Advancing Health Equity in Psychology

Aspirational goals for health equity are no longer sufficient. Health inequity is driving dire need and substantial physical and psychological suffering. Inequities are so great they warrant immediate transformative action.

This resolution is centered on race/ethnicity and racism as the key driver of health inequities. At the same time, APA recognizes that inequities are experienced through the intersection of multiple elements of identity, particularly those that are associated with limited political, social, and economic power. However, even in the context of intersectional identities, race/ethnicity carries disproportionate weight in determining health inequities. To advance health equity it is fundamentally necessary to implement broad steps related to addressing race/ethnicity and racism within our field. APA considered simultaneously identifying a range of interrelated and intersectional variables (e.g., socioeconomic status, gender and gender identity, sexual orientation, disability), and concluded that to do so would have the effect of diluting the clarity and focus of the resolution and its implementation, and that a staged approach was likely to be necessary. This resolution can provide a basis for similar actions focused on other identities and social characteristics.

Whereas, health equity, defined as “the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically” (World Health Organization, 2021), is an important foundation for advancing health services in psychology;

Whereas, health disparities, described as preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health experienced by socially disadvantaged populations (CDC, 2017), provide ample evidence that people of color have not experienced the mental health or health equity that is central to improving their psychological health and well-being;

Whereas, 2021 APA President Jennifer F. Kelly, PhD, ABPP, appointed a Presidential Task Force on Health Equity comprised of experts on the intersection of health equity and psychological science which compiled and analyzed the available scientific literature in order to make recommendations for psychological science, education and training, practice, public policy, and legislative advocacy, all of which informed this resolution;

Whereas, health inequities are inextricably linked to racism and resulting economic and education inequities that psychologists may help to address (APA Working Group on Health Disparities in Boys and Men, 2018; FitzGerald & Hurst, 2017; Khazanchi et al., 2020; Salter et al., 2018);

Whereas, in six U.S. states and in many U.S. metropolitan areas, people of color already constitute the majority of the population, as is expected to be the case for the U.S. as a whole within the next 20 to 25 years (Frey, 2018); around the globe, 85% of people live in low- and middle-income countries (World Bank, 2022) and people of color represent the overwhelming majority of the world’s population; and “people of the global majority” is increasingly being advanced as an alternative collective term for people of color that does not center Whiteness (Lim, 2020);

Whereas, trauma exposure, discrimination, and racism have resulted in people of color experiencing barriers of distrust toward health care and its professionals (Comas-Díaz et al., 2019; Jones, 2000);

Whereas, racialized health inequities have persisted, and at the intersection of multiple elements of identity, people of color are disproportionally at risk for inequities when compared with White Americans (CDC, 2017);

Whereas, psychologists possess expertise to address the social determinants of health (e.g., access to quality care, community environment, education, employment, socioeconomic status (SES), carceral status, and social networks) that drive health inequities (Artiga & Hinton, 2018; 50 Healthy People, 2030, 2021; Institute of Medicine, 2003; Klukoff et al., 2021; Kovera, 2019; Robert Wood Johnson Foundation, January 11, 2017; World Health Organization, 2008);

Whereas, eliminating health inequities would reduce direct and indirect medical care costs associated with illness and premature death (LaVeist et al., 2011); lost economic output is linked to the combined effect of inequities in health, education, incarceration, and employment opportunities (PolicyLink/PERE, National Equity Atlas, www.nationalequityatlas.org);

Whereas, psychology’s traditional focus on individual behavior change fails to acknowledge structures that perpetuate inequity and fails to engage the necessary work of transforming social systems to advance health equity (Holden et. al., 2016; Lee, 2006); the focus historically has been on the downstream within-person consequences of racism rather than addressing the upstream antecedents of social hierarchy and inequity (Williams et al., 2019; Williams & Mohammed, 2013);

