HARC’s Role in Advancing Health Equity

By design, home visiting programs and policies strive to promote family and child health equity. Health equity generally refers to individuals achieving their full potential through the elimination of health disparities [1]. Health disparities are driven by multiple factors, such as a broad array of biological, social, and environmental factors, health behaviors, and access to high quality services. Importantly, social and environmental factors are known to shape health behaviors and service access. Often referred to as social determinants of health, examples of such factors include family and community economic instability, food insecurity, lack of safe and affordable housing, low access to quality healthcare, and individual, institutional, structural, and systemic racism and discrimination.

For decades, home visitors have worked with families and communities experiencing health and health care disparities. Home visiting programs, including those funded by the federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program, often prioritize families who may experience health disparities, such as those living in communities characterized by low school achievement or communities that have been historically marginalized. Most home visiting programs use family-centered approaches and shared decision-making to identify goals and tailor services to the needs and preferences of families. Home visitors support families in addressing individual- and family-level social determinants of health and in adopting families’ desired health behaviors. By meeting families in their homes, home visitors improve access to services by removing barriers such as lack of transportation and childcare and making referrals and linkages to needed services within the broader system of care. Though home visiting cannot address all social and environmental factors directly, home visitors can help families navigate barriers and inequities they face.

Research and evaluation have a role to play in advancing health equity. In home visiting, research and evaluation can promote identification and understanding of disparities in home visiting outcomes and the root causes of those disparities. Disparities in home visiting outcomes can arise, in part, from how services are delivered – such as differences in home visiting outreach, access, and implementation quality. Disparities can also arise from families’ inability to access needed services within the broader system of care. Yet despite strong potential for advancing equity, research in home visiting and related fields has historically been dominated by Eurocentric approaches and research methodologies that have been incompatible with or harmful to non-white minority populations. This has contributed to mistrust of research in many communities, a lack of culturally responsive interventions, and disparities in access and quality of care [3]. In addition, there are many cultural, economic, institutional, and social barriers to inclusion in research [2]. We can do better. Equitable research requires questioning the status quo and dismantling power dynamics that perpetuate inequities between researchers and communities [3].

In the next section we discuss ways in which a precision research approach can help support equity and HARC’s and commitment to advancing equity, diversity, and inclusion in research and evaluation.

How can precision home visiting research support equity?

Advancing equity requires that the field of home visiting identify, understand, and address disparities in outreach, access, implementation quality, and outcomes that come about due to unfairness or injustice. Precision research can support these efforts by:

• Guiding research and evaluation focused on understanding the unique needs, preferences, and responsiveness to services among populations and communities that have been marginalized. Understanding what works best, for whom, and under what circumstances will allow home visitors to provide services in ways that optimize benefits for those experiencing health inequities.
• Promoting understanding of how context contributes to inequities. Contextual factors at multiple levels – systems, communities, organizations, families, and individuals – influence families’ experiences with home visiting. Contextual factors contribute to inequities in home visiting availability, access, implementation quality, and outcomes. Precision research can help disentangle sources of inequities at the family or provider level (e.g., language barriers, provider implicit bias) and organizational, community, and systems levels (e.g., organizational culture that limits inclusion, inadequate funding of services within a community, state policies that limit program eligibility, structural and institutional racism).
• Promoting bi-directional learning between researchers and home visiting communities. Precision research promotes shared language for talking about home visiting interventions to support meaningful dialogue and bi-directional learning among groups with diverse interests in home visiting, such as home visiting practitioners and participants, model developers, policy makers, and researchers and evaluators.
• Supporting the development and testing of adaptations. Precision research offers a framework for identifying why and how to refine home visiting interventions to optimize usage and outcomes for specific populations or contexts.
• Building knowledge more quickly. A shared language and framework also help build evidence more quickly through systematic reviews and other methods to identify of intervention components that have been shown to be effective for specific populations.
• Supporting streamlined, effective models. Precision research supports the development and testing of well-defined models that are grounded in theory, research evidence, and home visiting experience (e.g., experience of families, program staff, models, communities) to help promote reach and engagement, effectiveness, and sustainability over time.
• Supporting equitable research practices, by calling on researchers and evaluators to engage community partners to prioritize research questions, designs, methods, measures, and analytic techniques that reflect the assets, needs, concerns, culture, and preferences of individuals and communities with lived experience.

