What Sparked This?

Office of Health Equity transitions to Health in All Policies focus

In 2016, the Office of Health Equity (OHE) underwent an important transition in leadership, staffing, and vision. New staff brought with them a commitment to and experience working on health equity and environmental justice. An overarching component of the new vision was to incorporate a Health in All Policies focus into the Office of Health Equity’s work moving forward. One staff member had participated in Human Impact Partners’ first Public Health and Equity Cohort (now called the Health Equity Awakened Leadership Institute), which highlighted the importance of intersectoral, cross-governmental, and community-engaged work and provided numerous examples of health equity work happening in health departments across the United States.

Health Equity and Environmental Justice Collaborative members serve as ambassadors across the department

Around the same time, the Department’s Health Equity and Environmental Justice Collaborative (HEEJC) gained momentum, capacity, and support to advance health equity and environmental justice. Given the alignment between the offices, OHE and HEEJC coordinated and complemented each other’s activities as much as possible. HEEJC members came to be viewed as ambassadors across the health department, helping transmit learning and communications about equity and justice, as well as identifying opportunities to address equity within the work of each of their own divisions — for example, by changing hiring practices or collecting and analyzing data differently.

Health equity training leads to department conversations about equity

As described in the other CDPHE case study, HEEJC and OHE organized a 101 training for all CDPHE staff on health equity and environmental justice. The training provided a foundation to understand health equity and environmental justice topics and aimed to pique staff interest in the topics. The 101 training included facilitated discussions about how to embed equity in the day-to-day work of health department staff, wherever they work — as environmental health inspectors, program evaluators, public health nurses, grants and fiscal managers, etc.

Growing national awareness, research evidence of health determinants

Another key enabling factor was the extensive evidence that the social and built environment are more significant predictors of health than access to health care. Reports from County Health Rankings, Centers for Disease Control, the Institute of Medicine, World Health Organization, and others provided credible evidence that health is determined by socioeconomic factors and environment. They helped confirm that OHE and HEECJ’s perspective “was not just someone’s opinion” but rather rooted in compelling data that illustrated a need to do more work upstream.

Program Description

In 2016, the Office of Health Equity started to consider how they could use data to make the case for health equity. This led to thinking about: a) what data was already being collected, b) how it was being presented and shared, and c) how the data helped perpetuate (or mitigate) narratives around who/what was responsible for poor health and what needed to change to address inequities.

Discussions and changes in reporting population health data

Previously, many CDPHE staff felt their responsibility was to release data for public consumption, but not to interpret the data — they did not want to be viewed as biasing the data. For example, staff released reports stating that people of color had worse health outcomes without any contextual description or data on social or neighborhood conditions.

Through conversations with OHE staff, CDPHE staff began to recognize that the public has a worldview, and that worldview shapes how individuals see and interpret data, no matter what the data says. Building on the example above, if the public keeps seeing that people of color have higher rates of morbidity and mortality without context to help them interpret the data, it may lead some people to focus on individual behaviors.

To address this, OHE staff, epidemiologists, and other staff working with data began to consider the structural factors leading to these outcomes and began explicitly discussing those in data briefs and reports. For example, CDPHE issued a data brief on homicide rates in Colorado, and after stratifying the data they found that males of color were most likely to be involved in homicides. Before releasing the data, CDPHE staff had a conversation about the structural factors leading to homicide, and added language in the discussion section of the brief about the neighborhood and social factors and structural reasons that lead men of color to be more likely to be involved in homicide.

Incorporating equity into evaluation measures

OHE also began conversations with department staff about including health equity metrics in ongoing performance and evaluation measures. Specifically, OHE is now working with staff doing performance monitoring/quality improvement to incorporate meaningful measures to ensure staff are on the right path to advancing equity in their day-to-day work. OHE is also working with program evaluators to examine access to department resources and services and whether health equity is advanced through the department’s programs. For example, rather than just use a traditional public health measure of how many vaccinations were administered or screenings delivered, there should be analysis of who received those vaccinations and screenings, whether they were the populations most in need, and whether community partnerships were built to help expand outreach. Although sometimes the metrics are defined by the federal government or funders, there is often an opportunity to add additional measures into survey and evaluation instruments.

