What Sparked This?

Health Officer and Health System leadership focus on health equity and social determinants of health

In the early 2000s, Bay Area Regional Health Inequities Initiative (BARHII) health leaders began to strategize around how to build internal infrastructure within local health departments to tackle health inequities. The San Mateo County Health Officer was actively involved in and influenced by these conversations, which led to him to set up a Health Policy and Planning Program (HPPP) within the San Mateo County Health System. Building on their growing awareness of the social determinants of health (SDOH), HPPP focused on the built environment and school wellness.

Board of Supervisors and Health System prioritize policy and SDOH work

During this time, there was growing awareness nationally and among San Mateo County policymakers about the relationship between the built environment, childhood obesity, and other health outcomes. To eliminate these preventable health disparities, the County Board of Supervisors established the Get Healthy San Mateo County (GHSMC) Initiative and Task Force in 2004, which subsequently developed a Blueprint for the Prevention of Childhood Obesity. The blueprint was a call to action to guide San Mateo County’s work to build healthy communities and prevent childhood obesity. Coordinated by HPPP staff, the GHMSC Task Force developed 9 working committees to implement the blueprint in collaboration with cities, schools, hospitals, community-based organizations, and other leaders.

In 2010, 5 years after the GHSMC Initiative was launched, 93% of their objectives were completed or underway. The Task Force updated their objectives and strategies, recognizing that the field of childhood obesity had changed significantly during that time. Their new strategic plan, 2010–2015 Strategies for Improving Food and Physical Activity Environments, was guided by data, local and national best practices, evaluation recommendations, and insights gained from the GHSMC Task Force and Advisory Council and focused on implementing policy, environmental, and systems changes to address the social determinants of health.

Community engagement shifts health priorities upstream

As the 2010–2015 strategic plan drew to a close, HPPP staff planned for the next strategic plan with an increased focus on community engagement and health equity. In 2015, nearly 400 organizational and community leaders participated in workshops, multilingual surveys, and focus groups to develop a collective vision for a healthy, equitable San Mateo County. HPPP staff ensured participation was demographically aligned with the county and did additional outreach for surveys and focus groups to supplement missing demographic groups.

In 2015, HPPP staff released the new strategic plan, which built on local data, best practices, input from the extensive community engagement process, and guidance from the GHSMC Advisory Council. Rather than focusing solely on the food and physical activity environment as in past plans, the 2015–2020 Strategic Plan prioritized:

• Stable and affordable housing
• Complete neighborhoods (including transportation, land use, and food systems)
• High-quality education
• Strong local economy

Importantly, through the community process, the strategic plan mission and vision became more equity focused.

“Get Healthy San Mateo County succeeds when all residents, regardless of income, race/ethnicity, age, ability, immigration status, sexual orientation, or gender have the opportunity to reach their full potential.”

Program Description

HPPP staff sought to direct more resources to community-based organizations to advance the overall Get Healthy Initiative strategic priorities.

Community Implementation Funding grants

In 2011 GHSMC established Community Implementation Funding (CIF), which awards small grants annually to organizations, cities, committees, or groups of individuals committed to furthering GHSMC strategies and goals in their neighborhood. Between 2011 and 2015, the majority of organizations funded with GHSMC CIF were based in schools and lower-income communities to promote school gardens, healthy eating, and physical activity programs. CIF began with small grants, but staff made a concerted effort to expand funding as much as possible to reflect the vital role community leadership plays to advance health equity in local communities.

Request for proposals revised to reflect new strategic plan and 4 equity areas

The 2015–2020 GHSMC strategic plan established a new vision and strategies for advancing health in San Mateo County and a more explicit focus on equity. As a result, the 2016 CIF request for proposals (RFP) was revised to reflect these new strategies and objectives. The 2016 RFP stated, “The goal of the Community Implementation Funding strategy is to support efforts that prioritize health and equity by seeking to improve conditions for populations with limited opportunities to be healthy. These priority populations include:

(1) Lower income communities and communities of color that have the highest rates of obesity and preventable health issues in SMC.

(2) Older adults, children and people with disabilities, who face very specific challenges to healthful living.”

The RFP states that funding will “result in policies that prioritize health and equity in these four areas – healthy housing, healthy schools, healthy neighborhoods, and healthy economy.” Funding can be used for community education, city and regional planning processes, technical assistance to advance solutions locally, collaboration and partnerships, action-focused research, and promotion of systems change. All efforts should advance a policy or systems change agenda to achieve the 4 strategic priorities.

