key: cord-0778304-o46uzmbv
authors: Walker, Sarah Cusworth; White, Johnna; Rodriguez, Victor; Turk, Emily; Gubner, Noah; Ngo, Sally; Bekemeier, Betty
title: Cocreating evidence‐informed health equity policy with community
date: 2022-03-03
journal: Health Serv Res
DOI: 10.1111/1475-6773.13940
sha: 3239ac55dd7880d3742d6ecc95f97e937d7ee47e
doc_id: 778304
cord_uid: o46uzmbv

OBJECTIVE: To explore the feasibility of a rapid, community‐engaged strategy to prioritize health equity policy options as informed by research evidence, community‐voiced needs, and public health priorities. DATA SOURCES: Data came from residents in a midsized, demographically, and geographically diverse county over a period of 8 months in 2020 and an evidence review of the health equity policy literature during the same time period. STUDY DESIGN: A descriptive case study is used to explore the feasibility and potential value of a community codesigned approach to establish community priorities for health equity policy. DATA COLLECTION/EXTRACTION METHODS: Evidence synthesis of health equity policy was conducted parallel to 15 community listening sessions across the county to elicit information on health needs. We used scoping review methods to obtain literature from academic databases and scholarly public health and policy organizations. This information was cross walked with themes from the listening sessions to identify 10 priority policy areas, which were taken back to the community for 15 participatory discussion and ranking sessions. PRINCIPAL FINDINGS: The process appeared to authentically engage the input of 200 community members representative of minoritized groups while identifying 99 evidence‐informed policy levers to promote health equity. Discussion and ranking activities were successful in facilitating community discussion and policy decision making. Remote platforms may have limited the engagement of some residents while promoting the participation of others. Conducting information integration within the research team prior to community policy ranking sessions limited the community ownership over how policies were interpreted and communicated. CONCLUSIONS: A combination of information integration and community ranking activities can be used to achieve community‐engaged policy prioritization of options in a fairly rapid period of time. While this process provides an example of authentic community ownership of policy prioritization, the compressed timeline limited the community's engagement in the information integration phase.

of options in a fairly rapid period of time. While this process provides an example of authentic community ownership of policy prioritization, the compressed timeline limited the community's engagement in the information integration phase.

codesign, community health, community participatory design, health equity, policy making What is known on this topic • Communities of color and those in rural areas experience poorer health outcomes than White populations and suburban/urban areas.

• Poor health outcomes in communities of color are in part due to reduced political influence over policies affecting health.

• Community-engaged policy making and research is a growing area of interest in public health practice.

• A community-engaged approach to policy prioritization (termed policy codesign in this project) was feasible to conduct over 8 months.

• The process appeared to authentically engage community voices in two of the three key activities needed to produce policy priorities in a compressed timeframe.

Coproduction and other co-ownership methods of system and policy planning aspire to power sharing between community and government. 1 As a policy strategy, coproduction emerged in the 1970s with the aim of increasing democratic participation, as well as the fit and operation of government programs resulting from increased community input. This ideology is experiencing a resurgence. Palmer et al., in a 2018 article, referred to this last decade as a "participatory zeitgeist," in which community involvement in the process of systems improvement is becoming a routine, and perhaps soon ubiquitous, approach to community health improvement efforts. [2] [3] [4] Equity-focused health policy making requires attention to process, as well as product. As noted by Whitehead, 5 equity in health policy is not simply a matter of ensuring that policies benefit those most affected by health disparities. Rather, communities marginalized by racism and other identities should lead agenda-setting and design in determining that policies to be developed and enacted. Such involvement is expected to produce multiple benefits, including policies that fit local needs, as well as increased community mobilization and empowerment. Community-led policy making includes efforts such as People's Movement Assemblies, which are often facilitated by community organizer nonprofits and include large community meetings to move new policy proposals forward. 6 These community organizing efforts are often explicitly centered in a community vision of change and de-colonization in which the gathering of people seeks "to practice power through participatory governance and to determine action plans for systemic change." 7 The process by which research evidence may be used by these approaches to community-led policy making is not well understood as information arising from elite institutions, such as universities, is sometimes viewed with skepticism. 8 Knowledge of what has worked to improve health equity in regions outside the local context is, however, valuable for achieving the second aim of equity-focused health policy making, which is to effectively reduce health inequities. 5 A number of policies and policy-enabled community programs are effective in improving community health among communities that traditionally experience health disparities, [9] [10] [11] and it is reasonable to presume that incorporating information about these efforts will benefit local health equity policy formation. As noted, it is unclear how this information is typically viewed or used in community-led initiatives, 12 or much of government-led policy making.

