STRETCH-ing for Health: Operationalizing Health Equity in Public Health Agencies

AIKA ALUC:
Welcome. I'm your host, Aika Aluc, and I'm honored to be joined by Dr. Joan Duwve and Jade Ramsdell.

Today, we'll delve into the critical topic of operationalizing equity and fostering health equity outcomes in our communities. We'll explore how effective leadership and state initiatives are working together to achieve lasting systems change. Additionally, with innovative approaches to sustain funding, the role of public health in building healthier, more equitable communities.

So, our first question, Jade and Dr. Duwve. Operationalizing equity is about more than just surface level changes. But when we're thinking about creating systems level shifts that lead to lasting impact, it requires strong, committed leadership that is inclusive, diverse, centered, and empowerment. By involving stakeholders from diverse backgrounds and perspectives, we can develop comprehensive strategies that address the root causes of inequities. How has your participation in the STRETCH learning opportunity assisted you at operationalizing equity? And how has participating in the executive leadership circles, Dr. Duwve, assisted Kansas in aligning their equity work across the agency?

JOAN DUWVE:
I can start and just say that even before participating in STRETCH, the CDC Health Disparities Grant really helped set the groundwork for our equity work here in Kansas. And through that grant—but it was predominantly focused on COVID, because we know that health disparities became really critical to address during COVID in terms of poor health outcomes. But we wanted to build something that was sustainable for Kansas.

And so, in addition to the work that focused on COVID, we built standardized data collection tools for community health assessments; we provided infrastructure support for agency staffing, which is how we were able to find and hire Jade and her team; and we were able to mobilize some partnerships, including the COPE project—which stands for Communities Organizing to Promote Equity—and their local health equity action teams. So these are teams that are comprised of members representing and serving Kansas, from the community.

They're not the dot orgs or the usual people that we might invite to the table, but really people of lived experience. And we thought it was important to prioritize the needs of local communities by inviting community members to the table. And so, that was the groundwork against which Jade was hired and began the process of really institutionalizing this work.

And Jade, I'll kick it to you to talk a little bit more about how you've done that.

JADE RAMSDELL:
Absolutely. Thank you so much, Dr. Duwve.

I definitely say I echo your comments. And I definitely say that engaging in STRETCH has provided invaluable guidance for us here at the department in our pursuit of health equity. Really having, you know, a space where we were offered a structured way to operationalize work was instrumental. We had dedicated sessions and really thoughtful discussions around different ways to brainstorm our work plans and address potential barriers that we might face during this process, which ultimately help us shape our priorities and objectives effectively.

I would also say on the alternative side with Dr. Duwve's participation in executive leadership circles, it really helped to foster more frequent and strategic dialogues with influential figures like her here at the department, which enabled us to really develop more comprehensive approaches to address this intricate web of social determinants of health here in Kansas.

DUWVE:
Yeah, I think that the leadership circles really did provide the opportunity to engage leadership. I remember one leadership circle where I saw our director of finance on the meeting. I'm like, "Whoa, Dan, it's great that you're here." He may not have otherwise been central to those conversations, so it was a way to engage leadership that might have otherwise been peripheral and it created space for discussion around policy priority and the policy process. And I think also Jade and I, by participating in those conversations, were better able to align the way we thought about strategizing and moving this work forward.

ALUC:
That is so great, and it's making me think—with your surprise, seeing Dan there, right—it makes me think about sustainable funding. Sustainable funding is a common challenge faced by initiatives aiming to address equity. And so, how has the STRETCH program—including your participation in, as you elevated, the executive leadership circles, in addition to some of the work with Georgia Health Policy Center's funding navigator program—help you explore approaches to secure long-term funding for these critical projects?

DUWVE:
I can talk a little bit about how this work has been prioritized in our workforce development grant. We were thinking, at the end of the CDC funding for health disparities, how are we going to sustain this work?

Let me just back up for one second. I think the key to sustainability is just making it part of your everyday work process, right—you have to build it into the system. Once it's built into the system, then people just automatically think about, "How are we going to fund this work? This is work is integral to our agency that is now engaging the community." It's so involved and intertwined that it becomes almost second nature or necessary to sustain it.

And so, the Workforce Development Grant, we were able to leverage that grant funding to fund, to continue to fund, the work that Jade and her team are doing and to actually add to the work they're doing. And Jade, you can talk more about the Georgia Health Policy Center navigator program.

RAMSDELL:
Absolutely. My team was just elated to be able to participate in that program. And the funding navigator program really broadened our approach to extend resources and innovative solutions to historically marginalized communities here within our state—really focusing and centering on equitable, interest-based partnerships, as Dr. Duwve had mentioned.

This opportunity led to the creation of our own funding navigation and grant writing workshops in each of the regions here within our state. Addressing grant accessibility issues, we continue to do so in collaboration with the University of Kansas Medical Center's COPE project, as Dr. Duwve had mentioned. And they're really helping us to pull from more of a grassroots approach about outreach and promotion. And the idea behind the work we'll be doing is to later on bring in subject matter experts to support the conversations being more fruitful; and really ensuring that communities have the support that they need, as far as technical assistance goes, to address some of those social determinants of health areas that they're seeing need to be addressed within their communities—whether that be food security, transportation, or housing.

DUWVE:
And I'll just follow up on what Jade said about the COPE project. Initially, COPE had funded, through the health disparities grant, 20 communities. COPE now is funding 22 communities to do this work. And the extra two communities, with the help of the COPE project, have been able to identify sources of funding and sustainability. It was proof of concept that, with this funding, we'll do the work in communities, and the communities will find value in this work.

And we will be able to leverage that for sustainable support in just a couple of the projects that the local health equity action teams have been working on, which I think really highlight the importance of this work: our criminal record expungement and driver's license reinstatement; educating residents about home buying, including lead hazards; working with faith-based communities to increase youth physical activity—like I said, the community gets to decide what their priorities are. And through the disparities grant, they were given a small amount of funding, but this opportunity to leverage additional funding from different sources through the Georgia project I think is really going to transform this work and really keep the spirit of these teams and the work they're doing in the communities alive.

ALUC:
This is really great. Jade, is there anything else you'd like to add and bring into the space, too?

RAMSDELL:
I would really just go beyond to say that we've really begun to think more critically about layering and braiding of funding within a department. And I'll just echo Dr. Duwve in saying that's enabled us to really be very forward thinking with sustainability. And in some cases for projects, we are funding them for up to five years now—which we didn't think, at the start of our work, that was going to be a possibility. That's really furthered our mission in securing long term funding for essential equity initiatives, and it's ingrained in our work. We're even beginning to think about what the next steps after that those five years. And so, it's been really amazing to see come to fruition.

ALUC:
That's great. I'm hearing this aspect of establishing a culture of health equity to see where it can be embedded across the board: having sustainability in mind at the onset, thinking through intentional community engagement and collaboration, and how to elevate empowerment in the midst of all of that. And that aspect of you all thinking about sustainability, you're elevating a strategy of braiding and blending funding, and thinking about how sort of these efforts can have a continuum, have legs to stand on way past the period of a particular grant cycle.

It really brings me to this point around community integration and public health. Public health initiatives tend to be, and need to be, community driven and tailored to address a specific need for the people that are potentially the ones who live, play, and work and are being serviced in a particular area. And so by actively involving community members in program development, recommendations for policy implementation, we're really ensuring that those health initiatives are culturally sensitive and relevant.

You talked a little bit about this—even bringing Jade into the fold, Dr. Duwve—and some of the work that you have been doing and continue to do with communities. But how has Kansas been working to balance the team STRETCH project goals of level setting health equity knowledge across the agency, and centering the community voice in the development of standards and processes?

DUWVE:
Yeah, I think that's two questions across the agency. I think one of the things that Jade mentioned was participation in the STRETCH project actually introduced us to the culturally and linguistically appropriate standards, and I think that really resonated. Jade and her team have really latched on to making sure that these standards reframe the way we do business by using culturally and linguistically appropriate services, standards, and equity as sort of our North Star in the agency. So in the grants that we write, in the work that we do internally, and also the work that we do in community, we are translating those standards into action. And I think this is really important, and it's how we are embedding this equity work into the everyday process of the work we do as a health department.

Jade, I think another thing that would be really helpful to talk about is the training that you're doing with the support of the secretary.

RAMSDELL:
Yeah, absolutely. We know a key lever of this work is ensuring that everybody has the same level of baseline knowledge about some of these concepts that you're hearing surrounding equity and social determinants of health. We are being very forward thinking to consider what a train-the-trainer model looks like in our department, and just provide some just-in-time training for staff who we are seeing from our workforce assessments are really eager to learn more about equity and ways that they can bring equity into the work that they're doing.

Another significant step for us within our department, and really across Kansas, has been with our state health improvement process. We've developed what is a new kind of emerging priority workgroup leadership structure within this initiative, which includes community organizers and experts who are compensated for roles in supporting Healthy Kansans 2030. The wonderful thing about that is that this approach has helped to ensure that community voices are not only heard, but actively included in the process of developing standards from a systems standpoint here within our state.

And so KDHE serves as the backbone of that Healthy Kansans plan, but we've got folks within the communities who are very familiar with the ins and outs of what we're seeing our grassroots level, who are leading the pack, who are sitting at the head of that table. And they're really advising us on the ways that we can continue to improve as a department.

