Community-Led Health Equity Programs Deliver Results

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: how listening helps address public health challenges, and the humility that powers health equity zones.

KATIE LAMANSKY:
It's really important to make sure that we give the communities the platform and the voice to be able to say what their needs are; and for us to be able to step back—to have that humility, to step back and think, "How can I support them without giving them what I think they need?"

DR. NICOLE ALEXANDER-SCOTT:
We need to move away from the historic government or academic approach of swooping into a community, declaring what they're doing wrong and telling them they have a way to fix it, maybe helping to fix it, and then swooping out.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, a grassroots movement that's catching on across the nation: health equity zones. They allow communities to lead, empowered to set the agenda, and develop solutions to local challenges.

Katie Lamansky directs Idaho's effort called Get Healthy Idaho. Her department started its first two health equity zones during the pandemic. She's along later to tell us why and how they're doing.

But first, we hear from Dr. Nicole Alexander-Scott, director of the Rhode Island Department of Health. Her team issued the first call for projects in 2015. Today, Rhode Island has 15 health equity zones. What components need to be in place to implement and sustain a health equity zone?

ALEXANDER-SCOTT:
Well, a key element of the Rhode Island Health Equity Zones Initiative has been to put in place core public health principles for advancing health equity in our state; and so, certainly we need to ensure that we approach prevention work through the lens of health equity. What does it mean for certain communities that have been disadvantaged? What additional supports and resources do they need? How can we see the solutions through their eyes in understanding what's needed?

So, the other component is it being place-based—focusing on specific geographic communities. I often say that if you GIS-mapped so many different conditions or disparities that exist—whether various infectious diseases, domestic violence, behavioral health challenges—so many areas throughout the country, you would get heat map areas over the same communities. And so, it's that much more critical to make sure that our solutions are similarly place-based. It's not so much about the individuals themselves and their behaviors, but really looking at the social, economic, and environmental conditions that they are asked to live in, regardless of who they are. So, having that place-based focus is key.

And then, also ensuring that it's community-led. The solutions that are advanced must be identified and driven by community collaboration that includes a diverse range of stakeholders who are dealing with the conditions. We need to move away from the historic government or academic approach of swooping into a community, declaring what they're doing wrong and telling them they have a way to fix it, maybe helping to fix it, and then swooping out; but it's moreso understanding that the community understands what concerns are and absolutely knows what the solutions are, and needs to be equipped, supported, and resourced to be able to do that.

And so, that we are able to truly focus on going upstream to address the root causes of social, economic, and environmental determinants of health that exist.

JOHNSON:
Are you talking about community buy-in?

ALEXANDER-SCOTT:
To some extent. When you really value and have genuine respect for the community, it's not hard to get their buy-in because this is really focusing on driving towards solutions that are going to be beneficial for them. But it's really ensuring that the community is elevated as the valued leader that they are able to be, and can be supported and empowered to be so that we can have the sustained transformation that we know is needed.

I have always been thrilled when our health equity zones, for example, support individuals from the community who may not have ever considered it before now—running for city council or some other elected official office, or moving to gain another level of education, or open up their own business, or mobilize to hold specific elected officials accountable to what they said they were going to do.

It's really providing that opportunity for communities, with the public health tools and guidelines that we talked about, to drive towards a sustained action and transformation that we know is so needed at the community level.

JOHNSON:
We're talking about making changes in the community, but how about changes that are needed inside the public health agency? What sort of process is that? Is it easy?

ALEXANDER-SCOTT:
"Easy" is just not a part of a vocabulary in this; but "worth it" always is part of the vocabulary.

We have to see changes across the board to the culture of public health agencies, as well as changes at the community level. We know that with health inequities continuing to widen and to really negatively impact life expectancy for Americans, state and local health departments, community members, and everyone, we all have to reassess what our approaches are. The current approach is not adequately changing the structural drivers of health inequities or creating the desired improvements in population health outcomes.

