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How local health departments work towards health equity
Evaluation and Program Planning 65 (2017) 117–123
Contents lists available at ScienceDirect
Evaluation and Program Planning journal homepage: www.elsevier.com/locate/evalprogplan
How local health departments work towards health equity☆ a,⁎
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Rebeccah Sokol , Beth Moracco , Sharon Nelson , Jill Rushing , Tish Singletary , Karen Stanleyb, Anna Steinb a b
Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC 27599-7440, USA Division of Public Health, Chronic Disease and Injury Section, North Carolina Department of Health and Human Services, 5505 Six Forks Road, Raleigh, NC 27609, USA
A R T I C L E I N F O
A B S T R A C T
Keywords: Health equity Program planning Engagement
Background: Health inequities are exacerbated when health promotion programs and resources do not reach selected populations. Local health departments (LHDs)1 have the potential to address health equity via engaging priority populations in their work. However, we do not have an understanding of what local agencies are doing on this front. Methods: In the summer of 2016, we collaborated with informants from thirteen LHDs across North Carolina. Via semi-structured interviews, the research team asked informants about their LHD’s understanding of health equity and engaging priority populations in program planning, implementation, and evaluation. Findings: All informants discussed that a key function of their LHD was to improve the health of all residents. LHDs with a more comprehensive understanding of health equity engaged members of priority populations in their organizations’ efforts to a greater extent than LHDs with a more limited understanding. Additionally, while all LHDs identified similar barriers to engaging priority populations, LHDs that identified facilitators more comprehensively engaged members of the priority population in program planning, implementation, and evaluation. Conclusions: LHDs are ideally situated between the research and practice worlds to address health equity locally. To promote this work, we should ensure LHDs hold an understanding of health equity, have the means to realize facilitators of health equity work, and recognize the complex context in which health equity work exists.
1. Introduction Health equity occurs when every individual has the opportunity to attain her or his optimal health, regardless of social position or circumstances (Braveman, 2003; Whitehead, 1992). While several definitions of health equity exist, most connote an ethical and moral obligation to address social determinants of health in order to ensure all people have equal potentials to pursue health (Braveman & Gruskin, 2003; Dean, Roberts, Bouye, Green, & McDonald, 2016; Whitehead, 1992). Although similar, health inequity is distinct from health inequality. Health inequality refers to differences in health status, such as differences in cardiovascular fitness between younger and older individuals. However, health inequity denotes systematic differences in health between more and less advantaged social groups. Whitehead describes health inequities as: “differences which are unnecessary and avoidable but, in addition, are also considered unfair and unjust”. Over the past several decades, a focus on health equity has been
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The authors have no conflict of interests to report. Corresponding author. E-mail address: [email protected] (R. Sokol). 1 LHD: Local health department. ⁎
http://dx.doi.org/10.1016/j.evalprogplan.2017.08.002 Received 13 February 2017; Received in revised form 18 July 2017; Accepted 2 August 2017 Available online 05 August 2017 0149-7189/ © 2017 Elsevier Ltd. All rights reserved.
evident in national policy. In 1999, the Centers for Disease Control and Prevention initiated the Racial and Ethnic Approaches to Community Health program, and in 2010, the Affordable Care Act called for the creation of Offices of Minority Health within six agencies of the Department of Health and Human Services. Presently, an overarching goal of Healthy People 2020 is to “[a]chieve health equity, eliminate disparities, and improve the health of all groups” (Koh, Piotrowski, Kumanyika, & Fielding, 2011). Despite these and numerous other examples of federal agencies working to develop policies and programs to improve health equity, some sub-groups of people continue to face higher disease incidence, morbidity, and mortality. For example, there remains a large disparity in life expectancy between the Black and white population in the United States (Kochanek, Arias, & Anderson, 2013). Structural inequalities—including but not limited to income disparities, the built environment, education achievement gaps, and racism—are foundational to health inequities (Braveman,
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where disparities exist, and working to enact social determinants of health related policy. Engaging members of priority populations in the planning, implementation, and evaluation of LHD programs is one cited strategy that may facilitate these health equity actions (Iton, 2016; NACCHO, 2014). However, we know little about how this process unfolds at the LHD level. In order to learn more about this means to address health equity, we conducted in-depth interviews with LHDs in North Carolina. We used North Carolina as a case study to: 1) understand the degree to which different LHDs in the state work towards health equity and engage priority populations; and 2) describe the barriers and facilitators for engaging priority populations at the local level. 2. Methods In the summer of 2016, the project team recruited key informants from LHDs across the state to participate in telephone interviews. Two experts at the North Carolina Division of Public Health in regular contact with all 85 LHDs in North Carolina divided these LHDs into two groups based upon progress reports the LHDs submitted to the State Division: 1. LHDs that regularly engaged priority populations; and 2. LHDs who did not regularly engage priority populations. We randomly and equally sampled from these two groups by emailing potential key informants. Key informants were community health educators or other personnel responsible for overseeing community engagement activities. We conducted interviews and coded transcripts on a rolling basis, stopping when we reached saturation of information. Saturation occurred after we had conducted interviews with 13 LHDs, and contacted a total of 26 LHDs (50% response rate). The 13 LHDs and their corresponding counties covered a broad range of the population sizes, median household incomes, and poverty rates found in all counties in North Carolina (Table 1). Telephone interviews lasted 30–45 minutes. Following a semistructured interview guide, we asked questions regarding: 1) the LHD’s understanding of health equity and engaging priority populations; and 2) barriers and facilitators for engaging priority populations in health department programs and initiatives at the local level. As the research involved key informants reporting on institutions, the University of North Carolina Chapel Hill Institutional Review Board deemed it exempt from approval. We developed a codebook using the semi-structured interview guide as an outline for primary codes, and iteratively created secondary and tertiary codes as they arose throughout the analysis process. Once we created a new secondary or tertiary code, we reviewed previously coded transcripts to account for these additions. The team used ATLAS.ti™ (Muhr, 1997) to code and retrieve data. A primary coder reviewed and analyzed all transcripts and brought preliminary findings to the project team and key informants for their examination, input, and approval at several points throughout the process. Of note, the primary coder classified LHDs into different levels of health equity knowledge, planning engagement, implementation engagement, and evaluation engagement based on emergent categories (described below). Arnstein’s ladder of citizen participation informed the
Fig. 1. Modification of Arnstein’s ladder of citizen participation (Arnstein, 1969).
Egerter, & Williams, 2011). These health inequities are in turn exacerbated by a lack of (or inappropriate) interventions and resources directed at priority populations, making such populations hardly reached (Sokol, Fisher, & Hill, 2015). Priority populations are groups of people that a service provider (such as a health department) identifies as being at risk for poorer health outcomes on the basis of structural inequalities (Healthcare Research and Quality Act of 1999, 1999). However, priority populations’ passive receipt of services may lend to feelings of powerlessness, and empirical research suggests powerlessness is a broad risk factor for disease that can exacerbate health inequities (Wallerstein, 1992). Engaging priority populations in the planning, implementation, and evaluation of health promotion programs—so that programs are implemented with rather than delivered to communities—is one way to combat this powerlessness and work towards health equity (Wallerstein & Duran, 2008). Not all engagement is equally effective, however. Arnstein’s ladder of citizen participation (Fig. 1) depicts various levels of engagement, from nonparticipation, to tokenism, to citizen power—where the higher rungs (i.e. citizen power) are recognized as being more effective avenues for improving health outcomes but also require a greater power transfer from the service deliverers to the priority population (Arnstein, 1969). In the current context, the aim of engagement is to allow members of priority populations to gain enough power to make the program and resource gatekeepers responsive to their views, aspirations, and needs. Local Health Departments (LHDs) have the potential to conduct this type of engagement: LHDs are connected to both a State Division of Public Health (or similar organization)—where they receive resources to implement health programs and interventions—as well as to their local communities, where they understand their communities’ assets, needs, and culture. Various groups have developed handbooks and toolkits detailing how LHDs can advance health equity (BARHII, 2010; Iton, 2016; NACCHO, 2014). For example, the Bay Area Regional Health Inequities Initiative created a toolkit that helps local public health leaders identify and work towards realizing the skills, practices, and infrastructure needed to address health equity (BARHII, 2010). These materials provide valuable information regarding how LHDs can address health equity in numerous ways, including researching and evaluating the impact of their programs, collecting data to determine
Table 1 Population level demographic characteristics for sampled counties compared to all North Carolina counties.
