Massachusetts has one priority for the Crosscutting domain for 2015-2020:

1. Promote health and racial equity across all MCH domains by addressing racial justice and reducing disparities.

Priority: Promote health and racial equity across all MCH domains by addressing racial justice and reducing disparities.

The MA Title V program strives to promote health equity and racial justice in order to fulfill its public health mission. The Racial Equity Movement (REM) within the Bureau of Family Health and Nutrition (BFHN) and the Bureau of Community Health and Prevention (BCHAP), which comprise the majority of Title V programming, aims to eliminate structural racism in MDPH programs, policies, practices, and workplace. The focus is not on the actions of individuals, but the way that systems and policies advantage certain groups and disadvantage others. Focusing on racism and racial equity is not at the exclusion of other forms of inequity; rather, an explicit focus on racism can also increase Title V’s capacity to address inequities, such as those faced by people with disabilities or people for whom English is not their first language. Development of a racial equity framework, tools and resources can also be applied to other areas of MDPH and Title V’s work, improve outcomes for all communities, and achieve the goal of health equity. Being explicit about the role of racism in public health is key to being able to identify intentional, actionable strategies to promote health and racial equity. Recognizing how structural racism affects Title V’s work, workforce, and populations served will help to develop and implement programs that result in more equitable MCH outcomes. Over time, success of the REM will be demonstrated by a workplace that is more inclusive, stimulating and safer; staff who are engaged, aware, respectful, open-minded and healthy; programs that are community-centered, disparities-focused and equity-informed; policies that are actionable, practice-driven, systems-focused, and responsible; and communities that are inclusive and engage partners in meaningful change toward improved individual and community health.

From 2015-2020, progress towards this priority has been measured by the percent of MDPH staff in BFHN and BCHAP who participate in the REM.

SPM 3: Percent of MDPH staff in BCHAP and BFHN who participate in the Racial Equity Movement, including orientation and practice.

Racial Equity Movement

A significant accomplishment in addressing this priority was hiring a Racial Equity Coordinator in March 2019. This was a new position created with Title V funds, the purpose of which was to support increased staff knowledge of and capacity to promote racial equity; foster a more equitable work environment; improve engagement and communication within and across BFHN and BCHAP; and encourage racial equity in public health practice across MDPH and its providers in partnership with the communities and people served.

In FY19, a key focus of the REM was improving communication within and across BFHN and BCHAP, and sustaining and growing the movement across MDPH. In addition to hiring the Racial Equity Coordinator to support this effort, another key step was convening an all-day strategic planning session in September 2018 to answer the question: “how do we design a structure that will facilitate synergistic racial equity work across the bureaus while honoring the differences in history and current development of the work across BCHAP and BFHN?” The goal was to articulate a structure for how the REM works across bureaus and within the hierarchy of MDPH that maximizes transparency, accountability, trust, efficiency, and effectiveness. The session was facilitated by external racial equity training consultants, and 52 staff from BFHN, BCHAP, the Office of Health Equity, and the Bureau of Substance Addiction Services (BSAS) participated, 65% of whom identified as White and 35% as people of color. Attendees described the successes of the retreat as deepening relationships and connectedness to others, acknowledging progress of the REM to date, and seeing the commitment from the Bureaus and individual staff to this work. There were many ideas about how to improve the implementation of the REM moving forward, such as ensuring that managers support the effort, recognizing and addressing power dynamics, getting more people of color involved, and integrating the REM into external-facing work.

Building off of the previous four years of racial equity practice, and spurred on by this strategic planning session, a Cross-Department Racial Equity Collaborative (C-DREC) was founded in June 2019. C-DREC, co-chaired by the Title V/BFHN Director, is a community of MDPH staff representing Bureau-based Racial Equity Teams, working groups, and a new Coordinating Committee that will meet regularly to grow collective knowledge and skill, share best and promising practices, and align and support related activities happening across the Department.

While the C-DREC was being conceptualized and launched, the BFHN Racial Equity Steering Team (REST) and the BCHAP Racial Equity Leadership Team (RELT), continued to oversee the work of the REM in their respective bureaus. Functional workgroups operating across bureaus – including professional development, procurement, policy, communications, and evaluation – also continued to move the work forward.