As noted by the HPPP Senior Manager, “The Community Implementation Funding gives us a chance to ‘put our money where our mouth is’ and truly support community members and organizations that are doing the work to advance health equity in their neighborhoods.” In 2016, HPPP increased available CIF funding to reflect the plan’s expanded breadth of strategies and the heavy lift needed in vulnerable communities to advance the vision. Below are the impacts of a project funded in 2016 and 2017.

Sample Project: Funding restorative practices demonstration project

Through previous funding of school garden programs to address childhood obesity, HPPP staff learned that San Mateo County is very fragmented — with 27 school districts and 21 jurisdictions, and each jurisdiction experiencing different inequities and political and social cultures. To achieve change across the many jurisdictions of San Mateo County, the Health System needed to think about how to build centralized infrastructure and how to scale up small, successful projects in a single school or district to have countywide impact.

High quality education was a key priority in the 2015 strategic plan. Building on this, HPPP staff explored how to move their programmatic work in schools to be more upstream and equity focused. In addition, the focus was no longer solely on school wellness, but on educational attainment. After learning about the San Francisco School District’s restorative justice work and its positive effects on youth mental health, educational attainment, and conflict management, HPPP explored ways to pilot restorative practices in San Mateo County with an eye toward scaling up the program if successful.

In 2016, with support from HPPP, the San Mateo-Foster City School District (SMFCSD) applied for and received CIF funds to “implement a school-based program designed to promote effective, equitable disciplinary practices in SMFCSD that will provide all students access to a high-quality learning environment that equips them for career success and lifelong health.” Specifically, the demonstration project was developed to train staff and support implementation of restorative practices in 4 Foster City middle schools. Over 1 year, participating schools observed positive outcomes with decreases in conflict, suspensions, and missed school days.

Building on the positive outcomes from the San Mateo-Foster City demonstration project, HPPP staff partnered with the County Office of Education to build centralized leadership, support, and tools to expand restorative practices across the county’s school systems. Specifically, they held joint trainings, proactively reached out to superintendents, and are beginning a strategic planning process to scale up restorative justice work.

Outcomes and Impacts

• Positive changes in food and physical activity environments

  The GHSMC Initiative led to effective strategies to address food and physical activity environments including: 1) youth advocacy groups, healthy corner store makeovers, social marketing campaigns, and walkability audits; 2) school districts implementing school wellness policies including partnering with local farmers to integrate local fresh produce; 3) the establishment of 2 farmers’ markets in low-income neighborhoods; and 4) pedestrian and bicycling programs and infrastructure improvements in various cities. The impacts of this work are available at GHSMC’s Success Stories.

• Community voices shift Health System toward stronger equity focus

  Although health equity was a guiding GHSMC value, intentional work to engage historically marginalized communities shifted their vision and mission and subsequent strategies to more explicitly focus on addressing and preventing inequities.

• Better engagement and partnership strategies

  Community leaders are almost always involved in how HPPP implements its work. HPPP partners with the community by: co-developing projects, providing funding directly to community-based organizations, leading or co-leading collective partner engagement, or participating as technical advisors in community coalitions and groups convened by equity-focused groups to bring a health perspective. Specific examples of these approaches include:

Co-developed project: Decision making is shared among organizations based on their expertise. For example, HPPP partnered with Faith in Action (a faith-based organizing group) and Urban Habitat (a regional equity organization) to develop a curriculum on Building Healthy Communities through Housing Stability for community organizers and others. They co-conceptualized and co-facilitated the trainings with the intent of building power to advance health equity goals shared by the 3 organizations.

Funded project: Decision making is completely in the hands of the organization leading the project and HPPP is informed of any major changes. For example, HPPP funded the development and rollout of a restorative practice pilot at the San Mateo-Foster City School District in 4 middle schools. The goal was to bridge educational inequities that, to some extent, resulted from unfair disciplinary practices and a culture where students of color are disproportionately impacted.

Co-led collective effort: Decision making is shared between the co-hosts and heavily weighted by steering committees and members. For example, HPPP co-hosts the School Wellness Alliance with the County Office of Education, an initiative to bring community and school leaders together to advance a healthy schools agenda. They have an advisory committee representing 8 organizations, and they also survey alliance members to gauge interests and needs to set their annual agenda.

Participant in community-led efforts: Decision making is completely led by the community and HPPP collaborates where they add value. For example, HPPP participated in the Coalition for Community Benefits, which focused on advancing equity within the South San Francisco Downtown Plan. HPPP brought a health perspective and data, and provided strategic feedback. They were not part of the coalition, but were responsive as strategic technical partners.