Of note, advancing health equity requires vigilance. This means focused and ongoing efforts of the home visiting community – including researchers – and of broader society to address historical and contemporary injustices and health and health care disparities that contribute to inequities [4].

HARC is developing strategies to promote equity, diversity, and inclusion across all objectives.

As a research network, HARC is committed to understanding and promoting equitable research practices. How do we move forward? By taking a close look at what we do and how we do it. We understand that a focus on equity starts with critical reflection on current practices and norms. It requires increasing our own and others’ capabilities, motivation, and opportunity to use research practices – designs, methods, methodologies, measures, and analytic techniques – that are anti-racist and anti-oppressive and that will produce findings that are actionable for promoting equity. Below we share a few short-term goals to advance equity, diversity, and inclusion in advancing HARC’s core objectives. We will refine these broad goals and develop action steps in partnership with our vast practice-based research network, Leadership Team, National Advisory Council, and Diversity, Equity, and Inclusion Resource Group.

Broad Goals

• Work in partnership with the home visiting community – including families – to identify emerging issues, develop research questions and study designs, interpret data, and participate in the framing and reporting of findings
• Broaden our understanding of theories and innovative research methods and methodologies that promote equity
• Build capacity and opportunity for meaningful collaboration in research among all interested groups
• Identify and address economic, institutional, and social barriers to inclusion in the research workforce and strategies to promote belonging and authentic partnerships within research teams
• Support diversity and inclusion in the research workforce through mentoring and other opportunities
• Seek additional funding to support these and related action steps in advancing HARC’s objectives
• Increase diversity, equity, and inclusion within our HARC Leadership Team, National Advisory Council, and Practice-Based Research Network

HARC and the field of home visiting are part of something bigger. Home visiting is part of a much larger and complex service system that operates within diverse communities across Tribal communities, states, and territories across the U.S. Our efforts to promote precision and equity align with broad MCHB unifying frameworks, the National Institutes of Health priorities, and the U.S. Maternal and Child Health Bureau’s strategic vision to increase access, equity, workforce capacity and impact over the next 10-15 years, the Administration for Children and Families’ Strategic plan and with the National Home Visiting Network Call to Action to Advance Racial Equity in Home Visiting. We welcome collaborations with those who share our goals from within and outside the home visiting community.

Sources

[1] CDC Office of Health Equity. Accessed at https://www.cdc.gov/healthequity/index.html

[2] Gaynor KM, Azevedo T, Boyajian C, Brun J, Budden AE, Cole A, et al. (2022) Ten simple rules to cultivate belonging in collaborative data science research teams. PLoS Comput Biol 18(11): e1010567. https://doi.org/10.1371/journal.pcbi.1010567

[3] Lane A Jr, Gavins A, Watson A, Domitrovich CE, Oruh CM, …Spencer T. (2022). Advancing Antiracism in Community-Based Research Practices in Early Childhood and Family Mental Health. Journal of the American Academy of Child and Adolescent Psychiatry, 61(1), 15–22. https://doi.org/10.1016/j.jaac.2021.06.018

[4] Healthy People 2030. Accessed at https://health.gov/healthypeople.

Additional Resources

Chaiyachati BH, Peña MM, Montoya-Williams D. (2022). The Complicated Inadequacy of Race and Ethnicity Data. JAMA Pediatrics, 176(7):631-632. doi: 10.1001/jamapediatrics.2022.0525

George, S., Duran, N., & Norris, K. (2014). A systematic review of barriers and facilitators to minority research participation among African Americans, Latinos, Asian Americans, and Pacific Islanders. American journal of public health, 104(2), e16–e31. https://doi.org/10.2105/AJPH.2013.301706

University of Minnesota (n.d.). Conducting research through an anti-racist lens. Available at: https://libguides.umn.edu/antiracismlens