And so, until state and local health departments take a hard look at their structures and strategies, we risk continuing to perpetuate multi-generational health inequities. Sometimes we might not even be aware when this is happening and, particularly with the funding that is being pushed out now, recognizing the importance of health equity is even more critical to ensure that health departments, community-based organizations, and residents are equipped to understand what's needed at the community level to really ensure that these investments lead to the long-term transformation that we need.

And that's where our health equity zones initiative seeks to be a tool to help facilitate that.

JOHNSON:
Are there any barriers that could slow down the process inside a health department?

ALEXANDER-SCOTT:
Yeah, there are some, and it definitely requires infrastructure and operational change at every level. You know, starting with our federal partners, understanding that we cannot distribute funding to the community in an effective way if it's still just focusing on silos—the silo of prevention for, you know, maternal child health, the silo of prevention for cancer prevention, the silo of prevention for asthma prevention—knowing that the people on the other end of those silos are the same and that they're not siloing themselves up and are otherwise not seeing the improvements that they need nor in their communities. So, making that shift.

And then also, at the department and organizational level locally to ensure that we can best support getting funding to the community, we have to restructure ourselves so that we can break those silos, braid the funding, and give it in one bucket to the community so that they can focus on collective action and driving towards unified goals and objectives that they are measuring themselves against actually improving.

So, we've had to do an infrastructure overhaul of our finances, our grant oversight, and our ability to report back to the feds. And as I said earlier, "easy" is not a part of the vocabulary, but absolutely "worth it" definitely is.

JOHNSON:
How has the health equity zone initiative changed you as a leader?

ALEXANDER-SCOTT:
This has absolutely been transformative for me as a leader—life-changing. It's been the perfect synergy of what I was passionate about before this opportunity, and being able to put that together with the roadmap for advancing it forward—I am fully focused on action and really being able to execute so the communities that we're serving experience a difference.

We've had year after year of talking about the data and understanding that disparities exist and wondering why we know why we have solutions, and it's time to put those into action. And it's at this moment that I'm particularly excited, where funding and resources are being poured out across the country, we have a tool like health equity zones that's already ready-made to support jurisdictions—state and local health departments, community organizations—in advancing this very necessary community-led, place-based approach; because it's time to move the needle. There's never more crisis than now, seeing the disparities that exist and the environment that we're in.

And so, I'm thrilled to be able to contribute to some ready-made infrastructures, like the health equity zones model, that can be put into place and really drive towards action in a way that will be sustained. We've always said the health equity zones is not intended to just be a project, but it's intended to be a movement, and it's been life-changing for me to be a part of that.

JOHNSON:
If others in public health are considering health equity zones, what's your best advice to them?

ALEXANDER-SCOTT:
The value of the health equity zones initiative is to elevate the community's voice, to drive towards sustained action, and just understanding the importance of that. And knowing that it's not an easy road, but it's a necessary road and it's worth it really helps shape when folks use language like "hard to reach" or "challenging." No, this is what it takes.

There have been years, decades, centuries of discriminatory or other systemic challenges that have been put into place; and so, we need the commitment of every public health leader, of everyone who's engaged, to use with determination, innovation, cooperation, and respect whatever model and tool we have to help reverse that, knowing that it is going to take time, it is going to require a partnership with the community.

The health equity zones initiative was our department's solution to better support underserved communities and reverse troubling trends in morbidity, mortality, and healthcare spending. And so, we're thrilled to be able to share that so that others can build on the toolkit that has been created and adapt this model to your own states and jurisdictions. We hope that learning from our successes and learning from our mistakes will help others get a jumpstart on this work because there isn't any time to start from scratch, and it is necessary to begin moving the needle and building capacity at the community level.

JOHNSON:
Katie Lamansky is a big fan of health equity zones, her passion evident during this conversation. She guides Idaho's two health equity zones as manager for the state health department's Get Healthy Idaho campaign.

What do you like the most about health equity zones?

LAMANSKY:
I really think a lot of characteristics are very appealing to us. For us, this focus on collaboration among programs, braiding funding, and really bringing programs in alignment with each other across the agency—not just within our division of public health, but across the entire departments—we really saw that as having much greater impact within a community. In addition, the place-based focus allows us to work more deeply with the community and to be more intentional for a much longer duration of time.

So, for us—and similar to the health equity zones—in this case, it's four years, so we'll be addressing community needs and working alongside and helping to build that community power over a longer period of time. And the results of this model will really help the community long after our investment has ended. That community-led aspect was particularly compelling for us.

Through our public health experience, it's also helped illuminate kind of this concept that communities know best what their needs are, and our role can really come in as a support while allowing the community to lead. We're not coming into the community and telling them what needs to be done—and that's often the case when we have specific grant deliverables. To me, in this case, we're providing funding infrastructure and a framework, and allowing the community to really lead and drive the change themselves.

JOHNSON:
Tell us more about the two communities where you have projects now underway.

LAMANSKY:
So, our first community we funded in January of 2021—so just this year—and they really are through the first phase. So, we've kind of split our funding up into phases. So, this first phase that Elmore County focused on was really looking at building their collaborative, focusing on identifying much more deep-rooted health needs, and undergoing a much more qualitatively-focused community health assessment; and then bringing that community action team together to build an action plan that now, starting in October of this year, they've started implementing.

And our second community just came on board in October, so we're just in the very infancy stages with them.

JOHNSON:
Is the goal the same for both?

LAMANSKY:
They're really not.

The nice thing with our initiative we're calling "Get Healthy Idaho," and similar to the health equity zone model, is that we're allowing the community to tell us what their needs are. Initially, the community comes in and through their proposal is able to say through data, through that kind of qualitative narrative, what their health needs are—here's where we're finding health disparities.

And then, once funded, we do a much deeper dive into what are those root causes contributing to poor health outcomes in the community, and what did the community members—community leaders and the members of this collaborative—what do they have to say and believe will be solutions to those poor health outcomes that will really help improve health?

And so, looking at the two communities that we have funded, while both of them have similar health disparities—in terms of higher rates of diabetes, high rates of low socioeconomic status residents, looking at injury, high rates of unintentional injury and obesity, so just as examples—and then, additionally, there's a lot of behavioral health concerns within those communities. So, those are definitely some similar characteristics. But the populations are very different and have very different needs.

And so, really we know what the community Elmore County will focus on because they've been through this first phase; so, now they've gone through that deeper dive qualitative process and have an idea of what they want to move forward to improve in the community. We're still in those early drilling down into the true roots within our second community, so it'll be different—what they decide and where they find momentum will be different once we get them through this first stage.

JOHNSON:
You've been doing this planning during the pandemic. How has that figured into the work you're doing?

LAMANSKY:
Yeah, the pandemic was interesting.

So, we funded our first community just this year; so we really, with the pandemic, you know, early in 2020, and all of us moving into kind of this virtual space, it's brought some really interesting challenges and some interesting opportunities as we were really building up our initiative.

So, it did delay the process, some getting our funding together, meetings with programs internally to really get them on board with this concept. We can't do this without funding from our funding partners and our programs within the organization, so those conversations and just getting those pieces together were a bit more delayed in this virtual world that we find ourselves in.

But at the same time, I think it also allowed for us to have more flexibility in quickly meeting with partners externally rather than setting dates out in the future; so, we also had a lot of really great, very meaningful, and intentional conversations with partners—multi-sector partners external to our organization. So, I think there was, again, those kind of opportunities, but also some silver linings that we saw, you know, in some of the challenges.

JOHNSON:
Did the department undergo any sort of reorganization in order to support these two projects?

LAMANSKY:
Yeah. So, initially we did not have dedicated staff specifically focused on this effort. In 2019 as we were building out the internal infrastructure, we did identify dedicated resources to shift my position as health program manager from one area of the division to really help build and support the initiative. So since then, my position is now supported full-time; and since then we've brought on a project coordinator who helps to develop communications, build relationships with our communities.