Professional development provides the foundation on which the rest of this work builds, and has been the focus of the State Performance Measure for this priority for the past five years. BCHAP and BFHN hired external consultants (Nashira Baril, Abigail Ortiz, Bayard Love, and Meenakshi Verma-Agrawal) to develop and deliver trainings for staff to acquire a shared understanding of and support for a public health framework centered on racial equity and equip staff with tools for understanding their role in racial equity work. The trainings included a combination of two-day workshops (orientation) and half-day labs (practice). The objectives of the two-day workshops were to increase familiarity with racial equity and public health frameworks; provide exposure to and practice with tools that can be applied in everyday work; practice making the work meaningful on an individual level by integrating principles of the head and the heart for sustained racial equity work; and develop a shared understanding of how racial equity aligns with broader health equity work in the Bureaus and the Department. The half-day labs were designed for participants who complete a two-day workshop. The objective was to learn concrete skills to develop programs, policies, and practices that advance explicit racial equity work. Lab topics included racial equity re-framing, exploring the different roles of White people and people of color in this movement, and using a groundwater approach to address public health problems. As of May 2020, 35% (n=107) of staff in BFHN and BCHAP (including 100% of Title V leadership) had attended both a workshop and lab. This is short of the original 2020 objective that 50% of staff participate in both orientation and practice. Reasons for not meeting this objective are described below.

In order to develop MDPH internal capacity for racial equity facilitation and support, in FY19 a cohort of six staff members from BCHAP and BFHN completed participation and facilitation practice in at least three of the two-day workshops, and several half-day practice labs under the mentorship of the external consultants. These staff also participated in two retreats with the consultants to build their team of Racial Equity Facilitators (REFs) and continued to meet monthly in FY19. Facilitating in cross-racial teams, REFs have begun to offer a number of learning and practice opportunities including a two-day training for the Asthma Program, an introduction to racial equity for MA MIECHV grantees, and breakout discussions during a racial equity training for school nurses. Instead of leading structured half-day labs as originally intended (and as defined in the SPM), the REFs adapted to meet the emerging needs of the REM, and offered more tailored facilitation and technical assistance to programs starting their own racial equity and racial justice re-framing conversations. 

Racial identity affinity groups continued to provide an opportunity for ongoing learning and support following the trainings. Affinity groups are an assembly of people gathered with others who share a common element of identity – in this case, racial identity – to explore, celebrate, and process their experiences around their identity. Racial identity affinity groups underscore the different roles for White people and people of color in racial equity work and provide an opportunity for staff to deepen their understanding of their personal roles in promoting racial equity and contribute to productive dialogue on racism and health. In FY19, staff participated in quarterly “drop in” affinity groups and two structured affinity series that met weekly for six weeks. Affinity groups are offered for White allies, people of color, Asian American and Pacific Islanders, and men of color. Key challenges identified with the affinity groups include how to meaningfully sustain the work that begins in affinity and how to engage leadership in this process, as it can be difficult to share space and be vulnerable with people in differing positions of power.  

Other REM accomplishments in FY19 included:

• Developed a “why statement” for the REM that has been used in presentations, job announcements, and is posted on the BFHN webpage.
• Provided technical assistance to staff drafting procurements on how to integrate racial equity into the process.
• Disseminated guidance for BFHN and BCHAP bargaining unit staff interested in incorporating racial equity competencies into their job duties, annual goals or performance criteria as part of the Employee Performance Review System.
• Developed a self assessment tool for staff regarding their personal understanding and perception of racial equity in the context of professional development.  
• Held quarterly racial equity town hall meetings for all MDPH staff that provided the space to discuss, share, and learn from one another, improve community-building, and change the culture across Bureaus and throughout the Department.
• Presented at the 2018 CityMatCH Leadership and MCH Epidemiology Conference about lessons learned in explicitly addressing racial equity and structural racism within the Title V program.  

Finally, the BFHN/BCHAP Racial Equity Survey was conducted for a second time in April 2019. The purpose was to gain understanding of staff’s current knowledge, beliefs, and practices regarding racial equity work and change in these areas since the 2017 baseline survey. Of the 174 respondents, 29% identified as people of color and 71% identified as White. Key findings include:

• 78% of respondents feel comfortable explaining the difference between health inequities and health disparities (compared to 44% in 2017)
• 96% feel an individual responsibility in their job to promote racial equity (compared to 89% in 2017)
• 83% would like to use racial equity strategies to design, deliver and evaluate their programs (compared to 75% in 2017)

Findings from the survey indicate that a vast majority of staff are interested in greater access to resources and tools to integrate racial equity into their work. Although MDPH has created new tools or curated existing tools, some respondents expressed that they were not aware of tools or had trouble finding the tools. It was also made clear that there is room for improvement in fostering an equitable workplace culture at MDPH, such as with respect to hiring practices and opportunities for career growth/promotion.