Those advocating for more evidence-informed policy making promote methods that bring research evidence into discussions in formal ways, including evidence syntheses or research-practice partnerships. [12] [13] [14] Government may also commission forecasts to predict the effects of hypothesized policies using system modeling or policy analysis to attempt to approximate a precision approach to policy selection and design. 15, 16 These latter approaches value specialist knowledge and expertise, values that potentially conflict directly with People's Movement Assemblies and the de-colonization of decision making. Inherent in health equity policy making is a tension between the claims of community and those of researchers to authoritative knowledge. Community knowledge emphasizes process and the delegation of decision making and information gathering to those affected by policies, and research-based knowledge emphasizes the selection and application of policies shown to be effective in reducing health inequities as identified in the scholarly literature.

Codesign and other collaborative planning models in health sciences research are recommended as methods suited for addressing complexity, of which policy formulation is one type. 17 In their review of cocreative research methods, Greenhalgh et al. note the potential for these efforts to achieve higher social impact than investigator-led research efforts due to the greater buy-in from community stakeholders, as well as the crafting of research ideas more proximally relevant to health services. 3 They term this process "Value Cocreation," and identify four features common to cocreative model arising from diverse disciplines (e.g., business, digital health, participatory research).

These include a systems perspective, individual creativity, collaborative process, and better fit and sustainability.

Similarly, cocreative methods are well-suited to reconcile the tensions of knowledge authority in policy prioritization because they are an effective vehicle for moving decision making through a structured process while allowing for individual and collective creativity. 18 The growth of interest in cocreative models is signaling a shift in society's relationship with science, particularly in Europe and the Anglosphere countries (UK, Canada, Australia, New Zealand). These countries and others, including Norway and the European Union, have well-funded centers devoted to strengthening alliances between research, community, and health systems that value equal expertise and contribution. 19 To date, most of the work in cocreation focuses on knowledge production, that is, how to engage health care recipients and providers in the study of health care innovation. Applying cocreation in knowledge translation, that is, how is knowledge from research brought into real-world decision making, raises a different set of interesting questions around power and equity than those raised in knowledge production alone. 20 Existing models of policy planning, even those adopting a participatory frame, do not always describe the methods of decision making clearly. Cocreative methods can be used to enhance the transparency of decision making process while also centering the creativity and participation of the individual. 21 For policy, this means various sources of information can be woven into the design process, including community input and pre-existing research evidence relevant to the topic.

In this paper, we present a case study of the first phase of an approach to policy codesign (prioritization) that sought to partially reconcile the goals of community ownership and evidence-informed policy making. We provide an overview of the conceptual grounding of the approach, which we term policy codesign. We then discuss what is gained and lost in this type of participatory enterprise and how the field might move forward to expand the study of similar approaches.

