The racial, ethnic, and urban-rural disparities experienced during the COVID-19 pandemic highlight the need for public health leaders to address health equity both nationally and internationally. The resulting attention and resources dedicated to health equity have made the answer to the question of "How can multilevel and multisector systems change strategies transform community health outcomes?" one of the most important contemporary challenges facing health departments.

Many promising approaches to health equity are focused at the local level and are tailored to and informed by the community residents. Communities bring with them different perspectives, needs, and expectations, often rooted in historical context and experience.

In a previous column, we described work to define tangible outcomes of multisectoral partnerships in addressing social determinants of health, which are the main predictors of equity and health outcomes.1 State and territorial health departments can take important steps to support these partnerships. In addition, there are several evidence-based surveillance, workforce, and organizational issues that states and territories can implement to move toward health equity.

In this column, we present a technical package of interventions we have prioritized at ASTHO to support state efforts. We also present an approach to working with rural and frontier communities, as well as a policy statement we have developed to support efforts to address structural racism at the public health agency level.

A Technical Package of Focused Interventions

ASTHO technical packages are based on our subject matter experts' assessment of evidence-based interventions, expert recommendations, overviews of current activities, and a review of the Centers for Disease Control and Prevention (CDC) and other federal funding guidance. They are not intended to be comprehensive. They provide a more focused and proactive approach to our technical assistance roles. Based on this assessment process, ASTHO has prioritized specific areas of work-outlined in Supplemental Digital Content Table 1 (available at http://links.lww.com/JPHMP/A985)-that will guide our technical assistance work.

Our efforts will focus on improving the collection of accurate race and ethnicity data. Public health agencies cannot address inequities in access to services, quality of care, and health outcomes without these basic demographic data. We will also work with states, the National Association of County and City Health Officials (NACCHO), and the newly formed National Association of Community Health Workers (NACHW) to expand and support the community health worker (CHW) workforce in state and local public health departments, as well as explore similar classifications in US territories and freely associated states. CHWs are one of the few interventions shown to both improve outcomes and reduce disparities,2 and many states have expanded their use during the COVID-19 pandemic.

In partnership with the National Organization of State Offices of Rural Health (NOSORH), we will support states to increase their capacity to address geographic health disparities, as well as interagency engagement strategies specific to remote locations, and understand the unique challenges facing rural populations, as well as those facing US territories and freely associated states.

Finally, we will engage with state leaders to address social determinants of health through policy interventions to promote economic mobility, with an emphasis on expanded access to paid family and sick leave.

Disparities in Rural Communities and Remote Areas

The COVID-19 pandemic demonstrated the urgent need to address disparate public health outcomes. And, for Americans who call more rural areas home, vanishing access to quality health care further marginalized the population's ability to gain access to testing, treatment, and accurate messaging during the pandemic. COVID-19 health disparities experienced by rural and remote populations are associated with a lack of hospitals and health care facilities, insufficient testing sites with walk-in/drive-up options, inconsistent access to transportation, less than 30-minute drive times, and inaccurate information regarding testing availability.

Addressing geographic health disparities will require neighborhood-based, community-centered approaches and federal support to states. CDC created a multifactor Social Vulnerability Index (SVI) used to identify vulnerable rural populations at a greatest risk of impact by hazardous events. Public health leaders serving rural populations can utilize this tool to plan prevention efforts and respond to COVID-19 and other widespread and potentially catastrophic health events.

Utilizing an existing framework, this tool helps rural populations target limited resources to the areas with the greatest need and monitor and better respond to changing needs over time. Investments in data management systems can increase public health capacity to make decisions using data visualization products such as the SVI and other geographic information system mapping (GIS mapping).

Addressing Discrimination and Structural Racism

Even with proposed modernization of public health data systems, and augmenting the community public health work force, strategies will fail to achieve health equity without acknowledging and addressing the implications of historical discrimination and structural racism. Without the fundamental understanding of how structural racism creates and maintains a system of inequities, our efforts will fail to achieve their end goals of improving health for all.

Structural racism describes the way in which governmental policies and procedures have historically been constructed and maintained, resulting in racial inequalities in many of the social determinants of health, and ultimately leading to inequities in health and opportunity. Public health agencies have a role to play in ending structural racism. The solutions identified in the technical package are health equity-centered and align with the key recommendations from ASTHO's policy statement, Achieving Optimal Health for All by Eliminating Structural Racism.3 This statement acknowledges structural racism as a fundamental cause of health inequities and provides a series of recommendations for state and territorial health agencies.

The technical package prioritizes promising upstream interventions to address health equity, which ASTHO defines as follows:

...when everyone has a fair and just opportunity to be as healthy as possible in a society that values each member equally through focused and ongoing efforts to address avoidable inequities, historical and contemporary injustices, and the elimination of disparities in health and health care.

Conclusion

Public health agencies are encouraged to create a culture of health equity by examining their institutional practices and supporting organizational changes, which include adopting anti-racist policies and improving the collection of race and ethnicity data. Doing so will strengthen the evidence base on racial health inequities.

Public health agencies are also part of the communities they serve. It follows, then, that engaging in local partnerships that foster community leadership and create community-led solutions will contribute to promising interventions and provide workforce opportunities. This work begins with hiring a workforce that reflects, and is from, the community being served-as is seen with CHWs. Finally, ASTHO's policy statement and technical package emphasize leveraging law and policy as a critical tool to advance equity. Policy approaches to expand sick leave and paid family leave benefits are a timely approach to address underlying inequities in the social determinants of health.

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