Opportunities for psychologists to advance health equity: Using liberation psychology to identify key lessons from 17 years of praxis.

Health and health care inequities persist because the efforts to eliminate them have ignored structural racism, typically using a power neutral approach to diagnose and solve the problem. Critical theory can address many of the conceptual weaknesses of current approaches, help identify how racism operates in health care, and open the door for more effective individual employee and organizational actions to advance health equity. We apply Martín-Baró's (1996) liberation psychology to lessons we learned through implementing a transdisciplinary national health and health care equity program. The program, which began in 2005, conducts equity-focused health services interventions and research, using the best available evidence to assist health and health care policymakers, payers, community-based organizations, care delivery organizations, and patients to transform and align their activities in order to advance health equity. It serves as a rare model to explore how misconceptions resulting from racist structures can hinder progress, even when everyone involved is highly motivated to address health and health care inequities. Liberation psychology guides our interpretation of the lessons learned and recommendations for the field of psychology. Psychologists advancing equity in health and health care should integrate liberation psychology and other critical theories into their own work. In addition, partnerships with other disciplines and communities outside of academia and professional health services are key to success. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Advancing health equity through partnerships of state Medicaid agencies, Medicaid managed care organizations, and health care delivery organizations.

Background: Reducing health inequities in marginalized populations, including people with Medicaid insurance, requires care transformation to address medical and social needs that is supported and incentivized by tailored payment methods. Collaboration across health care stakeholders is essential to overcome health system fragmentation and implement sustainable reform in the United States (U.S.). This paper explores how multi-stakeholder teams operationalized the Roadmap to Advance Health Equity model during early stages of their journey to (a) build cultures of equity and (b) integrate health equity into care transformation and payment reform initiatives. Methods: Advancing Health Equity: Leading Care, Payment, and Systems Transformation is a national program in the U.S. funded by the Robert Wood Johnson Foundation that brings together multi-stakeholder teams to design and implement initiatives to advance health equity. Each team consisted of representatives from state Medicaid agencies, Medicaid managed care organizations, and health care delivery organizations in seven U.S. states. Between June and September 2021, semi-structured interviews were conducted with representatives (n = 23) from all seven teams about experiences implementing the Roadmap to Advance Health Equity model with technical assistance from Advancing Health Equity. Results: Facilitators of building cultures of equity included (1) build upon preexisting intra-organizational cultures of equity, (2) recruit and promote diverse staff and build an inclusive culture, and (3) train staff on health equity and anti-racism. Teams faced challenges building inter-organizational cultures of equity. Facilitators of identifying a health equity focus area and its root causes included (1) use data to identify a health equity focus and (2) overcome stakeholder assumptions about inequities. Facilitators of implementing care transformation and payment reform included (1) partner with Medicaid members and individual providers and (2) support and incentivize equitable care and outcomes with payment. Facilitators of sustainability planning included (1) identify evidence of improved health equity focus and (2) maintain relationships among stakeholders. Teams faced challenges determining the role of the state Medicaid agency. Conclusions: Multi-stakeholder teams shared practical strategies for implementing the Roadmap to Advance Health Equity that can inform future efforts to build intra- and inter-organizational cultures of equity and integrate health equity into care delivery and payment systems.

Developing Standards for Cultural Competency Training for Health Care Providers to Care for Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual Persons: Consensus Recommendations from a National Panel.

Purpose: Lesbian, gay, bisexual, transgender, queer, intersex, and/or asexual and other sexual and gender diverse persons (LGBTQIA+ or SGD persons) experience barriers to equitable health care. The purpose of this article is to describe a collaborative process that resulted in core cultural competency recommendations addressing training for those who provide health care and/or social services to LGBTQIA+ patients. Methods: In 2018 and 2019, Whitman-Walker Health, a Federally Qualified Community Health Center in Washington, DC, and the National LGBT Cancer Network purposively selected leaders of community clinics and community-based organizations, cultural competency trainers, and clinicians and researchers with expertise in SGD health with diverse lived experiences to develop consensus-based cultural competency recommendations. Recommendations were developed through a synthesis of peer-reviewed studies, publicly accessible curricula, and evaluations of SGD cultural competency trainings; two in-person convenings; and iterative feedback from diverse stakeholders. Results: Five anchoring recommendations emerged: (1) know your audience; (2) develop and fine-tune the curriculum; (3) employ both adult and transformational learning theories; (4) choose multiple effective trainers; and (5) evaluate impact of training. These recommendations promote an ongoing process of individual and organizational improvement and a stance of humility rather than competence to be mastered. Conclusion: By setting core cultural competency standards for all persons involved in health care and social services, these recommendations complement existing clinical competency recommendations to advance SGD health equity.

