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This toolkit is designed to support public health leaders in leveraging the policy development process to achieve health equity in their jurisdiction.

Explore the transformative power of community engagement and community power building in public health research, and learn how these initiatives can enhance racial and health equity. Discover strategies for addressing structural determinants of health and empowering communities to drive positive change.

State and federal efforts to bolster health care access for underserved rural communities.

Centering the Community’s Voice in State-Led Health Equity Initiatives health equity, public health departments, health outcomes, michigan public health institute, health disparities, underserved populations, marginalized communities, people of color, indigenous people, premature deaths, minority health, cultural competency, public health, life expectancy, improving health, american indians, health service, african american, native american, social determinants of health, sexual orientation, mortality rate, socioeconomic status, covid-19 pandemic, higher rates, alaska natives, group of people, racial groups, social economic, population health, department of health, astho, association of state and territorial health officials Lana McKinney, Jessica Fepelstein Establishing the community voice in health policy discussions. Over the past two years, ASTHO has worked directly with state public health departments and their communities to build capacity for improving health outcomes. These public health departments are building a culture of health equity through policies, practices, and quality improvement measures. This includes the Strategies to Repair Equity and Transform Community Health (STRETCH) Initiative—a 10-state learning community hosted by ASTHO, the CDC Foundation, and the Michigan Public Health Institute. STRETCH supports states in operationalizing health equity and preventing the constant pressures caused by negative health outcomes on their communities. For example, poverty can create constant pressures just as water pushes against a dam, which can build to the point of breaking and push people into poverty. Additionally, ASTHO supports state and territorial recipients of CDC’s COVID-19 Health Disparities grant to improve the health of high-risk and underserved populations disproportionately impacted by the COVID-19 pandemic. Health disparities impact the quality-of-life and financial well-being of communities, with the economic burden of health disparities increasing from $320 billion in 2014 to $451 billion in 2018. This includes associated costs of excess premature deaths, lost labor market productivity, and excess medical care for Americans of color as compared to their white counterparts. Events in recent years, such as the COVID-19 pandemic, revealed the pressures that Black, Indigenous, People of Color (BIPOC) and other marginalized communities experience because of health disparities. Aligned with the technical assistance received by public health departments, several states have taken concrete steps to achieve optimal health for all by supporting training of public health staff and increasing engagement of under-represented and underserved communities in the policy process. Promoting Staff Health Equity Training Ensuring that public health staff and other leaders are equipped with the knowledge, skills, and attitudes necessary to provide culturally competent and equitable care to all patients, regardless of their social background or identity can improve health outcomes. In recent years, states have worked to expand access to cultural competency and humility training for health system workers. Nevada enacted legislation (AB 267) requiring the state Board of Health to establish the frequency for medical facilities and dependent care facilities to conduct cultural competency training for employees who have direct patient contact. It also (1) requires the Office of Minority Health and Equity and Department of Health and Human Services to establish and maintain a public-facing list of approved courses for cultural competency training, and (2) require nurses, psychologists, marriage and family therapists, counselors, social workers, and behavioral analysts to complete a minimum of three hours of cultural competency training to successfully renew their license. At least four other states—Illinois (SB 2427), Massachusetts (S 1413), Virginia (SB 1440), and Vermont (H 512)—considered bills expanding access to cultural competency training for health care professionals. Vermont’s bill would implement the recommendations of the Health Equity Advisory Commission to provide training and continuing education for health care providers to improve cultural competency, cultural humility, and antiracism in Vermont’s health care system. Public health agencies can also promote health equity training by allocating funding and providing training. For example, the Arizona Department of Health Services leveraged funding from CDC’s COVID-19 Health Disparities grant to establish the Advancing Health Equity, Addressing Disparities (AHEAD AZ) program with the University of Arizona Center for Rural Health, which supports the health care and public health workforce, including support for Arizona’s 17 Critical Access Hospitals health equity strategic plans, and implementing a COVID-19 testing program that provided testing to communities most in need regardless of socioeconomic or immigration status, including those living in correctional facilities and unhoused people. Health Equity Commissions Health equity commissions play a critical role in advancing optimal health for all by bringing together experts, stakeholders, and policymakers to draw on evidence-based approaches that address the root causes of health disparities and to develop strategies to prevent them. At least two states proposed legislation related to health equity commissions in 2023. Colorado passed a law (SB 23-151) extending its Health Equity Commission through 2029. New Jersey is considering S 3136, which would establish and require a Commission on Health Equity to, among other things, recommend implicit bias training requirements for health care providers. Empowering Community Members to Engage in the Policy Process Hearing directly from community members, particularly those with lived experience, provides health agencies with unique insights into the community’s needs and daily life, and helps gain support from those most affected by the policy. There can be several barriers to holistic community engagement, particularly for community members who have fewer resources. Policymakers can take steps to lower these barriers by providing access to childcare, supporting transportation costs to a meeting, and/or compensating community members for their time and effort supporting the policy development process. In 2022, Washington enacted SB 5793 to compensate community members with lived experience for their time and expertise when serving on boards, commissions, councils, committees and other similar policymaking groups. The law directed the state’s Office of Equity to develop equity-driven compensation guidelines for all state agencies, which Washington’s Department of Health used to create and implement its Community Compensation Guidelines. These compensation guidelines outline how and when community members can be paid for their time and expenses when engaging in the policy process. Such methods are particularly valuable because the communities facing the most inequity are also the ones most systemically marginalized. Similarly, in 2023 Oregon’s legislature considered SB 694 to create a Task Force and Work Group Stipend Fund. The fund would provide for providing members who do not otherwise receive compensation for their participation to be compensated for their time and travel for task force or workgroup related work. ASTHO will continue to monitor policy developments supporting health equity programs and initiatives, providing relevant updates. Special thanks to Maggie Davis, JD, ASTHO’s director of state health policy, for her contributions to this blog. Additional Resources to Help Public Health Leaders Increase Community Engagement ASTHO’s Programmatic Health Initiatives and Strategies Georgia Health Policy Center’s Guide to Funding Navigation to help communities design and sustain equity-advancing investment. <!-- Strategies to Repair Equity and Transform Community Health (STRETCH) Initiative framework. --> website yes