The approach to participatory policy codesign used in this effort was informed by participatory action research, Kingdon's policy streams theory, 22 and codesign methods in health services research. We also note the similarities in approach to emerging models of public policy codesign that reference systems theory, complexity theory, and design thinking in social innovation. 20 (Figure 1) Participatory action research (PAR) is a reflective approach to sources of knowledge. It is skeptical of truth claims and is mindful of the extent to which knowledge is used to represent the interests of powerful institutions and people, thus reinforcing their positions in society. 23 It is a method inextricable from the intent to improve the conditions of under-resourced individuals and groups. PAR is a knowledge production method that serves as an alternative to positivist methods, and the concepts of power, truth claims, and action can be readily applied to knowledge transfer efforts. 24 Kingdon's policy streams theory is widely used for its simplicity and explanatory power. 22 Policy streams theory proposes that three conditions must occur simultaneously for a policy to be supported (i.e., the law passed, the resolution adopted). These streams include (1) the problem stream, which indicates agreement among multiple sectors about a problem that needs to be solved; (2) the policy stream in which a viable solution to the problem appears to be available; and (3) the political stream in which the political will among the voters or other necessary constituents is organized around the solution. In addition to these three conditions, the theory proposes that the existence of a policy champion, someone or an organization, is critical for shepherding the policy through revisions, iterations, and the unpredictable conditions of policy making. 22 Cocreation is a quickly expanding and evolving field. 23, 24 The differing approaches and emerging schools of cocreation, and codesign in particular, provide a number of methods that could be applied within policy coproduction. These efforts generally proceed in four stages: Setting the design question, Information gathering/integration, Prototyping, and Beta-testing. [25] [26] [27] In health services innovation, the design question often comes from the investigator team (e.g., how can we improve the use of clinical guidelines by primary care physicians). In policy making, the design question is more likely to arise from negotiations between the government and stakeholders. This may begin with a broad area of interest (e.g., how can better land use support health in this community) that is narrowed over time with community input. 27 This case study focuses on the use of codesign methods to identify community-directed policy priorities. We describe methods used in the first two phases of codesign, which included (1) setting a design question and (2) information gathering/integration. County has a population of about 900,000 residents, encompassing 15 cities and five towns, and is predominantly White, non-Latinx (65.7%), followed by Latinx (11.4%), Black/African-American (7.7%), Asian (7.1%), mixed-race (7.4%), American Indian/Alaska Native (1.8%), and Native Hawaiian or other Pacific Islander (1.8%).

According to the US Census Bureau, about 9.4% of the population lives in poverty. 29 The policy codesign effort was a collaboration between the local health department (Tacoma-Pierce County Public Health Department, TPCPHD) and a university-based team through a subcontract from the county to the university using funds from the United States Coronavirus Aid, Relief, and Economic Security (CARES) Act. The methods used to gather information from this study were conducted as part of a local public health department activity and intended to inform local policy making rather than generalizable research. Community residents participating in these meetings were informed that their responses would be publicly shared as aggregated data. The methods of collecting data adhered to ethical standards and no identifying individual information was collected or stored as part of community listening and ranking sessions. The data presented in this paper are publicly available in two documents published by the Tacoma-Pierce County Health Department. 30, 31 Because the data used in this case study is publicly available and the participants were informed that it would be aggregated and shared in public reports, the activities did not fall under human subjects review. 30, 31 2.2 | Case study and phases of policy codesign

The design question guiding the project was intentionally broad and focused on eliciting community health policy priorities under the general goal of health equity. The parameters for the policy effort set by the county required a focus on health inequity, policy, and participatory process. The TPCHD was already using the term "health equity" in multiple forums, including the facilitation of a multi-sector "Equity Action Network," in which equity was defined as "opportunity for all," and focused efforts on communities with lower indices of social advantage and health. 32 Consequently, the design question guiding the subsequent activities to elicit community input was phrased as, "What health equity policies will build community health resilience, reflect community-state health needs and reflect community priorities?" The core team leading the work included the TPCHD health equity manager, TPCHD government relations and health policy coordinator, and the university staff (lead investigator, operations specialist, research scientist). The advisory group included the TPCHD director of health, two PhD public health faculty, and a diverse group of business, health, government, and 

To identify the most relevant and likely effective health equity policies for the county, we gathered information using two methods, (1) a scholarly review of the literature and (2) A rapid scoping review was conducted to identify policies with demonstrated effectiveness in promoting health equity or policies that addressed a need known to contribute to health equity. The terms used in the rapid scoping review were selected to follow the TPCHD's definitions of health equity, described above as "opportunity for all."