Critical Theory, Culture Change, and Achieving Health Equity in Health Care Settings.

Achieving optimal health for all requires confronting the complex legacies of colonialism and white supremacy embedded in all institutions, including health care institutions. As a result, health care organizations committed to health equity must build the capacity of their staff to recognize the contemporary manifestations of these legacies within the organization and to act to eliminate them. In a culture of equity, all employees-individually and collectively-identify and reflect on the organizational dynamics that reproduce health inequities and engage in activities to transform them. The authors describe 5 interconnected change strategies that their medical center uses to build a culture of equity. First, the medical center deliberately grounds diversity, equity, and inclusion efforts (DEI) in critical theory, aiming to illuminate social structures through critical analysis of power relations. Second, its training goes beyond cultural competency and humility to include critical consciousness, which includes the ability to critically analyze conditions in the organizational and broader societal contexts that produce health inequities and act to transform them. Third, it works to strengthen relationships so they can be change vehicles. Fourth, it empowers an implementation team that models a culture of equity. Finally, it aligns equity-focused culture transformation with equity-focused operations transformation to support transformative praxis. These 5 strategies are not a panacea. However, emerging processes and outcomes at the medical center indicate that they may reduce the likelihood of ahistorical and power-blind approaches to equity initiatives and provide employees with some of the critical missing knowledge and skills they need to address the root causes of health inequity.

Framework for Integrating Equity Into Machine Learning Models: A Case Study.

Predictive analytic models leveraging machine learning methods increasingly have become vital to health care organizations hoping to improve clinical outcomes and the efficiency of care delivery for all patients. Unfortunately, predictive models could harm populations that have experienced interpersonal, institutional, and structural biases. Models learn from historically collected data that could be biased. In addition, bias impacts a model's development, application, and interpretation. We present a strategy to evaluate for and mitigate biases in machine learning models that potentially could create harm. We recommend analyzing for disparities between less and more socially advantaged populations across model performance metrics (eg, accuracy, positive predictive value), patient outcomes, and resource allocation and then identify root causes of the disparities (eg, biased data, interpretation) and brainstorm solutions to address the disparities. This strategy follows the lifecycle of machine learning models in health care, namely, identifying the clinical problem, model design, data collection, model training, model validation, model deployment, and monitoring after deployment. To illustrate this approach, we use a hypothetical case of a health system developing and deploying a machine learning model to predict the risk of mortality in 6 months for patients admitted to the hospital to target a hospital's delivery of palliative care services to those with the highest mortality risk. The core ethical concepts of equity and transparency guide our proposed framework to help ensure the safe and effective use of predictive algorithms in health care to help everyone achieve their best possible health.

Development, implementation, and use of an "equity lens" integrated into an institutional quality scorecard.

Few healthcare provider organizations systematically track their healthcare equity, and fewer enable direct interaction with such data by their employees. From May to August 2019, we enhanced the data architecture and reporting functionality of our existing institutional quality scorecard to allow direct comparisons of quality measure performance by gender, age, race, ethnicity, language, zip code, and payor. The Equity Lens was made available to over 4000 staff in September 2019 for 82 institutional quality measures. During the first 11 months, 235 unique individuals used the tool; users were most commonly from the quality and equity departments. Two early use cases evaluated hypertension control and readmissions by race, identifying potential inequities. This is the first description of an interactive equity lens integrated into an institutional quality scorecard made available to healthcare system employees. Early evidence suggests the tool is used and can inform quality improvement initiatives.

Teaching Intersectionality of Sexual Orientation, Gender Identity, and Race/Ethnicity in a Health Disparities Course.