The successes and challenges experienced in FY19, including those evidenced by the survey results, show that the REM is part of transformational organizational change. MDPH strives to make short-term gains to maintain momentum and staff engagement, with the understanding that real, lasting change takes time.

Additional activities to promote health and racial equity across all MCH domains

MDPH Epidemiology Conference

In November 2019 MDPH sponsored its sixth annual professional development conference for over 100 epidemiologists across the Department. This annual conference provides an opportunity for epidemiologists to network, learn new techniques for conducting epidemiologic studies, share best practices and enhance their skills. The theme of the 2019 was “The Journey to Health Equity: From Data to Action.” The keynote speaker was Dr. Mary T. Bassett, the Director of the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University, and the FXB Professor of the Practice of Health and Human Rights at the Harvard School of Public Health. With more than 30 years of experience in public health, Dr. Bassett has dedicated her career to advancing health equity. Dr. Bassett formerly served as Commissioner of Health for New York City, where she worked to ensure that every New York City neighborhood supported the health of its residents, with the goal of closing gaps in population health across the city.  

Conference attendees also participated in oral presentations and poster sessions by their peers and a panel discussion with staff from BFHN, BCHAP, BSAS, and the Office of Performance Management and Quality Improvement. The panel was moderated by staff from the Office of Health Equity and highlighted the role of epidemiologists in monitoring and presenting disaggregated data by race and ethnicity whenever possible, and most importantly the need to supplement secondary with primary data (personal stories by the real experts).

Infant Mortality CoIIN

In FY19, MA continued participating in the Infant Mortality Collaborative Improvement and Innovation Network (CoIIN) Social Determinants of Health (SDOH) Learning Network, led by the Association of Maternal and Child Health Programs (AMCHP). The SDOH Learning Network aims to advance fairness and increase access to quality health care for all by acknowledging historic patterns of institutional bias and discrimination that continue to negatively affect the health of marginalized communities. The foundation of the approach includes the social and environmental determinants of health. The aim statement, anchored in systems change, is that by spring 2020, all state teams will develop, adopt, or improve at least two policies and/or practices at the state or local level which will directly affect determinants of health.

The MA team is comprised of representatives from Title V and Boston Healthy Start, which is administered by the Boston Public Health Commission (BPHC). BPHC is focused on improving policies and practices to address social determinants of health in their Healthy Start in Housing (HSiH) program. HSiH addresses housing as a social determinant of health for homeless high risk pregnant women. The goals are to improve birth outcomes, long term health of mothers, infants and families and housing retention. Through the CoIIN, BPHC has conducted Plan-Do-Study-Act (PDSA) cycles to improve client engagement during the initial HSiH application process and decrease the time of prescreening from initial application to housing application submission to Boston Housing Authority.  

Title V is leveraging the CoIIN to further the work of the REM, with a focus on data as a tool to eliminating structural racism. There was a need identified in BFHN and BCHAP for greater capacity to collect and use data for action to promote racial equity in MDPH-funded programs and initiatives. To meet this need, a cross-bureau team was formed in August 2018 to develop a Racial Equity Data Road Map. The Road Map is a collection of guiding questions, tools and resources that offers a suggested methodology for using data to assess progress in addressing racial and ethnic inequities in service delivery and health outcomes.

In FY19, the team met biweekly to outline, draft, and pilot the Road Map. Sections were piloted with the Welcome Family home visiting program (administered by Title V staff), and their applied experience integrated into subsequent versions. It was also reviewed by epidemiologists, program staff and senior leaders at MDPH, as well as the MA CoIIN coach, Dr. Joia Crear-Perry, founder/president of the National Birth Equity Collaborative. The Road Map is organized into seven sections:

1. Applying a Racial Equity Reframe: Describes the importance of reframing data with a racial equity lens and introduces a Racial Equity Reframing Tool for programs to apply to the topic or focus of their work
2. Assessing Program Readiness to Use a Racial Equity Data Reframe: Encourages programs to complete a self-assessment to determine the extent to which systems are in place to support data-driven racial equity work.
3. Disaggregating Data and Assessing for Inequities: Describes the importance of disaggregating data (i.e., analyzing data in smaller units such as race, ethnicity, or zip code) and provides guidance on how to disaggregate. Provides guidance on comparing disaggregated data across population sub-groups to determine whether inequities exist.
4. Contextualizing Data: Provides guidance on how to frame data with historical and structural context, with an emphasis on engaging the community in this process.
5. Prioritizing Strategies: Introduces tools to support the process of identifying the most striking inequities feasible for intervention and creating a plan to address them.
6. Developing an Equity Spotlight to Highlight the Data: Outlines important questions and considerations in designing materials used to communicate the data to key stakeholders, such as key components to include and formatting tips.
7. Moving from Data to Action: Describes how to plan, implement, and assess the effectiveness of interventions to address the inequities.

