Moving from data to action

A crucial step in the process of using data to address racial inequity is translating the data to meaningful action. This section introduces tools to tailor public health interventions to address identified inequities, test and measure the effectiveness of these interventions, and prepare for and support change.

Intro summary

When moving from data to action, interventions to address racial inequities should be evidence-based or informed, tailored to and co-created with the population most affected by the inequity, and designed to address the root causes of the inequity. It is also important to consider interventions that have been previously tested and shown to be effective through formal evaluation or community experience. Ideally, plans for measuring the effectiveness of interventions are designed in alignment with the implementation plan to allow for real-time assessment and timely modifications to improve health outcomes.  

Health Impact Pyramid

Figure 8.1: The Health Impact Pyramid

Figure 8.1 Source: A Framework for Public Health Action: The Health Impact Pyramid - PMC (nih.gov)

The Health Impact Pyramid (Figure 8.1) describes the impact of interventions at different levels and provides a framework to improve health outcomes¹. At the base of the pyramid are efforts that address social determinants of health (e.g., poverty), which have the greatest potential to improve population health. Upstream and multi-system strategies impact this level. As you move up the pyramid, interventions require more individual effort (e.g., healthy eating) and tend to have smaller population impact. Since the causes of racial inequities are complex, effective interventions should address multiple levels of the pyramid.    

When planning interventions, it is important to consider factors that might influence the intervention’s success in a specific community, including the likelihood it can be put into place, cultural environment, resource availability, and political will²⁷ . Engaging community partners and using other sources of data to uncover causes of the observed inequity can be used to adapt the intervention to match your community’s context, needs, and goals.  

There are a number of sources of information on existing evidence-based public health interventions, including: 

• CDC’s Community Guide, a collection of evidence-based findings of the Community Preventive Services Task Force that can help organizations select interventions to improve health and prevent disease. 
• MCH Evidence, a resource for maternal and child health (MCH) programs to develop evidence-based action plans and strategies to improve MCH outcomes. 
• Real World Examples from the Finding Answers: Disparities Research for Change project, a collection of innovative projects across the country that designed and implemented interventions to reduce quality of care disparities in cardiovascular disease, diabetes, and depression.   

Developing and assessing the effectiveness of interventions  

The equity-adapted model for improvement

If your interventions focus on higher levels of the Health Impact Pyramid – for example, individual counseling or education about healthy eating and exercise – then conducting rapid cycle tests of change is a good approach to testing improvements and measuring their impact. A frequently used model is the Institute for Healthcare Improvement’s Model for Improvement. The Model for Improvement consists of two parts: a series of three core questions followed by a Plan, Do, Study, Act (PDSA) cycle. PDSA is a problem-solving model used for improving a process or carrying out a change in a series of small steps. An adaptation of the Model for Improvement with equity framing is shown below (Figure 8.2). When centering racial equity, consider additional questions to the three core questions (shown in Figure 8.2). Once you have answered these questions, you are ready to develop an aim statement.  

Figure 8.2 Source: Adapted from the Institute for Healthcare Improvement, Associates in Process Improvement

Setting SMARTIE aims 

In quality improvement work, one of the first steps in the change process is writing an aim statement. The aim statement summarizes what you hope to achieve over a specific amount of time including the magnitude of change or reduction in inequity to be achieved.   

The Institute for Healthcare Improvement’s guidance on setting effective aims³ recommends considering the following questions:

• What are we improving?
• By what date and how much do we want to improve?
• For/with whom are we doing this work?
• Where is the improvement taking place? 

By answering the questions “what?,” “by when?,” “how much?,” “for whom?,”  and  “where?” you can develop an aim statement that is SMART (specific, measurable, attainable, realistic, and time-bound). However, to ensure the improvement activity is conducted equitably, add two additional components, I=Inclusive and E=Equitable to develop a SMARTIE aim statement.⁴

Inclusive – It brings traditionally marginalized people, particularly those most impacted, into processes, activities, and decision- and policy-making in a way that shares power.  

Equitable – It includes an element of fairness or justice that seeks to address systemic injustice, inequity, or oppression. 

Here is an example of a SMART aim statement improved to a SMARTIE aim statement:  

Table 8.1: Developing SMARTIE aims from SMART aims

SMART Aim Statement	SMARTIE Aim Statement
Improve enrollment in the program from 50% to 65% by December 31, 2024.	Improve enrollment in the program from 50% to 65% with at least a 10% increase among people of color, who are often lost to follow up, by December 31, 2024.
By December 31, 2024, we will increase the home visit completion rate by 3%.	By December 31, 2024, we will increase the home visit completion rate for Hispanic caregivers by 3% so that services are distributed more equitably across races and ethnicities.