Population size, na Median income, USDa Percent white, % Percent in poverty, %
Average for sampled counties (range)
Average for all counties (range)
178.8 (11.0–500+) 42.4 (30.8–55.3)
88.7 (4.0–500+) 41.0 (28.4–63.7)
81.3 (53.0–97.0) 19.0 (13.2–31.3)
74.2 (33.0–97.0) 19.6 (6.0–32.3)
Notes: Data from 2010 US Census data and 2012 US Census estimates; ain thousands.
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equity?
identification of emergent categories and the overall classification process (Arnstein, 1969). Specifically, we considered categories in which there was a greater power transfer from the service deliverers to the priority population (e.g. ‘comprehensive engagement’, below) as effective avenues for improving health outcomes (Arnstein, 1969). The project team confirmed that the findings and classifications were consistent with the spirit of the transcripts, and they identified additional emergent themes from these findings. Results, including emergent categories, were shared with key informants to establish validity of interpretations—an intensive process requiring informant buy-in. Sharing findings with LHD contacts ensured that themes preserved the nature of the material that informants provided.
Key informant: Not that I can say […] Interviewer: Is the term health equity used in conversations? Key informant: It has started to be used in conversations but it’s not one that we’re using prevalently right now.” Despite these differences in explicit definitions of health equity and the variation from comprehensive to limited understanding of the term, all informants discussed how their LHDs’ work was aimed at ensuring everyone has an equal opportunity for optimal health—consistent with several definitions of health equity that appear in the literature (Braveman & Gruskin, 2003; Dean et al., 2016; Whitehead, 1992).
3. Results 3.2. Engaging priority populations 3.1. Degree of health equity understanding When asked about engagement, most informants provided examples of how they included priority populations in program planning. However, informants needed more time to identify ways to involve priority populations in program implementation, and very few informants had examples of including priority populations in program evaluation.
When asked to explicitly define health equity, the informants illuminated variability in both the frequency of use and understanding of the term across LHDs. 3.1.1. Comprehensive understanding of health equity Informants from six of the LHDs reported their LHDs had an understanding of health equity that: 1. Reflected the need to ensure equal opportunities for optimal health; and/or 2. Encouraged the redistribution of resources such that all individuals have equal opportunity for optimal health. The following informant discussed how achieving health equity requires a redistribution of resources so that previously disadvantaged groups have the opportunity to meet their full potential.
3.2.1. Engaging priority populations in program planning All informants demonstrated either comprehensive (six informants) or developing engagement (seven informants) of priority populations in program planning; no LHD exhibited limited or no engagement of priority populations in planning. Comprehensive engagement included inviting residents to participate in planning prior to the onset of planning, whereas developing engagement included asking residents for input on initiatives that the LHD had already planned. When informants discussed involving members of the priority population in the planning of programs, it was typically in the form of existing coalitions or advisory boards. Many informants discussed how they involve members of the priority population in their Community Health Needs Assessment—an assessment that guides the work that the LHD plans to do in the upcoming three to four years. LHDs which practiced comprehensive engagement of priority populations in program planning enabled members of the priority population to identify program needs. In these situations, the priority population also guided what programs would be planned. Below, one informant discussed how the LHD encourages engagement at the outset of program planning:
“Health equity, if we were doing it to its full potential, we’d have an outcome where all individuals receive everything they need to have a full and complete quality of life. But to get there the process of implementing health equity means supporting individuals, families, and groups—at every stage of the socioecological model—to different degrees.” Moreover, LHDs with a comprehensive understanding reported that their LHD has been using the term for decades. These informants noted that health equity was a high priority and integrated throughout their LHD, rather than restricted to a specific department. 3.1.2. Developing understanding of health equity Four informants established that their organization was beginning to talk about health equity but did not have it integrated in daily conversations or across the LHD. Several individual informants revealed that they believed achieving health equity requires addressing various social determinants of health, but they explained that their LHD did not universally demonstrate this same attitude. In some cases, informants provided a definition of health equity that equated to common definitions of health equality—when everyone has access to the same health resources. The following quote demonstrated this perception:
“I go back to the community health assessment […]. I try to go out to different areas of the community where we reach a variety of people—races, ages, socioeconomic status […]. After we gather the data, we have a community forum, and we make that available to anyone in the community. We try and get all of our community partners to encourage people to attend and then we get feedback on what the health priorities should be for the county. […]. Next we try and recruit different people from the community that maybe have had a personal issue with a particular health issue or a personal interest in it, and we get them to be a part of developing the action plans for health.”
“Well, I guess I’m kind of speaking more from my own personal definition. I don’t know that there’s ever really been a discussion departmentwide with all employees about what does health equity mean to them. But from what I can understand the idea is making sure that everybody has equal access to health services in a community.”
In several instances, informants demonstrated that their LHD practiced a developing level of engagement of priority populations in program planning. In these situations, members of the priority population were invited to assist in planning after planning had started. As illustrated below, this form of engagement sometimes manifested as conducting evaluations with members of the priority population for program improvement:
3.1.3. Limited understanding of health equity In three instances, informants indicated that health equity was not discussed much—if at all—within their LHD. In some of these cases, health equity might have been a priority within one section of the LHD, but it was not a priority for the entire LHD. In other cases, the understanding of health equity was limited across the organization, as illustrated by the following quote:
“[W]e do surveys periodically to get feedback from the participants of that program, asking what they like about the program, what they didn’t like—trying to get some ideas about things that we might need to change.”
“Interviewer: And then how does your health department define health 119
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exemplified below:
3.2.2. Engaging priority populations in program implementation With regard to involving members of the priority population in program implementation, there was notable variability across LHDs from comprehensive engagement to no engagement. 6 LHDs practiced comprehensive engagement, whereby LHDs engaged priority populations in multi-faceted ways, including hiring individuals from the priority population to deliver programs, recruiting community volunteers to facilitate a curriculum, and enabling local residents to spearhead the creation and dissemination of informational materials. Moreover, comprehensive engagement of priority populations in program implementation entailed members of the priority population driving program delivery and being appropriately recognized for doing so. One informant discussed how they practiced this type of engagement through a breast cancer initiative:
“Interviewer: And then do you have any examples of engaging priority populations in the evaluation of programs? Key Informant: Mhmmm…not that I can think of right off the top of my head.” Moreover, limited engagement of priority populations in program evaluation was demonstrated by asking community members to provide data (such as through a survey) while excluding them from discussions of the collected data. Many informants revealed their LHD practiced this type of non-engagement: “The health department does a ‘how are we doing survey’ that we take to the community and ask people how are we doing.”
“We just received a grant for breast cancer prevention and we are providing a stipend to one of the women who is an advocate at one of her churches. She would be much more influential than we could ever be. We recognize that and want to put a value on that, and show her that she’s a partner in this work. […]. We considered if we should use this funding for our own staff, or if we should use this funding to provide a living wage stipend for someone who is actually already in the community. Why repeat her efforts? […]. We don’t want to take advantage of that particular individual, because that could be symbolic of taking advantage of the community when we’re trying to meet certain goals.”
3.3. Barriers to engaging priority populations Informants identified various barriers to engaging priority populations, which we categorized into: providing accommodation, generating interest, establishing trust, and navigating sensitive issues. A common thread to all identified barriers was the time required to properly engage priority populations. Regardless of where an LHD ranked in terms of health equity knowledge or priority population engagement, all LHDs identified similar numbers and content of barriers to engagement.
Four other LHDs demonstrated that they were beginning to develop engagement of priority populations in program implementation, but this was not yet comprehensive. In these cases, members of the priority population were involved in program delivery but did not control it. Examples included members of the priority population recruiting participants into a program, the LHD using community spaces to deliver programs, or community members delivering one out of a series of program sessions. Lastly, three informants demonstrated that their LHD practiced limited engagement of priority populations in program implementation. These informants either equated engaging individuals in program implementation with delivering programs to individuals or could not think of instances where members of their priority populations were involved in the implementation of programs.
3.3.1. Accommodation Several informants mentioned difficulties with accommodating members of priority populations. These issues largely surrounded how to invite and encourage priority populations to participate when these groups have competing demands and priorities. One informant discussed how a barrier to engaging priority populations was working around availability, priorities, and transportation to accommodate overall life demands: “I think they are the same barriers that everybody has when you are trying to involve volunteers. Their time. Their time and availability. Transportation. Their priorities. Because this may not be a priority in their life. Several people have several challenges and other things on their plate.”
“Well, we’ve not really ever done that. So I’m not real sure how to answer that. I know in order to be successful we definitely need to have them as part of that process, so that’s new to us.”
3.3.2. Interest Some informants expressed the difficulty involved in generating interest in health department strategies among priority populations. One informant discussed that individuals are often not interested in the activities of the health department, but that the health department should bear some of the responsibility for generating such interest:
3.2.3. Engaging priority populations in program evaluation No informant noted that their LHD practiced comprehensive engagement of priority populations in program evaluation. Such comprehensive engagement would entail members of the priority population helping to determine how to judge the success of the program, what data to collect, how to collect the data, or collecting the data, as well as working with the community to interpret the data and develop recommendation for future programming. Most informants had difficulty identifying an example of involving members of the priority population in program evaluation. Five informants identified examples of a developing level of engagement with priority populations during program evaluation. This engagement involved sharing and discussing evaluation results with members of the priority population. The below quote demonstrated such presentation of evaluation reports to members of the priority population:
“Sometimes people just don’t want to be involved in the planning. They want the service or they want the program but they don’t want the work that goes with it to provide it. Sometimes there is a lack of interest and sometimes the health department doesn’t provide enough opportunity for that. So it’s a two-way street.” 3.3.3. Trust Informants also spoke to the intensity and time required to build trust and respect within a community. They discussed that although trust is integral to success, it is difficult to foster: “[Y]ou can only develop trust by having been there. And the County Health Department needs to spend a lot of time in the community.”
“So [the taskforce] gets copies of the evaluation, and they discuss it. For example, one coalition meets this week and part of their board meeting is going to be the updated report on a specific program because they serve as the community advisory council to that program.”
3.3.4. Sensitive issues Some informants discussed how navigating sensitive issues can be difficult in the pursuit of engaging priority populations. For example, stigma is associated with various health issues such as opioid overdoses
Lastly, eight informants revealed that their LHD practiced limited or no engagement of priority populations in program evaluation, as 120
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Fig. 2. Relationships between the health equity knowledge spectrum, program engagement spectrum, barriers, and facilitators.
and sexually transmitted infections, and such stigma can be a barrier to engaging members of priority populations. Additionally, there may be stigma attached to being identified as a member of a priority population, which also impedes engagement:
maybe where their children are. […] We go out to them. We go out to veterans’ groups. Sorority and fraternities. Religious groups. We go to family gatherings. Family reunions.”
“One of the barriers is helping them understand that they are a priority population.[…] So, helping them understand why they’re a priority population without necessarily feeling like they have been singled out or are being targeted.”
3.4.3. Incentivizing participation Many informants discussed how it is crucial to value the participation of community members, which can be expressed through incentivizing and recognizing individuals. Informants discussed how this can range from a gesture as simple as offering food, to a more involved action such as providing a stipend:
3.4. Facilitators to engaging priority populations
“Making them recognize the value of their contribution. Providing an incentive for them. If you’re providing lunch for them or some other incentive, that’s a big benefit. I see people really appreciate it more, that you appreciate what they’re doing.”
Along with barriers, informants identified practices at their LHDs or characteristics of their communities that promote the engagement of priority populations. Specific actions that foster engagement with priority populations included: identifying influential residents, going into the community, incentivizing participation, and partnership building with other local organizations. LHDs that identified more facilitators to engagement were more likely to exhibit comprehensive engagement of priority populations and a higher level of health equity understanding compared to those that identified fewer facilitators to engagement.
3.4.4. Partnership building Forming relationships with other agencies across the community—such as parks and recreation departments, churches, and Rotary Clubs—was an often cited facilitator for engaging members of the priority populations, as these organizations have unique resources and connections with community members that can augment the efforts of LHDs. One informant described the reciprocal relationships the LHD developed with other organizations:
3.4.1. Identifying influential residents Many informants highlighted the importance of identifying key leaders and residents within the community to both represent the community and motivate others to participate:
“I think we have a nice give and take system. We don’t ask for anything without wanting to give in return. Building those relationships and continuing to build those partnerships, is I think one of the big keys to our success.”
“We just try to find someone in that area, whatever we’re trying to do, to help facilitate that. I mean somebody in that priority population, or somebody that works with that population to pull in, to help us either get the word out or get their assistance or help.”
3.5. Relationships among knowledge, engagement, barriers, and facilitators
3.4.2. Outreach in the community Several informants mentioned that their LHDs’ efforts are more successful when they conduct outreach into the community rather than expecting individuals come to the health department. One informant described the various strategies and community locations where they reach members of the priority population:
Knowledge of health equity, engagement of priority populations, and facilitators/barriers to this engagement were intertwined. As illustrated by the double-headed arrows in the leftmost column of Fig. 2, health equity knowledge and priority population engagement were associated, whereby LHDs with a comprehensive health equity knowledge were more likely to demonstrate comprehensive engagement of priority populations in program planning and implementation, while LHDs with limited health equity knowledge were more likely to demonstrate limited or no engagement of priority populations in program
“Going to them. Reaching them where they are. Engaging them where they work, where they play, where they live, where they worship, and 121
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for improving community health identified by other studies (Roussos & Fawcett, 2000). All LHDs identified similar barriers to engagement, but LHDs with comprehensive engagement compared to those with limited or no engagement identified a higher number of engagement facilitators. This may suggest that it is not the mere presence of barriers that predicts engagement, but rather how the LHD leverages its assets—such as influential residents, going into the community, incentivizing participation, and partnership building. As with any research, this study has a number of limitations. The presence of a single primary coder may bias results, but we worked to abate this concern through the research team cross-checking findings with transcripts and soliciting feedback from informants to ensure we preserved the authenticity of the interviews. We interviewed one person per LHD, and these key informants may not be aware of every health equity and community engagement activity occurring within their organization. However, we interviewed the LHD personnel responsible for community engagement, and we therefore expected these individuals to have the most knowledge regarding our research question. As this study was restricted to North Carolina, findings may not generalize to other states. However, this case study provides meaningful insights regarding the experiences that North Carolina LHDs have with health equity work that may resonate with LHD staff in other states. Moreover, as with all qualitative research, the aim of the study is not to generalize or make causal inferences, but to obtain in-depth insight about a particular topic and/or process—in this case about perceptions and specific processes around health equity work. Overall, this work demonstrates that although there is variability in the understanding of health equity and engaging priority populations, LHDs in North Carolina are motivated by the goal of improving the health of all community members. Future resources should be directed at ensuring LHDs understand the meaning of health equity. Moreover, health inequity is a wicked problem; addressing it requires various strategies from multiple actors. Future research should investigate the various strategies that LHDs can and do employ—beyond community engagement—that advance equity.