Development of boilerplate language

Inspired by a Minnesota Department of Health report on health equity that publicly acknowledged the importance of structural inequities in creating health inequities, OHE staff drafted a statement with a similar intent. The boilerplate language was presented to CDPHE leadership and approved for use on any kind of CDPHE publication (e.g., report, presentation, issue brief, etc.). This language was disseminated via division directors, communication liaisons, members of HEEJC, and in a daily broadcast to CDPHE employees.

Outcomes and Impacts

• Framing memo being developed for population health data analysts

  OHE staff are developing a framing memo with input from epidemiologists and data analysts, to support ongoing consideration of how to frame and contextualize population health data. The goal is to ensure the department is not reinforcing a blaming narrative in data publications and to make the connection between health and upstream factors more explicit and prominent.

• Boilerplate language used in CDPHE documents

  Since its creation in fall 2016, the language describing how CDPHE acknowledges structural inequities has been used in data reports, grant applications, presentations, and a number of other CDPHE documents. Staff feel that doing this is helping to shift the narrative around the determinants of health and how to effect change.

• Leadership buy-in helps contribute to cultural shift

  While all staff may not agree with the boilerplate language, the leadership signing off on its use in CDPHE documents reflects that there is a cultural shift beginning to happen across the department.

Future Steps

Only 1 year into their new vision and work plan, the Office of Health Equity has much to do to help change the narrative around data collection and dissemination within the health department. As one staff member stated, collecting data differently is happening slowly and is “like trying to turn around a ship in the ocean,” especially at the state level where there are federal guidelines to follow on how to do data collection. Future OHE steps include:

• Continue working with population health data analysts and epidemiologists to “slice and dice” the data in intentional ways and be intentional in the way they communicate the data
• Continue working with staff doing performance monitoring and quality improvement to identify internal metrics for measuring progress on equity in day-to-day work across the department
• Continue working with program evaluators to identify opportunities to include equity metrics in program evaluations
• Conduct outreach to fiscal and grants managers to discuss potential ways to incorporate equity metrics into future financial plans and grant applications

Advice for Local Health Departments

• Use boilerplate language to open doors for important conversations

  OHE staff found that having text written that can be included in different documents, fact sheets, presentations, grants applications, policy briefs, etc., helped to further the conversation about health equity in the department. While all staff may not agree with the statement, using the language in CDPHE publications opened doors for important conversations about what they are doing to work toward health equity, why, and what else needs to happen.

• Start small and a snowball effect can occur

  At the beginning, it may be unlikely that leadership would sign off on boilerplate language or language describing the social determinants of health on every health department document. However, you can approach some leadership (e.g., branch or division directors) and ask whether they would be willing to feature the language in particular documents. And from there, it may have a snowball effect, like it’s having at CDPHE.

• Rely on facts and data

  As a field, public health prides itself on data and uses it to make many decisions. Data can be a good entry point to advancing health equity because it’s part of the culture of public health. And as described above, there is extensive data available about how inequities are making communities sick.

• Emphasize a health department’s role is to keep populations healthy

  Most people who work in public health are motivated to do so because they want to help and have a positive impact. Public health is about the public, and if there are populations that aren’t healthy, then public health isn’t doing its job as well as it could be. Health disparities in the United States aren’t getting better, and in many cases are getting worse. Some people may feel defensive in response to a call for change, but public health has to do something different as a field, and it needs to involve everyone.

Strategic practices leveraged in this case study

Change the Conversation

Change Internal Practices and Processes

Prioritize Upstream Policy Change

Develop Leadership and Support Innovation

Build Organizational Capacity

Mobilize Data, Research, & Evaluation

Additional Resources

• Konopka Institute Health Disparities & Pediatrics Framing PPT
• JCPES Segregated Spaces, Risky Places
• CADH Advancing Community Health: Health Equity Alliance Project Report