Leading Change at Berkeley Public Health: Building the Anti-racist Community for Justice and Social Transformative Change.

A transformative change grounded in a commitment to antiracism and racial and health equity is underway at the University of California, Berkeley, School of Public Health. Responding to a confluence of national, state, and local circumstances, bold leadership, and a moral and disciplinary imperative to name and address racism as a root cause of health inequities, our community united around a common vision of becoming an antiracist institution. Berkeley Public Health has a long history of efforts supporting diversity, equity, inclusion, belonging, and justice. Building upon those efforts, we pursued an institution-wide initiative, one that creates a more equitable and inclusive school of public health that models and supports the development of future public health leaders, practitioners, scholars, and educators. Grounded in the principles of cultural humility, we recognized that our vision was a journey, not a destination. This article describes our efforts from June 2020 through June 2022 in developing and implementing ARC4JSTC (Anti-racist Community for Justice and Social Transformative Change), a comprehensive, multiyear antiracist change initiative encompassing faculty and workforce development, student experience, curriculum and pedagogy, community engagement outreach, and business processes. Our work is data informed, grounded in principles of change management, and focused on building internal capacity to promote long-term change. Our discussion of lessons learned and next steps helps to inform our ongoing work and antiracist institutional change efforts at other schools and programs of public health.

Don't change who we are but give us a chance: confronting the potential of community health worker certification for workforce recognition and exclusion.

BACKGROUND: For community health workers (CHWs) and promotores de salud (CHWs who primarily serve Latinx communities and are grounded in a social, rather than a clinical model of care), the process of certification highlights the tension between developing a certified workforce with formal requirements (i.e., certified CHWs) and valuing CHWs, without formal requirements, based on their roles, knowledge, and being part of the communities where they live and work (i.e., non-certified CHWs). California serves as an ideal case study to examine how these two paths can coexist. California's CHW workforce represents distinct ideologies of care (e.g., clinical CHWs, community-based CHWs, and promotores de salud) and California stakeholders have debated certification for nearly twenty years but have not implemented such processes. METHODS: We employed purposive sampling to interview 108 stakeholders (i.e., 66 CHWs, 11 program managers, and 31 system-level participants) to understand their perspectives on the opportunities and risks that certification may raise for CHWs and the communities they serve. We conducted focus groups with CHWs, interviews with program managers and system-level participants, and observations of public forums that discussed CHW workforce issues. We used a thematic analysis approach to identify, analyze, and report themes. RESULTS: Some CHW participants supported inclusive certification training opportunities while others feared that certification might erode their identity and undermine their work in communities. Some program managers and system-level participants acknowledged the opportunities of certification but also expressed concerns that certification may distance CHWs from their communities. Program managers and system-level participants also highlighted that certification may not address all challenges related to integrating CHWs into health care systems. CHWs, program managers, and system-level participants agreed that CHWs should be involved in certification discussions and decision making. CONCLUSIONS: To address participant concerns, our findings recommend California stakeholders build a voluntary certification process structured with multiple pathways to overcome entry barriers of traditional certification processes, maintain CHW identity, and protect diversity within the workforce. Positioning CHWs as decision makers will be critical when designing state certification processes.

State Politics And The Uneven Fate Of Medicaid Expansion.

Under the Affordable Care Act (ACA), state governments play a central role in deciding whether millions of low-income Americans have access to Medicaid. During the early years of ACA implementation, conservative opposition stalled the expansion of eligibility for Medicaid in many Republican-controlled states, even in the face of strong fiscal incentives. Can any forces overcome this partisan divide? In this article we consider the role of several key mechanisms that have affected Medicaid expansion over the past decade, including electoral competition, ballot-box initiatives, interest-group coalitions, and entrepreneurial administrators. While each mechanism has helped place Medicaid expansion on the agenda, they have done so unevenly. In Republican-controlled states where electoral competition is weak and ballot initiatives are unavailable, Medicaid expansion remains unlikely. Even when expansion is successful at the ballot box, however, state legislatures and governors have been able to delay or reverse voter-led initiatives. Moreover, the highly salient and partisan nature of Medicaid expansion has made it difficult for interest-group coalitions and progressive administrators to play a leading role in policy change. The future of Medicaid expansion, as well as other significant portions of the ACA, will continue to depend on the character of representative democracy in the states.

