Health Equity Curricula Within Health Policy and Management Concentrations in U.S. Public Health Graduate Programs

Abstract

Achieving health equity is a national priority in the United States and having a public health workforce equipped to make health policy and administrative decisions that reduce disparities is needed. We examined 50 schools that offered an on-campus Master of Public Health and are accredited by the Council on Education for Public Health with concentrations or tracks in health policy and management (HPM). Nationally, only 6 (12%) HPM tracks required students to take a course in health equity and/or disparities. Of the optional courses offered within HPM tracks, 30.5% were focused on specific health conditions, and 28% were focused on broadly defined inequities. A smaller portion of health equity courses covered topics in sexual and reproductive health (5.1%), women and gender (3.4%), immigration (1.7%), and LGBTQ populations (1.7%). If health equity is to be achieved in health policy and management, educating all students earning a Master of Public Health in HPM tracks on these issues and equipping them with competencies to effectively tackle health inequity is a starting place.

Keywords

MPH training programs health policy curriculum public health education health equity

Introduction

Eliminating health disparities and achieving health equity are national priorities in the United States. For example, health equity goals were recently incorporated into the Healthy People 2020 goals, which is a nationwide initiative led by the U.S. Department of Health & Human Services that identifies goals in health promotion and disease prevention to be achieved by 2020. One of the four overarching goals of Healthy People 2020 is to “achieve health equity, eliminate disparities, and improve the health of all groups” (Office of Disease Prevention and Health Promotion, 2018). Additionally, in 2010, the National Institutes of Health elevated the National Institute of Minority Health and Disparities to a full institute “with the mission to lead scientific research to improve minority health and reduce health disparities” (U.S. Department of Health & Human Services, 2018). Recent reports by the National Academy of Medicine (formerly the Institute of Medicine) have also targeted health disparities for elimination and adopted a social determinants of health framework to address disparities and to promote health equity (Institute of Medicine, 2003a; Meads & Moore, 2013). These efforts complement initiatives at the global level, including the World Health Organization’s Commission on Social Determinants of Health’s final report—Closing the Gap in a Generation, which called for the implementation of public policies that address the varied and complex structural causes that promote health inequities (Commission on Social Determinants of Health, 2008).

In order to advance health equity in the 21st century, there must be a public health workforce equipped with the core competencies and skill-sets to design health policy, public health programs, and clinical interventions that reduce and eliminate health disparities (Institute of Medicine, 2003b; Mitchell & Lassiter, 2006). However, according to a recent review of 49 Schools of Public Health and 101 public health programs affiliated with the Association of Schools and Programs of Public Health (ASPPH), there were only nine certificate programs and six opportunities for degree specialization in health equity, disparities, and/or inequalities in the United States—most of which were located in urban areas along the east coast (Elias et al., 2017). This study builds on previous research (Elias et al., 2017; Njoku & Wakeel, 2018) examining health equity content within the curriculum of a specific public health core field: health policy and management (HPM).

We examined the prevalence of health equity–specific courses within HPM tracks in Master of Public Health (MPH) graduate programs given the importance of health reform and public policy on health outcomes for vulnerable populations (Adepoju, Preston, & Gonzales, 2015). Whether intentional or not, public policy and administrative decisions can shape all aspects of human health, including health outcomes, access to medical care, and the social determinants of health (Heiman, Lerissa Smith, McKool, Mitchell, & Bayer, 2015; McFarlane & Gordon, 1992). According to previous research, most HPM training programs emphasize health care delivery, health care finance, organizational theory, and health care quality in their curriculum (Heiman et al., 2015). Of 33 peer-reviewed articles on the role of health policy education across different disciplines (e.g., psychology, sociology, medicine, nursing, public health, and public policy), only 4 (12%) previous studies mentioned any content on underserved populations, health disparities, and/or health equity (Heiman et al., 2015). While this represents an important step toward understanding the role of health equity training within HPM programs, these findings may not adequately represent the training received by future public health professionals.

To assess the extent and scope of health equity courses required within HPM tracks, we conducted an exploratory analysis of MPH programs in the United States that offer health policy and/or management as a degree concentration or specialized track. We identified how many HPM tracks require their students to take a course on health disparities or health equity. Then, for the tracks teaching health disparities and health equity within HPM, we examined the range of course topics offered. Understanding the breadth of health equity courses in HPM tracks promises to identify gaps in training and potential areas for improvement.