A mid-session legislative update on five of ASTHO's top 10 public health state policy issues to watch in 2023: data privacy and modernization, reproductive health, health equity, strengthening public health agencies, and immunization.

Looking to the future, states are improving access to care, providing subsidies for tuition costs, expanding hours of licensed facilities, increasing access, and meeting the needs of both parents and children.

Public health agencies are working to reduce dementia risk and to optimize the health and well-being of people living with dementia and their caregivers.

While COVID-19 is still present and ever-changing, public health professionals must also grapple with new challenges such as monkeypox, increasing firearm homicide, and widespread heat waves. In the wake of such emergencies, public health preparedness is more critical than ever.

There are significant disparities in pregnancy-related outcomes in the United States. Many of these deaths considered preventable, so state and federal policy makers are taking steps to improve health outcomes for pregnant people.

The COVID-19 pandemic has negatively impacted youth mental health, particularly as a result of school closures, social isolation, family economic hardship, fear of family loss or illness, and reduced access to healthcare. However, states have many strategies to choose from to improve youth mental health and reduce suicide.

Engaging Communities Is a Critical Tobacco Control Strategy Community Engagement Tobacco Control, Menthol Cigarette Disparities, Tobacco Control Learning Collaborative, Culturally Tailored Tobacco Interventions, Flavored Tobacco Product Legislation, United States, Flavored Tobacco Product, Health Equity, Youth and Young Adults, Tobacco Free, Cigarettes Smoked, Community Partners, Young People, Community Health, Youth Tobacco Survey, Flavored E-Cigarettes, Smoking Cessation, Tobacco Industry, Smoking Behavior, Study Showed, African American, Smoking Rates, Tobacco Marketing, Minority Populations, Hispanic Black, ASTHO, Association of State and Territorial Health Officials Charla Sutton, Matta Sannoh, Josh Berry, Kenny Ray, Ashley Hebert, Iman Byfield For decades, the tobacco industry has disproportionately targeted communities of color increasing rates of menthol cigarette use and tobacco-related health disparities. By prioritizing community efforts, health agencies can confront these disparities by fostering trust, inclusivity, and cultural responsiveness. Funded by CDC’s Office of Smoking and Health (OSH) and in partnership with The Center for Black Health & Equity (The Center), ASTHO initiated the Increasing State Menthol Capacity Learning Collaborative consisting of eight state tobacco use prevention teams each paired with a local community-based organization. The program fosters strong linkages between state commercial tobacco control programs and community-based partners to reduce menthol and flavored product use. The Role of Community Engagement Community-based initiatives are pivotal in tobacco control efforts, as they enable stakeholders to: Understand history, context, culture, and geography. Underserved communities possess a keen awareness of the origins of their problems and how decision-making processes affect them. Embrace community voices. “No one asked us” is the most common feeling communities most impacted by a problem share when decision-makers act without including them. Build organizational capacity that sustains change, creates credibility with decision-makers, and empowers communities to meet challenges head-on and garner support for their initiatives. Barriers to effective community engagement include insufficient training, funding, communication, and planning, plus disorganization, under-acknowledged communities, over-committed leaders, and inability to change course. Learning Collaborative at a Glance Eight state health teams (IN, MN, NY, PA, RI, MI, WA, WI)—each paired with a community-facing organization—kicked off the Increasing State Menthol Capacity Learning Collaborative in January 2023 with a shared vision and plan to reduce menthol and flavored product use. The Collaborative worked to: (1) improve capacity to identify and implement strategies to prevent menthol and other flavored tobacco product use, (2) strengthen collaboration between state commercial tobacco control programs and community-based partners, (3) tailor interventions to those most affected, and (4) understand the role of policy interventions and/or systems change and culturally-appropriate cessation strategies. ASTHO, OSH, and The Center provided peer-to-peer learning, technical assistance, and networking opportunities to help project teams draw from the group’s various resources, expertise, and experiences. For example, each state team participated in five virtual, expert-led learning sessions, which provided training on SMARTIE goals, equity-centered community engagement strategies, and effective communication messages for policies that restrict or eliminate the sale of flavored tobacco products. In addition, technical assistance provided the project teams guidance on their established workplan objectives and helped them navigate community-specific challenges. Menthol Capacity Building Strategies Each team worked to address health inequities of their chosen target population with culturally-tailored actions in one of three strategies: (1) Policy, Systems, and Environmental Change, (2) Menthol Cessation, or (3) Counter Marketing/Public Education. Teams focused on African Americans (nearly two-thirds of whom start by using tobacco with menthol), youth, Latinx, immigrant populations, and the LGBTQ+ community. Each team curated state-specific infographics, factsheets, webpages, and media campaigns to examine the role of policy in reducing menthol and flavored tobacco product use. Others engaged legislators or held educational events. Key Takeaways and Next Steps Community Engagement and the Menthol Landscape: Despite challenges, preemption should not stop community engagement work. While state or federal laws and regulations may change, the communities most impacted—and their voices, experiences, and advocacy efforts—remain and are essential in driving meaningful change. Ongoing awareness of the disproportionate impact of menthol and other flavored tobacco products on marginalized communities underscore a continuous need for community engagement and policies that prioritize health equity. Partnering for Influence and Advocacy: Community engagement fosters awareness of the unique challenges that marginalized populations face, ensuring that initiatives are tailored accordingly. In the face of preemption and other regulatory challenges, community voices are critical for national change. Mobilizing Support through Collaboration: Partnerships between state agencies and local organizations allow capacity building and resource sharing. Such partnerships help mobilize broader support with both constituents and legislators, share best practices/lessons learned, and collectively address challenges. Funding Local Initiatives: Effective community engagement often requires financial resources. Examples include facilitating quality meetings as needed, developing educational tools for community dissemination, using paid and social media, and obtaining individuals to implement key activities (e.g., employees or subject matter experts). The collaborative’s participants further encourage: Sustaining and strengthening partnerships with community-based organizations, state health agencies, and national partners to leverage stakeholder expertise and insights. Investing in ongoing capacity building efforts to equip communities with the knowledge, skills, and resources to address tobacco-related challenges effectively (e.g., training, resource sharing, offering technical assistance, and funding community-led initiatives). Engaging with policymakers, community leaders, and others to raise awareness about the negative impact of menthol and other tobacco products. Advocate for evidence-based policies (e.g., e-cigarette flavor restriction) at the local and state level to inform national discussion. Sharing lessons learned—both successes and challenges—with others. website yes

This infographic highlights 10 high-level strategies to advance work in school behavioral health.