Introduction: Intersectionality considers how different identities simultaneously affect an individual's experiences. Those of multiple minority statuses may experience effects of intersecting systems of oppression. Most health disparities curricula do not focus on intersectionality. We studied the impact of an innovative module teaching intersectionality of sexual orientation, gender identity, and race/ethnicity issues in the required Pritzker School of Medicine course Health Care Disparities: Equity and Advocacy. Methods: A short lecture reviewed sexual and gender minority (SGM) health disparities, intersectionality, minority stress, and shared decision making (SDM) to establish shared language among 83 first-year medical students. Students then viewed four videos of SGM patients of color (POC) describing their health care experiences, each followed by moderated discussion about how compounded minority stress affects lived experiences and health and how to improve SDM for SGM POC. One video interviewee attended the session and answered students' questions. Evaluation was performed using pre- and postsurveys. Results: Feeling somewhat/completely confident in defining intersectionality increased from 57% to 96%. Prior to the session, 62% of respondents reported feeling somewhat/completely confident in identifying barriers to care for SGM patients, and 92% after. Thirty-three percent felt somewhat/completely confident in asking SGM patients about their identities before the session, and 81% after. Eighty-four percent rated the session as very good or excellent. Discussion: The session was well received, improved student knowledge of intersectionality, and improved confidence in communicating with and caring for SGM patients. Future iterations could include condensing the lecture and including a patient panel and/or small-group discussion.

Healthcare Experiences of Transgender People of Color.

BACKGROUND: Transgender people and racial/ethnic minorities separately report poor healthcare experiences. However, little is known about the healthcare experiences of transgender people of color (TPOC), who are both transgender and racial/ethnic minorities. OBJECTIVE: To investigate how TPOC healthcare experiences are shaped by both race/ethnicity and gender identity. DESIGN AND PARTICIPANTS: Semi-structured, in-depth individual interviews (n = 22) and focus groups (2; n = 17 total); all taken from a sample of TPOC from the Chicago area. All participants completed a quantitative survey (n = 39). APPROACH: Interviews and focus groups covered healthcare experiences, and how these were shaped by gender identity and/or race/ethnicity. The interviews and focus groups were audio recorded, transcribed verbatim, and imported into HyperRESEARCH software. At least two reviewers independently coded each transcript using a codebook of themes created following grounded theory methodology. The quantitative survey data captured participants' demographics and past healthcare experiences, and were analyzed with descriptive statistics. KEY RESULTS: All participants described healthcare experiences where providers responded negatively to their race/ethnicity and/or gender identity. A majority of participants believed they would be treated better if they were cisgender or white. Participants commonly cited providers' assumptions about TPOC as a pivotal factor in negative experiences. A majority of participants sought out healthcare locations designated as lesbian, gay, bisexual, and transgender (LGBT)-friendly in an effort to avoid discrimination, but feared experiencing racism there. A minority of participants expressed a preference for providers of color; but a few reported reluctance to reveal their gender identity to providers of their own race due to fear of transphobia. When describing positive healthcare experiences, participants were most likely to highlight providers' respect for their gender identity. CONCLUSIONS: TPOC have different experiences compared with white transgender or cisgender racial/ethnic minorities. Providers must improve understanding of intersectional experiences of TPOC to improve quality of care.

Bivalent rLP2086 (Trumenba®): Development of a well-characterized vaccine through commercialization.

The phrase "Process is the Product" is often applied to biologics, including multicomponent vaccines composed of complex components that evade complete characterization. Vaccine production processes must be defined and locked early in the development cycle to ensure consistent quality of the vaccine throughout scale-up, clinical studies, and commercialization. This approach of front-loading the development work helped facilitate the accelerated approval of the Biologic License Application for the well-characterized vaccine bivalent rLP2086 (Trumenba®, Pfizer Inc) in 2014 under Breakthrough Therapy Designation. Bivalent rLP2086 contains two rLP2086 antigens and is licensed for the prevention of meningococcal meningitis disease caused by Neisseria meningitidis serogroup B in individuals 10-25years of age in the United States. This paper discusses the development of the manufacturing process of the two antigens for the purpose of making it amenable to any manufacturing facility. For the journey to commercialization, the operating model used to manage this highly accelerated program led to a framework that ensured "right the first time" execution, robust process characterization, and proactive process monitoring. This framework enabled quick problem identification and proactive resolutions, resulting in a robust control strategy for the commercial process.

Solving Disparities Through Payment And Delivery System Reform: A Program To Achieve Health Equity.

Payment systems generally do not directly encourage or support the reduction of health disparities. In 2013 the Finding Answers: Solving Disparities through Payment and Delivery System Reform program of the Robert Wood Johnson Foundation sought to understand how alternative payment models might intentionally incorporate a disparities-reduction component to promote health equity. A qualitative analysis of forty proposals to the program revealed that applicants generally did not link payment reform tightly to disparities reduction. Most proposed general pay-for-performance, global payment, or shared savings plans, combined with multicomponent system interventions. None of the applicants proposed making any financial payments contingent on having successfully reduced disparities. Most applicants did not address how they would optimize providers' intrinsic and extrinsic motivation to reduce disparities. A better understanding of how payment and care delivery models might be designed and implemented to reduce health disparities is essential.