We followed guidance for rapid evidence reviews, 33 including restricting our search to the last 10 years of published scholarly work and searching primarily for systematic or conceptual reviews of health equity policies (see Appendix A). The review was supported by two PhD level public health research and practice experts with broad knowledge of the field, an MPH scholar who conducted the review, and a PhD level translational researcher with experience conducting scoping reviews. The experts reviewed terms and suggested additional gray literature sources to identify relevant policies. The search terms for the scholarly literature included "health equity policy,"

"health in all policies," "health equity impact," "health inequity," "health inequality," "social determinants of health policy," and "public policy and health" and "review." Given the goal to conduct this review rapidly, we selected papers that explicitly referenced health equity (and related terms) in a title or keyword. This excluded papers that focused on a policy area likely related to health equity (e.g., housing affordability) but did not use eligible terms.

In addition to the academic literature search, eight professional organizations were identified for a gray literature search ( Table 1 ). The two searches yielded 19 documents that were coded to extract policy recommendations with an impact on health equity. Coding involved a description of the policy, the specific policy lever (e.g., regulation, ordinance, tax, funding for a program), the effectiveness of the policy as described by the authors, and the evaluation or research method referenced in the study. Three individuals, two PhD level researchers, and one MPH evidence synthesis expert, established coding reliability by separately coding three articles and discussing minor discrepancies. Coding involved assigning a score of "1" for each policy area (of the final 28) mentioned in each session. Separate listening sessions were grouped by community type (e.g, Latinx, Native American, Community of Focus), and summed policy areas scores across each community type. From these totals, the policy areas with the highest scores (e.g., mentioned across multiple community types) were selected as a high priority. These high-priority policy areas were compared to health priorities previously identified and published by the TPCHD. 30 Policies identified on both lists were selected, as well as the next highest ranked policies from the community listening sessions, in order to identify 10 final policies ( Table 2 ).

Following the identification of the 10 priority policy areas, the design team facilitated community participatory discussion and ranking exercises to engage broad-based (horizontal) engagement with the community, including and extending beyond community groups involved in the EAN listening sessions. The participatory ranking is a strategy used in low resource areas and, increasingly, high-income countries to engage the community directly in making policy-level decisions. We adapted a process used by the CPC Learning Network. 34 In its original form, the participatory ranking exercise involved community members placing objects in physical locations to vote on different community priorities. Our adaptation used web-based video (Zoom) and ranking (Mentimeter) primarily because the codesign project occurred during the COVID-19 pandemic and in-person meetings were not an option.

In two sessions, real-time language translation was provided in Spanish. All other ranking sessions were conducted in English.

A total of 14 community groups, largely organized around race/ ethnicity cultural identification, participated in the participatory ranking sessions, and a total of 163 community members participated in the ranking ( Table 2 ). The ranking sessions began with a short presentation of the participatory policy codesign initiative, the process for narrowing policy options down to the 10 priority areas, and a brief discussion along with a definition of each policy area. Following this overview, participants were asked to rank the options from 1 to 10 by navigating to a weblink pasted into the video-call chat-box. Those who could not access the weblink were asked to share their rankings in the chat or raise their hand to verbalize their rankings. Following the first ranking, the group reviewed live results, and the facilitators prompted a discussion with reflective questions, including "what influenced your choice to rank behavioral health policy more highly than affordable housing?" In larger meetings, participants were placed in breakout rooms for discussion. After a period of discussion, the group was given the option to re-rank their choices using a new poll.

The numeric rank-order scores from each session were averaged to produce an average ranking score for each policy area. The top three policies (Economic equity, Housing affordability, Behavioral and physical health care access) were selected for inclusion in a second phase of codesign that is still ongoing. The currently ongoing second phase of the PPCD process involves bringing a community and policy design team together to prototype out a specific policy to address the top three priorities identified in the first phase of the project.

This case study is provided to illustrate the methods used to execute a fairly rapid community engagement and knowledge synthesis pro- The codesign approach provided scholarly information in a manner that followed community-grounded preferences by using a "pull" rather than "push" approach to information-gathering. 35 

This paper has described, with a conceptual framework and case study, the key considerations in the community priority setting the stage of a health equity policy codesign initiative. We use this case study to reflect on the capacity of codesign to address power, transparency, appropriate use of scholarly knowledge, and authentic community engagement in policy formation.