Method

This study reviewed curricula information available online from HPM training programs in the United States. A list of 50 HPM programs was compiled using the Academic Program Finder on the Association of Schools & Programs of Public Health (ASPPH, 2018) website (see the Supplemental Appendix, available in the online version of this article, for a complete list of HPM programs evaluated in this study). This analysis was restricted to on-campus MPH degree programs with concentrations in HPM that were accredited by the Council on Education for Public Health (CEPH). More specifically, we restricted our sample using the following inclusion criteria in four search fields on the Academic Program Finder portal: (1) areas of study were restricted to (a) health policy and (b) health management; (2) the degree field was restricted to MPH; (3) the institution field was restricted to CEPH-accredited; and (4) the alternative field was restricted to on-campus programs. Schools with executive or 1-year accelerated programs in HPM were excluded from this analysis to describe the modal type of MPH program with concentrations in HPM: full-time, 2-year MPH programs. The final sample included 50 CEPH-accredited MPH programs offering concentrations in HPM.

We analyzed the curriculum requirements and health equity courses offered by 50 CEPH-accredited HPM programs based on information extracted from each university’s website. Data (i.e., course names and course descriptions found in curriculum documents, course catalogs, and student guidebooks available on HPM concentration websites) on class offerings were collected using publicly available information on the schools’ official websites. The few schools (n = 2) missing information on their websites were inquired directly via email (the email expressed interest in the MPH program and requested class listings for HPM tracks). We identified and compared the prevalence of required courses in HPM tracks, including whether an HPM track required students to take one of the following courses: health policy (or health policy analysis), health care management, health economics, health politics, health care quality, and/or health disparities (or health equity). Then, we reviewed the types of required and elective health equity courses offered by HPM tracks. All required health equity courses were identified, and elective health equity courses were classified into topical categories by first and second reviewers (NQ and GG). Reviewers created and refined a codebook to guide data abstraction using a collaborative consensus-based process. Reviewers incorporated principles from grounded theory (Charmaz, 2014), whereby classes were grouped into subcategories and subcategories into primary topical categories. The following eight topical categories emerged: (1) race, culture, and ethnicity; (2) socioeconomic status (SES), poverty, income, and social class; (3) immigration, migrants, and refugees; (4) lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations; (5) sexual and reproductive health; (6) women and gender; (7) human rights, social justice, equity, and broadly defined inequities; and (8) specific health conditions (e.g., HIV/AIDS, cancer), illnesses, and disabilities. All required and elective courses identified for this review were offered through HPM tracks, which was determined by evaluating the list of course offerings on HPM websites and course numbers (i.e., abbreviations indicating that courses were offered through HPM tracks) provided on university websites and student guidebooks.

Results

Table 1 presents required courses in HPM curricula. Of the 50 HPM tracks evaluated, 100% (n = 50) required a course in health policy or health policy analysis; 72% (n = 36) required a course in health economics. Approximately three quarters (76%; n = 38) of the 50 HPM tracks required students to take a course on health care management. Meanwhile, approximately 22% (n = 14) HPM tracks required students to take a course in health politics, and 14% (n = 7) required students to take a course on health care quality. Six (12%) HPM tracks required students to take a course in health equity and/or health disparities. The six HPM tracks (Table 2) requiring health disparities or health equity courses were located at the Colorado School of Public Health, Loma Linda University School of Public Health, Oregon State University College of Public Health and Human Sciences, the University of Maryland School of Public Health, the University of New Mexico College of Population Health, and the University of Wisconsin–Milwaukee School of Public Health. Table 2 lists the course titles and course numbers of required health equity courses in MPH programs with concentrations in HPM.

Table 1.

Required Courses in Health Policy and Management Curricula.

Programs	n	%
All programs examined	50	100
Programs requiring a course in health policy (or policy analysis)	50	100
Programs requiring a course in health care management	38	76
Programs requiring a course in health economics	36	72
Programs requiring a course in health politics	11	22
Programs requiring a course in health care quality	7	14
Programs requiring a course in health equity	6	12

Note. Information extracted from university websites.

Table 2.

Required Health Equity Courses in Master of Public Health Programs with Concentrations in Health Policy and Management.

