What’s Public Health Got to Do with…Operationalizing Equity at the State Level?

The promise of health equity is both aspirational and challenging, and has become a standard for public health, healthcare, aging services, and those conducting research on the needs of older adults and caregivers.  Achieving health equity, however, seems almost impossible when you think about the changes in policies, systems, and environments that have historical and structural foundations.

Despite the challenges, because ensuring health equity among all populations is one of the most pressing public health issues today, many state health departments and departments of aging are tackling this challenge through incremental, innovative programs. The March 2024 AFPHS training provided examples of how two states, Tennessee and California, are operationalizing equity through state-level programming and policy changes. 

About 17 percent of the Tennessee population is older than 65, and in the coming years, the older adult population within the state is expected to exceed that of people under 18. There are over 120,000 people living with Alzheimer’s disease and related dementias, and the majority of the state’s population resides in one of Tennessee’s 89 rural counties, compared to only 6 metropolitan counties. 

Given this diverse landscape, the Tennessee Department of Health’s (TDH) Office of Patient Care Advocacy has created and executed multiple exciting projects to improve health equity among the state’s older adults. Through collaboration with the Office of Primary Prevention, the Office of Patient Care Advocacy has supported all 95 counties in Tennessee in developing primary prevention plans to target a variety of health behaviors, ranging from substance use to healthy eating. One component of this program is the Stay Active and Independent for Life (S.A.I.L.) program, which was created in response to elevated fall rates in some areas of the state and has successfully decreased falls in older adults. 

The two agencies have awarded over $84,000 in grants for the Healthy Built Environments program, with a focus on providing funds to counties that experience disparities in physical health outcomes. This program supports community engagement, accessible infrastructure, promotion of healthy lifestyles, and access to food and healthcare through changes to the built environment. These changes have included creating more inviting public spaces, affordable housing built near transportation options, and walkable neighborhoods.

The California Department of Aging (CDA) is expanding its health equity strategies by collecting data about the older adult population and sharing this information with partners and the public. They are currently developing an Equity Index as part of the California Master Plan for Aging (MPA), which will allow the department to quantify inequities among populations. Once completed, the Equity Index will enable the CDA to identify communities and populations that experience the greatest health disparities and target these communities for interventions. As part of the CDA’s larger equity data framework, the Equity Index will contribute to the department’s ability to quantify and track equity over time, as well as to create features and outputs which allow for data to be actionable. Because the Equity Index indicators will be publicly available in the future, it will also be a useful tool for starting conversations about equity within and across multiple sectors.

The CDA is also collecting data on the experiences of LGBTQIA+ older adults in the state, a population that has been historically underrepresented in research and underserved by resources. The data from this recently launched survey will inform policy makers, healthcare providers, and advocates, as well as advance the goals and strategies of the MPA.

Advancing health equity is at the core of the AFPHS 6Cs Framework. Here are further examples of how the Framework can guide efforts for integrating equity and healthy aging at the state level:

  1. Creating and leading a commitment to integrate health equity into work across the age-friendly ecosystem. 
  2. Connecting and convening multi-sectoral partners to act on health disparities from a variety of perspectives and with a diverse range of collaborators at the state level.
  3. Coordinating with relevant state agencies to support robust data collection and find new ways to collaborate on equity-related issues.
  4. Collecting, analyzing, and translating data to ensure that all older adult communities are well-represented in data profiles and dashboards, especially hard-to-reach populations or those that have typically been underrepresented in research.
  5. Communicating health information in culturally and linguistically accessible formats, as well as through channels that are proven to be effective with older adults.
  6. Complementing existing state-level programs that work to mitigate health disparities in the older adult population.

See these resources for additional information: