Health equity feasibility grid
If more than one inequity has been identified, you will want to prioritize which to focus on first. A recommended approach for prioritizing is using the Health Equity Feasibility Grid (Figure 6.1) to plot each inequity.
Note: if only one equity is identified, move to the Systems Level Approach & Inequities Matrix below.
First, think through the feasibility of addressing the inequity by considering practical supports (e.g., funding, internal capacity, partnerships, etc.) and constraints (e.g., timing of funding, political will, etc.). Is the feasibility of addressing the inequity low, medium, or high?
Next, consider the potential impact of addressing the inequity. If the inequity is reduced or eliminated, what impact will that have on the community you are centering? Is the impact low, medium, or high? Plot your inequities on the grid based on their feasibility and potential impact.
Finally, review where the inequities fall on the grid. Which one will the team address first? The team may decide to start with the inequity that is most feasible, or where there is a simple solution. With time and practice, however, the team should begin to address more challenging inequities as well.
Note: The Health Equity Feasibility Grid can be used to plot the feasibility/impact of any initiatives or projects, even those unrelated to inequities. This is why it is critical to first identify the inequities and then plot them separately from other issues your program may be addressing.
Systems level approach & inequities matrix
Once you have an inequity to address, move to plotting current and potential program initiatives and strategies related to addressing that inequity. This is done to assess the degree or severity of the inequity and whether initiatives and strategies take a systems-level approach.
It is important to engage collaborators and community members in this process. While it is likely the team understands the program and its structure, it is critical to include the voices of those who are receiving services or with lived experience/expertise. They will have insight into barriers and conditions impacting outcomes.
Using the matrix (Figure 6.2), consider whether the current program initiatives and strategies use a downstream (direct or clinical services), upstream (policies or environment), or interconnected systems (groundwater1) approach. At the same time, consider the degree or severity of the inequity. Are current strategies addressing the larger system and how many people are the strategies impacting? Plot each initiative/strategy in the appropriate location in the matrix.
Groundwater is a metaphor for structural racism developed by the Racial Equity Institute. It demonstrates that racial inequity looks the same across multiple systems, such as health care, education, law enforcement, and child welfare.
As solutions are being designed, continually revisit these guiding questions:
- What inequity is this strategy (i.e., activity or program) trying to address?
- Who will benefit from this strategy?
- Who could be harmed by this strategy? What will you do to avoid this?
- Who influences how this activity or program is put into place? Who else should provide input or influence this activity or program?
- Who decides how the activity or program is put into place?
It may seem as if there is an obvious change or solution to address the inequity. However, it is important to maintain a critical racial equity focus and to challenge assumptions when easy fixes are identified. Think about both using a groundwater approach and focusing on the social determinants of health to plan new strategies and interventions. Challenge yourself to think about ways to push your strategies towards more upstream and multi-system approaches (see Figure 6.3). Remember the analysis is the tool for helping to identify the most appropriate action to address the inequity.
Figure 6.3. Source: DPH Bureau of Community Health and Prevention SDOH Interventions Framework and Moving Massachusetts Upstream (MassUo) Conceptual Framework, both adapted from the Bay Area Regional Health Inequities Initiative. White paper on "The Ground Approach: building a practical understanding of structural racism" by Bayard Love and Deena Hayes-Greene of the Racial Equity Institute
Figure 6.3 is adapted from the Bay Area Regional Health Inequities Initiative Framework for reducing health inequities. The graphic shows the continuum of health interventions ranging from downstream interventions (on the right side of the graphic) to groundwater interventions (on the left side of the graphic). Downstream interventions focus on individual-level factors such as risk behaviors, like smoking, poor nutrition, and alcohol or drug use that can cause diseases and injury and can result in premature death. Interventions to improve outcomes at this level focus on healthcare, case management, and individual health education.
Midstream interventions (in the center of the graphic) focus on the social determinants of health – those living conditions such as the physical environment, economic and work environment, social environment, and service environment that shape the conditions in which children, adolescents and their families live, work and play. Interventions at this level include community capacity building, community organizing and civic engagement.
Moving further upstream (to the left of the image) are institutional inequities seen in corporations, government agencies, schools, laws and regulations; and social inequities by class, race/ethnicity, gender, etc. that drive the social determinants of health.
DPH added an additional level to the BARHII Framework, focusing on moving efforts further upstream to the groundwater, where inequities are seen in interconnected systems. Interventions at this level must involve strategic partnerships and advocacy efforts.
Most current public health practices live in the downstream or midstream areas while emerging public health practice aims to implement upstream and groundwater interventions.
Reflection
As you prioritize the inequities and assess current and potential strategies to address the inequity, check in with your team about whether you are ready to move on to effectively communicating the root causes of the inequity and proposed solutions.
- Have you done enough to understand that the solutions considered are informed by the community?
- Did you share ideas about upstream and multi-system approaches to addressing the problem?
The solutions you have developed are crucial for success. Do not hesitate to go back to a previous section if you do not feel you have the information or solutions you need to proceed.