Whereas, health inequities have been a significant contributor to and exacerbator of the COVID-19 pandemic (APA, May 27, 2020; CDC, April 16, 2021; Moore et al., 2020); and COVID-19 has demonstrably worsened health inequities that will challenge the U.S. and its psychologists, and exposed shortcomings of health services and systems, including psychological services, to effectively advance health equity in the U.S. (APA, October 20, 2020; Novacek et al., 2020);

Whereas, health inequities compound the risks to people of color because of climate change, a significant threat to well-being and important priority of APA (Swim et al., 2009);

Whereas, racialized education and training, science, and clinical practice, including by psychologists, have contributed to health inequities by mismatching mainstream psychological methods and practices to communities of color with vastly different cultural perspectives; and training models often neglect to educate psychologists in culturally appropriate methods for addressing health equity (Adames et al., 2013; Aiello et al., 2021; Buchanan et al., 2020; Hartwell et al., 2017);

Whereas, given limited representation of students and professionals of color in the field of psychology, and particularly in science-focused academic positions, there are persistent barriers to meeting the physical and mental health care needs of communities of color (Buchanan et al., 2020; Lin et al., 2018); academic hierarchical culture is not well-matched to the more collectivistic cultures of some communities of color; and education and training in health equity, EDI (equity, diversity, and inclusion), and structural racism is heterogeneous and often lacking in consistency over time (Adames et al., 2013; Bernstein et al., 2020; Fuentes et al., 2020; Hartwell et al., 2017; Matsumoto, 2000; Tynan & Garbett, 2007);

Whereas, people of color are significantly underserved by research (Barr, 2019); and health equity research continues to be undervalued by funding agencies, academic audiences, and community settings (Kaiser Family Foundation, 2018; Srinivasan & Williams, 2014);

Whereas, few psychologists have expertise in approaches that can enhance understanding and responsively address racialized health inequities such as Community Based Participatory Research (De Maio et al., 2019; Wallerstein et al., 2017);

Whereas scholars of color are significantly underrepresented on editorial boards in ways that bias publications (Bhaumik & Jagnoor, 2019; Esquierdo-Leal & Houmanfar, 2021); scholars of color, especially early career, women, and LGBTQ professionals, are often burdened with heavy and disproportionate service demands that interfere with scholarship based on ostensible concerns about representation (Misra et al., 2021); and inequities associated with intersectional id entities are often overlooked, while cultural strengths are typically ignored and undervalued (Collin & Blidge, 2020; Nash, 2008);

Whereas, population-based interventions that address multiple dimensions of wellness are needed for those without mental health diagnoses (Payne, 2017; Young, 2004); interventions are needed to address implicit racism inherent in health care systems, agencies, and organizations (Blume, 2016); practitioners often lack competence and confidence in addressing race and racism in clinical encounters (Buchanan & Wiklund, 2020; Estaban & Battle, 2003); there is a need for greater accessibility of clinical services to populations that fall through the cracks where financial structures disincentivize care for individuals from lower and middle SES communities and people of color, and need exists for equitable and sustainable health care reimbursement (Palozzi et al., 2020); psychological assessment does not adequately capture culturally-responsive constructs central to health equity work (Braveman, 2006); and the Examination for Professional Practice in Psychology (EPPP) may have an impact that is counter to the goal of achieving a diverse practice workforce (Macura & Ameen, 2021);

Whereas, there is a pressing need to enlist authentic stakeholder and community engagement in which communities and stakeholders bilaterally collaborate to address health inequity (Robert Wood Johnson Foundation, 2017); and there is a critical need for more deliberate and impactful interprofessional partnerships (e.g., with AMA, APHA, SBM, and policymakers) to advance health equity (Gomez et al., 2021; Muraleetharan et al., 2021);

