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Recap the state legislative sessions in 2025 thus far, spanning maternal health, infectious disease, and other important public health issues.

Equip your agency with field-tested strategies for effective communication in public health.

Discover measures that will allow you to truly and meaningfully track community engagement in public health.

An Ounce of Prevention (and Public Health Fund) Is Worth a Pound of Cure Catherine Murphy The Prevention and Public Health Fund (PPHF) is critical to state public health work. Historically it has faced cuts even though prevention has proven return on investment. Read the latest information the future of PPHF in this week's Health Policy Update. Among federal funding for public health programs, one line is particularly unique. The Prevention and Public Health Fund (PPHF) is the nation’s first mandatory fund for prevention and public health programs. Before enacting PPHF, there was no fund that guaranteed investment in prevention programs that was not contingent on the annual appropriations process. PPHF was part of the 2010 Patient Protection and Affordable Care Act and it helps provide funding for crucial programs. During the past 15 years, PPHF has been utilized across agencies including CDC, CMS, HRSA, and SAMHSA. In fact, about 95% of PPHF funding goes to CDC. In FY24, the fund contributed 13% of CDC’s overall budget. From FY25 through FY30, PPHF is projected to provide $9.8 billion in funding to achieve these goals. Where the Money Goes As the adage goes, “an ounce of prevention is worth a pound of cure.” Through dollars distributed by CDC — more than 70% of CDC’s budget supports the work of state and local health organizations — PPHF funds numerous critical nationwide efforts including immunization, epidemiology and laboratory capacity, tobacco use, heart attack and stroke, childhood lead poisoning, and the Preventive Health and Health Services Block Grant. Many of these programs receive a majority, if not all, of their funding from PPHF, and the demonstrated return-on-investment is significant. For example, California’s tobacco control program saved $155 in health care cost savings for every $1 invested. CDC has found that removing lead hazards from children's environment can, “generate approximately $84 billion in long-term benefits per birth cohort. Sustained Commitment for the Decade Ahead Unfortunately, PPHF has historically been subject to cuts via budget agreements, including the Bipartisan Budget Act (2018), and to calls to repeal and replace the Affordable Care Act. Since its enactment, PPHF has been amended five times, ultimately resulting in a reduction in appropriations for the fund. Recently, President Trump’s “Skinny” Budget Proposal outlined cuts to a number of PPHF-funded programs, indicating that the overall funding could be at risk. Eliminating PPHF would open a significant funding gap for preventive health programs across the nation. These programs have proven records of promoting health and preventing infectious and chronic disease. Loss of funding would likely result in greater disease burden and health care costs. Investing in prevention isn’t just smart policy, it’s smart economics. The PPHF is designed to build a strong public health foundation, brick by brick, community by community. Over the years, ASTHO has worked in coalition with public health organizations to share the importance of PPHF and to advocate for sustained investment to the fund. ASTHO will continue to monitor discourse and share the importance of this funding in interactions with lawmakers. Table - Blog - An Ounce of PPHF Is Worth a Pound of Cure article yes

Understanding Digital Accessibility Before the ADA Title II Deadline Emily Lapayowker, Adrianna Evans With the ADA Title II deadline looming, learn how to prioritize and improve digital accessibility on your agency’s website. Digital accessibility ensures the digital world is usable for everyone. And while it is an increasingly prominent topic in public health, there is still much to learn. This resource can help public health agencies understand digital accessibility basics and promote accessible communications for the disability community, which is typically underserved in public messaging. Government Laws and Requirements ADA The Americans with Disabilities Act is a federal civil rights law that prohibits discrimination against and requires equitable access for people with disabilities. ADA’s connection to digital accessibility may not be immediately apparent, but digital accessibility is covered under the large umbrella of equal access to public areas that ADA guarantees. In fact, Title II of ADA enforces digital accessibility compliance by requiring state and local government websites and digital tools be accessible to people with disabilities — the Department of Justice has announced a compliance deadline of April 24, 2026, for jurisdictions of 50,000+ people and April 26, 2027, for smaller entities. Sections 504 and 508 Section 504 of the 1973 (Vocational) Rehabilitation Act requires any entity that gets federal funding to provide equal access to electronic information technologies for people with disabilities. Section 508 requires the federal government to meet those same standards. These sections were initially written in 1998 and then updated in 2018 to include requirements for mobile technology. WCAG Is the Industry Standard The Web Content Accessibility Guidelines, or WCAG, is published by the World Wide Web Consortium (W3C), an international organization that establishes open web standards. WCAG is currently in its second version. When evaluating compliance, there are three different WCAG conformance levels: A (lowest), AA (middle), and AAA (greatest). Interestingly, W3C recommends that all web-based information aim to hit AA because it is not possible for some types of content to reach AAA compliance. WCAG 3.0 is currently in development and expected to be a major paradigm shift. POUR Principles WCAG standards are principle-based, which means that rather than requiring all web browsers to meet a specific technical standard, WCAG requires that digital content adheres to the POUR principles. All four principles focus on the user’s experience: Perceivable: All information must be presented in a way that ensures users can perceive it using at least one of their senses. Operable: A website is considered operable if all users can effectively navigate it, even those who employ assistive technology, such as screen readers. Understandable: This is a two-pronged principle — users must be able to understand how to use a site and understand its content. Robust: Content must be robust enough that multiple technologies, including assistive devices like screen readers, can interpret it. These laws and guidelines are minimally prescriptive to promote longevity. Remaining principle-based rather than tech-based means these standards will not become obsolete as technology advances. Where and How to Make the Biggest Impact Health agencies can make small changes to digital content in a few key places that will make a world of difference for users with visual, hearing, physical, and cognitive disabilities. Some examples include emails, PDFs, website and social media content, and staff resources. Link Smart and Sparingly Screen reader technology allows low-vision users to navigate webpages and other digital content in a variety of ways. One is by jumping from link to link without referencing the content around that link. So, make your linked text descriptive enough to stand on its own. Also, avoid typing out URLs whenever you can — screen readers will read aloud the URL as phonetically as possible, which is not a great user experience. Additionally, when a screen reader reaches a link in the content, the software will announce it. Use links sparingly to avoid major disruption to the reading experience, as over-linking can make it hard to keep track of the content. Use the Built-In Text Styles Document hierarchy is another essential part of accessibility remediation. The built-in font styles, such as headers and lists, are for more than just aesthetic — screen readers use these styles to navigate Word documents, PDFs, and webpages. Use headers in order (i.e., never skip a heading level), and deploy ordered and unordered lists thoughtfully. For example, if you list specific steps in a process, use an ordered list. If you list symptoms of a viral infection, an unordered list is a better fit. Use Color and Contrast Correctly Do not rely on color alone to convey important information, because users with low vision or colorblindness may have trouble differentiating between different colors or shades. Best practice is to use additional visual markers to signal the presence of important information and ensure there is at least a 3:1 contrast ratio for graphics. Follow Alt Text Best Practices Screen readers read alternative text (or alt text) to allow users with visual or specific cognitive disabilities to understand the content and purpose of an image, table, or informational graphic. Some alt text best practices: Be succinct. The ideal length is between a few words and a couple of short sentences (use the average length of a post on X as a guide, about 250 characters). The goal is to be brief but still convey the image’s vital information. Avoid phrases like “image of” because screen readers will identify all images as such, which makes this redundant. The context around the image is just as crucial as the alt text. If there is already a detailed description of a virion’s shape in the document's body, repeating all that information in the alt text is unnecessary. Not all images convey information. In those cases, it’s important to use null alt text, which will let assistive technology know that the image is decorative. To do this, either add “decorative” in the alt text field, or mark it as decorative in the platform, if that option is available. When creating complex images such as charts or graphs, communicate what the graph is telling users rather than just what it looks like. Learn More There is a whole world to learn about within digital accessibility, but there are resources and experts to help. You can connect with internal experts on your IT team or external disability and accessibility organizations for support. You can also learn more about digital accessibility at the following resources: Introduction to the Americans with Disabilities Act by U.S. Department of Justice. Civil Rights Division Section 508 (Federal Electronic and Information Technology) by U.S. Access Board What Is Plain Language? by Plain Language Action and Information Network Constructing a POUR Website by WebAIM WCAG 101: Understanding the Web Content Accessibility Guidelines by Level Access Glossary of Disability-Related Terms by University of Washington Accessibility Online by Great Lakes ADA Center Related Content-Blog - DELPH Magazine 4 article yes