University and/or school	Course number and title
Colorado School of Public Health	HSMP 6602 Health Equity
Loma Linda University School of Public Health	HADM 545 Government Policy and Health Disparities
Oregon State University College of Public Health and Human Sciences	H 520 Health Disparities
University of Maryland School of Public Health	HLSA 787 Minority Health and Health Equity
University of New Mexico College of Population Health	PH 554 Health Policy, Politics, and Social Equity
University of Wisconsin–Milwaukee School of Public Health	PH 700 Structures of Inequality and Population Health

Note. Information extracted from university websites.

Meanwhile, approximately 68% (n = 34) of HPM tracks offered elective courses in health equity and disparities within their HPM department (data not shown). Table 3 presents the categories of elective health equity courses eligible for credit in HPM tracks. Of the elective health equity courses offered within HPM departments, 30.5% were focused on specific conditions or disabilities (e.g., mental health, HIV/AIDS, disabilities, and populations with special health care needs). Approximately 28% of the elective courses on health equity were on human rights, which included courses on social justice and broadly defined inequities (i.e., example courses were listed as health and human rights; social justice and public health; health disparities; and vulnerable populations); 16.9% of courses focused on race and ethnicity; 12.7% of courses were on social class and SES. A smaller portion of the health equity courses covered topics in sexual and reproductive health (5.1%), women and gender (3.4%), immigration (1.7%), and LGBTQ populations (1.7%).

Table 3.

Categories of Elective Health Equity Courses Eligible for Credit in Health Policy and Management Training Programs.

Only health policy and management courses	n	%
Specific Conditions and Disabilities	36	30.5
Human Rights	33	28.0
Race and Ethnicity	20	16.9
Socioeconomic Status	15	12.7
Sexual and Reproductive Health	6	5.1
Women and Gender	4	3.4
Immigration	2	1.7
Lesbian, gay, bisexual, transgender, and queer	2	1.7

Note. Information extracted from university websites.

There was a wide variety of health equity and health disparities courses offered in HPM tracks. Table 4 presents examples of health equity courses offered by HPM tracks. Most courses were offered for two to three credits (or units). Many MPH degree programs offering health equity courses in their HPM concentrations were located along the eastern coast of the United States, but others were found in the midwestern and western United States. Example elective courses were wide-ranging and included broad topics, such as health disparities, minority health policy, and health care for vulnerable populations. Other courses were more specific in title and centered on specific diseases or populations, including Mental Health Policy in the United States, American Indian Health Policy, and Making Equity a Priority in Cancer Care Quality. Finally, some courses emphasized the upstream causes and social determinants of health disparities, such as Health Disparities: Systemic, Structural, Environmental, and Economic.

Table 4.

Example Elective Health Equity Courses Offered by Health Policy and Management Tracks.

School or university	Course number and title	Credits
Columbia University Mailman School of Public Health	HPMN P8513 Providing Healthcare to Vulnerable Communities	1.5
Drexel University Dornsife School of Public Health	HMP 550 Health Disparities: Systemic, Structural, Environmental, & Economic	3.0
Emory University Rollins School of Public Health	HPM 565 Health Care for the Indigent	2.0
George Mason University	HAP 662 Health Policy for Elders and People with Disabilities	3.0
George Washington University Milken Institute School of Public Health	PUBH 6372 Minority Health Policy	2.0
Georgia State University School of Public Health	PH 7555 Disability & Public Health	3.0
Harvard T.H. Chan School of Public Health	HPM 211 The Health Care Safety Net and Vulnerable Populations	2.5
Louisiana State University Health Sciences Center School of Public Health	HPSM 6290 Public Health Law, Ethics, and Human Rights	2.0
New York Medical College, School of Health Sciences and Practice, and Institute of Public Health	HPMM 6060 Alternative Health Delivery Settings: Exploring Behavioral and Correctional Health	NA
Rutgers School of Public Health	HSAP 0674 U.S. Mental Health Policy	3.0
Saint Louis University College for Public Health and Social Justice	HMP 5480 Social Justice and Social Ethics in Community Benefit	NA
Temple University College of Public Health	HPM 5107 Forced Migration and Refugee Health	3.0
Tufts University School of Medicine (Public Health Program)	PH 238 Mental Health: Law, Science, & Public Health Policy	NA
Tulane University School of Public Health and Tropical Medicine	GHSD 6760 Health Systems Strengthening: International Family Planning	2.0
UCLA Fielding School of Public Health	HPM206 Healthcare for Vulnerable Populations	4.0
University at Albany School of Public Health	HPM 660 Poverty, Behavioral Health and Health Policy	3.0
University of Alabama at Birmingham School of Public Health	HCO 629/729 Immigrant Health	3.0
University of Arizona Mel and Enid Zuckerman College of Public Health	PHPM 568 American Indian Health Policy	NA
University of California, Berkeley School of Public Health	PB HLTH 221B Understanding and Overcoming Health Care Disparities	2.0
University of Georgia College of Public Health	HPAM 7050 Health Policy and Obesity	3.0
University of Illinois at Chicago School of Public Health	HPA 459 Introduction to Health Inequities in the United States	3.0
University of Maryland School of Public Health	HLSA 611 Introduction to Health Equity	3.0
University of Massachusetts-Amherst School of Public Health and Health Sciences	HPP 639 Health Disparities	3.0
University of Michigan School of Public Health	HMP626 Race, Ethnicity, Culture and Policy	3.0
University of North Carolina Gillings School of Global Public Health	HPM 707 Lesbian, Gay, Bisexual, and Transgender Health: A Population Perspective	3.0
University of South Carolina Arnold School of Public Health	HSPM 509 Fundamentals of Rural Health	3.0