Whereas, the role of APA and of psychologists in advancing health equity is consistent with APA’s guiding principles to build on a foundation of science, advocate for psychology and psychologists, champion diversity and inclusion, respect and promote human rights, and lead by example; advancing health equity is central to APA’s strategic goal to utilize psychology to make a positive impact on critical societal issues, including the objective of employing psychology to improve population health, increase access to services, and reduce disparities, and the objective of fostering the advancement of human rights, fairness, diversity, and inclusion through the application of psychological science (APA, 2019; APA Center for Psychology and Health, 2016);

Whereas health equity has been identified as a guiding principle of the APA/APASI advocacy priorities (APASI, 2021a); APA in 2021 adopted an Equity, Diversity, and Inclusion Framework (APA, 2021b); a range of activities focused on antiracism and health equity have been or are being undertaken by the Central Office Directorates and other programmatic units (e.g., APA, 2021c), including APA divisions (e.g., APA Division 45, 2020); APA Council of Representatives is considering a proposed resolution on the Apology for the Role of the American Psychological Association in Promoting, Perpetuating, and Failing to Challenge Racism, Discrimination, and Human Hierarchy in the United States (pending COR approval, October 2021) which indicates that “APA will prioritize efforts in clinical practice and health equity, such as those that elevate both advocacy for and training in culturally competent, easily accessible care models; and those that improve the discipline’s knowledge of and responsiveness to the needs of communities of color”; an APA Ad Hoc Committee on Health Equity was appointed in 2021; and the aim of the Resolution on Advancing Health Equity in Psychology is to provide a unifying framework at the highest level of priority for programmatic activity across the different areas of the Association and its governance;

Therefore, be it resolved that APA will continue to support comprehensive evaluation of early psychology exposure, recruitment, admission, and retention processes to identify ways to effectively recruit, admit, and retain students of color at all levels, from high school through postdoctoral training. This should specifically focus on pathways for scientists as well as practitioners.

Therefore, be it resolved that APA will support effective outreach and recruitment programs targeting undergraduate programs, tribal colleges, and high schools in communities that have historically experienced inequities to increase exposure, recruitment, admission, and retention of students of color in both science and practice areas, including by highlighting the careers of psychologists of color who have advanced health equity.

Therefore, be it resolved that APA will leverage its influence to promote the use of resources for the inclusion of health equity in psychology curricula. This will include the use of innovative methodologies and tools to integrate community resources and diverse approaches to address health equity topics.

Therefore, be it resolved that APA will encourage flexible training models for graduate education in psychology and doctoral internships that reduce barriers for students with multiple life demands (e.g., who need to support their families).

Therefore, be it resolved that APA will support mentoring programs (e.g., the Minority Fellowship Program) across all levels of training and throughout all stages of career development for people of color.

Therefore, be it resolved that APA will support training programs throughout the training sequence that provide exemplary training in health equity and supportive environments for students and faculty of color, based on an evaluation of the level of resources and supports provided to students, trainees, and early career psychologists of color.

Therefore, be it resolved that APA will support funding for curriculum development with the goal of incorporating health equity concepts into the psychology curriculum across levels of training from high school to postgraduate and continuing education.

Therefore, be it resolved that APA will support Continuing Education (CE) courses on health equity and encourage their broad dissemination.

Therefore, be it resolved that APA will serve as a resource for health equity training and other programs and efforts in this area.

Therefore, be it resolved that APA will advocate with federal research funding agencies (e.g. NIH, NSF, HRSA, PCORI) and private foundations for dedicated, sustained, and increased funding for research in health equity, that include a broader focus on social, institutional, and structural issues as key drivers of health outcomes and health equity; research on understudied populations and groups with intersectional identities: and research utilizing innovative, culturally responsive methodologies, such as community based participatory research methods.

Therefore, be it resolved that APA will advocate for federal research funding agencies to specifically include scholars of color and scholars knowledgeable about health equity issues to guide the development of research in this area, and to serve on their advisory councils more generally.

Therefore, be it resolved that APA will continue to support federal research funding opportunities that promote collaborative opportunities across HBCUs, HSIs, and tribal colleges on topics of health equity.