Learn how states are using policy to promote mosquito control and reduce the transmission of mosquito-borne disease in this Health Policy Update.

States are taking steps to ban or limit the use of food dyes. Learn more about recent state legislation.

Programa de Puerto Rico Apoya a las Poblaciones Vulneradas ASTHO Island Support El Programa de Equidad en Salud del Departamento de Salud de Puerto Rico implementó una iniciativa innovadora para apoyar a diversas instituciones, con el objetivo de abordar los determinantes sociales de la salud y promover la equidad en salud entre las poblaciones vulneradas. Esta iniciativa brindó oportunidades a sectores diversos como empresas privadas sin fines de lucro, universidades y hospitales. El proyecto fue evolucionando a lo largo de su desarrollo, demostrando el poder del financiamiento local y la importancia de la flexibilidad en la administración de los programas. Inicio del Proyecto Proceso de Adjudicación y Capacitación Durante la segunda oportunidad de fondos disponibles, 30 organizaciones tenían interés en someter propuestas. Sin embargo, ante una rúbrica detallada y rigurosa solo se recibieron seis solicitudes. De éstas, se otorgaron cuatro subvenciones. El equipo evaluó las propuestas según la rúbrica y asignó fondos para apoyar a poblaciones vulneradas, como personas viviendo en zonas rurales, personas con diversidad funcional, mujeres embarazadas y  población adulta mayor. Implementación y Buenas Prácticas Una vez que el Programa de Equidad en Salud otorgó las subvenciones, se diseñó un plan de trabajo detallado, incluyendo indicadores clave para monitorear y dar seguimiento al progreso de las organizaciones beneficiarias. Se implementó un sistema de seguimiento basado en en una plataforma de SharePoint para la entrega de informes y documentación, y se llevaron a cabo reuniones mensuales para asegurar la cohesión y una comunicación efectiva entre todos los partes involucrados. Este enfoque colaborativo permitió un proceso de monitoreo eficiente y transparente. “Fue un proceso en conjunto, ya que las instituciones conocen mejor a su población. Solo queríamos asegurar un plan sistemático y consistente porque estos asuntos son clave para el progreso y monitoreo de los proyectos.” — Miguel Cruz, PhD, Coinvestigador Principal del Proyecto Evolución del Proyecto El programa inicialmente financió una institución y debido a su impacto positivo, surgieron oportunidades adicionales para proporcionar financiamiento a otras cuatro instituciones. El tema principal giró en torno a la alfabetización en salud como una estrategia para alcanzar la equidad en salud entre las personas que viven en áreas rurales, población adulta mayor, población sin hogar, individuos con diversidad funcional y aquellos con algún desafío de salud mental. Estas cuatro nuevas instituciones cubrieron el área oeste, el centro y otras zonas rurales, ampliando la cobertura dentro de comunidades tradicionalmente desatendidas. Flexibilidad Administrativa y Estrategias de Comunicación Administrativamente, el programa tuvo que ser flexible en los procesos previos y posteriores a la adjudicación de fondos, asegurando el cumplimiento con las regulaciones estatales y federales. Esto incluyó la revisión de anuncios y la creación de planes. Además, el programa desarrolló documentación, como plantillas, y brindó asistencia técnica para aclarar las directrices de cumplimiento, con el fin de garantizar la transparencia y el uso adecuado de los fondos. El programa implementó estrategias de comunicación efectiva para informar a todas las instituciones sobre las oportunidades de financiamiento. Esto incluyó, desde publicaciones en medios de comunicación masivos y redes sociales formales del Departamento de Salud. También se creó un comité externo como canal oficial de comunicación para evaluar las propuestas. Para este propósito, se creó una rúbrica detallada que facilitó la evaluación apropiada, imparcial, y oportuna de cada propuesta. Desafíos y Soluciones Tecnológicas Uno de los desafíos a lo largo del proyecto fue el uso de la tecnología para recibir, procesar y manejar la documentación. Para mitigar estos obstáculos, se facilitó un espacio compartido en la plataforma de SharePoint para colaborar en documentos y solicitudes de formularios e informes entre cada institución subvencionada y el Programa. El equipo del Programa de Equidad también compartió respuestas colectivamente para garantizar que todas las organizaciones estuvieran informadas con los mismos datos y pudieran completar el proceso sin contratiempos y en igual ventaja. Lecciones Aprendidas Una evaluación final del proceso reveló que la anticipación de los desafíos por parte del equipo de trabajo fue clave para el éxito del proyecto. Sin embargo, aún existen áreas de mejora: Una de ellas es la optimización de los procesos financieros por parte de las organizaciones. Es importante ser puntual para someter la evidencia del uso de fondos, así como la rectitud en la reconciliación de facturas en el tiempo en que el dinero fue utilizados. Las organizaciones también deben conciliar los procesos internos con los parámetros que se establece al otorgar fondos. En la medida que se cumplan estos parámetros el proceso por parte del Departamento de Salud podría ser más ágil ya que, aunque los beneficiarios tienen un profesional de contabilidad asignado la documentación tiene que pasar por la oficina Fiscal para evaluación. Otro desafío que enfrentaron las instituciones fue la retención de participantes en las sesiones de capacitación ofrecidas como parte de la subvención. Por ello, se deben establecer mecanismos que garanticen una participación activa y continua en futuras intervenciones. El Programa de Equidad en Salud identificó la oportunidad de estandarizar los procesos de evaluación para las organizaciones. Todas las instituciones trabajaron proyectos diversos. Para evaluar se tomaba en consideración el plan de trabajo de las instituciones con el informe de progreso. Pero, entienden que una evaluación estandarizada podría ser más eficiente en futuras intervenciones. Sostenibilidad y Recomendaciones Varias de las instituciones que recibieron fondos  lo utilizaron como punto de partida para desarrollar iniciativas más grandes. “Las organizaciones utilizaron este financiamiento como un fondo inicial para proyectos que ahora están recibiendo más apoyo financiero. Otros  desarrollaron recursos internos que les permiten continuar trabajando en temas claves de salud. Como ejemplo, han optimizado el uso de bibliotecas digitales, expandido el alcance de adiestramiento y replicado proyectos, que se hicieron con este fondo, en otros municipios.” — Miguel Cruz, PhD, Coinvestigador Principal del Proyecto Para otras agencias que busquen implementar programas similares, la recomendación es clara: agilizar los esfuerzos para mantener la coherencia y consistencia, afirmó el Cruz. Conclusión La comunicación clara, transparente y una administración flexible con enfoque en la equidad en salud, genera un impacto positivo en las poblaciones vulneradas. Esto puede constatarse con el aumento en conocimiento, el incremento en las destrezas de los participantes, sus cambios en actitudes, la inclusión en los servicios, el aumento en el uso de la tecnología por parte de los adultos mayores y las destrezas de equidad en los trabajadores. Este proyecto demuestra cómo los departamentos de salud pueden colaborar con otros sectores para abordar los determinantes sociales y garantizar un acceso equitativo a los recursos. article yes