The Road Map guides its users to authentically engage the community, frame data in the broader historical and structural contexts that impact health, communicate that inequities are unfair, unjust and preventable, and design solutions that address the root causes of these issues. A first complete draft was shared with MDPH staff in April 2020. It is intended to be a living document that is regularly updated based on feedback from its users.

Culturally and Linguistically Appropriate Services (CLAS)

The National CLAS standards seek to eliminate barriers to access, improve quality of care, and address the social determinants of health that drive disproportionate rates of disease between different populations. The MDPH Office of Health Equity (OHE) systematically supports and monitors MDPH’s internal and external efforts to meet the CLAS standards and ensure the use of CLAS as a framework for continuous quality improvement.

A CLAS Self-Assessment Tool is required to be included in every annual contract renewal packet for vendors. MDPH contract managers review their vendors’ CLAS work plans, discuss progress during site visits and provide feedback during performance reviews. In FY19, OHE provided several trainings to MDPH staff, as well as technical assistance to contract managers and vendors upon request. OHE also conducted key informant interviews with contract managers who administer the CLAS Self-Assessment to their vendors. The two key findings were that CLAS is still not systematically integrated into contract management across all programs, and that the lack of a dedicated budget line for interpretation/translation creates a barrier for vendors that provide unit-rate reimbursement services.

OHE also administers the CLAS Internal Assessment Tool annually to monitor the degree to which MDPH programs meet the CLAS Standards. This tool asks all programs to identify a CLAS-related priority to inform their work plans. There were 52 respondents to the 2019 Internal Assessment, 30 of whom manage direct-service contracts. Key findings include: 58% of respondents report that their programs collect individual-level data on race, 63% collect data on ethnicity, and 62% had internal goals that address racial and ethnic disparities. The goals most frequently prioritized, based on potential impact and feasibility, were to improve language access, followed by workforce development and data collection. Forty six percent of respondents reported translating written materials, 33% provide interpreters, 33% share print and online materials in an accessible format, and 21% ensure vital documents are written at a 6th grade reading level. The most common strategy used to recruit a diverse workforce was specifying in job postings that cultural competence is desired (62%), followed by specifying in job postings that fluency in languages other than English is desired (40%), promoting job openings among programs and networks that work with people with disabilities (27%) and promoting job openings on ethnic media and minority networks (25%).

Health Equity Working Group

OHE serves as an in-house consultant to all MDPH programs, supporting and guiding their efforts to achieve health equity. OHE facilitates the Health Equity Working Group (HEWG), a round-table community of practice formed in FY16 to share tools and practices, reduce duplication of efforts, increase synergy and create consistent messaging in MDPH’s efforts to eliminate health inequities. In FY19, the CLAS Coordinator in OHE took on the chairmanship of the HEWG and led bi-monthly meetings. Activities this year included updating the group’s charter and repurposing the group as a community of practice; identifying and recruiting new members from MDPH programs not currently represented; and enhancing contract management tools to include measures for monitoring and supporting vendors’ efforts to meet racial equity principles.

Determination of Need Program

The Determination of Need (DoN) program at MDPH supports the development of innovative health delivery methods and population health strategies within the health care system and ensures that resources are made reasonably and equitably available to everyone in the state. In collaboration with the DoN program, OHE assesses and monitors compliance with federal and state laws requiring health care institutions to provide quality health/medical interpreter and assistive services. Through this monitoring process, OHE provides technical assistance to modify and improve existing services to ensure compliance. The differing needs and resources of each institution and the populations they serve require flexibility in program design to provide meaningful access to non-English, limited English proficiency persons, and individuals who speak American Sign Language.

In FY19, OHE’s Health Care Interpreter Services Coordinator finalized reporting measures and questions and revised the Language Access and CLAS Requirements for DoN Holders. In addition, OHE met twice with the Forum for Coordinators of Interpreter Services (FOCIS) and twice with FOCIS’ Executive Committee to discuss a plan for updating the Best Practice Recommendations for Healthcare Facilities Interpreter Services. In addition, OHE provided annual site visits and technical assistance to 22 health care facilities. ​