial disparities in these birth outcomes requires further study.

Centering Equity and Developing the Maternal Health Workforce: Building the National Maternal Health Learning and Innovation Center.

PURPOSE: The purpose of this article is to describe the development of the Maternal Health Learning and Innovation Center (MHLIC), a national initiative designed to enhance workforce capacity of maternal health professionals in the United States. DESCRIPTION: The mission of the MHLIC is to foster collaboration and learning among diverse stakeholders to accelerate evidence-informed approaches advancing equitable maternal health outcomes through engagement, innovation, and policy. Working to center equity in all efforts, the MHLIC builds workforce capacity through partnership, training, technical assistance, coaching, facilitation of peer learning, and a national resource repository. ASSESSMENT: The MHLIC employed several assessment strategies in its first year, including a baseline learning survey of awardees, a stakeholder survey of potential collaborators in maternal health, and advisory convenings. Internally the MHLIC team assessed its own intercultural development. Assessment results informed internal and external approaches to workforce development. CONCLUSIONS: Telehealth implementation, access to services for rural populations, racial inequities, and data use and dissemination were the primary gaps that awardees and other stakeholders identified. The MHLIC is unique in its collaborative design approach and the centering of equity as foundational to the structure, subject, and culture of its work. The MHLIC utilizes a collaborative approach that capitalizes on academic and practice partners' extensive expertise in maternal health systems. Key to the success of future maternal health efforts is workforce development that builds the awareness and capacity to advance racial and geographic equity for public health, community, and clinical professionals.

What Is a "Racial Health Disparity"? Five Analytic Traditions.

What exactly is a "racial health disparity"? This article explores five lenses that have been used to answer that question. It contends that racial health disparities have been presented-by researchers both within academia and outside of it-as problems of five varieties: biology, behavior, place, stress, and policy. It also argues that a sixth tradition exploring class-and its connection to race, racism, and health-has been underdeveloped. The author examines each of these conceptions of racial disparities in turn. Baked into each interpretive prism is a set of assumptions about the mechanisms that produce disparities-a story, in other words, about where racial health disparities come from. Discursive boundaries set the parameters for policy debate, determining what is and is not included in proposed solutions. How one sees racial health disparities, then, influences the strategies a society advocates-or ignores-for their elimination. The author ends by briefly discussing problems in the larger research ecosystem that dictate how racial health disparities are studied.

Use of smartphone mobility data to analyze city park visits during the COVID-19 pandemic.

Introduction: The COVID-19 pandemic focused attention on city parks as important public resources. However, monitoring park use over time poses practical challenges. Thus, pandemic-related trends are unknown. Methods: We analyzed monthly mobility data from a large panel of smartphone devices, to assess park visits from January 2018 to November 2020 in the 50 largest U.S. cities. Results: In our sample of 11,890 city parks, visits declined by 36.0 % (95 % CI [27.3, 43.6], p < 0.001) from March through November 2020, compared to prior levels and trends. When we segmented the COVID-19 period into widespread closures (March-April) and reopenings (May-November), we estimated a small rebound in visits during reopenings. In park service areas where a greater proportion of residents were White and highincome, this rebound effect was larger. Conclusions: Smartphone data can address an important gap for monitoring park visits. Park visits declined substantially in 2020 and disparities appeared to increase.

Infant Safe Sleep in the District of Columbia: Better for Both.

Sudden unexpected infant death (SUID) rates within the District of Columbia (DC) vary, with rates 3 times higher in certain geographical areas than the cumulative rate in DC and 7 times higher than the national rate. The majority SUIDs are due to unsafe sleep practices. Although safe sleep education and resources are available in these areas, the high sleep-related infant mortality suggests unmet barriers to infant safe sleep. We sought to investigate potential contributions to local infant mortality through focus groups regarding infant sleep practices among DC caregivers. In this qualitative study, caregivers were probed regarding barriers and facilitators of infant sleep practices. Data were collected until thematic saturation was reached, then coded. Themes were developed and revised in an iterative manner. Fifteen caregivers participated in three focus groups. Themes included sources of infant sleep knowledge, challenges for infant sleep, and motivators for infant sleep choice. All caregivers reported knowledge of safe sleep practices. Infant sleep practices varied, and included unsafe practices such as bed sharing, co-sleeping, and use of swings or bouncers for infant sleep. Challenges of adhering to safe sleep practices included infant needs, competing family demands, the overwhelming nature of newborn sleep, threats, and conflicting information. Motivators for infant sleep practices included better sleep, convenience, safety, tradition, and needs of the infant and caregiver. Although caregivers report knowledge of safe sleep recommendations, actual infant sleep practices vary and include unsafe sleep practices. More focused interventions are needed to address this gap between safe sleep knowledge and practice.

Moving Towards Racial Equity in the Child and Youth Mental Health Sector in Ontario, Canada.

In the aftermath of high-profile incidents involving Black, Indigenous and People of Color (BIPOC) in North America, there is a growing awareness of the pervasiveness of systemic racism and the role that agencies play in perpetuating racism and racial inequities. In the child and youth mental health sector, the journey to improving racial equity is impeded by a lack of consistent frameworks or guidelines. In this commentary, we explore five domains of organizational practices that are prominent in the literature and support diverse clients, communities and staff, including: (1) organizational leadership and commitment, (2) inter-organizational and multisectoral partnerships, (3) workforce diversity and development, (4) client and community needs and engagement, and (5) continuous improvement. As we highlight these domains, we urge researchers, policy makers, and child and youth mental health service providers to work together to advance racial equity in meaningful ways.

'It's like you don't have a roadmap really': using an antiracism framework to analyze patients' encounters in the cancer system.

Background: Cancer patients can experience healthcare system-related challenges during the course of their treatment. Yet, little is known about how these challenges might affect the quality and completion of cancer treatment for all patients, and particularly for patients of color. Accountability for Cancer Care through Undoing Racism and Equity is a multi-component, community-based participatory research intervention to reduce Black-White cancer care disparities. This formative work aimed to understand patients' cancer center experiences, explore racial differences in experiences, and inform systems-level interventions.Methods: Twenty-seven breast and lung cancer patients at two cancer centers participated in focus groups, grouped by race and cancer type. Participants were asked about what they found empowering and disempowering regarding their cancer care experiences. The community-guided analysis used a racial equity approach to identify racial differences in care experiences.Results: For Black and White patients, fear, uncertainty, and incomplete knowledge were disempowering; trust in providers and a sense of control were empowering. Although participants denied differential treatment due to race, analysis revealed implicit Black-White differences in care.Conclusions: Most of the challenges participants faced were related to lack of transparency, such that improvements in communication, particularly two-way communication could greatly improve patients' interaction with the system. Pathways for accountability can also be built into a system that allows patients to find solutions for their problems with the system itself. Participants' insights suggest the need for patient-centered, systems-level interventions to improve care experiences and reduce disparities.

Phoenix Rising: The Evolution of Holyoke's Collaborative Organizing for Healthy Food Resilience.

In the Holyoke Food & Fitness Policy Council (HFFPC) case study, the challenges of providing equitable multistakeholder organizing are examined. The importance of housing the work in the community, power sharing, and having community representation in the leadership is made clear. The HFFPC partnership began with vigor, encountered challenges of trust, transparency, aligned goals and values; it dissolved, and reformed. Because it began with shared values of strong communities and healthy people, the partnership continues to evolve, build local leadership, change narratives, and articulate the need for racial equity in their food system, while shifting local systems and policies that frame who has access to healthy food and safe spaces to exercise in a low-income Latino community.