Leading Health Security Efforts Through Strategic Collaboration and Innovation Margaret Nilz This blog post illustrates how health agencies' strategic plans can improve health security and emergency preparedness. Strategic planning is a cornerstone of effective public health systems, guiding organizations in preparing for and responding to health threats. Three pivotal documents—the CDC Office of Readiness and Response (ORR) Strategic Plan, the ASTHO Strategic Plan, and the ASTHO Environmental Scan—are part of the foundation of ASTHO’s work. Each plays a critical role in shaping public health policies and practices. Understanding their synergies and differences is beneficial and crucial for enhancing our collective efforts in safeguarding public health. ASTHO’s Environmental Scan tracks U.S. public health concerns and trends. Through qualitative analyses of select health agency materials and health official feedback, this blog identifies state, territorial, and freely associated state health agencies’ (S/THAs) top current and emerging priorities across public health programs, infrastructure, and health equity and agency strategies to address them. Across 2023 and 2024, S/THAs consistently identified emergency preparedness and response as a critical priority. Callout 1-Blog - Leading Health Security Efforts through Strategic Collaboration and Innovation It is essential to align strategic plans and address emerging public health priorities in order to effectively respond to new health challenges. The ORR and ASTHO Strategic Plans share several common goals, such as implementing equitable, evidence-based practices, partnering for sustainable infrastructure improvements, and focusing on operational excellence while providing technical assistance. However, each plan also has unique missions. Callout 2-Blog - Leading Health Security Efforts through Strategic Collaboration and Innovation ASTHO’s Health Security team has a unit mission and vision that align with ORR goals and focus on supporting the needs of ASTHO members, as identified in the Environmental Scan. Callout 3-Blog - Leading Health Security Efforts through Strategic Collaboration and Innovation Aligning these strategic goals with current public health priorities is crucial in addressing existing and emerging health threats. Values The ORR and ASTHO plans express shared values like collaboration and innovation. These values guide strategic decisions and foster a cohesive public health community. Table-Blog - Leading Health Security Efforts through Strategic Collaboration and Innovation Competencies and Priorities Both organizations focus on developing competencies like leadership and technical expertise. ORR concentrates heavily on competencies specific to preparedness, including planning, response, and research for public health emergencies. ASTHO emphasizes competencies to support S/THAs, such as technical assistance, communication, capacity building, and advocacy. Building and aligning these competencies is essential for improving public health outcomes and ensuring workforce preparedness. With that in mind, ASTHO’s competencies are specifically aimed at aiding and supporting its members, and consequently the nation, in achieving the ORR competencies. Environmental Scan Observations The ASTHO Environmental Scan thoroughly evaluates current public health trends, challenges, and opportunities. Key highlights from the 2023 and 2024 Environmental Scans include: Focus on emerging threats such as infectious diseases and the impact of climate change. Changes in public health funding and resource availability. Technological advancements and their implications for public health practice. Common trends identified include a heightened focus on health equity, the importance of data-driven decision-making, and the need for increased interagency collaboration. Organizational competencies, including performance management and quality improvement, were listed as current priority areas for public health infrastructure and capacity-building. Focus issues include financial infrastructure, business processes, including procurement, recruitment, and grants management, policy development, and public health governance structures. Workforce development was listed as a priority for public health infrastructure and capacity building. Focus issues include recruitment and retention, local academic pipelines and training opportunities, staff compensation, and staff salary gaps. Data modernization and informatics are priority areas in states with state health improvement and strategic plans and were listed as current public health infrastructure and capacity-building priorities. Accountability, performance management, and quality improvement are priority areas in states with state health improvement and strategic plans and were listed as current public health infrastructure and capacity-building priorities. Implementation While ORR and ASTHO aim to achieve similar overarching goals of supporting health agencies, their implementation strategies vary. The ORR Strategic Plan focuses on four primary strategies that directly address the emerging threats and challenges highlighted by S/THAs, including: Modernizing and integrating data and systems across multidisciplinary public health entities to support data readiness and interoperability. Advancing readiness and response science to improve public health practice, including maturing and implementing evidence-based research in preparedness. Building and enhancing the response capability of CDC and state, tribal, local, and territorial health departments and driving collaboration among partners to enable rapid and effective response to public health emergencies through improved capabilities, partnerships, and funding mechanisms. Conducting rapid and ongoing readiness and response evaluation to inform continuous improvements across the detection of public health threats, readiness science, and emergency operations. While ASTHO’s Strategic Plan is less explicitly focused on preparedness, its guiding mission in supporting, equipping, and advocating for S/THOs and their agencies with a focus on leadership development highlights several strategic priorities critical to improving public health preparedness and addressing emerging priorities. Health and Racial Equity: A state and territorial public health system that prioritizes implementing policies and programs advancing health and racial equity to achieve optimal health for all. Workforce Development: A diverse state and territorial public health workforce that is engaged, well-resourced, well-trained, and connected to the communities it serves. Data Modernization and Interoperability: A state and territorial public health system supported by an enterprise-level data infrastructure in which public health data systems are interoperable, secure, and supported by a well-trained workforce. Collaborative Opportunities Maximizing the impact of these strategic plans involves leveraging the strengths of each organization through collaboration and innovation. There are numerous areas where ORR and ASTHO can collaborate to enhance public health outcomes: Joint programs leveraging CDC’s national scope and ASTHO’s state-level connections. Shared research initiatives pooling resources and expertise from both organizations. Coordinated emergency response efforts that create a unified front addressing public health emergencies. By continuing to communicate, these organizations can effectively address complex public health challenges and enhance overall public health resilience. Future Outlook Looking ahead, the strategic efforts of ORR and ASTHO will play a crucial role in shaping the future of public health infrastructure and preparedness. Engaging with and supporting these initiatives is essential for all stakeholders. To adapt to the changing health security threats, future iterations of all documents must be routinely updated to meet the needs of the nation and ASTHO’s members. A collective effort is required to improve public health resilience and response capabilities, ensuring we are well-prepared for future challenges. Ultimately, the synergy between ORR and ASTHO’s strategic plans presents a powerful opportunity to enhance public health outcomes. We can create a more resilient and effective public health system by fostering collaboration, building competencies, and addressing emerging trends and challenges. website yes