Plan Do Study Act (PDSA) cycles

Once you have developed your SMARTIE aim statement, you can conduct a PDSA cycle. This is a problem-solving model used for improving a process or carrying out a change in a series of small steps which include Plan, Do, Study, and Act.

In the Plan stage, you can make predictions about the expected result, including whether the intervention will benefit populations equitably. You should also determine how the effect of the change should be measured, and how you will assess whether there are unintended consequences for certain groups of people. Once again, it is critical to engage the populations most affected by the problem in the Plan stage to ensure that the change strategies you are testing are acceptable and relevant to the community. 

The Do stage is when the planned test is carried out and any problems and observations are documented. Measurement is an important part of implementing and testing change and is necessary for monitoring whether the strategy put in place is achieving the desired aim. Data should be collected on a series of measures⁵ including: 

• Process measures – is the process performing as intended? 
• Outcome measures – how is the intervention affecting the outcome of interest?  
• Balancing measures – are there unintended effects on other parts of the system? 

Choose process measures that allow you to monitor whether the intervention is being implemented equitably to all populations served. PDSA cycles do not require overhauling data collection methods or processes, and programs do not need a formal data system to be able to conduct PDSAs. 

In the Study stage, analyze the data collected during the Do stage and consider the following:  

• Did the observed inequities improve or worsen? 
• If improved, by how much? Do all populations benefit equitably? 
• Is the objective for improvement met?  Is it met among all populations? 
• Were barriers experienced more among some populations compared to others? 

In the Act stage, review the results of your PDSA cycle and determine if it led to the intended results. Based on these results, decide whether you will adapt, adopt, or abandon the strategy being tested: 

• Adapt: If the inequity did not improve, reflect on why and further refine or plan another test cycle. 
• Abandon: Based on your analysis, you might decide to start from scratch and plan a new test cycle altogether. Since the problem is unresolved, you would then move back to the Plan stage to consider new options for implementation. At this point, it is crucial to re-engage the community to identify alternative solutions to test.   
• Adopt: If the inequity improves, you should determine if the improvement is adequate and should be sustained. 

As you learn from your results, you may need to refine or change your aim statement, your change strategy, and/or your measures. You might conduct multiple cycles of PDSAs that are linked together and build upon one another (called “ramp cycles.”)  

Each step of the PDSA cycle should be documented so you have a record of the result and can share what you learned with other collaborators. Consider using a PDSA presentation template or worksheet for presenting the components of the PDSA.  

Assessing systems change

If your change strategies include policy and systems changes focused on the base of the health impact pyramid, implementation science can assist you in assessing the effectiveness of the interventions. Implementation science provides a framework for translating evidence-based/informed practices into programs and policies that impact health outcomes. For more information about implementation science, visit the National Implementation Research Network’s Active Implementation Hub – a free, online learning environment for use by anyone involved in the active implementation and scaling up of programs and innovations. The goal is to increase the knowledge and improve the performance of people engaged in actively implementing any program or practice.  

Figure 8.3: IHI Psychology of Change Framework, adapted from the original IHI image

Assessing the impact of systems change interventions is complex and can be challenging, and a detailed overview of systems change evaluations is beyond the scope of this Road Map. The Tamarack Institute is an excellent resource for information and guidance on designing, planning and evaluating systems change.  

Change can be hard, and there are resources to help teams move through change in a productive way.  

Learn more about change management and overcoming resistance to change on the American Society for Quality (ASQ) website. The Institute for Healthcare Improvement IHI Psychology of Change Framework (Figure 8.3) may help in understanding the underlying psychology of change and using its power to impact quality improvement efforts and achieve breakthrough results, sustainably, and at scale.    

Reflection 

Now that you have selected your change strategy based on analysis of the data and community input, developed your implementation plan, and determined how you will monitor the effectiveness of your intervention, consider the following questions: 

• What can be done to increase the chances of success? 
• Whose support is needed for this change strategy? 
• What results will show that this innovation is working? 
• How long will it take for those results to appear? 
• How might you amplify – or help people see – these results sooner? 
• What barriers do you foresee in sustaining the effort? How might those be overcome?  

¹ Frieden TR. A Framework for Public Health Action: The Health Impact Pyramid. Am J Public Health 2010; 100(4):590-595. 

² CDC. A Framework for Public Health Action: The Health Impact Pyramid - PMC 

³ The Institute for Healthcare Improvement, Model for Improvement: Setting Aims

⁴ The Management Center, SMARTIE Goals Worksheet. Accessed on 12/09/2019 

⁵ Institute for Healthcare Improvement, Science of Improvement: Establishing Measures

⁶ Institute for Healthcare Improvement, Model for Improvement: Testing Changes