The COVID-19 pandemic has impacted both the physical and mental health well-being of youth. Disruptions in both their home and school life have put youth at risk for poor mental health outcomes that include increased anxiety, depression, and risk of suicide. This Mental Health Month we examine state and territorial legislation that addresses youth mental health.

An increasing body of research finds racism can have a significant impact across one’s lifespan. Research shows that persistent exposure to racial discrimination may result in premature aging, poor health outcomes, and increased prevalence of certain chronic diseases. At every level of government, policymakers are seeking to acknowledge the systemic oppression of people of color that persists and to elevate racism as an urgent public health crisis comparable to other public health emergencies.

The ASTHO State Health Policy team provides brief updates on 5 of the ten state health policy issues to watch in 2022: mental and behavioral health, rural health, e-cigarettes and flavored tobacco products, HIV and PFAS.

More than 100 rural hospitals have closed since 2010, and an additional 25% are at high risk of closure, and COVID-19 has magnified the existing stressors on rural healthcare. As a result, states are using a variety of measures to address and prevent more rural hospital closures.

Many states have introduced bills to strengthen and increase access to these prenatal, delivery, and postpartum services, building a solid foundation of care for women who must navigate the healthcare system and make difficult decisions during public health emergencies.

COVID-19 has elevated our nation’s stress level. When not managed properly (or without any buffers like social support) stress is associated with increased depression and anxiety. Because COVID-19 impacts risk factors for suicide, such as depression, anxiety, substance misuse, and unemployment, the implications for suicide prevention are many. And with September being Suicide Prevention month, it’s a good time to take stock of how public health leaders can reduce suicide risk during this pandemic.