This approach to policy prioritization was particularly concerned with whether the separate goals of evidence-informed policy making and community ownership could be reconciled. As noted by Greenhalgh et al., the field has yet to develop a coherent scientific paradigm for how cocreation intersects with the science of research use in public policy. 3 The field of "research use," "use of research," "evidence-informed policy making," and increasingly, "policy implementation science," begin from the values stance that research evidence has something to offer public policy formation in the individual (federal, state, county, city) case. This may include epidemiological evidence that specific groups have poor health outcomes that should be the focus of policy making efforts (e.g., Black maternal mortality) or evidence showing that specific policies can affect population-level health (e.g., soda tax and obesity). To the extent the current field offers prescriptive guidance for policy formation, it is either to select the optimal policy levers to promote other evidence-based practices or programs, such as funding mechanisms, 38, 39 or to identify the communication and planning strategies needed to implement an identified policy. 40 Our case study presents an alternative method for the selection of evidence-informed policies that achieved a meaningful integration of community-engaged decision making and scholarly information with some limitations. This approach still imposed limits on community ownership, largely due to the pressure to work within a compressed timeframe.

A participatory stance views the facilitator (often a researcher or content expert intermediary) as a holder rather than the intellectual owner of a design process. 41 This stance was adopted in the TPCHD project by deferring all decision making to a transparent process that engaged two levels of community voice (Equity Action Network representation and individual community participants). The only constraint placed upon community decision making was the lack of participation in integration information from the community listening session and evidence review. This gave the core team control over interpretation, as well as how policy options were defined and communicated, which generally adopted language common in the scholarly area (e.g., built environment).

A more transparent and community-engaged process would share or entirely delegate interpretation to community representatives.

Such an approach would be better aligned with Participatory Action

Research (and CBPR) values and would likely have served to (1) More broadly engage the community in feeling ownership over the identifies policy priorities; and (2) Build capacity among the community to interpret and use policy-relevant knowledge. It is also possible that including community members in synthesis and interpretation would have strengthened interpretation and made the prioritization process more accurately reflect community strengths and needs. The core team made the choice to keep synthesis internal at this phase because the core team planned to engage more active community participation in interpreting knowledge in the prototyping phase. The next phases of the codesign approach (Prototyping and Beta-testing) will involve bringing a new design team together to prototype a specific policy as guided by the prioritization process. The design team will be structured to capitalize on existing relationships and political sway so that the policy developed by the team will be championed by those who are positioned to take it forward through implementation.

The approach and data used in this case study analysis include some limitations. The political climate in Pierce County is friendly to community-engaged approaches and friendly to the use and application of the term "health equity." These two orientations will vary by county. Some county political climates may be highly responsive to populace concerns, while others may prefer to more tightly manage knowledge and decision making. Given this, it is likely that not all communities will be good candidates for health equity-focused policy design, and not all counties will be ready to apply participatory strategies.

This case study presents codesign methods used to integrate three sources of knowledge, the evidence-based, public health priorities, and community-expressed needs, in a way that engaged community decision making in setting public health policy priorities. By leveraging existing processes and relationships, the public health department was able to rapidly mobilize community groups to contribute to policy priority setting through listening sessions and participatory ranking sessions. Similarly, the core team was able to rapidly glean key policies from the academic literature using rapid review methods and integrate these with community information using thematic coding and quantitative summaries. More study is needed to assess how well community members authentically grasped policy options in community ranking exercises and how the policy priorities emerging from these methods compare to priorities that may have emerged from lengthier community engagements. The focus of the scoping review was dictated by the county public health department and a department's interest in improving health equity. As described in the manuscript, the Tacoma Pierce County

Public Health Department had previously defined health equity as "opportunity for all," and the researchers involved in the scoping review worked closely with TPCPH staff in identifying search terms.

