Designing an Overdose Monitoring and Response Plan Evaluation to Advance Health Equity 

The root causes of drug overdose health inequities encompass a range of intrapersonal, interpersonal, organizational, and systemic factors operating through racism, sexism, classism, homophobia, transphobia, and xenophobia, among others. According to Dr. David Satcher, a former US Surgeon General and a former CDC Director, “Getting from science to policy and practice can be greatly hampered by stigma.” Stigma has been an established contributor to the inequities encountered by individuals with OUD. The stigma around opioid use disorder when intertwined with racial stigma and stigma around mental health disorders further complicates the solution, given the association between these issues all of which have an immense social and economic impact on today’s society.  

Historically, drug overdose inequities have also been introduced through systemic biases in policies and practices in addition to community-level factors such as structural deprivation, and lack of social support. Planning and implementing the OMAR plan in any community mandates bringing together multiple resources and community partners who play key roles in decision-making. This presents a great opportunity to address drug overdose health inequities by designing evaluations that intentionally use equity as a value criterion. The Bay Area Regional Health Inequities Initiative (BARHII) developed a conceptual framework illustrating the connection between social inequalities and health and focuses attention on measures that have not characteristically been explored by public health epidemiology. This framework exemplifies how measures of social and institutional inequities such as race/ethnicity, gender, laws, and regulations can influence social determinants of health, thereby affecting individual risk behaviors, and eventually morbidity and mortality. The BARHII framework and toolkit are designed to equip local health departments with better tools to address health inequities and is a great resource to start or advance your health equity efforts. 

After reviewing existing literature on drug overdoses, the National Association of County and City Health Officials (NACCHO) has classified drug overdose health inequities into the following categories:

1. Social inequities – class, race/ethnicity, immigration status, sex, lesbian, gay, bisexual, transgender, queer, intersex, and agender/asexual plus (LGBTQIA+) status.
2. Institutional inequities – law and regulation, organizations, media.
3. Living conditions – Social determinants of health: physical environment, economic & work environment, social environment, service environment
4. Individual-level factors – overdose, polysubstance use, co-morbidities, mortality.

NACCHO’s review suggests individual-level factors can be positively impacted by placing an emphasizing on social and institutional inequities and living conditions. Evaluating health equity knowledge and skills of personnel working in overdose response planning and offering training and avenues to incorporate these skills into their work can be a great step towards achieving equitable outcomes. Incorporating health equity measures in the outcome or impact evaluation of OMAR plan will shed light on what interventions are needed in your community to eliminate barriers to equal healthcare access. The findings from these evaluations will contribute to an increase in awareness, inform changes required in program implementation and monitoring, impact organizational policies and practices.

Some ideas to create evaluation questions to advance equity are enlisted below.

• Incorporating process measures to advance health equity.
  • Measuring staff capacity building to evaluate whether agency staff has skills and knowledge to advance equity. Some examples are the number of staff who have attended a training/workshop on health equity, the number of attendees who used skills/knowledge they learned at least once within 3 months of the training/workshop, how have they used these knowledge/skills, etc.
  • Understanding organizational culture to examine various practices and policies that affect the organizational workforce, such as percentage of interview or hiring panels that have diverse reviewers (“diverse” could be based on different types of demographics), percentage of staff who agree that advancing equity or justice is part of their job, percentage of individual employee performance goals that incorporate equity or justice (usually part of the annual review process), etc.
  • Evaluating community engagement practices to examine whether adequate opportunities are provided for meaningful participation of communities experiencing health inequities. Some examples include rating of amount and quality of community member participation by program evaluator, percentage of community members who agree or strongly agree on having a clearly defined role, etc.
  • Examining the effectiveness of communication by answering questions such as these:
    • Number of times analyses are conducted using tools such as health impact assessment to examine and demonstrate impact on health inequities across sectors.
    • Number of times the agency formats and communicates data findings so that they are useful for action by all sectors, community stakeholders, and at all levels of government (as perceived by these external stakeholders).
    • Percentage of reports that incorporate one or more of the social determinants of health in its data analysis
    • Percentage of reports that stratify data across population groups, e.g., race, zip code, language.
    • Number of times the agency utilizes a tool such as the WHO Commission on Social Determinants of Health Framework for planning purposes, such as conducting health needs assessments and program logic models.
    • The agency can demonstrate improved communication and outreach to communities of color, LES communities, and low-income communities through an increased number of translated documents and materials, increased number, and quality of outreach activities over the previous year.
    • Percentage of community members from impacted populations who feel the agency’s communication methods are effective.
  • Evaluating health equity through contracts and procurement.
    • What percentage of budgets have line items for equity activities?
    • How is the effectiveness of programs in reducing racial/ethnic disparities assessed?
    • How was cultural competency ensured among grantee staff working with the priority population?

• Incorporating outcome measures to advance equity.
  • How much does an individual with OUD earn for every dollar an individual without OUD earns? Does this vary by race and gender?
  • What percentage of individuals with OUD show up for a follow-up healthcare visit? How does this compare to individuals with other diseases? What are the barriers preventing them from showing up?
  • What is the incarceration rate by race in the OUD population in your community?
  • What percentage of children living in a household that has a member suffering from OUD have been suspended from school more than once? Does this change by race and/or gender?