Assessing the future of the federal Supplemental Nutrition Assistance Program (SNAP).

Learn how embedding disability specialists into health agencies improved preparedness programs and initiatives in this blog.

States and municipalities are adopting tobacco retailer licensing (TRL) policies to control tobacco prevalence and impact. Learn more about TRL programs.

Strategies for Accessible Health Care for People with Disabilities Living in Rural Communities Accessible Healthcare for People with Disabilities Association of state and territorial health officials, astho, public health, people with disabilities, rural communities, accessible healthcare, access to care, healthcare infrastructure, chronic health conditions, frequent mental distress, health officials, community engagement, behavioral risk factor surveillance system, healthcare resource, inclusion, health agencies, health equity, health equity programming, expand accessibility, emergency preparedness Ty B. Aller, Audrey Juhasz There is a need to expand support for people with disabilities in rural communities. Access to adequate care can often be difficult in rural communities, where public health and health care infrastructure is stretched. Rural communities are in need of more robust services to effectively improve the well-being and quality of life for people with disabilities who also experience chronic health conditions (CHCs) and frequent mental distress (FMD). Services to address these concerns are already underfunded and stressed. Effective solutions will require both specialization and community engagement to be successful. To help aid health officials address these growing concerns, researchers at the Institute for Disability Research, Policy and Practice at Utah State University, aided by funds from CDC and in collaboration with ASTHO and The Association of University Centers on Disabilities, sought to better understand the prevalence and trends of CHCs and FMD among people with disabilities living in the intermountain west. Using data from the Behavioral Risk Factor Surveillance System collected by CDC, researchers wanted to understand how urbanicity impacted the prevalence of CHCs and FMD. These two aspects were selected because they represent aspects of both physical and psychological health. In two reports, researchers found that adults with disabilities in the United States were more likely than people without disabilities to experience CHCs and FMD. Surprisingly, CHCs and FMD were both not more common among people with disabilities living in rural communities compared to urban communities. This is critically important because it suggests that people with disabilities living in rural areas are just as likely to develop a CHC or experience mental distress as those living in urban areas. However, health care resource availability is typically lower in rural communities compared to urban communities due to differences in economic and health care infrastructure. This suggests that although people with disabilities are just as likely to develop concerning physical and psychological conditions, they may have more difficulty getting the services they need. To address these disparities, it is critical that public health and health care infrastructure is expanded in rural areas. However, rural communities can be resistant to sudden and large change instituted by those outside of the community, so balance and community buy-in are vital to long-lasting and sustainable change. Actionable Strategies for Health Agencies Step 1: Shift focus from “curing” disease processes to promoting community engagement, inclusion, and well-being. Too often, programming for people with disabilities emphasizes trying to find “cures” for their concerns rather than promoting well-being through meaningful engagement and inclusion. People with disabilities may not view their disability as something to be cured or fixed but as an integral part of their identity to be seen and supported. As health agencies continue developing responses to complicated health challenges, they can focus programming that improves health equity for people with disabilities and promotes meaningful engagement and genuine inclusion. Step 2: Include and empower people with disabilities in planning state-wide responses to increase accessibility of health care services. States are making concerted efforts to include communities in the development and delivery of health equity programming. However, a lot of work remains to expand accessibility to people with disabilities. This is especially important when considering delivery of programming through internet-based services, as broadband internet access is still severely lacking in the United States. Empowering communities to lead these efforts is crucial for long-term sustainability and effectiveness. This can be done by directly including people with disabilities in planning and also collaborating with groups like community health workers that can help tailor the development and dissemination of programming in ways that are more likely to be useful for communities. For example, following the COVID-19 pandemic, communities include people with disabilities in emergency preparedness planning to ensure that services are more accessible to all. Step 3: Leverage the power of scalable, transdiagnostic programs. The sheer variety and diverse needs of people with disabilities experiencing CHCs and FMD make it very challenging to provide effective programming to improve health equity. Because of this, it is essential for health agencies to consider using and/or incentivizing transdiagnostic programs that can simultaneously address varying conditions, like CHCs and FMD, while improving well-being. Online self-guided mental health programs are widely available and are often provided in low-cost, easily scalable formats. These programs work by having individuals practice mental health skills in a self-guided format that includes interactive activities based on empirically validated psychosocial interventions that are commonly used in in-person services. These programs are cost-effective and can be easily nested and disseminated in existing public health and health care infrastructure. Building upon these frameworks provides health agencies with low-effort, high-impact actions that can be included in strategic state-wide plans. Ultimately, addressing the health care needs of people with disabilities in rural communities requires a multifaceted and inclusive approach. By focusing on community engagement, inclusion, and the empowerment of individuals with disabilities, health agencies can develop sustainable strategies that promote health equity. Leveraging scalable, transdiagnostic programs can further enhance the accessibility and effectiveness of health care services, ensuring that all individuals, regardless of their location, receive the care and support they need. website yes