implementation or evaluation. Moreover, LHDs that fell higher on the spectrum for one type of engagement were also more likely to fall higher on the spectrum for another type of engagement. Fig. 2 also depicts the relationship of barriers and facilitators with levels of knowledge or engagement. The single-headed facilitators arrow progressing towards the right indicates that LHDs that identified more facilitators possessed higher health equity knowledge and were more likely to comprehensively engage members of the priority populations. The double-headed barriers arrow demonstrates that all LHDs—regardless of their knowledge and engagement—identified similar barriers to health equity work. 4. Discussion This study demonstrates that the degree to which LHDs are working towards health equity and engaging priority populations is variable across the state of North Carolina. Despite this variability, all informants believed that their LHDs work to improve the health of all people in their community. While a comprehensive understanding of the meaning of health equity might be foundational to the work of fully achieving health equity (as LHDs with comprehensive health equity knowledge demonstrated more developed engagement of priority populations in program planning and implementation compared to LHDs with a developing or limited understanding of the term), the present analyses do not demonstrate a linear nor causal link between these two concepts. These descriptive findings are situated in a complex system of contextual, political, and organizational dimensions, each of which influence an LHD’s ability to respond to social determinants of health and health equity (Brassolotto, Raphael, & Baldeo, 2014; Raphael, Brassolotto, & Baldeo, 2015). For example, through qualitative interviews with staff persons from Ontrario public health units, Raphael, Brassolotto and Baldeo argue that major barriers to addressing health equity include both macro-level traditions and individual-level attitudes that treat health as individualized and depoliticized (Brassolotto et al., 2014; Raphael & Brassolotto, 2015). Based on the present finding’s situation within this literature, health equity knowledge may be a necessary—but not sufficient—step towards engaging members of priority populations. Future analyses should explore how LHD health equity knowledge is situated within a complex interplay of contextual, political, and organizational dimensions that influence an LHD’s ability to address health equity. Across all interviews, informants more easily discussed involving priority populations in program planning compared to program implementation and evaluation. No LHD reported limited engagement of priority populations in planning, and no LHD reported comprehensive engagement in evaluation. This may be partly explained through considering Arnstein’s Ladder of Citizen Participation: engaging priority populations in the implementation and evaluation of programs requires the LHD to forfeit more power to the priority populations than engaging them in the planning (Arnstein, 1969). In program planning, priority populations can be engaged via processes at the lower rungs of the ladder without transferring a substantial amount of power to them; however, these more basic practices do not transfer to program implementation and evaluation (Arnstein, 1969). Because the work of engaging priority populations varies among, LHDs across North Carolina a more time, experience, training, and technical assistance is required for them to develop more comprehensive engagement of communities. This could include effectively transferring more power to their priority populations and making intentional efforts to engage them in implementation and evaluation. Aside from this power transfer, informants identified why it is difficult to engage priority populations. Such barriers included: providing accommodation, generating interest, establishing trust, and navigating sensitive issues. A common thread to all barriers was the time required to properly engage priority populations, which aligns with the barriers
5. Lessons learned It is not the mere presence of barriers that restrains LHDs from priority population engagement; even the LHDs with the highest levels of engagement faced a myriad of barriers. Rather, leveraging community assets allows LHDs to work towards health equity. In addition to ensuring LHDs understand the meaning of health equity, state health departments and program planners should direct resources at helping LHDs identify how they can use their communities’ assets to facilitate health equity work. LHDs have the capacity to address health equity locally, and efforts should be directed at enabling them to do so. Acknowledgements We would like to thank the local health departments and their key informants who took part in these interviews and provided us with a deeper understanding of this work. This work was supported by the Richard Bland Fellowship awarded by the Graduate School at the University of North Carolina, Chapel Hill. References Arnstein, S. R. (1969). A ladder of citizen participation. Journal of the American Institute of Planners, 35(4), 216–224. BARHII (2010). Local Health Department Organization self-assessment for addressing health inequities. Oakland, CA: Bay Area Regional Health Inequities (BARHII). Brassolotto, J., Raphael, D., & Baldeo, N. (2014). Epistemological barriers to addressing the social determinants of health among public health professionals in Ontario, Canada: A qualitative inquiry. Critical Public Health, 24(3), 321–336. Braveman, P., & Gruskin, S. (2003). Defining equity in health. Journal of Epidemiology and Community Health, 57(4), 254–258. Braveman, P., Egerter, S., & Williams, D. R. (2011). The social determinants of health:
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Wallerstein, N., & Duran, B. (2008). The theoretical, historical, and practice roots of CBPR. Community-based Participatory Research for Health: From Process to Outcomes, 2, 25–46. Wallerstein, N. (1992). Powerlessness, empowerment, and health: Implications for health promotion programs. American Journal of Health Promotion, 6(3), 197–205. Whitehead, M. (1992). The concepts and principles of equity and health. International Journal of Health Services, 22(3), 429–445. http://dx.doi.org/10.2190/986l-lhq62vte-yrrn.
Coming of age. Annual Review of Public Health, 32, 381–398. http://dx.doi.org/10. 1146/annurev-publhealth-031210-101218. Braveman, P. A. (2003). Monitoring equity in health and healthcare: A conceptual framework. Journal of Health, Population and Nutrition, 181–192. Dean, H. D., Roberts, G. W., Bouye, K. E., Green, Y., & McDonald, M. (2016). Sustaining a focus on health equity at the centers for disease control and prevention through organizational structures and functions. Journal of Public Health Management and Practice, 22, S60–S67. Healthcare Research and Quality Act of 1999 (1999). Iton, A. (2016). Health equity: Moving from the margins to the center. NACCHO Exchange, 15(2), 1–5. Kochanek, K. D., Arias, E., & Anderson, R. N. (2013). How did cause of death contribute to racial differences in life expectancy in the United States in 2010. NCHS Data Brief, 125, 1–8. Koh, H. K., Piotrowski, J. J., Kumanyika, S., & Fielding, J. E. (2011). Healthy People a 2020 vision for the social determinants approach. Health Education & Behavior, 38(6), 551–557. Muhr, T. (1997). Atlas. ti. Berlin: Scientific Software Development. NACCHO (2014). Expanding the boundaries: Health equity and public health practice. National Association of County & City Health Officials. Raphael, D., & Brassolotto, J. (2015). Understanding action on the social determinants of health: A critical realist analysis of in-depth interviews with staff of nine Ontario public health units. BMC Research Notes, 8(1), 105. Raphael, D., Brassolotto, J., & Baldeo, N. (2015). Ideological and organizational components of differing public health strategies for addressing the social determinants of health. Health Promotion International, 30(4), 855–867. Roussos, S. T., & Fawcett, S. B. (2000). A review of collaborative partnerships as a strategy for improving community health. Annual Review of Public Health, 21(1), 369–402. Sokol, R., Fisher, E., & Hill, J. (2015). Identifying those whom health promotion hardly reaches: A systematic review. Evaluation and the Health Professions, 38(4), 518–537. http://dx.doi.org/10.1177/0163278715605883.
