How local health departments work towards health equity

Individual and organizational factors associated with public health workforce competencies to advance health equity

Little is known about how to develop public health workforce capacity for health equity work. We explored associations of individual and organizational characteristics of local public health departments (LHDs) with competencies essential for advancing health equity. Data included responses of 29,751 staff from 742 LHDs in 48 states to the 2021 Public Health Workforce Interests and Needs Survey, plus LHD characteristics and county demographics. Logistic regression assessed associations between key factors and staff-reported "knowledge of" and "confidence in addressing" structural racism, health equity, social determinants of equity (SDoE), social determinants of health (SDOH), and environmental justice, as well as belief and involvement in addressing racism through one's work. Staff with a master's degree or higher compared to others had greater odds of reporting confidence in addressing structural racism (adjusted odds ratio [AOR] = 1.23) and health equity (AOR = 1.56), agreeing that addressing racism should be a part of their work (AOR = 2.45) and being involved in such efforts (AOR = 1.57). Staff identifying as Black, compared to white, had greater odds of reporting confidence in addressing all concepts: structural racism (AOR = 1.98), health equity (AOR = 1.34), SDoE (AOR = 1.53), SDOH (AOR = 1.21), and environmental justice (AOR = 1.72) and agreeing that addressing racism should be a part of their work (AOR = 2.11). Patterns were similar among staff identifying as Hispanic/Latino and other persons of color. Black (AOR = 0.68) and Hispanic/Latino (AOR = 0.83) staff had lower odds, however, of reporting engagement in activities to address racism. Finally, competencies positively associated with nearly all outcomes included cross-sector collaboration, ability to incorporate health equity into programming, and policy advocacy. LHD workforce development should include training that involves explicitly naming structural racism's effects and complementary skills, such as policy development and cross-sector partnership building. Further exploration is needed into how best to grow commitment among white staff and to support staff of color in health equity work.

Racial Health Equity Plans in the 30 Largest US Cities

BACKGROUND

Racial inequities in life expectancy vary significantly across US cities, with city-level gaps ranging from zero to more than 10 years. Given that these inequities are rooted in racism and maintained through social structures and policies, population-level solutions are needed. Local health departments (LHD) are well-situated to lead these types of changes.

METHODS

We conducted an environmental scan and document review of formal health plans of the LHDs with jurisdictions covering the 30 most populous US cities. We assessed the inclusion of equity priorities and specific and measurable equity goals. Secondary outcomes related to organizational structures, data, formal declarations, and other practices were also assessed. Data were collected between January and August 2022.

RESULTS

The extent of focus on racial equity in the identified strategic health plans varied. Less than half of the cities with a formal public health plan (13 of 29) listed racial health equity as an area of focus. Only seven cities (all of which had a health plan focusing on racial health equity) had specific goals related to racial health equity. Twenty-five LHDs provided local data on racial health inequities. All but seven cities had declared racism a public health crisis. About half of the LHDs had positions or divisions focused on racial equity, or specified equity as an area of focus for Covid-19 efforts.

CONCLUSIONS

These findings reveal that few large cities translate growing support for anti-racism into their formal planning. While most LHDs acknowledge (and provide data pointing to) gaps in racial health equity in their jurisdictions, more attention is needed to incorporate specific and measurable racial health equity goals into strategic plans, and provide adequate structure and resources to attain those goals.

Implementing a Needs Assessment to Advance Health Equity in Overdose Prevention and Surveillance Initiatives

OBJECTIVES

State, local, and federal agencies have expanded efforts to address the root causes of overdoses, including health inequity and related social determinants of health. As an Overdose Data to Action (OD2A) technical assistance provider, the Association of State and Territorial Health Officials (ASTHO) conducted the first national needs assessment to understand capacity and technical assistance needs of OD2A jurisdictions in advancing health equity.

METHODS

ASTHO designed and disseminated the OD2A Recipient Health Equity Needs Assessment (RHENA) to 66 OD2A-funded jurisdictions from February to March 2022. OD2A principal investigators and staff were contacted via email and asked to complete the needs assessment within 6 weeks. One coder manually coded open-ended responses, conducted a thematic analysis on the qualitative data, and performed a simple frequency analysis on the quantitative data.

