One of the 9 Strategic Skills for Public Health Practice, policy engagement "[i]nvolves working to inform, influence, implement, and evaluate legislation strategies at federal, state, and local levels in order to leverage long-lasting systems changes to protect and improve the public's health and well-being."1 The more that public health professionals are engaged in the policy-making process, the greater influence and impact they can have on the public's health.

Equity is a key principle for effective policy making, and we should approach policy change with equity in mind. It is important to highlight that policies have played a major role in how social determinants of health such as housing, transportation, or education affect health. Described as the political determinants of health, these policies influence the social determinants of health and other drivers of health to create inequities.2 Health equity historically has not been prioritized in the policy process, due, in part, to structural racism, power imbalances, and deep siloes that characterize how our systems function.

Tools to Advance Equitable Policies

Several tools can be used during the policy process to intentionally consider health equity and racial equity, including health impact assessments (HIAs), health notes, and racial equity impact assessments (REIAs). These tools are designed to create a process by which the potential effects, benefits, and harms of a proposed policy are named and measured through various methods.

The outcomes of the assessments, which show how health could be impacted if a certain proposal moves forward, are then shared with policy makers with the hope that they can make decisions that will not exacerbate existing inequities or harm health. These tools are being used to dismantle and address some of the policies, programs, and systems that have perpetuated inequities and contributed to disparities, and, when implemented effectively, they can be used to advance more equitable policies.

Health impact assessment

The National Research Council defines an HIA as "a structured process that uses scientific data, professional expertise, and stakeholder input to identify and evaluate public health consequences of proposals and suggests pragmatic actions that could be taken to minimize adverse health impacts and optimize beneficial ones."3 The HIA process provides timely, useful judgments based on the best available knowledge and public health expertise. HIAs focus on solutions, offering feasible recommendations that can help minimize risks and maximize benefits.

HIAs examine potential health effects and the distribution of those effects within a population. They also center equity by involving an array of stakeholders at every step of the process, including community members who will be affected by a decision, policy makers, and others with an interest in the outcome. Evaluations of HIAs show that they help impacted populations and decision makers weigh trade-offs and understand the direct and indirect health impacts of a proposal, as well as increase community capacity and address community concerns.4,5

Health notes

HIAs are not always the right tool to bring health and equity to the policy process. To address this, a team at the Health Impact Project created and promoted a "health note." A health note provides brief, objective, and nonpartisan summaries of how proposed legislation could affect health. The analysis draws on the best available published research and public health expertise to help legislators understand the connections between their decisions and the health of their constituents. Health notes describe positive and negative effects on health and include available local data to amplify how the bill could impact specific populations by race, ethnicity, gender, and ability.

Racial equity impact assessments

A third tool, the REIA, aims to address racial equity during policy formulation. Washington, DC's Council Office of Racial Equity (CORE) defines REIAs as a "careful and organized examination of how a proposed bill will affect different racial and ethnic groups in the District of Columbia."6 The analysis examines a bill's potential impact on residents of color and concludes whether the bill would likely make progress toward racial equity (ie, the elimination of racial disparities), maintain the status quo, harm or improve outcomes, or have a negligible impact. When data are mixed or limited, an REIA may conclude that the impact on racial equity is inconclusive.

Policy Engagement as the Solution

These tools to advance equitable policies represent several of the numerous ways that public health practitioners can engage in the policy process. No matter how practitioners choose to engage, one fact is clear: policy change makes it possible to advance health equity so that everyone has a fair opportunity to be as healthy as possible. While the current state of the world may make it difficult to believe this is possible, we believe it is.

This column is adapted from Strategic Skills for Public Health Practice: Policy Engagement, available from APHA Press and the de Beaumont Foundation. Learn more about this book and the Strategic Skills for Public Health Practice series at debeaumont.org/books/strategic-skills-for-public-health-practice-policy-engagement.

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