Note. Information extracted from university websites. NA = not available.

Discussion

Public health programs accredited by the Council on Education in Public Health (CEPH) must demonstrate that graduating students have acquired 22 foundational public health competencies, of which 7 include explicit health equity–relevant knowledge and skills (Council on Education for Public Health, 2016). Of those, at least three competencies focus on diverse populations and health equity in the HPM domains. CEPH-accredited MPH programs must have at least one specific, required assessment activity for each competency (Council on Education for Public Health, 2016). Individual programs can choose to develop standalone courses that incorporate health equity content in HPM graduation requirements or they can integrate the content and skill-building activities into other courses in the curriculum. Of the 50 MPH programs in HPM that were evaluated in this study, we found that only 6 programs required students to enroll in standalone health equity coursework. This may be a disservice to future health policy practitioners, analysts, and managers—especially if health equity is not fully integrated into current teaching programs. According to our assessment of the types of classes offered, gaps in HPM curricula suggests that future health policy makers and administers may not be fully informed by health equity principles and goals, which are a national priority.

While there is merit in weaving health equity content into the fabric of the public health curriculum, there is no guarantee that the requisite breadth and depth of health equity knowledge, skills, and competencies are attained through this approach. Additionally, a broad focus on vulnerable populations, health disparities, and health equity might not provide the level of detail to know which subpopulations may be incorporated or missing from HPM curricula. A comparison can be drawn between health equity and ethics training. Baetz and Sharp (2004) found that a requirement to incorporate ethics content into the core business curriculum resulted in faculty without training or expertise in ethics being expected to teach the area competently (Baetz & Sharp, 2004). Another study found faculty in accounting programs identified a lack of ability, subject materials and other curricular constraints as reasons for not incorporating ethics in their courses (Mintz, 1990). Some researchers argue for standalone courses in ethics, where the content area becomes the sole focus of the course as opposed to an add-on or superficial element (Piper, Gentile, & Parks, 1993). Other benefits, they posit, include an integrated reasoning process focused on the content area, enhanced legitimacy, and importance of the area in the overall curriculum (Piper et al., 1993). A core required course in health disparities or health equity creates a common foundation in the content area for future public health practitioners and promises a greater depth of learning and application for students and faculty alike (Piper et al., 1993).

It cannot be expected that future HPM practitioners will recognize the importance of health equity if they have not been exposed to the area in a substantive and intentional way during their MPH training. MPH programs should take into consideration the indirect impact this could have on our most vulnerable populations. The goal of developing strong health equity education is not just to develop competencies to eliminate health disparities but also to recognize the role and responsibility that public health professionals have in shaping policies and programs that can address them. Our analysis suggests that there is room to enhance this training in HPM programs. Many courses in health equity or health disparities were offered predominantly in coastal and urban areas. Unfortunately, courses in health equity were not common in places where some health disparities are the widest (at least those based on race, ethnicity, SES, gender, and sexual orientation): in the southern United States. Moreover, our analysis of health equity courses taught within HPM departments illuminates that instruction on disparities topics is not the same. Courses on health equity disproportionately focus on different health conditions, human rights, and race/ethnicity. Fewer elective courses focus on women, immigrants, and LGBTQ populations. This finding is alarming given that these populations are underrepresented in the health care workforce and are populations experiencing substantial disparities in health outcomes, access to care, and health services utilization. Future research should explore why women, immigrants, and LGBTQ populations are underrepresented in HPM curriculum. Other work should identify best practices for recruiting and retaining faculty studying and teaching these issues in HPM departments. Enhancement of the current HPM curricula should include both integrated and standalone health equity coursework to better educate and prepare students to address these issues in their fields.