We followed guidance for rapid evidence reviews, 33 including restricting our search to the last 10 years of published scholarly work and searching primarily for systematic or conceptual reviews of health equity policies. The review was supported by two PhD level public health research and practice experts with broad knowledge of the field, an MPH scholar who conducted the review, and a PhD level translational researcher with experience conducting scoping reviews.

The experts reviewed terms and suggested additional gray literature sources to identify relevant policies. Given the rapid nature of the review, the team did not register the protocol as a scoping review.

To be eligible for further review, the title or subtitle of the document needed to include one of our search strings related to "health equity" (see below), and the abstract, title page, or table of contents needed to reflect a focus on reviewing specific policies and their relationship to health equity.

The search terms for the scholarly literature included "health equity policy," "health in all policies," "health equity impact," "health inequity," "health inequality," "social determinants of health policy,"

and "public policy and health" and "review." Given the goal to conduct this review rapidly, we selected papers that explicitly referenced health equity (and related terms) in a title or keyword. This excluded papers that focused on a policy area likely related to health equity (e.g., housing affordability) but did not use eligible terms. Search databases included PubMed, Academic Search Complete, and Web of Science for the scholarly literature restricted to review articles. We did not identify any review articles (systematic, scoping, umbrella) summarizing the evidence of health equity policies. We did identify review articles addressing approaches to developing health equity policy, but did not provide a review of the policies developed. Thus, these articles did not meet our eligibility requirements. Given the lack of peer- Below is the specific process used to develop the Long List: 

The problem and promise of coproduction: politics, history, and autonomy

The participatory zeitgeist: an explanatory theoretical model of change in an era of coproduction and codesign in healthcare improvement

Achieving research impact through Cocreation in community-based health services: literature review and case study

Unintended effects of emphasizing disparities in cancer communication to African-Americans

The concepts and principles of equity and health

What is the people's movement assembly process? The Michigan Citizen

The peoples movement assemblies offer spaces for us to practice community governance and to coordinate together across multiple strategies and multiple geographies

Successful and unsuccessful participatory arrangements: why is there a participatory movement at the local level?

Communities in Action: Pathways to Health Equity

The effects of public health policies on health inequalities in high-income countries: an umbrella review

The role of public policies in reducing mental health status disparities for people of color

Understanding evidence-based public health policy

Understanding evidence: a statewide survey to explore evidence-informed public health decision-making in a local government setting

Knowledge translation strategies to improve the use of evidence in public health decision making in local government: intervention design and implementation plan

Change what? Identifying quality improvement targets by investigating usual mental health care

Identifying and evaluating robust adaptive policy responses to climate change for water management agencies in the American west

Studying complexity in health services research: desperately seeking an overdue paradigm shift

Design thinking: a unified framework for innovation

Policy Initiatives to Enhance the Impact of Public Research: Promoting Excellence, Transfer and Co-Creation

The promise of co-design for public policy

Co-creation and the new landscapes of design

Update Edition, with an Epilogue on Health Care

Participatory action research

Participatory Research in Health: Issues and Experiences. Zed Books (UK)

Using codesign to develop a culturally tailored, behavior change mHealth intervention for indigenous and other priority communities: a case study in New Zealand

Frameworks for supporting patient and public involvement in research: systematic review and co-design pilot

A scoping review of codesign approaches for evidence-informed public health improvement: revisiting design for, with, and by community

A personal interpretation

United States Census Bureau. Quick Facts Pierce County

Tacoma Pierce County Health Department. Pierce County COVID-19 health equity assessment

CoLab for Community and Behavioral Health Policy. Policies to advance health equity

Tacoma Pierce County Health Department. Equity action network

Rapid reviews to strengthen health policy and systems: A Practical Guide

Participative ranking methodology: a brief guide

Bridging the gap between prevention research and practice: the interactive systems framework for dissemination and implementation

What works to increase the use of research in population health policy and programmes: a review

Do policy-makers find commissioned rapid reviews useful?

Toward a policy ecology of implementation of evidence-based practices in public mental health settings

Aligning dissemination and implementation science with health policies to improve children's mental health

Predicting research use in a public health policy environment: results of a logistic regression analysis

Ambiguity as agency: critical opportunists in the neoliberal city