How to Support Youth Post COVID-19 With More Flexible Policies Caitlin Langhorne Griffith, Victoria Pless, Martha Yeide Over the past few months, COVID-19 has highlighted how current policies and funding do not support an equitable approach to health. However, states and territories have begun to leverage statutory and regulatory flexibilities to improve health outcomes for the disproportionately affected during this pandemic. One of the ways that states and territories can support these groups and maximize these flexibilities during and post-COVID-19 is by deploying a Shared Risk and Protective Factor (SRPF) Framework to address negative health outcomes. Research has demonstrated that addressing both the risk and protective factors across sectors can lead to multiple improved health outcomes, including heart disease, asthma, depression, and substance use. Because youth are at increased risk of exposure to Adverse Childhood Experiences (ACEs), and have fewer supportive resources, they are a particularly vulnerable group potentially affected by COVID-19 policies and funding. ACEs are a risk factor shared across numerous health outcomes, such as substance use disorder, chronic disease, and mental health. However, implementing the SRPF Framework can promote protective factors in upstream ways, like reducing and mitigating the impact of ACEs. During the COVID-19 response, some areas where state officials can take advantage of policy flexibilities to better support youth and reduce some ACEs include youth experiencing food insecurity, youth with incarcerated parents, and youth witnessing violence in the home. Ultimately, these examples illustrate the benefits of extending innovative policies to decrease negative outcomes and promote health across the lifespan beyond COVID-19. Youth and Food Insecurity Food insecurity is a public health issue that plagues the United States and has been associated with negative health outcomes including obesity and unhealthy brain development. More than 11 million children in the U.S. live in food insecure homes, with an estimated 11 percent of households reporting food insecurity at least some time during 2018. New data show that food insecurity has increased for youth during the COVID-19 pandemic, with almost one in five of mothers — 17.4 percent —with children ages 12 and younger reporting their children were undereating because they could not afford enough food. When state officials closed schools to prevent the spread of COVID-19, food access was upended for youth who participate in free-or-low-cost school meal programs. States can mitigate this disruption by safeguarding access and expanding these programs to ensure the continued physical and mental development of youth. Jurisdictions have implemented innovative practices allowed under expanded flexibilities to ensure that youth receive regular nutrition during COVID-19. Vermont is conducting telephone appointments for the Women, Infants and Children (WIC) nutrition program due to social distancing, and has also expanded the list of foods available through WIC during the COVID-19 pandemic. Forty-seven states and territories have implemented the Pandemic Electronic Benefit Transfer (EBT) benefit passed as part of the CARES Act. This allows households to offset the cost of meals that would have been consumed at school by youth. Wyoming has adapted its WIC program services, which includes providing curbside deliveries and conducting phone screenings. Youth with Incarcerated Parents It is estimated that between 1.7-2.7 million youth have incarcerated parents. This leaves them at a higher risk of adverse outcomes, including mental health problems, poor school-based outcomes, and increased antisocial behavior later in life. Parental closeness between incarcerated parents and youth can be an effective strategy to promote resiliency, and jurisdictions are implementing programs focused on connecting the incarcerated individuals with loved ones. The Pennsylvania Department of Corrections has created a virtual visitation program for all state-run facilities, and all inmates are eligible to participate. In Connecticut, organizations such as Children with Incarcerated Parents have created programs that provide free calls with incarcerated parents each month during the COVID-19 pandemic. Other innovative avenues to connect children with incarcerated parents include the Governor of Illinois issuing an executive order suspending the transfer of some inmates from county jails into the Illinois Department of Corrections during the public health emergency. This approach may increase the likelihood that inmates remain geographically closer to home. Washington executive order 20-47 suspended statutes that limit an individual’s ability to receive post-conviction relief, as well as prosecutors’ and courts’ ability to file and process criminal cases. Washington executive order 20-50 broadened the Governor’s authority to grant clemency to reduce the prison population. New Jersey Gov. Phil Murphy issued an executive order establishing an Emergency Medical Review Committee, which will review which inmates can be released to home confinement—identified by the Board of Parole—and outlined the process for ensuring those who are released are aware of reentry benefits. Youth Witnessing Violence in the Home Witnessing violence at home also is associated with a higher risk of negative health outcomes, as well as experiencing or perpetrating violence later in life. "Stay at home" or "shelter in place" orders during the COVID-19 response has corresponded with increased risk of family violence and increased calls to domestic violence hotlines, posing another public health crisis as many children have been exposed to violence in their homes. While trends also show a decrease in reports of child neglect and abuse, this decline may be due to restrictions on the child welfare surveillance systems that monitor and intervene in situations of abuse and neglect. State lawmakers have offered help to those experiencing domestic violence, despite restrictions on travel. Massachusetts and Maine ordered all state hotels to only provide rooms for vulnerable populations or essential workers, including those that may be experiencing domestic violence. New Hampshire established the COVID-19 Emergency Domestic and Sexual Violence Services Relief Fund for shelters across the state to aid those who may be experiencing domestic or sexual violence. Nevada developed a process for individuals to file online temporary domestic violence protective orders. The District of Columbia developed a process so individuals can file an extreme risk protection order through an online form and phone call, which can remove firearms from individuals who may be dangerous. Finally, California released a safety planning guide for those who may be experiencing domestic violence. The COVID-19 response has prompted states to provide flexibilities in funding and suspend or modify policies that would have made it more difficult to protect the public’s health — and in turn would have exacerbated negative health outcomes among youth. Through innovative practices these efforts have worked to mitigate the negative impacts of food insecurity, youth with incarcerated parents, and youth experiencing violence in the home. Health officials can be at the forefront of this innovation to ensure that protective factors are leveraged to reduce disparities and impact multiple outcomes with upstream approaches for youth. website

The 2020 holiday season is coinciding with a nationwide surge of COVID-19 cases. With great concern that holiday travel to see loved ones may exacerbate community spread of the virus, many states are increasing public health measures before the winter holiday season. As of November 16, 2020, 13 states and D.C. had a quarantine requirement for out-of-state travelers. The U.S. territories also have instituted travel restrictions to limit the spread of COVID-19.