DUWVE:
And I'm so glad you mentioned that, Jade, because it's one of the things I had on my list to talk about. I was so impressed when I read the state health assessment. The vision for that assessment is that all people in Kansas reach their full health potential through sustainable, equitable, and empowered communities. So again, community at the center of our state health assessment process; so, to me, that spoke volumes.

We know that, in general, people think about Kansas as a healthy place to live—we're always in the middle, at least now. But the state health assessment really did take a deep dive. And it allowed us to really see, by using data, the disparities in health that exist for those that are living in both our most rural communities and in our urban centers, and for Kansans from communities of color, individuals who are living with a disability, and members of our community who identify as LGBTQ plus. And as a result of this health assessment and the Healthy Kansans 2030 plan, people have started asking questions about why Kansas has fallen in health rankings from: 8th in 1991, to 31st, currently.

And so now, at the highest levels of leadership, we are asking how can we crosswalk the work we do and demonstrate the positive impact of our public health programs on health metrics. So, this work has already begun to make a difference.

ALUC:
You touched upon a little bit of what I was thinking about—this aspect of leadership buy-in, right. And so I want to turn this question over to Jade. Thinking through just the dynamic of getting leadership buy-in—making sure the appropriate people with decision making power are in the conversation—what and how has this experience been for you to have executive leadership, Dr. Duwve, be so closely connected with STRETCH and connected to the integration of community efforts and community engagement into this space of the efforts and projects in Kansas? But also, how has it been helpful to have them integrated with the STRETCH project?

RAMSDELL:
That's such a wonderful quiet question, Aika. And something I would say—Dr. Duwve and I joked about yesterday—is we don't feel like we've identified the secret sauce, but I definitely feel like this has been the core of how we can successfully move forward. It's just that continued dialogue, knowing that support is there, and being able to be innovative and be encouraged to be innovative and think through new ways to do things as a department has really been very fulfilling. And for my team, there's not a point in any meeting where we're not brainstorming new ideas and new ways to do things. We're really challenging ourselves.

I think that because a lot of our work here in our center revolves around public health accreditation, quality improvement, and performance management, it also enables us to think about what the next step looks like. And that's something that's fully supported at every level here at the department. It comes very naturally for us to be very forward thinking in innovative approaches and ways in which we can really bake in, we're starting to hear, those equity initiatives into everything that we do.

DUWVE:
I was going to say exactly what Jade said. I think that originally, we had conversations about leadership, and "if you lead, people will follow.” But I think a course correction that occurred midway is that we recognized that the center of leadership for this initiative really belonged in Jade's bureau, where staff engagement and training were prioritized as part of performance improvement and workforce development—with agency leadership support, of course. But Jade and her very expert and diverse team really had the experience, and the knowledge, and the tools to really lead this initiative agency-wide. And I think we're seeing that people are following and people are hungry for this information.

ALUC:
So good to hear. And Jade, you mentioned public health accreditation. As soon as you said that, what started buzzing in my mind was data equity, right.

And so, bringing in the importance of data in this space, I'm just curious: what are some of the strategies that you all have leveraged when thinking about data equity, when thinking about data sharing, when thinking about how to leverage data and the information you're getting to propose and innovate new programs, to better collaborate with communities, and to also source opportunities for funding?

RAMSDELL:
Absolutely. What I'd say is that we know that data is power, and it's really an opportunity to tell a story. It's enabled us to pull a picture of what's truly happening within communities in which we serve. It's also served as an opportunity for us to continue to grow and develop. That data is telling us something and ways in which we can do things better, and so we're bringing that to the table. And we're really thinking strategically about how we can continue to address these things that are bubbling up for us.

Another thing that I'll say is that data is really the center of the new funding that we've seen with workforce development. And so, we're seeing commitments at the department to build out a more sustainable infrastructure, a larger infrastructure, with a significant amount of time and commitment going into those efforts as well. So I would say that data has become even more critical with the work that we're doing as we consider public health infrastructure as a whole, the workforce, and some of the decreases in the workforce that we've seen.

DUWVE:
And at the more macro level, there are conversations about data sharing that are happening not only within the agency but between agencies, and also conversations about health information exchange that have really been quiescent over the past maybe 10 years or so. Really the opportunity to restart those conversations, to relaunch conversations about even internally data sharing.

Also, I'll mention that during COVID, it became really apparent that sometimes people just overlook the boxes about race and ethnicity, and gender, and where they exist, and sometimes they don't get checked. Other times people use their own sort of their visual inspection of an individual to check the box, which may not be representative of that individual. Also, sometimes we don't ask the right questions, and maybe there's not a box that a person identifies with. And this is particularly true with the gender questions that we ask, so we know that we have work to do in that space.