Therefore, be it resolved that APA will continue to develop and adopt models of language and practice for authors, journal reviewers, and journal editors that minimize bias and harmonize the consistent reporting of demographic characteristics, extending on the work of bias-free language and transparent reporting practices in the APA Style Manual. This includes the use systems-centered language (O’Reilly, 2020), which emphasizes the active nature of the systemic forces that act on communities of color and underlie many health inequities (e.g., saying that a particular community is “exposed to additional harm” rather than saying it is “at risk”).

Therefore, be it resolved that APA will promote the development of psychometrically sound research measures to assess constructs related to health equity with guidance from scientific experts and key stakeholders, including experts in collectivistic methodologies and related practices, to optimize culturally-informed, ecologically valid health equity research. These efforts should enhance existing programs aimed at developing and disseminating measurement tools for broad use (e.g., PROMIS, PhenX Toolkit [https://www.phenxtoolkit.org/index.php]).

Therefore, be it resolved that APA will promote the standard use of best-available metrics of diversity, including race, ethnicity, sex, gender, socioeconomic status, sexual orientation, age, ability status, religion, national origin, etc. to promote comparability across studies as a strategy for advancing health equity. APA will also promote transparency in the reporting of these metrics and in APA journals, books, and other publications, including guidelines, reports, and other communications produced by APA.

Therefore, be it resolved that APA will continue and expand existing efforts to increase representation of scholars of color on its journal and publication editorial boards, particularly including experts in health equity where appropriate. In addition, APA will encourage and support training on EDI, including a focus on health equity, for all members of the editorial team of APA journals.

Therefore, be it resolved that APA will support practice innovations that deliver competent and financially viable clinical assessment, intervention, and prevention services to diverse populations and communities. This includes the development and expansion of models for integrating psychological practice in the community and for collaboration with other health professionals (e.g., Community Health Workers) to address social determinants of health and health inequities. Examples include models of clinical and system-based assessment to address treatment barriers and service delivery challenges, as well as preventive interventions and wellness practices that attend to individual, interpersonal, and structural determinants of health in communities of color.

Therefore, be it resolved that APA will continue to develop and disseminate continuing education programs for practitioners to enhance their learning about EDI and race/racism as they relate to health equity when they deliver professional services to populations of color, communities, and organizations.

Therefore, be it resolved that APA will advocate for federal (e.g., CMS) and private (e.g., health insurance) service reimbursement formulas and models that support clinical practices that deliver competent and culturally appropriate clinical assessment, intervention, and prevention services to diverse populations and communities.

Therefore, be it resolved that APA will support current and future workforce pathway initiatives for practitioner psychologists that increase their ability to address health equity issues, with a particular focus on people of color and their various intersectional identities (e.g., gender, LGBTQI, socioeconomic status).

Therefore, be it resolved that APA will support the development of training materials and modules on health equity advocacy, with the goal of encouraging graduate students, psychology department faculty members, psychology internship and predoctoral training facility staff and professional practitioners to engage in related local, state, and federal advocacy efforts.

Therefore, be it resolved that APA will support training programs to help psychologists enhance their advocacy skills and strategies and facilitate their connections with policymakers on health equity concerns.

Therefore, be it resolved that APA will continue to develop and engage in partnerships and coalitions with other professional and policymaking organizations to address health equity issues in communities of color.

• AMA: American Medical Association
• APHA: American Public Health Association
• CMS: Centers for Medicare and Medicaid Services
• EDI: Equity, Diversity, and Inclusion
• EPPP: Examination for Professional Practice in Psychology
• HBCU: Historically Black Colleges and Universities
• HSI: Hispanic-Serving Institution
• HRSA: Health Resources and Services Administration
• LGBTQI: Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex
• NIH: National Institutes of Health
• NSF: National Science Foundation
• PCORI: Patient-Centered Outcomes Research Institute
• PROMIS: Patient-Reported Outcomes Measurement Information System
• SBM: Society of Behavioral Medicine