Rebeccah Sokol is a PhD student in Health Behavior at the University of North Carolina, Chapel Hill. Beth Moracco is a research associate professor and director of the master’s program in Health Behavior at the University of North Carolina, Chapel Hill. Sharon Nelson is a project manager at the Chronic Disease and Injury Section of the North Carolina Division of Public Health. Jill Rushing is an evaluator at the Chronic Disease and Injury Section of the North Carolina Division of Public Health. Tish Singletary is project specialist at the Chronic Disease and Injury Section of the North Carolina Division of Public Health. Karen Stanley is project specialist at the Chronic Disease and Injury Section of the North Carolina Division of Public Health. Anna Stein is a legal specialist at the Chronic Disease and Injury Section of the North Carolina Division of Public Health.
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Contents lists available at ScienceDirect
Evaluation and Program Planning journal homepage: www.elsevier.com/locate/evalprogplan
How local health departments work towards health equity☆ a,⁎
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MARK b
Rebeccah Sokol , Beth Moracco , Sharon Nelson , Jill Rushing , Tish Singletary , Karen Stanleyb, Anna Steinb a b
Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC 27599-7440, USA Division of Public Health, Chronic Disease and Injury Section, North Carolina Department of Health and Human Services, 5505 Six Forks Road, Raleigh, NC 27609, USA
A R T I C L E I N F O
A B S T R A C T
Keywords: Health equity Program planning Engagement
Background: Health inequities are exacerbated when health promotion programs and resources do not reach selected populations. Local health departments (LHDs)1 have the potential to address health equity via engaging priority populations in their work. However, we do not have an understanding of what local agencies are doing on this front. Methods: In the summer of 2016, we collaborated with informants from thirteen LHDs across North Carolina. Via semi-structured interviews, the research team asked informants about their LHD’s understanding of health equity and engaging priority populations in program planning, implementation, and evaluation. Findings: All informants discussed that a key function of their LHD was to improve the health of all residents. LHDs with a more comprehensive understanding of health equity engaged members of priority populations in their organizations’ efforts to a greater extent than LHDs with a more limited understanding. Additionally, while all LHDs identified similar barriers to engaging priority populations, LHDs that identified facilitators more comprehensively engaged members of the priority population in program planning, implementation, and evaluation. Conclusions: LHDs are ideally situated between the research and practice worlds to address health equity locally. To promote this work, we should ensure LHDs hold an understanding of health equity, have the means to realize facilitators of health equity work, and recognize the complex context in which health equity work exists.
1. Introduction Health equity occurs when every individual has the opportunity to attain her or his optimal health, regardless of social position or circumstances (Braveman, 2003; Whitehead, 1992). While several definitions of health equity exist, most connote an ethical and moral obligation to address social determinants of health in order to ensure all people have equal potentials to pursue health (Braveman & Gruskin, 2003; Dean, Roberts, Bouye, Green, & McDonald, 2016; Whitehead, 1992). Although similar, health inequity is distinct from health inequality. Health inequality refers to differences in health status, such as differences in cardiovascular fitness between younger and older individuals. However, health inequity denotes systematic differences in health between more and less advantaged social groups. Whitehead describes health inequities as: “differences which are unnecessary and avoidable but, in addition, are also considered unfair and unjust”. Over the past several decades, a focus on health equity has been
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The authors have no conflict of interests to report. Corresponding author. E-mail address: [email protected] (R. Sokol). 1 LHD: Local health department. ⁎
http://dx.doi.org/10.1016/j.evalprogplan.2017.08.002 Received 13 February 2017; Received in revised form 18 July 2017; Accepted 2 August 2017 Available online 05 August 2017 0149-7189/ © 2017 Elsevier Ltd. All rights reserved.
evident in national policy. In 1999, the Centers for Disease Control and Prevention initiated the Racial and Ethnic Approaches to Community Health program, and in 2010, the Affordable Care Act called for the creation of Offices of Minority Health within six agencies of the Department of Health and Human Services. Presently, an overarching goal of Healthy People 2020 is to “[a]chieve health equity, eliminate disparities, and improve the health of all groups” (Koh, Piotrowski, Kumanyika, & Fielding, 2011). Despite these and numerous other examples of federal agencies working to develop policies and programs to improve health equity, some sub-groups of people continue to face higher disease incidence, morbidity, and mortality. For example, there remains a large disparity in life expectancy between the Black and white population in the United States (Kochanek, Arias, & Anderson, 2013). Structural inequalities—including but not limited to income disparities, the built environment, education achievement gaps, and racism—are foundational to health inequities (Braveman,
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where disparities exist, and working to enact social determinants of health related policy. Engaging members of priority populations in the planning, implementation, and evaluation of LHD programs is one cited strategy that may facilitate these health equity actions (Iton, 2016; NACCHO, 2014). However, we know little about how this process unfolds at the LHD level. In order to learn more about this means to address health equity, we conducted in-depth interviews with LHDs in North Carolina. We used North Carolina as a case study to: 1) understand the degree to which different LHDs in the state work towards health equity and engage priority populations; and 2) describe the barriers and facilitators for engaging priority populations at the local level. 2. Methods In the summer of 2016, the project team recruited key informants from LHDs across the state to participate in telephone interviews. Two experts at the North Carolina Division of Public Health in regular contact with all 85 LHDs in North Carolina divided these LHDs into two groups based upon progress reports the LHDs submitted to the State Division: 1. LHDs that regularly engaged priority populations; and 2. LHDs who did not regularly engage priority populations. We randomly and equally sampled from these two groups by emailing potential key informants. Key informants were community health educators or other personnel responsible for overseeing community engagement activities. We conducted interviews and coded transcripts on a rolling basis, stopping when we reached saturation of information. Saturation occurred after we had conducted interviews with 13 LHDs, and contacted a total of 26 LHDs (50% response rate). The 13 LHDs and their corresponding counties covered a broad range of the population sizes, median household incomes, and poverty rates found in all counties in North Carolina (Table 1). Telephone interviews lasted 30–45 minutes. Following a semistructured interview guide, we asked questions regarding: 1) the LHD’s understanding of health equity and engaging priority populations; and 2) barriers and facilitators for engaging priority populations in health department programs and initiatives at the local level. As the research involved key informants reporting on institutions, the University of North Carolina Chapel Hill Institutional Review Board deemed it exempt from approval. We developed a codebook using the semi-structured interview guide as an outline for primary codes, and iteratively created secondary and tertiary codes as they arose throughout the analysis process. Once we created a new secondary or tertiary code, we reviewed previously coded transcripts to account for these additions. The team used ATLAS.ti™ (Muhr, 1997) to code and retrieve data. A primary coder reviewed and analyzed all transcripts and brought preliminary findings to the project team and key informants for their examination, input, and approval at several points throughout the process. Of note, the primary coder classified LHDs into different levels of health equity knowledge, planning engagement, implementation engagement, and evaluation engagement based on emergent categories (described below). Arnstein’s ladder of citizen participation informed the
Fig. 1. Modification of Arnstein’s ladder of citizen participation (Arnstein, 1969).