The data that we're collecting may not be 100% representative of the people that we're serving, it may be incomplete. It may be that they didn't find a box to check there. So how can we be more inclusive? And then, how can we share that data more openly within our agency and with people outside our agency? And I've seen, just about the data sharing, some really great progress internally. And I'm hoping that—I know that it will continue.

RAMSDELL:
Aika, I'll add one more thing to the conversation as it relates to STRETCH and how it's necessitated these discussions surrounding data sharing. It's facilitated a lot of discussions for us with our community partners about data disaggregation and the importance of disaggregation, but also the importance of data sovereignty when we're working with MOUs and we're looking at sharing data, and specifically working with our tribal communities.

ALUC:
Thank you for sharing that. And I know our listeners will be just excited to hear some of the movement especially on data, especially with the onset of the pandemic, and just how we're using and leveraging the information that we're receiving.

And so, Jade, you mentioned workforce and infrastructure. And that has just been a huge topic for folks, especially onset of the pandemic and the past few years. And so, when thinking about workforce and infrastructure in Kansas and continuous staffing for efforts that are rooted in health equity, what is the continued vision and aspirations that you all want as it relates to just continuing to embed a culture of equity in Kansas?

RAMSDELL:
That's such a wonderful question. We are extremely fortunate to have a new HR director here who's really helping to embed those ideas within our culture. Not that they weren't there before, but we're thinking very differently about retention and the impact of the pandemic on our workforce and ways that we can do things differently. And I think one of the central key points has been ensuring that the root of our work—the root of especially from a personnel services standpoint—is looking at inclusivity and belonging at the department. Fostering this environment for folks where they want to stay, but they also want to go tell five people about what we're doing here at the department and bring them on.

And so that has been phenomenal to see. We're seeing different initiatives that have taken place here in the department—whether that be regarding recognition, or team building, softball games, popcorn on Fridays—those kinds of things where folks are facilitating more dialogue with each other and even some of our remote staff are feeling included in things. And we're just constantly considering ways to evolve as a department. I think we'll see continuous impacts and changes, and diversity and the changes in our workforce as a result of that commitment.

DUWVE:
And as background, I think that the governor and her policies really for maternity-paternity leave. And then, also the health department has a bring-your-baby-to-work policy through six months. And those things, too, have allowed us to be more flexible, and to really accommodate work-from-home if needed, to really accommodate good parenting. I just think that it's things like this that create a culture of inclusivity.

Everybody starts at a different place, and everybody has different needs. So offering a menu of options—and the softball game was great, but that's not going to be for everyone. And it's the state and the agency meeting people where they are and saying we want to support you wherever you are, whatever phase you are in your life.

ALUC:
Absolutely. Thank you both so much.

As we close out this conversation, I want to invite you both to think about what's one thing you would want to leave listeners with when thinking about operationalizing equity and your participation in the STRETCH project.

DUWVE:
I think the one thing that really resonates with me, and I try to live this every day, is to understand that I am still a learner. And there are definitely things that tripped me up, and I have to continuously recognize my biases that come from my years of upbringing in my family, and hold those out so that I can be authentic on this journey.

And so, in that respect, I think that it starts with all of us: making sure that the language we use is inclusive, making sure we recognize our bias, making sure we're open to suggestions to learning, and leading with our hearts.

RAMSDELL:
That was a wonderful response. I was going to say much of the same thing as Dr. Duwve, so I'll just add to what she's mentioned. For us, it's taking a step back and just simply listening more, inviting more, sitting at tables and really hearing. And sometimes they're not the most favorable things you want to hear at the time, but those are things that make us better, right. And so, as we learn about ways in which we can be doing things better, we take that in, we spread that news across the department, and then we institute it. And that's been a very beautiful thing. It's been humbling.

And, as Dr. Duwve mentioned, it's an opportunity for us to continuously check our biases and be able to ensure that we're serving everyone here within our state to the utmost ability that we can. And that's a commitment we have here at the department. And by utilizing these practices, we just continue to commit to that and show up.

ALUC:
I want to thank you both, Jade Ramsdell and Dr. Joan Duwve, for joining us today as we explored how leadership, states, and public health work together to operationalize equity and foster health equity outcomes.

I want to thank you for your participation in STRETCH, and just telling your story about how the integration of the STRETCH project, framework, and initiatives is really helping you support and create routes and establish a culture of health equity in Kansas. Lasting systems change requires collaborative efforts, innovative funding, and community integration to create a healthier and more equitable future for all.

Thank you for telling us and talking to us about how you all are doing that today.

DUWVE:
Thank you, Aika.

RAMSDELL:
Thank you so much.

ALUC:
Thank you again for joining this important conversation. Please find additional resources in the description and visit astho.org for all your public health information.