A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care.

Over the past decade, researchers have shifted their focus from documenting health care disparities to identifying solutions to close the gap in care. Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation, is charged with identifying promising interventions to reduce disparities. Based on our work conducting systematic reviews of the literature, evaluating promising practices, and providing technical assistance to health care organizations, we present a roadmap for reducing racial and ethnic disparities in care. The roadmap outlines a dynamic process in which individual interventions are just one part. It highlights that organizations and providers need to take responsibility for reducing disparities, establish a general infrastructure and culture to improve quality, and integrate targeted disparities interventions into quality improvement efforts. Additionally, we summarize the major lessons learned through the Finding Answers program. We share best practices for implementing disparities interventions and synthesize cross-cutting themes from 12 systematic reviews of the literature. Our research shows that promising interventions frequently are culturally tailored to meet patients' needs, employ multidisciplinary teams of care providers, and target multiple leverage points along a patient's pathway of care. Health education that uses interactive techniques to deliver skills training appears to be more effective than traditional didactic approaches. Furthermore, patient navigation and engaging family and community members in the health care process may improve outcomes for minority patients. We anticipate that the roadmap and best practices will be useful for organizations, policymakers, and researchers striving to provide high-quality equitable care.

Evaluating interventions to reduce health care disparities: an RWJF program.

The Robert Wood Johnson Foundation's Finding Answers: Disparities Research for Change program funds evaluation of interventions to reduce racial and ethnic disparities in cardiovascular disease, depression, and diabetes. Of the 177 applications received in 2006, the most prevalent proposed interventions were patient or provider education (57 percent), community health workers (25 percent), case management (24 percent), integrated health care (24 percent), and cultural modification (24 percent). Policy interventions, including pay-for-performance (P4P) incentives, were lacking. The eleven grantees target patients, providers, patient-provider communication, health care organizations, and communities in innovative ways. We identify important future research questions.

Interventions to reduce racial and ethnic disparities in health care.

In 2005, the Robert Wood Johnson Foundation created Finding Answers: Disparities Research for Change, a program to identify, evaluate, and disseminate interventions to reduce racial and ethnic disparities in the care and outcomes of patients with cardiovascular disease, depression, and diabetes. In this introductory paper, we present a conceptual model for interventions that aim to reduce disparities. With this model as a framework, we summarize the key findings from the six other papers in this supplement on cardiovascular disease, diabetes, depression, breast cancer, interventions using cultural leverage, and pay-for-performance and public reporting of performance measures. Based on these findings, we present global conclusions regarding the current state of health disparities interventions and make recommendations for future interventions to reduce disparities. Multifactorial, culturally tailored interventions that target different causes of disparities hold the most promise, but much more research is needed to investigate potential solutions and their implementation.

Marketing malpractice: the cause and the cure.

Ted Levitt used to tell his Harvard Business School students, "People don't want a quarter-inch drill--they want a quarter-inch hole." But 35 years later, marketers are still thinking in terms of products and ever-finer demographic segments. The structure of a market, as seen from customers' point of view, is very simple. When people need to get a job done, they hire a product or service to do it for them. The marketer's task is to understand what jobs periodically arise in customers' lives for which they might hire products the company could make. One job, the "I-need-to-send-this-from-here-to-there-with-perfect-certainty-as-fast-as-possible"job, has existed practically forever. Federal Express designed a service to do precisely that--and do it wonderfully again and again. The FedEx brand began popping into people's minds whenever they needed to get that job done. Most of today's great brands--Crest, Starbucks, Kleenex, eBay, and Kodak, to name a few-started out as just this kind of purpose brand. When a purpose brand is extended to products that target different jobs, it becomes an endorser brand. But, over time, the power of an endorser brand will surely erode unless the company creates a new purpose brand for each new job, even as it leverages the endorser brand as an overall marker of quality. Different jobs demand different purpose brands. New growth markets are created when an innovating company designs a product and then positions its brand on a job for which no optimal product yet exists. In fact, companies that historically have segmented and measured markets by product categories generally find that when they instead segment by job, their market is much larger (and their current share much smaller) than they had thought. This is great news for smart companies hungry for growth.