• Staff build trust with community partners

  HPPP had to build trust with community partners, particularly those representing marginalized populations, to build partnerships. HPPP did this by: 1) showing up where needed for local communities — not just requesting the community show up for HPPP; 2) providing funding for their leadership; 3) utilizing HPPP’s privilege and capital to advance the health equity agenda; and 4) building strong individual relationships between staff and community leaders based on mutual respect and humility. As a result, HPPP was accountable to their communities and strategic plan, and also increased their capacity to advance policies that address inequities.

• CIF supported SDOH and equity work

  CIF helped support implementation of GHSMC strategies and priorities. In 2016 and 2017, CIF funding was allocated to support community engagement in housing policy development, community transportation needs assessments, youth leadership capacity building, access to local fruits and vegetables in schools, legal services for low-income small business owners, and restorative justice work in schools. See 2016 recipients and projects and 2017 recipients and projects for more information on the impact of CIF funding.

• Restorative practices built up across the county

  Building on the success of the demonstration project, the County Office of Education applied for and received 2017 CIF funds to develop a School Climate Train-the-Trainer program. The goal is to “provide training and tools and build capacity within San Mateo County schools to shape supportive environments in which students, teachers, and administrators are able to address students’ social-emotional needs and create more inclusive, resilient schools and communities.”

Future Steps

Given the success of the Get Healthy San Mateo County Initiative, the County Health System will continue supporting HPPP’s work. Staff will continue to grow and deepen their work with community organizations and identify ways to collaborate with each other.

HPPP and the County Office of Education hired a consultant to facilitate a strategic planning process to identify how to implement restorative practices sustainably across the county’s 27 school districts, while also engaging school communities throughout the process. This process will involve doing surveys and focus groups with youth, mental health providers, teachers and school administrators, and others to identify what would make the initiative successful across the county.

Advice for Local Health Departments

• Maintain your focus on equity

  As the field of public health has evolved, its understanding about what influences health and related policy and planning initiatives has evolved as well. For example, built environment work to address physical activity, healthy eating, or affordable housing has focused on issues impacting low-income people and people of color, but other work has not. Doing upstream work is not always the same as doing equity work. Make sure to maintain a focus on who is disproportionately impacted, how you engage those people, and how you identify and implement solutions with and for them.

• Use “both/and” strategies

  Equity work does not have to be either/or — for example, by thinking that you can only work building healthy communities or on an anti-displacement strategy. If you focus solely on transit-oriented development and walkable/bikeable communities, you may inadvertently be increasing housing costs and contributing to involuntary displacement of low-income communities and communities of color. Building healthy communities with a deep focus on ensuring equitable access to those communities is critical. This work is often synergistic, and using a “both/and” approach can identify overlap and complementary goals to further multiple policy agendas.

• Use deep community engagement to inform your strategy

  Meaningfully engaging the communities that are most impacted by the social determinants of health and health inequities is important in holding health departments accountable to advance equity. Deeper community engagement in strategic planning provided the justification for HPPP’s allocation of resources to community organizations, and empowered the Health Department to say that developing healthy schools, housing, neighborhoods, and economy is a health agenda. This has allowed the Health Department to use funding to advance this agenda, which was more difficult in the past.

• Leverage relationships

  It is helpful to develop relationships with others who share your commitment to equity and to keep in regular contact and explore how you can leverage each other’s relationships. HPPP regularly meets with a local foundation that is advancing regional equity policy change. They’ve invited HPPP staff to be on review committees, and HPPP in turn helped fund or find donors for programs and projects that were beyond the scope of the Health Department but would help advance health equity. Through this shared learning, the foundation can fund and expand the work in other counties as well.

• Make sure that your advisory boards/committees reflect your strategic vision

  In many counties, the advisory councils that inform health department planning are primarily comprised of hospital representatives and health care providers. Although they can be important partners in transforming health systems to advance health equity and can provide valuable resources like funding and data, they should not be the only ones at the advisory table. Wherever possible, it’s important to make sure that communities impacted by health inequities are represented, as well as advocacy and grassroots organizations addressing the social determinants of health.

Strategic practices leveraged in this case study

Allocate Resources

Build Community Alliances

Develop Leadership and Support Innovation

Prioritize Upstream Policy Change

Develop a Shared Analysis

Additional Resources

• Bay Area Regional Health Inequities Initiative