RESULTS

Fifty-two jurisdictions (78.8%) responded, including 36 states, 12 cities/counties, and 2 territories. Most jurisdictions (n = 46; 88.5%) reported having a formal or informal health equity lead in place. Common barriers included a lack of access to data sources (n = 37; 71.2%), lack of partnerships (n = 20; 38.5%), and lack of funding (n = 14; 26.9%). Respondents reported needing more information sharing among jurisdictions and partner organizations, coaching on best practices, and routine discussions such as peer-to-peer learning sessions.

CONCLUSION

Findings suggest that gaps remain in programmatic policies and principles to address inequities in overdose prevention. Results are being used to identify additional technical assistance opportunities, jurisdictional capacity, and approaches to advance health equity.

A Scoping Review of Health Equity Interventions in Governmental Public Health

CONTEXT

Despite major efforts in research, practice, and policy, racial and ethnic disparities in health and health care persist in the United States. Interventions in collaboration with governmental public health may provide ways to address these persistent racial and ethnic health and health care disparities and improve health outcomes.

OBJECTIVE

To conduct a comprehensive review of health equity interventions performed in collaboration with public health agencies.

DESIGN

This scoping review includes intervention studies from Ovid MEDLINE, PsycINFO, and Academic Search Premier, published between 2017 and 2023. The search strategy used terminology focused on 4 concepts: race/ethnicity, equity, health departments, and epidemiologic studies.

ELIGIBILITY CRITERIA

The following inclusion criteria were determined a priori: (1) intervention tailored to reduce racial/ethnic health disparities, (2) public health department involvement, (3) health outcome measures, (4) use of epidemiologic study methods, (5) written in English, (6) implemented in the United States, (7) original data (not a commentary), and (8) published between January 2017 and January 2023.

MAIN OUTCOME MEASURES

This review focused primarily on 4 dimensions of racial health equity interventions including intervention components, intervention settings, intervention delivery agents, and intervention outcomes.

RESULTS

This review indicated that health equity interventions involving public health agencies focused on the following categories: (1) access to care, (2) health behavior, (3) infectious disease testing, (4) preventing transmission, and (5) cancer screening. Critical strategies included in interventions for reaching racial/ethnic minoritized people included using community settings, mobile clinics, social media/social networks, phone-based interventions, community-based workers, health education, active public health department involvement, and structural/policy change.

CONCLUSIONS

This scoping review aims to provide an evidence map to inform public health agencies, researchers, and funding agencies on gaps in knowledge and priority areas for future research and to identify existing health equity interventions that could be considered for implementation by public health leaders.

Characterizing Organizational Health Equity Capacity Assessments for Public Health Organizations: A Scoping Review

OBJECTIVE

Organizational health equity capacity assessments (OCAs) provide a valuable starting point to understand and strengthen an organization's readiness and capacity for health equity. We conducted a scoping review to identify and characterize existing OCAs.

METHODS

We searched the PubMed, Embase, and Cochrane databases and practitioner websites to identify peer-reviewed and gray literature articles and tools that measure or assess health equity-related capacity in public health organizations. Seventeen OCAs met the inclusion criteria. We organized primary OCA characteristics and implementation evidence and described them thematically according to key categories.

RESULTS

All identified OCAs assessed organizational readiness or capacity for health equity, and many aimed to guide health equity capacity development. The OCAs differed in regard to thematic focus, structure, and intended audience. Implementation evidence was limited.

CONCLUSIONS

By providing a synthesis of OCAs, these findings can assist public health organizations in selecting and implementing OCAs to assess, strengthen, and monitor their internal organizational capacity for health equity. This synthesis also fills a knowledge gap for those who may be considering developing similar tools in the future.

Developing and Implementing Racial Health Equity Plans in Four Large US Cities: A Qualitative Study

CONTEXT

Local health departments (LHDs) and their partners are critical components of the fight for racial health equity, particularly given the variation in levels of, and pathways to, inequities at the local level.

OBJECTIVE

To inform continued progress in this area, we qualitatively examined the development and implementation of equity-related plans and initiatives of LHDs within 4 large US cities: Baltimore, Boston, Chicago, and Philadelphia.

DESIGN AND MEASURES

We conducted 15 semistructured interviews with 21 members of LHDs, academic institutions, health systems, and community-based organizations involved with health equity strategies or activities in their respective cities. Outcomes included perceptions of the effectiveness of the local health equity plan, participation in other equity-related initiatives, stakeholder engagement, and best practices.