Integrating Health Equity into State and Local Data Sharing Practices Morgan Zialcita, Lana McKinney, Christina Severin, Reema Mistry, Melissa Lewis It is crucial that health agencies incorporate health equity principles into policies and relationships that advance state and local data sharing. Timely and efficient public health data sharing improves public health response and decision-making. It enables local public health agencies (PHAs) to enhance community-level interventions and state PHAs to provide equitable response and allocation of resources within the jurisdiction. However, data sharing between state and local PHAs can be challenging due to resource capacity constraints, factors that limit technical solutions, and sensitivities and complexities associated with public health data collection and dissemination. Adopting policies to advance state and local data sharing and incorporating health equity principles into these relationships can help PHAs better identify and address data disparities, utilize resources effectively, and create an equity-centered public health data infrastructure. Equity Impact Assessment for Policy Changes Adopting data sharing policies using a health equity-focused framework can mitigate unintentional harm to specific populations. An equity assessment requires the systematic examination of available data and expert input to understand how a policy, program, or process will affect various groups, especially those who are either at risk of or experiencing health disparities. The Health Equity Impact Assessment (HEIA), designed to address racial disparities and root causes of inequities that could arise from policy changes, can help agencies explore potential inequities that may result from a policy initiative. Health Equity Considerations for Key State and Local Data Sharing Priorities Informatics Workforce Developing a diverse workforce that is representative of the communities it serves is important for advancing an equitable, inclusive approach to data modernization. However, recruiting and retaining diverse informatics staff—with strong technical, relationship-building, and change management skills—can be challenging for PHAs, especially in resource-limited locations. Health agencies can incorporate health equity principles into their workforce strategies in several ways: Consider soft skills, such as communication and collaboration, alongside technical expertise. These skills are important in establishing and maintaining state and local data sharing relationships. Include data sharing tasks in job descriptions to promote accountability and transparency amongst staff. This approach helps identify the role(s) responsible for data sharing activities and can also support sustainability by minimizing staff turnover. Prioritize inclusive practices and invest in ongoing development of agency staff. For example, provide training on cultural humility and data sovereignty to better equip staff working with tribal nations on data-sharing initiatives, and provide on-the-job training to help employees grow and build capacity. Reassess location, remote work, salary, and tenure policies to attract a diverse and skilled informatics workforce. Agency Alignment and Governance The type of public health governance model in a given state (e.g., centralized, decentralized, shared, or mixed) can influence how state and local PHAs work together both overall and on data-focused initiatives. The following health equity-focused recommendations are applicable across governance types: Establish strong communication channels and processes across partners to ensure all parties explore and understand the health equity considerations associated with data sharing initiatives. Consider options for shared resources to leverage expertise and promote collaboration on data-sharing initiatives (e.g., shared training programs, IT systems, and liaison roles that could perform epidemiology or informatics functions). This shared approach can bridge resource and knowledge gaps between state and local PHAs, especially for communities with limited resources. Consider ways to include local PHA input and ongoing feedback (e.g., through advisory boards) to encourage shared decision-making. Establish processes and policies to identify appropriate levels of data access across both local and state PHAs, so that shared data can inform population health analysis and reporting purposes at community, state, territory, tribal, and federal levels. Data Sharing Agreements and Organizational Policies When pursuing a new or amended data sharing relationship, engaging with legal experts is essential to safeguard sensitive public health data and ensure compliance with all relevant laws. Failure to successfully navigate these relationships and the inherent complexities associated with certain types of data can limit access to valuable information for important public health initiatives that improve equitable outcomes. Health agencies can take the following actions to promote effective collaboration between program, technical, and legal staff: Share the scope of the data relationship, the details of the proposed data exchange, and the overall programmatic purpose of the arrangement with the legal team. This is necessary for effective discussions with legal counsel and will help inform the agency’s approach to documenting the data relationship (e.g., in the form of a data-sharing agreement or DSA). Use decision-support tools, such as the HEIA, alongside the legal team to consider how the new proposed data sharing policy may impact equity across populations. Use clear and accessible language in DSAs and related protocols and policies, with support from legal counsel. Documents written in plain language support transparency, help build trust, and facilitate understanding among interested parties. Foster a culture of knowledge sharing between program, technical, and legal staff. For example, consider inviting legal staff to join advisory committees, listening sessions, or town halls about data sharing considerations to enhance program staffs’ understanding of legal considerations, address perceived barriers, and promote relationships and knowledge exchange between program teams. Conclusion In addition to adopting policies that make data accessible across government levels, it is important to develop mechanisms for communicating with communities about how their data is being used. For example, developing public-facing data dashboards (such as Alaska Department of Health’s Public Health Data Hub) that are easily accessible and understandable can be an effective way to increase transparency and build trust with the public. By committing to these strategies, PHAs can support a more collaborative, coordinated, and equitable approach to state and local data sharing, and strengthen PHAs’ capacity to address public health challenges. website yes