Egerter, & Williams, 2011). These health inequities are in turn exacerbated by a lack of (or inappropriate) interventions and resources directed at priority populations, making such populations hardly reached (Sokol, Fisher, & Hill, 2015). Priority populations are groups of people that a service provider (such as a health department) identifies as being at risk for poorer health outcomes on the basis of structural inequalities (Healthcare Research and Quality Act of 1999, 1999). However, priority populations’ passive receipt of services may lend to feelings of powerlessness, and empirical research suggests powerlessness is a broad risk factor for disease that can exacerbate health inequities (Wallerstein, 1992). Engaging priority populations in the planning, implementation, and evaluation of health promotion programs—so that programs are implemented with rather than delivered to communities—is one way to combat this powerlessness and work towards health equity (Wallerstein & Duran, 2008). Not all engagement is equally effective, however. Arnstein’s ladder of citizen participation (Fig. 1) depicts various levels of engagement, from nonparticipation, to tokenism, to citizen power—where the higher rungs (i.e. citizen power) are recognized as being more effective avenues for improving health outcomes but also require a greater power transfer from the service deliverers to the priority population (Arnstein, 1969). In the current context, the aim of engagement is to allow members of priority populations to gain enough power to make the program and resource gatekeepers responsive to their views, aspirations, and needs. Local Health Departments (LHDs) have the potential to conduct this type of engagement: LHDs are connected to both a State Division of Public Health (or similar organization)—where they receive resources to implement health programs and interventions—as well as to their local communities, where they understand their communities’ assets, needs, and culture. Various groups have developed handbooks and toolkits detailing how LHDs can advance health equity (BARHII, 2010; Iton, 2016; NACCHO, 2014). For example, the Bay Area Regional Health Inequities Initiative created a toolkit that helps local public health leaders identify and work towards realizing the skills, practices, and infrastructure needed to address health equity (BARHII, 2010). These materials provide valuable information regarding how LHDs can address health equity in numerous ways, including researching and evaluating the impact of their programs, collecting data to determine
Table 1 Population level demographic characteristics for sampled counties compared to all North Carolina counties.
Population size, na Median income, USDa Percent white, % Percent in poverty, %
Average for sampled counties (range)
Average for all counties (range)
178.8 (11.0–500+) 42.4 (30.8–55.3)
88.7 (4.0–500+) 41.0 (28.4–63.7)
81.3 (53.0–97.0) 19.0 (13.2–31.3)
74.2 (33.0–97.0) 19.6 (6.0–32.3)
Notes: Data from 2010 US Census data and 2012 US Census estimates; ain thousands.
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equity?
identification of emergent categories and the overall classification process (Arnstein, 1969). Specifically, we considered categories in which there was a greater power transfer from the service deliverers to the priority population (e.g. ‘comprehensive engagement’, below) as effective avenues for improving health outcomes (Arnstein, 1969). The project team confirmed that the findings and classifications were consistent with the spirit of the transcripts, and they identified additional emergent themes from these findings. Results, including emergent categories, were shared with key informants to establish validity of interpretations—an intensive process requiring informant buy-in. Sharing findings with LHD contacts ensured that themes preserved the nature of the material that informants provided.
Key informant: Not that I can say […] Interviewer: Is the term health equity used in conversations? Key informant: It has started to be used in conversations but it’s not one that we’re using prevalently right now.” Despite these differences in explicit definitions of health equity and the variation from comprehensive to limited understanding of the term, all informants discussed how their LHDs’ work was aimed at ensuring everyone has an equal opportunity for optimal health—consistent with several definitions of health equity that appear in the literature (Braveman & Gruskin, 2003; Dean et al., 2016; Whitehead, 1992).
3. Results 3.2. Engaging priority populations 3.1. Degree of health equity understanding When asked about engagement, most informants provided examples of how they included priority populations in program planning. However, informants needed more time to identify ways to involve priority populations in program implementation, and very few informants had examples of including priority populations in program evaluation.
When asked to explicitly define health equity, the informants illuminated variability in both the frequency of use and understanding of the term across LHDs. 3.1.1. Comprehensive understanding of health equity Informants from six of the LHDs reported their LHDs had an understanding of health equity that: 1. Reflected the need to ensure equal opportunities for optimal health; and/or 2. Encouraged the redistribution of resources such that all individuals have equal opportunity for optimal health. The following informant discussed how achieving health equity requires a redistribution of resources so that previously disadvantaged groups have the opportunity to meet their full potential.
3.2.1. Engaging priority populations in program planning All informants demonstrated either comprehensive (six informants) or developing engagement (seven informants) of priority populations in program planning; no LHD exhibited limited or no engagement of priority populations in planning. Comprehensive engagement included inviting residents to participate in planning prior to the onset of planning, whereas developing engagement included asking residents for input on initiatives that the LHD had already planned. When informants discussed involving members of the priority population in the planning of programs, it was typically in the form of existing coalitions or advisory boards. Many informants discussed how they involve members of the priority population in their Community Health Needs Assessment—an assessment that guides the work that the LHD plans to do in the upcoming three to four years. LHDs which practiced comprehensive engagement of priority populations in program planning enabled members of the priority population to identify program needs. In these situations, the priority population also guided what programs would be planned. Below, one informant discussed how the LHD encourages engagement at the outset of program planning:
“Health equity, if we were doing it to its full potential, we’d have an outcome where all individuals receive everything they need to have a full and complete quality of life. But to get there the process of implementing health equity means supporting individuals, families, and groups—at every stage of the socioecological model—to different degrees.” Moreover, LHDs with a comprehensive understanding reported that their LHD has been using the term for decades. These informants noted that health equity was a high priority and integrated throughout their LHD, rather than restricted to a specific department. 3.1.2. Developing understanding of health equity Four informants established that their organization was beginning to talk about health equity but did not have it integrated in daily conversations or across the LHD. Several individual informants revealed that they believed achieving health equity requires addressing various social determinants of health, but they explained that their LHD did not universally demonstrate this same attitude. In some cases, informants provided a definition of health equity that equated to common definitions of health equality—when everyone has access to the same health resources. The following quote demonstrated this perception:
“I go back to the community health assessment […]. I try to go out to different areas of the community where we reach a variety of people—races, ages, socioeconomic status […]. After we gather the data, we have a community forum, and we make that available to anyone in the community. We try and get all of our community partners to encourage people to attend and then we get feedback on what the health priorities should be for the county. […]. Next we try and recruit different people from the community that maybe have had a personal issue with a particular health issue or a personal interest in it, and we get them to be a part of developing the action plans for health.”
“Well, I guess I’m kind of speaking more from my own personal definition. I don’t know that there’s ever really been a discussion departmentwide with all employees about what does health equity mean to them. But from what I can understand the idea is making sure that everybody has equal access to health services in a community.”
In several instances, informants demonstrated that their LHD practiced a developing level of engagement of priority populations in program planning. In these situations, members of the priority population were invited to assist in planning after planning had started. As illustrated below, this form of engagement sometimes manifested as conducting evaluations with members of the priority population for program improvement:
3.1.3. Limited understanding of health equity In three instances, informants indicated that health equity was not discussed much—if at all—within their LHD. In some of these cases, health equity might have been a priority within one section of the LHD, but it was not a priority for the entire LHD. In other cases, the understanding of health equity was limited across the organization, as illustrated by the following quote:
“[W]e do surveys periodically to get feedback from the participants of that program, asking what they like about the program, what they didn’t like—trying to get some ideas about things that we might need to change.”