RESULTS

We contacted 49 individuals, of whom 2 declined and 21 accepted our interview invitation. Recruitment was stopped after we reached saturation. Thematic analysis identified 5 themes across interviews: (1) organizations were flexible in reallocating resources to address racial and health equity; (2) multidisciplinary teams are necessary for effective development and implementation of health equity plans; (3) community collaboration is required for meaningful and sustainable change; (4) there is a direct relationship between racism, structural inequities, and health outcomes; and (5) health departments have prioritized health equity plan development, but further work is required to address root causes.

CONCLUSIONS

In the United States, health departments have begun to develop and implement strategic health plans focused on equity. However, the extent to which these plans result in actual initiatives (both internal and external) varied across cities. The current study increases our understanding of how different partners are working to implement structural changes, programs, and policies to reach equity-related goals in our largest urban areas, providing valuable insight for urban health advocates across the country.

The Workforce Needed to Address Population Health

Policy Points Although a single definition of the population health workforce does not yet exist, this workforce needs to have the skills and competencies to address the social determinants of health, to understand intersectionality, and to coordinate and work in concert with an array of skilled providers in social and health care to address multiple health drivers. On-the-job training programs and employer support are needed for the current health workforce to gain skills and competencies to address population health. Funding and leadership combined are critical for developing the population health workforce with the goal of supporting a broad set of workers beyond health and social care to include, for example, those in urban planning, law enforcement, or transportation professions to address population health.

The DASH model: Data for addressing social determinants of health in local health departments

Recent frameworks, models, and reports highlight the critical need to address social determinants of health for achieving health equity in the United States and around the globe. In the United States, data play an important role in better understanding community-level and population-level disparities particularly for local health departments. However, data-driven decision-making-the use of data for public health activities such as program implementation, policy development, and resource allocation-is often presented theoretically or through case studies in the literature. We sought to develop a preliminary model that identifies the factors that contribute to data-driven decision-making in US local health departments and describe relationships between them. Guided by implementation science literature, we examined organizational-level capacity and individual-level factors contributing to using data for decision-making related to social determinants of health and the reduction of county-level disparities. This model has the potential to improve implementation of public health interventions and programs aimed at upstream structural factors, by elucidating the factors critical to incorporating data in decision-making.

Advancing health equity: Organizational characteristics emphasized by health department nurse lead executives

OBJECTIVE

To compare nurse and non-nurse lead executives' relationship with organizational characteristics supporting performance and health equity in local health departments (LHD).

DESIGN

This was a cross-sectional quantitative study.

SAMPLE

The final national sample consisted of 1447 LHDs using the 2019 Profile of Local Health Departments survey.

MEASUREMENTS

We used multivariable logistic and negative binomial regression analyses to explore the relationship between nurse versus non-nurse LHD lead executives and involvement in ten organizational characteristics including community health assessment (CHA) and community health improvement plan (CHIP) completion and policy activities related to the social determinants of health (SDOH).

RESULTS

Multivariable logistic regression models showed that, for nurse lead executives, the odds of having completed a CHA is 1.49 times, and the odds of having completed a CHIP is 1.56 times, that of non-nurse lead executives. Negative binomial regression models predicted nurse lead executives, compared to non-nurses, to perform 1.18 times more SDOH-related policy activities.

CONCLUSION

Results suggest that nurse lead executives are more likely than non-nurses to emphasize assessment in their work and engage in upstream-focused policy activities. As such, they are important partners in work to facilitate health equity.

Addressing Health Disparities: The Health Department Nurse Lead Executive's Relationship to Improved Community Health

CONTEXT

The nurse-trained local health department (LHD) lead executive has been shown to be positively associated with LHD performance; however, no other research has explored whether this association translates to improved community health.

OBJECTIVE

To investigate the relationship between the type of LHD leadership-whether or not the lead executive is a nurse-and changes in health outcomes.

DESIGN

This study used a multivariate panel time series design. Each model was estimated as a pooled time series and using time and unit fixed effects, with a 1-year lag used for all covariates and the main predictor.

SETTING

A national, county-level data set was compiled containing variables pertaining to the LHD, community demographics, and health outcomes for the years 2010-2018.

PARTICIPANTS

The unit of analysis was the LHD. The data set was restricted to those counties with measurable mortality rates during at least 8 of the 9 time periods of the study, resulting in a total of 626 LHDs.

MAIN OUTCOME MEASURES

The outcomes of interest were changes in 15- to 44-year-old all-cause mortality, infant mortality, and entry into prenatal care.

RESULTS

In models with combined time and unit fixed effects, a significant relationship exists between a nurse-led LHD and reduced mortality in the 15- to 44-year-old Black population (-5.2%, P < .05) and a reduction in the Black-White mortality ratio (-6%, P < .05). In addition, there is a relationship between the nurse-led LHD and a reduction in the percentage of the population with late or no entry to prenatal care.

CONCLUSIONS

The evidence presented here helps connect the known positive association between nurse lead executives and LHD performance to improvements in community health. It suggests that nurse leaders are associated with health improvements in line with addressing health inequities.

Development of a measurement tool to assess local public health implementation climate and capacity for equity-oriented practice: Application to obesity prevention in a local public health system

OBJECTIVE

The objective of this study was to develop a measurement tool to capture local public health department (LHD) organizational characteristics that align with implementation of equity-oriented practice, which may be used to gauge progress in building public health structures and functions that address the needs of vulnerable populations and reduce health inequities.

METHODS

We developed and tested a measurement tool, with practitioner input, based on an implementation science framework and informed by previous work defining public health essential services and practice recommendations for health equity. Measures assessed types of vulnerable populations served by the LHD, organizational climate, and four equity-oriented practice areas, including: assessment and planning, monitoring and analysis, leadership support, and obesity prevention. We also assessed opportunities for capacity building by identifying training needs of practitioners. Primary data were collected from Missouri local health department practitioners (n = 92, 80% response rate) via an online questionnaire, with a subset of the sample providing data for test-retest reliability.

RESULTS

Measures of equity-oriented implementation climate indicated areas of variability with respect to strengths and gaps across LHDs. While implementation climate was strong with respect to perceived importance (86%), a substantial proportion of LHDs cited concern over other priorities conflicting with equity-oriented implementation (32%). Likewise, a strong internal push (67%) was often accompanied by limited external political (25%) and community support (40%). Implementation climate measures generally had good to excellent reliability and were significantly associated with areas of equity-oriented practice. Frequently identified (>70%) training needs included improving skills in applying frameworks, assessment methods, and evaluating collaborations around equity.

CONCLUSION

We developed a theory-based, practitioner-informed questionnaire to assess capacity for equity-oriented practice and identify opportunities for capacity building in local public health departments to engage in effective change toward health equity.

Values are not enough: qualitative study identifying critical elements for prioritization of health equity in health systems

Background

Health system policies and programs that reduce health inequities and improve health outcomes are essential to address unjust social gradients in health. Prioritization of health equity is fundamental to addressing health inequities but challenging to enact in health systems. Strategies are needed to support effective prioritization of health equity.

Methods

Following provincial policy recommendations to apply a health equity lens in all public health programs, we examined health equity prioritization within British Columbia health authorities during early implementation. We conducted semi-structured qualitative interviews and focus groups with 55 senior executives, public health directors, regional directors, and medical health officers from six health authorities and the Ministry of Health. We used an inductive constant comparative approach to analysis guided by complexity theory to determine critical elements for prioritization.

Results

We identified seven critical elements necessary for two fundamental shifts within health systems. 1) Prioritization through informal organization includes creating a systems value for health equity and engaging health equity champions. 2) Prioritization through formal organization requires explicit naming of health equity as a priority, designating resources for health equity, requiring health equity in decision making, building capacity and competency, and coordinating a comprehensive approach across levels of the health system and government.

Conclusions

Although creating a shared value for health equity is essential, health equity - underpinned by social justice - needs to be embedded at the structural level to support effective prioritization. Prioritization within government and ministries is necessary to facilitate prioritization at other levels. All levels within health systems should be accountable for explicitly including health equity in strategic plans and goals. Dedicated resources are needed for health equity initiatives including adequate resourcing of public health infrastructure, training, and hiring of staff with equity expertise to develop competencies and system capacity.

Rationale and Design of Distance-Based Training to Persuade Local Health Department Employees that Addressing Social Determinants of Health Is Their Job, Too

Public health workers in local health departments frequently rate skills needed to address social determinants of health among their top training needs. These workers have the ability to impact social determinants of health, but many may believe this responsibility is not part of their job description or that they do not have the necessary skills or resources. Guided by the Elaboration Likelihood Model of Persuasion and employing the case study method of instruction, the Region 2 Public Health Training Center designed a 45-minute, self-paced, online training module, titled Strategies to Advance Health Equity: How Health Departments Can Promote Living Wages, to persuade public health workers that addressing social determinants of health, especially those related to income disparities, is part of their day-to-day responsibilities. This article describes the module design, promising preliminary assessment data, and the formal evaluation plan.