Partner Spotlight: Q&A with Lilly Kan, Project Director, The Pew Charitable Trusts Q&A: Importance of Data Sharing Between Healthcare & Public Health ASTHO Staff Lilly Kan, project director at The Pew Charitable Trusts, discusses the importance of data sharing between the healthcare system and public health. State and territorial health agencies need access to timely, standardized, and high-quality health information, which healthcare providers can report seamlessly through automated data sharing using modern scalable response-ready systems. As ASTHO’s Public Health Data Modernization Policy Statement notes, this core capacity requires not only technological and workforce investments but also strong policies that facilitate the exchange and governance of public health data. We speak with Lilly Kan, project director of Public Health Data Improvement at The Pew Charitable Trusts, who asserts that data sharing between the healthcare system and public health forms the basis for timely public health action. She explains how staff in state health departments have informed Pew’s efforts, including an upcoming 50-state report, and can support the drive to modernize public health data exchange. Tell us about Pew’s work to improve public health data sharing. The public health data improvement project follows our previous work around the interoperability and usability of electronic health record systems and focuses on leveraging those technologies to improve data sharing with public health departments. Our aim is to identify strategies that facilitate more seamless sharing of timely and complete data from those who collect it (e.g., doctors, labs, and other providers or care settings) with those who need it in our public health agencies, reducing provider burden and helping to protect their communities. Some of our work is at the federal level, as we are engaging with agencies like CMS, CDC, and the Office of the National Coordinator for Health Information Technology on rules governing topics such as incentives for data sharing. In addition, we’re developing a 50-state report that reviews data sharing policies throughout the country, discusses how data between healthcare and public health gets shared in practice, and includes interviews with public health officials that provide deeper context on their needs and challenges. We’re aiming to release the report this fall and look forward to showcasing steps state health agencies are taking that may be useful for their peers as well as highlighting some of the most common trends we’ve seen throughout the country. What role does the healthcare system play in the public health data infrastructure? The billions of data points generated by doctors’ offices and hospitals every year could yield a dynamic, high-definition picture of the nation’s health and provide insight into potential threats, but only if public health agencies have timely access to it. What we’ve heard in conversations with providers is that they see public health data as a potential benefit for them as well. The data state health agencies compile and analyze could be a boon for patient care if providers receive bidirectional access to it. Building connections with partners in the healthcare system could make it easier for everyone to work together and support healthier communities. Which partners are important to this project and how can they help to support it? Since our project is focused on supporting health departments, public health officials in states, counties, and cities are critical—they know their operating environment and what policy changes would be best for them. We’ve been speaking with officials throughout the country as well as organizations supporting public health departments, such as ASTHO, from the start, but we’re also thinking of the groups that collect data (e.g., hospitals, individual practitioners, and labs). Additionally, elected officials at the state level may be responsible for shepherding policy changes into law. Every one of those groups has important perspectives to offer and different questions they’ll need answered. How have your conversations with public health officials shaped Pew’s approach? At its core, our work needs public health practitioners’ experiences, perspectives, and voices. We have heard from public health officials that having quality data isn’t enough; having the people and systems in place to analyze it and harness it is equally important. Sorting through reams of faxes when every hour counts for contact tracing is not a good position for health agencies to be in, especially if they are understaffed. As such, resources are a frequent concern for people we speak to—as anyone who works in public health will understand, making improvements without further financial and staff support is an immensely difficult task. We also recognize the importance of understanding a state’s specific challenges. What if a state has less access to high-speed broadband internet, and faxes or phone calls are the best way for some providers to contact patients? What if new systems or connections would be an undue financial or staff burden? That’s why, again, the biggest takeaway in our conversations is that we need to understand states’ specific situations before we provide guidance. That is critical for our work going forward. Finally, we know that there is no one-size-fits-all solution to advance data sharing between healthcare and public health. Every state comes at this from a different starting point and with different needs and challenges, and public health officials are working heroically in their own specific environments every day. But we also know that there are common themes or aspects across different states’ policies and practices that peers could adopt in their own settings. As we work to better understand where states are in this process and what policy changes might get us closer to seamless electronic data sharing, we know a single top-down strategy will not work; collaborating with people who face these issues every day is key to finding the solutions that will work for them. What do you have planned for the continuation and/or expansion of this work? We’re also conducting research into states that have implemented successful data sharing practices between their public health agencies, other state agencies, and even external partners beyond the government—all of which could help other states take steps of their own, based on the experiences of their peers. We’ll aim to highlight some of those in case studies to come over the next year. Ultimately, our goal is to help better prepare our country for the next public health challenge before it arises. The best time to make these changes is when we aren’t facing a health crisis—so we can take the time to ensure we’re ready for the next one and better able to deal with existing issues in our communities that may need extra intervention. Health departments are essential for that, and we’re looking forward to working with them further. website yes

Public Health Leader Profile: Joy Borjes on Leading Teams Through Change ASTHO Staff, Center for Health Care Strategies Staff ASTHO | Joy Borjes of Texas HHS shares perspectives on leading teams through change. Introduction As a child, Joy Borjes witnessed firsthand the power of state programs to improve the lives of those they serve: Joy’s parents received government support related to their disabilities, which inspired her to become a civil servant. “I grew up seeing that government services can make a difference, and I wanted to be a part of that,” she reflected. Now as part of the Texas Health and Human Services Commission (HHSC), Joy supports programs that impact the lives of more than 7.5 million Texans every month. In 2022, after working in state government for more than 10 years, Joy was promoted to a new position as the associate commissioner for family health strategy in HHSC's family health services division and began leading a team working on women’s and children’s health initiatives. In this role, she oversees the coordination of programs within the women’s health portfolio, which includes family planning services and breast and cervical cancer services. Across the country, health care policy at the state level is often complicated by evolving dynamics, changing demographics, and emerging needs; state public health leaders must navigate the confluence of relationships, policy, and change. With help from Joy’s leadership, the family health services division has celebrated several recent successes, including the impending release of a redesigned long-acting reversible contraceptive (LARC) toolkit, strengthened partnerships with external groups, and a 65% increase in funding through the Texas Legislature for the state family planning program in 2024. To support some of these achievements, Joy and her HHSC colleagues joined the Contraception Access Learning Community (CALC), led by ASTHO in partnership with the Center for Health Care Strategies. The learning community offered an opportunity for dedicated staff time and external support to work on improving women’s health outcomes in the state. This leadership profile highlights lessons from Joy’s nearly 12-year career working for the state, with a focus on her successes in advancing women’s health access through strategic oversight of the learning community workgroup. Rich Text Block-Blog - Joy Borjes on Leadership - CALC Leadership Lessons Investing in Relationships The learning community workgroup Joy pulled together included staff from the family health services division and Texas Medicaid, along with external advocates from the Texas Women’s Healthcare Coalition (TWHC), academic researchers, and others. For the workgroup to succeed, Joy knew the importance of cultivating relationships and fostering trust, especially with people she had not worked with before. “As we were coming together with our external partners, we had frank conversations with them about what our roles were, what our goals would be, and what capacity we had,” Joy shared. The workgroup decided their first goal would be to redesign a 2018 provider toolkit that focused on increasing knowledge and effectively using LARCs. Redesigning the toolkit had long been a desire of the family health strategy team, but competing priorities prevented them from doing so without extra support. Because Joy had invested in building relationships with her workgroup members, she knew their expertise, passions, and priorities. Joy was able to explain the importance of redesigning the toolkit to the workgroup’s external members and increase their investment in this work. Through collaboration and with momentum and support from the learning community, the workgroup is nearing completion of the redesigned toolkit. Rich Text Block-Blog - Joy Borjes on Leadership - Key 1 Motivating a Team Through Change At the start of the learning community, HHSC underwent a reorganization of the commission’s client services programs, including Joy’s family health strategy team and the women’s health programs with which her team works. Simultaneously, Joy’s external partners restructured. This concurrent period of transition disrupted the work of the learning community workgroup, as members were focused on their own internal reorganization. Leading the workgroup through these changes was difficult; the workgroup struggled with high staff turnover both at HHSC and within TWHC. The remaining members had limited work capacity, with many taking on work left by their previous colleagues. Through the restructuring and staff departures, the workgroup lost key experts and the priorities of the workgroup became unclear. In reflecting on this period, Joy shared, “I wish I had been more intentional about reaching out to our external partners in the learning community to explain what we were doing, instead of making assumptions that everyone knew. We struggled because of the change and lack of clarity.” Throughout this period of uncertainty, Joy realized the power of leading with transparency and vulnerability. “There’s value in being vulnerable by acknowledging when work is difficult,” Joy reflected. “I don’t sugarcoat things, but even when things get tough, I’m still enthusiastic about the work we’re doing to serve Texans.” After a few months of reprioritization, Joy was able to reconvene and motivate the learning community workgroup to continue working toward its goals. Rich Text Block-Blog - Joy Borjes on Leadership - Key 2 Setting a Vision Through “Yes, and...” Many leaders struggle to find time to plan strategically—it is easy to get tunnel vision, focusing only on the present. After the multi-organizational restructuring, Joy met with workgroup members to discuss new roles, responsibilities, and goals for the learning community. As the workgroup thought about their goals, Joy realized the potential to leverage the time and resources of the learning community to prepare for her other large focus: the 89th Texas legislative session starting in 2025. The Texas Legislature convenes every two years to pass laws and make decisions that impact HHSC and other state agencies. For state officials, preparing for the biennial legislative session is a crucial part of their work. During the 88th legislative session in 2023, Joy partnered with HHSC’s family planning program leadership to request increased program funding. Together, they saw a 65% increase in funds allocated to the agency’s family planning programs. Knowing that planning for the 2025 session would help both the family health services team and their partners, Joy leveraged the learning community to set a vision for the legislative session. She noted, “I wanted to make sure we were prepared for the next session instead of getting stuck with focusing only on the present one. The legislative cycle moves so fast. The 89th session will be here before we know it, and it only lasts 140 days. So, a little bit of planning—making sure the agency knows what our stakeholders will be advocating for, for instance—can go a long way in helping legislators make complicated policy and funding decisions.” In developing a vision for the next legislative session, Joy encouraged the workgroup to collaborate in shaping their goals. She reflected, “In my interpersonal interactions, I’m a believer in the ‘yes, and’ approach, borrowed from improvisational theatre. Even in difficult moments, being able to say, ‘I see your point and here’s something I can do to build off of that idea,’ helped keep our team motivated and excited about the work.” Rich Text Block-Blog - Joy Borjes on Leadership - Key 3 Closing Joy’s approach to leading both the HHSC family health strategy team and the learning community workgroup highlights key lessons for public sector leaders. Under Joy’s leadership, the updated LARC toolkit will reach thousands of providers across the state, and the increase in funding the Texas Legislature provided will allow Joy and her partners to increase access to their family planning programs in 2024. The successes of Joy’s team were driven by her approach to leadership. Joy invested in relationships by making time to talk with others in her field. She set the right goals for the right time by taking advantage of available resources and support. Finally, Joy embraced authenticity by leading with self-awareness and transparency. Contraception Access Learning Community Arnold Ventures Funding website yes