“Interviewer: And then how does your health department define health 119
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exemplified below:
3.2.2. Engaging priority populations in program implementation With regard to involving members of the priority population in program implementation, there was notable variability across LHDs from comprehensive engagement to no engagement. 6 LHDs practiced comprehensive engagement, whereby LHDs engaged priority populations in multi-faceted ways, including hiring individuals from the priority population to deliver programs, recruiting community volunteers to facilitate a curriculum, and enabling local residents to spearhead the creation and dissemination of informational materials. Moreover, comprehensive engagement of priority populations in program implementation entailed members of the priority population driving program delivery and being appropriately recognized for doing so. One informant discussed how they practiced this type of engagement through a breast cancer initiative:
“Interviewer: And then do you have any examples of engaging priority populations in the evaluation of programs? Key Informant: Mhmmm…not that I can think of right off the top of my head.” Moreover, limited engagement of priority populations in program evaluation was demonstrated by asking community members to provide data (such as through a survey) while excluding them from discussions of the collected data. Many informants revealed their LHD practiced this type of non-engagement: “The health department does a ‘how are we doing survey’ that we take to the community and ask people how are we doing.”
“We just received a grant for breast cancer prevention and we are providing a stipend to one of the women who is an advocate at one of her churches. She would be much more influential than we could ever be. We recognize that and want to put a value on that, and show her that she’s a partner in this work. […]. We considered if we should use this funding for our own staff, or if we should use this funding to provide a living wage stipend for someone who is actually already in the community. Why repeat her efforts? […]. We don’t want to take advantage of that particular individual, because that could be symbolic of taking advantage of the community when we’re trying to meet certain goals.”
3.3. Barriers to engaging priority populations Informants identified various barriers to engaging priority populations, which we categorized into: providing accommodation, generating interest, establishing trust, and navigating sensitive issues. A common thread to all identified barriers was the time required to properly engage priority populations. Regardless of where an LHD ranked in terms of health equity knowledge or priority population engagement, all LHDs identified similar numbers and content of barriers to engagement.
Four other LHDs demonstrated that they were beginning to develop engagement of priority populations in program implementation, but this was not yet comprehensive. In these cases, members of the priority population were involved in program delivery but did not control it. Examples included members of the priority population recruiting participants into a program, the LHD using community spaces to deliver programs, or community members delivering one out of a series of program sessions. Lastly, three informants demonstrated that their LHD practiced limited engagement of priority populations in program implementation. These informants either equated engaging individuals in program implementation with delivering programs to individuals or could not think of instances where members of their priority populations were involved in the implementation of programs.
3.3.1. Accommodation Several informants mentioned difficulties with accommodating members of priority populations. These issues largely surrounded how to invite and encourage priority populations to participate when these groups have competing demands and priorities. One informant discussed how a barrier to engaging priority populations was working around availability, priorities, and transportation to accommodate overall life demands: “I think they are the same barriers that everybody has when you are trying to involve volunteers. Their time. Their time and availability. Transportation. Their priorities. Because this may not be a priority in their life. Several people have several challenges and other things on their plate.”
“Well, we’ve not really ever done that. So I’m not real sure how to answer that. I know in order to be successful we definitely need to have them as part of that process, so that’s new to us.”
3.3.2. Interest Some informants expressed the difficulty involved in generating interest in health department strategies among priority populations. One informant discussed that individuals are often not interested in the activities of the health department, but that the health department should bear some of the responsibility for generating such interest:
3.2.3. Engaging priority populations in program evaluation No informant noted that their LHD practiced comprehensive engagement of priority populations in program evaluation. Such comprehensive engagement would entail members of the priority population helping to determine how to judge the success of the program, what data to collect, how to collect the data, or collecting the data, as well as working with the community to interpret the data and develop recommendation for future programming. Most informants had difficulty identifying an example of involving members of the priority population in program evaluation. Five informants identified examples of a developing level of engagement with priority populations during program evaluation. This engagement involved sharing and discussing evaluation results with members of the priority population. The below quote demonstrated such presentation of evaluation reports to members of the priority population:
“Sometimes people just don’t want to be involved in the planning. They want the service or they want the program but they don’t want the work that goes with it to provide it. Sometimes there is a lack of interest and sometimes the health department doesn’t provide enough opportunity for that. So it’s a two-way street.” 3.3.3. Trust Informants also spoke to the intensity and time required to build trust and respect within a community. They discussed that although trust is integral to success, it is difficult to foster: “[Y]ou can only develop trust by having been there. And the County Health Department needs to spend a lot of time in the community.”
“So [the taskforce] gets copies of the evaluation, and they discuss it. For example, one coalition meets this week and part of their board meeting is going to be the updated report on a specific program because they serve as the community advisory council to that program.”
3.3.4. Sensitive issues Some informants discussed how navigating sensitive issues can be difficult in the pursuit of engaging priority populations. For example, stigma is associated with various health issues such as opioid overdoses
Lastly, eight informants revealed that their LHD practiced limited or no engagement of priority populations in program evaluation, as 120
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Fig. 2. Relationships between the health equity knowledge spectrum, program engagement spectrum, barriers, and facilitators.
and sexually transmitted infections, and such stigma can be a barrier to engaging members of priority populations. Additionally, there may be stigma attached to being identified as a member of a priority population, which also impedes engagement:
maybe where their children are. […] We go out to them. We go out to veterans’ groups. Sorority and fraternities. Religious groups. We go to family gatherings. Family reunions.”
“One of the barriers is helping them understand that they are a priority population.[…] So, helping them understand why they’re a priority population without necessarily feeling like they have been singled out or are being targeted.”
3.4.3. Incentivizing participation Many informants discussed how it is crucial to value the participation of community members, which can be expressed through incentivizing and recognizing individuals. Informants discussed how this can range from a gesture as simple as offering food, to a more involved action such as providing a stipend:
3.4. Facilitators to engaging priority populations
“Making them recognize the value of their contribution. Providing an incentive for them. If you’re providing lunch for them or some other incentive, that’s a big benefit. I see people really appreciate it more, that you appreciate what they’re doing.”
Along with barriers, informants identified practices at their LHDs or characteristics of their communities that promote the engagement of priority populations. Specific actions that foster engagement with priority populations included: identifying influential residents, going into the community, incentivizing participation, and partnership building with other local organizations. LHDs that identified more facilitators to engagement were more likely to exhibit comprehensive engagement of priority populations and a higher level of health equity understanding compared to those that identified fewer facilitators to engagement.
3.4.4. Partnership building Forming relationships with other agencies across the community—such as parks and recreation departments, churches, and Rotary Clubs—was an often cited facilitator for engaging members of the priority populations, as these organizations have unique resources and connections with community members that can augment the efforts of LHDs. One informant described the reciprocal relationships the LHD developed with other organizations:
3.4.1. Identifying influential residents Many informants highlighted the importance of identifying key leaders and residents within the community to both represent the community and motivate others to participate:
“I think we have a nice give and take system. We don’t ask for anything without wanting to give in return. Building those relationships and continuing to build those partnerships, is I think one of the big keys to our success.”
“We just try to find someone in that area, whatever we’re trying to do, to help facilitate that. I mean somebody in that priority population, or somebody that works with that population to pull in, to help us either get the word out or get their assistance or help.”