Making Strides Toward Health Equity: The Experiences of Public Health Departments

OBJECTIVES

We explored the definition of health equity being used by public health departments and the extent of engagement of public health departments in activities to improve health equity, as well as facilitators and barriers to this work.

DESIGN

We conducted 25 semistructured qualitative interviews with lead public health officials (n = 20) and their designees (n = 5). All interviews were transcribed and thematically analyzed.

SETTING

We conducted interviews with respondents from local public health departments in the United States (April 2017-June 2017).

PARTICIPANTS

Respondents were from local or state public health departments that were members of the Big Cities Health Coalition, accredited or both.

RESULTS

Many departments were using a definition of health equity that emphasized an equal opportunity to improve health for all, with a special emphasis on socially disadvantaged populations. Improving health equity was a high priority for most departments and targeting the social determinants of health was viewed as the optimal approach for improving health equity. Having the capacity to frame issues of health equity in ways that resonated with sectors outside of public health was seen as a particularly valuable skill for facilitating cross-sector collaborations and promoting work to improve health equity. Barriers to engaging in work to improve health equity included lack of flexible and sustainable funding sources as well as limited training and guidance on how to conduct this type of work.

CONCLUSIONS

Work to improve health equity among public health departments can be fostered and strengthened by building capacity among them to do more targeted framing of health equity issues and by providing more flexible and sustained funding sources. In addition, supporting peer networks that will allow for the exchange of resources, ideas, and best practices will likely build capacity among public health departments to effectively do this work.

Adapting a health equity tool to meet professional needs (Québec, Canada)

While numerous tools are available to better incorporate equity into population health actions, they are limited mainly by their lack of adaptation to professional practices and organizational realities. A study was conducted in Québec to identify and understand, from the perspective of future users, conditions that would facilitate use of a tool (Reflex-ISS) targeted at supporting collaborative action to improve consideration of social inequalities in health (SIH) within population health actions. Concept mapping and focus groups were implemented as complementary methods for investigating the conditions. Significant results that emerged were strong participant interest in the tool and the need for resources to better take SIH into account. The conditions for use that were identified referred to the tool itself (user-friendliness and literacy) and to resources for appropriating the tool, competency development, as well as the role and responsibilities of organizations and policies in promoting use of the tool in daily activities and more fundamentally in acting against SIH in general. Models for organizational innovation give an idea of the dimensions that need to be considered to strengthen the integration of equity into organizations and to support the changes in practice that result from using the tool. They provide a reminder that a health equity tool cannot be the cornerstone of an organizational strategy to fight against SIH; rather, it must be incorporated as part of a systemic strategy of professional and organizational development.

Contribution to healthy places: Risks of equity free health impact assessment

While health equity is central to health impact assessment [HIA], in reality, less is known about potential impacts of equity-free HIA on social inequalities. We assessed equity-free HIA case in a small city east of Montreal, which took place in a context of urban revitalization. We applied a combination of a quantitative review of community characteristics with a qualitative descriptive approach based on in-depth semi-structured interviews and a focus group with multiple stakeholders to shed light on the pitfalls of equity-free HIA. Our results pointed to gentrification process with a gradual relocation of low-income residents in the end. To mitigate mediating circumstances of gentrification and displacement, the municipality should support social housing or at least should ensure rent stabilization ordinance.

Evidentiary needs of US public health departments with a mission to advance equity and health: a qualitative analysis

OBJECTIVES

We sought the perspectives of lead public health officials working to improve health equity in the USA regarding the drivers of scientific evidence use, the supply of scientific evidence and the gap between their evidentiary needs and the available scientific evidence.

DESIGN

We conducted 25 semistructured qualitative interviews (April 2017 to June 2017) with lead public health officials and their designees. All interviews were transcribed and thematically analysed.

SETTING

Public health departments from all geographical regions in the USA.

PARTICIPANTS

Participants included lead public health officials (20) and their designees (5) from public health departments that were either accredited or part of the Big Cities Health Coalition.

RESULTS

Many respondents were using scientific evidence in the context of grant writing. Professional organisations and government agencies, rather than specific researchers or research journals, were the primary sources of scientific evidence. Respondents wanted to see more locally tailored cost-effectiveness research and often desired to participate in the planning phase of research projects. In addition to the scientific content recommendations, respondents felt the usefulness of scientific evidence could be improved by simplifying it and framing it for diverse audiences including elected officials and community stakeholders.

CONCLUSIONS

Respondents are eager to use scientific evidence but also need to have it designed and packaged in ways that meet their needs.