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Roots of Equity: Addressing Health Disparities and Advancing Inclusive Solutions in Michigan Ninah Sasy Addressing historical inequities and health disparities to promote health equity and well-being in Michigan. Social determinants of health (SDOH)—e.g., socioeconomic status, education, employment, housing, access to health care, and environmental factors—profoundly shape individual and population health. SDOH includes social and cultural factors such as racism, discrimination, and bias (based on race, ethnicity, gender, sexual orientation, disability, or other marginalized identities) that contribute to health inequities by creating barriers to resources, opportunities, and fair treatment. Understanding and addressing these factors is essential for promoting health equity and improving overall well-being. The Historical Landscape of Systemic Discrimination My grandparents were born in the late 1930s and early 1940s, during which a significant number of discriminatory practices and policies directly impacted their career trajectory and the stability of their family. Jim Crow laws enforced racial segregation, leading to inequities in education, housing, and employment opportunities. Like many African Americans, my grandparents relocated from the South to northern states for better opportunities (specifically Flint, MI, to join the automobile industry). When they arrived, they encountered additional discrimination, including redlining. The practice of redlining involved discriminatory lending practices by financial institutions, explicitly denying or limiting financial services, such as loans or insurance, to certain neighborhoods or communities, often based on the perceived risk of racial or ethnic minorities. Despite that, my grandparents were fortunate to live the American Dream of owning a home; I remember their beautiful green lawns and my grandmother’s flower gardens from when I was a child. Importantly, African Americans weren’t the only ones impacted by discriminatory laws and practices. My maternal grandmother, who was Native American, faced discrimination as well through forced assimilation, a direct contrast to the Indian Reorganization Act of 1934, which was intended to promote cultural preservation. Many minority populations and impoverished farmers faced unimaginable discrimination—and the repercussions are still evident today. Health Inequities and Racial Weathering Health inequities persist when comparing African Americans to their White counterparts. Most recently, during the COVID-19 pandemic, significant disparities in mortality rates became apparent. Understanding the origins of these disparities connects back to the historical landscape of our country and the antiquated policies that perpetuate these inequities. In addition to the Jim Crow laws creating an unfair advantage for some Americans to achieve generational wealth, there are day-to-day infractions that persist today. Racial weathering describes the cumulative physical and psychological toll of experiencing systemic racism and discrimination over time. This phenomenon manifests through chronic stressors such as microaggressions, unequal access to resources, and institutionalized racism, which can have profound effects on individuals' health outcomes. Research suggests that racial weathering contributes to disparities in chronic illnesses, mental health conditions, and overall well-being among marginalized communities. The cumulative physical and psychological toll of experiencing systemic racism and discrimination over time. This phenomenon manifests through chronic stressors such as microaggressions, unequal access to resources, and institutionalized racism, which can have profound effects on individuals' health outcomes. Research suggests that racial weathering contributes to disparities in chronic illnesses, mental health conditions, and overall well-being among marginalized communities. My grandparents and their neighbors took pride in their homes. However, several factors, including the closure of numerous factories, have contributed to disinvestment in the Flint, MI community. When the primary employer, the automobile industry, departed, so did a portion of the population to seek employment in other communities. Consequently, there was a lack of investment in the school systems, as they relied heavily on property taxes. This domino effect resulted in food insecurity and housing instability. Once vibrant homes with lush lawns and blooming flowers were replaced with abandoned properties and businesses. As a result, individuals must travel 20 to 30 minutes by car to reach a grocery store instead of taking a 10-minute walk for fresh produce. Transforming Public Health in Michigan Culturally Appropriate Solutions According to the Michigan State Plan on Aging, approximately 2.5 million people in Michigan (or 25.3% of the state’s population) are 60 or older. Considering the comprehensive policy and programmatic needs to support this growing population, we must better understand and create culturally appropriate solutions. It is also critical that we acknowledge and address the longstanding historical inequities intertwined in laws, policies, and social structure that have created health inequities in our aging minority populations. Addressing these inequities is crucial to support health equity and improve the overall well-being of all older adults in Michigan. We are fortunate to have the Michigan State Plan on Aging at the state level. The Plan was developed and implemented with the support of diverse voices by integrating fundamental principles such as health equity, elder justice, person-centered practices, and evidence-informed approaches across all goal areas through Michigan Department of Health and Human Services (MDHHS) leadership. Michigan Department of Health and Human Services (MDHHS) leadership. Building a Statewide SDOH Strategy As the Policy and Planning Director, I have the privilege of leading the development and implementation of our statewide SDOH strategy. This strategy aims to create a healthier and more equitable society by tackling the social and environmental factors influencing health outcomes. It is imperative to address health disparities to guarantee that everyone, regardless of their background, has an equitable chance to enjoy a healthy and satisfying life. The strategy strives for a future where innovative concepts and community-led solutions are central to dismantling health disparities and fostering the comprehensive well-being of communities. Representation Is Key Representation matters because it ensures that diverse voices and perspectives are heard and considered in decision-making. MDHHS recognizes the importance of representation and continually gathers information from community partners and residents to inform its work. Within the MDHHS SDOH policy team, I have taken proactive steps to assemble diverse leaders to provide insights and guidance for collaborative efforts. My leadership goal is to cultivate a culture where every team member feels appreciated and empowered to share their viewpoints, nurturing an atmosphere of transparency and mutual regard. Convening diverse partners is essential for fostering inclusive and practical solutions to complex societal challenges, particularly in public health. By garnering a wide range of perspectives, experiences, and expertise, these partnerships can better identify and address the root causes of health disparities and inequities. Through intentional engagement with our SDOH task forces, advisory councils, and SDOH Community Influencer Program, we strive to build trust and longstanding collaborative relationships. By prioritizing diversity and inclusion in our engagement efforts, MDHHS seeks to create policies and initiatives that genuinely reflect the needs and experiences of the communities we serve. However, there is always room for improvement. As public health leaders, we should continually assess how we engage with the community to ensure we build longstanding relationships. Healing Historical Wounds Reflecting on the Michigan initiatives makes me proud to be a public health leader. However, having lost two of my grandparents before they reached the age of 70 and remembering the challenges that they endured throughout their lives, I continue to feel disheartened. Many factors impact health care outcomes for the aging population, especially for BIPOC communities. Navigating the social and health care system is challenging. The digital divide, the deeply ingrained distrust in health care, and the rekindling of past traumas are just a few additional barriers for the aging population, which are further compounded in minority and low-income populations. As leaders in public health, it is crucial to continuously enhance our community engagement practices, ensuring that our programs and policies accurately reflect the community's needs. This involves: Cultivating solid relationships with community partners to reach our most vulnerable populations, particularly the elderly, effectively. Actively pursuing opportunities for professional growth, such as anti-bias and cultural competency training. Taking proactive steps to eliminate barriers to partnerships by reforming grant-making procedures, promoting flexibility in program design, and refining our community engagement strategies to capture the invaluable perspectives the community offers entirely. Embracing collaborative decision-making processes is essential. Advocating for policies like the Caregivers Act, which removes barriers for family members to care for their aging loved ones, aligning with culturally competent care. Prioritizing equitable solutions that address not only socioeconomic disparities but also the underlying inequalities among minority groups should be an essential aspect of policy reform discussions. Our commitment to investing in the elderly will benefit future

ASTHO develops resources and facilitates learning communities to help health officials reduce maternal mortality, a Healthy People 2030 leading health indicator.