3.5. Relationships among knowledge, engagement, barriers, and facilitators
3.4.2. Outreach in the community Several informants mentioned that their LHDs’ efforts are more successful when they conduct outreach into the community rather than expecting individuals come to the health department. One informant described the various strategies and community locations where they reach members of the priority population:
Knowledge of health equity, engagement of priority populations, and facilitators/barriers to this engagement were intertwined. As illustrated by the double-headed arrows in the leftmost column of Fig. 2, health equity knowledge and priority population engagement were associated, whereby LHDs with a comprehensive health equity knowledge were more likely to demonstrate comprehensive engagement of priority populations in program planning and implementation, while LHDs with limited health equity knowledge were more likely to demonstrate limited or no engagement of priority populations in program
“Going to them. Reaching them where they are. Engaging them where they work, where they play, where they live, where they worship, and 121
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for improving community health identified by other studies (Roussos & Fawcett, 2000). All LHDs identified similar barriers to engagement, but LHDs with comprehensive engagement compared to those with limited or no engagement identified a higher number of engagement facilitators. This may suggest that it is not the mere presence of barriers that predicts engagement, but rather how the LHD leverages its assets—such as influential residents, going into the community, incentivizing participation, and partnership building. As with any research, this study has a number of limitations. The presence of a single primary coder may bias results, but we worked to abate this concern through the research team cross-checking findings with transcripts and soliciting feedback from informants to ensure we preserved the authenticity of the interviews. We interviewed one person per LHD, and these key informants may not be aware of every health equity and community engagement activity occurring within their organization. However, we interviewed the LHD personnel responsible for community engagement, and we therefore expected these individuals to have the most knowledge regarding our research question. As this study was restricted to North Carolina, findings may not generalize to other states. However, this case study provides meaningful insights regarding the experiences that North Carolina LHDs have with health equity work that may resonate with LHD staff in other states. Moreover, as with all qualitative research, the aim of the study is not to generalize or make causal inferences, but to obtain in-depth insight about a particular topic and/or process—in this case about perceptions and specific processes around health equity work. Overall, this work demonstrates that although there is variability in the understanding of health equity and engaging priority populations, LHDs in North Carolina are motivated by the goal of improving the health of all community members. Future resources should be directed at ensuring LHDs understand the meaning of health equity. Moreover, health inequity is a wicked problem; addressing it requires various strategies from multiple actors. Future research should investigate the various strategies that LHDs can and do employ—beyond community engagement—that advance equity.
implementation or evaluation. Moreover, LHDs that fell higher on the spectrum for one type of engagement were also more likely to fall higher on the spectrum for another type of engagement. Fig. 2 also depicts the relationship of barriers and facilitators with levels of knowledge or engagement. The single-headed facilitators arrow progressing towards the right indicates that LHDs that identified more facilitators possessed higher health equity knowledge and were more likely to comprehensively engage members of the priority populations. The double-headed barriers arrow demonstrates that all LHDs—regardless of their knowledge and engagement—identified similar barriers to health equity work. 4. Discussion This study demonstrates that the degree to which LHDs are working towards health equity and engaging priority populations is variable across the state of North Carolina. Despite this variability, all informants believed that their LHDs work to improve the health of all people in their community. While a comprehensive understanding of the meaning of health equity might be foundational to the work of fully achieving health equity (as LHDs with comprehensive health equity knowledge demonstrated more developed engagement of priority populations in program planning and implementation compared to LHDs with a developing or limited understanding of the term), the present analyses do not demonstrate a linear nor causal link between these two concepts. These descriptive findings are situated in a complex system of contextual, political, and organizational dimensions, each of which influence an LHD’s ability to respond to social determinants of health and health equity (Brassolotto, Raphael, & Baldeo, 2014; Raphael, Brassolotto, & Baldeo, 2015). For example, through qualitative interviews with staff persons from Ontrario public health units, Raphael, Brassolotto and Baldeo argue that major barriers to addressing health equity include both macro-level traditions and individual-level attitudes that treat health as individualized and depoliticized (Brassolotto et al., 2014; Raphael & Brassolotto, 2015). Based on the present finding’s situation within this literature, health equity knowledge may be a necessary—but not sufficient—step towards engaging members of priority populations. Future analyses should explore how LHD health equity knowledge is situated within a complex interplay of contextual, political, and organizational dimensions that influence an LHD’s ability to address health equity. Across all interviews, informants more easily discussed involving priority populations in program planning compared to program implementation and evaluation. No LHD reported limited engagement of priority populations in planning, and no LHD reported comprehensive engagement in evaluation. This may be partly explained through considering Arnstein’s Ladder of Citizen Participation: engaging priority populations in the implementation and evaluation of programs requires the LHD to forfeit more power to the priority populations than engaging them in the planning (Arnstein, 1969). In program planning, priority populations can be engaged via processes at the lower rungs of the ladder without transferring a substantial amount of power to them; however, these more basic practices do not transfer to program implementation and evaluation (Arnstein, 1969). Because the work of engaging priority populations varies among, LHDs across North Carolina a more time, experience, training, and technical assistance is required for them to develop more comprehensive engagement of communities. This could include effectively transferring more power to their priority populations and making intentional efforts to engage them in implementation and evaluation. Aside from this power transfer, informants identified why it is difficult to engage priority populations. Such barriers included: providing accommodation, generating interest, establishing trust, and navigating sensitive issues. A common thread to all barriers was the time required to properly engage priority populations, which aligns with the barriers
5. Lessons learned It is not the mere presence of barriers that restrains LHDs from priority population engagement; even the LHDs with the highest levels of engagement faced a myriad of barriers. Rather, leveraging community assets allows LHDs to work towards health equity. In addition to ensuring LHDs understand the meaning of health equity, state health departments and program planners should direct resources at helping LHDs identify how they can use their communities’ assets to facilitate health equity work. LHDs have the capacity to address health equity locally, and efforts should be directed at enabling them to do so. Acknowledgements We would like to thank the local health departments and their key informants who took part in these interviews and provided us with a deeper understanding of this work. This work was supported by the Richard Bland Fellowship awarded by the Graduate School at the University of North Carolina, Chapel Hill. References Arnstein, S. R. (1969). A ladder of citizen participation. Journal of the American Institute of Planners, 35(4), 216–224. BARHII (2010). Local Health Department Organization self-assessment for addressing health inequities. Oakland, CA: Bay Area Regional Health Inequities (BARHII). Brassolotto, J., Raphael, D., & Baldeo, N. (2014). Epistemological barriers to addressing the social determinants of health among public health professionals in Ontario, Canada: A qualitative inquiry. Critical Public Health, 24(3), 321–336. Braveman, P., & Gruskin, S. (2003). Defining equity in health. Journal of Epidemiology and Community Health, 57(4), 254–258. Braveman, P., Egerter, S., & Williams, D. R. (2011). The social determinants of health:
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Rebeccah Sokol is a PhD student in Health Behavior at the University of North Carolina, Chapel Hill. Beth Moracco is a research associate professor and director of the master’s program in Health Behavior at the University of North Carolina, Chapel Hill. Sharon Nelson is a project manager at the Chronic Disease and Injury Section of the North Carolina Division of Public Health. Jill Rushing is an evaluator at the Chronic Disease and Injury Section of the North Carolina Division of Public Health. Tish Singletary is project specialist at the Chronic Disease and Injury Section of the North Carolina Division of Public Health. Karen Stanley is project specialist at the Chronic Disease and Injury Section of the North Carolina Division of Public Health. Anna Stein is a legal specialist at the Chronic Disease and Injury Section of the North Carolina Division of Public Health.
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