One of the foundational public health competencies required by CEPH for MPH graduates is to, “explain the social, political, and economic determinants of health and how they contribute to population health and health inequities” (Council on Education for Public Health, 2016). Equipping future decision makers with the tools to address these issues through their formal education in HPM programs is essential. HPM programs that lack requirements for classes on health equity or health disparities and/or offer few classes on these topics may underprepare a future public health workforce with the requisite competencies to effectively tackle public health problems and health disparities. These programs have room for improvement and should consider offering evidence-based training and guidance to solve these pressing issues. The public health discipline excels at documenting and identifying health inequities, but more work is needed in translating research to practice. Future research should identify best practices for teaching a core set of principles in health equity and approaches to eliminating disparities through HPM.

Limitations

There were several limitations to our study. First, our study was limited to publicly available and cross-sectional data collected from 50 accredited HPM programs offering the MPH degree between September 2017 and May 2018. Although data available online may be updated regularly for potential and current students, some information may be outdated and inaccurate. Variation in the timing and quality of routine website management may bias our results and underestimate the role of health equity in HPM curricula—especially if more health equity courses are offered than listed online. Our sample does not consider other HPM programs that have not been accredited by CEPH, nor does our sample consider data from courses in accredited programs where health disparities and health equity may be emphasized (e.g., community health; social and behavioral health sciences; health education; and global health). Students with direct interests in health equity may be drawn to non-HPM programs, which affects the demand for HPM-based courses in health equity. Relatedly, some HPM students may enroll in health equity courses offered outside of the HPM department. Our analyses may be biased downward to the extent that HPM students are receiving health equity training outside of their home department.

Also missing from our data are topics covered in required HPM courses, such as health policy and health economics. Some courses may devote entire units to a specific health equity issue or vulnerable populations, but reviewing the syllabi for each course was beyond the scope of this study. We examined broad course titles and course descriptions when available. Meanwhile, not all classes examined in this analysis had course descriptions, which would have been helpful for classifying classes into specific subcategories. For instance, although numerous classes focused on specific diseases and illnesses that represented vulnerable populations, we had no way of knowing whether theories in health disparities and health equity were actually covered in those classes.

Another limitation we encountered was limited data on the timing of course offerings. While we were able to document the types of courses offered in HPM programs, we were not able to determine how frequently courses were offered, which likely depends on course demand and the availability of instructors. Some courses identified in this analysis may no longer be available or may not be offered every year. Relatedly, some program websites may not be updated regularly or recently. Although we examined HPM websites in the past year, some websites may not be updated frequently.

Conclusion

This descriptive study examined 50 CEPH-accredited MPH programs that offered a concentration in HPM to determine the scope of health equity taught in HPM tracks. We found that most master’s level graduate programs do not require students to study health equity, health disparities, or vulnerable populations. Of the 50 MPH programs with concentrations in HPM examined in this study, only 6 programs, or 12% of all HPM tracks, require HPM students to take a class in health equity or health disparities. Among the health equity and disparities classes offered in HPM tracks, the majority of classes focused on specific conditions and disabilities followed by race and ethnicity, and SES. This analysis identified gaps in HPM concentration curricula when it comes to health equity education and the topics taught under the umbrella of health equity. If health equity is to be achieved, educating all HPM students on these issues and equipping them with competencies to effectively tackle health inequity is a starting place. Additionally, the health equity topics can be broadened to include more diverse communities recognizing that MPH graduates may work with a variety of populations. Increasingly, public health agencies and organizations are establishing offices dedicated to health equity. Future policy makers, health policy researchers, and health care administrators must have a foundation of health equity education to draw on if they are to take part in helping close the gaps that health inequity has created.

Supplemental Material

PHP814024_Supplemental_Appendix – Supplemental material for Health Equity Curricula Within Health Policy and Management Concentrations in U.S. Public Health Graduate Programs

Supplemental material, PHP814024_Supplemental_Appendix for Health Equity Curricula Within Health Policy and Management Concentrations in U.S. Public Health Graduate Programs by Gilbert Gonzales, Nicole Quinones, BA and Marie Martin in Pedagogy in Health Promotion

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material

The Supplemental Appendix is available in the online version of this article at .

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