Female sex workers use power over their day-to-day lives to meet the condition of a conditional cash transfer intervention to incentivize safe sex.

Female Sex Workers are a core population in the HIV epidemic, and interventions such as conditional cash transfers (CCTs), effective in other health domains, are a promising new approach to reduce the spread of HIV. Here we investigate how a population of Tanzanian female sex workers, though constrained in many ways, experience and use their power in the context of a CCT intervention that incentivizes safe sex. We analyzed 20 qualitative in-depth interviews with female sex workers enrolled in a randomized-controlled CCT program, the RESPECT II pilot, and found that while such women have limited choices, they do have substantial power over their work logistics that they leveraged to meet the conditions of the CCT and receive the cash award. It was through these decisions over work logistics, such as reducing the number of workdays and clients, that the CCT intervention had its greatest impact on modifying female sex workers' behavior.

Going for the cure: patient interest groups and health advocacy in the United States.

Citizen groups, though celebrated during their sudden arrival on the lobbying scene, are vastly outnumbered by groups representing elite, occupationally based interests. Sensitive to the odds that nonoccupational groups face, this study asks what factors have allowed patient groups to form and become active in federal politics. Using three distinct data sets--a survey of patient groups, content analysis of group websites, and in-depth interviews with group representatives and policy makers in Washington, DC--this study assesses the activities of patient groups in the United States and argues that patient advocacy organizations garner stability from the relatively easy provision of selective and solidary benefits. Larger patient groups are especially likely to make use of these structural advantages to pursue congressional lobbying strategies. However, even these groups seek out noncompetitive, distributive political environments. Moreover, the study finds that patient groups rarely form coalitions across diseases, forgoing the potential to collectively speak for shared patient interests.

Evolving strategies, opportunistic implementation: HIV risk reduction in Tanzania in the context of an incentive-based HIV prevention intervention.

BACKGROUND: Behavior change communication (BCC) interventions, while still a necessary component of HIV prevention, have not on their own been shown to be sufficient to stem the tide of the epidemic. The shortcomings of BCC interventions are partly due to barriers arising from structural or economic constraints. Arguments are being made for combination prevention packages that include behavior change, biomedical, and structural interventions to address the complex set of risk factors that may lead to HIV infection. METHODS: In 2009/2010 we conducted 216 in-depth interviews with a subset of study participants enrolled in the RESPECT study - an HIV prevention trial in Tanzania that used cash awards to incentivize safer sexual behaviors. We analyzed community diaries to understand how the study was perceived in the community. We drew on these data to enhance our understanding of how the intervention influenced strategies for risk reduction. RESULTS: We found that certain situations provide increased leverage for sexual negotiation, and these situations facilitated opportunistic implementation of risk reduction strategies. Opportunities enabled by the RESPECT intervention included leveraging conditional cash awards, but participants also emphasized the importance of exploiting new health status knowledge from regular STI testing. Risk reduction strategies included condom use within partnerships and/or with other partners, and an unexpected emphasis on temporary abstinence. CONCLUSIONS: Our results highlight the importance of increasing opportunities for implementing risk reduction strategies. We found that an incentive-based intervention could be effective in part by creating such opportunities, particularly among groups such as women with limited sexual agency. The results provide new evidence that expanding regular testing of STIs is another important mechanism for providing opportunities for negotiating behavior change, beyond the direct benefits of testing. Exploiting the latent demand for STI testing should receive renewed attention as part of innovative new combination interventions for HIV prevention.

Assessment of pain in the cognitively impaired older adult in long-term care.

This study's objectives were twofold: to identify pain assessment methods used by caregivers of cognitively impaired older adults in long-term care, and to identify medications ordered and administered to them. Over 60% of RNs, with fewer LPNs and CNAs, used formal pain assessment tools. Patient records identified that 77.5% of cognitively impaired patients had a regularly ordered pain medication and 91% had a PRN pain medication order. Thirty percent of patients received at least one PRN medication in a 1-week period. No one diagnosis was significantly associated with a greater tendency for PRN pain medications to be administered, with cancer a possible exception. Eighty-two percent of cognitively impaired patients had a PRN order for acetaminophen. Using minimum data set (MDS) criteria, this study found that patients with greater communication impairments received fewer pain medications.