And then peripherally, we've also restructured where our initiative Get Healthy Idaho now lives within our organizational structure and a new work unit, which we're calling equity and strategic partnerships. And so, none of that existed prior to really lifting this initiative off the ground.

In addition, we've also hired CDC Foundation staff whose sole focus is on equity, so we now have dedicated staff with dedicated roles focused on relationship building, partnerships, equity, and really enhancing collaboration within our organization and with external partners.

JOHNSON:
Did the process require people to change their approach to public health?

LAMANSKY:
This was a pretty big mind shift, a mindset shift for staff, really. We had to start by laying the foundation with this new model and really helping staff and even partners external to our agency to help understand the importance of moving upstream, of working on the social determinants of health, and really understanding what is our "why" behind this initiative, as it is such a significant shift from the traditional public health mindset.

So, this really helped us, I guess, kind of present our vision and strategy more broadly. I think that, not so much as barriers, but just building that knowledge base and, in doing so, that really helped us to identify programs who are supportive of this initiative and can align with us to really get the buy-in both from our partners and our programs internally, as well as our partners external who can provide additional support and technical assistance to future funded communities.

So, thinking about just the infrastructure and what we needed to do internally to get this model lifted off the ground, that first year—you know, late 2019 and into 2020—was truly what we like to refer to as building our plane while we're flying it. It was building that internal infrastructure and shifting the knowledge to really understand the importance and why this work is so vital for us to improve health in Idaho.

JOHNSON:
What's been the community's reaction to health equity zones?

LAMANSKY:
I think a couple of things come to mind for me with community reaction.

So, certainly with our first funded community, we have received a lot of positive feedback in that kind of traditional public health approach has been single year contracts, and it's really hard to build sustainable policy system and environmental change and community power in a single year. So, what we have heard from our first funding community is truly gratitude, really focusing on the importance of this funding lasting more than a single year—so, we're with them for four years. That's allowed our community collaborative to build that trust, to know that we're not just here to assess, we're not just here to hopefully get what we need from the community to satisfy grant deliverables or grant objectives. We're really here to build that community power and trust and help it be sustaining over the long term. So, thinking about the community that's funded, from their perspective it's been really helpful, I think, and gratifying that this initiative isn't just a single shot and done, that we're truly invested in improving their health.

And I think some of our partners, when we had some initial planning meetings and just kind of getting this off the ground, we had a lot of very positive comments from partners, "Certainly this is going to be hard and we know that and we acknowledge that, but also the it's about time." So, I think when we heard that, that feedback really made us feel like, "Gosh, you know, we're in the right space, we're still learning and it's going to be a learning journey, but we're in it for the long haul." And our partners have been really supportive.

JOHNSON:
We talked earlier about the impact of COVID during your planning phase. Did the projects, though, help inform or direct or improve your COVID response?

LAMANSKY:
So, I think that's an important question. The same mindset shift that we implemented with Get Healthy Idaho has really helped us in our COVID response; so specifically the piece about asking, "What do you need?" versus assuming we know the needs and communities, we're a lot more comfortable now with that ambiguity and with folding equity into conversation.

So, specific to COVID, you know, how COVID is disproportionately impacting certain populations, and how do we respond and ensure that resources are deployed equitably, ensuring that we're listening to the voices within communities and providing them with the right fit of resources to meet their needs—that's helped greatly with our COVID response. And that's really some of those basic tenets that we're using with our Get Healthy Idaho initiative, as well.

JOHNSON:
As we wrap up here, I'd like you to tell public health people listening to this podcast why they ought to consider a health equity zone model in their jurisdiction.

LAMANSKY:
I really, again, believe in the power of asking communities what they need.

I think as public health practitioners and public health experts, we have a lot of knowledge—we know the best practices, we know the theories and the models; but not being from the community, it's really important to make sure that we give the communities the platform and the voice to be able to say what their needs are, and for us to be able to step back—to have that humility to step back and think, "How can I support them without giving them what I think they need?" That's really been the biggest, I think, humbling experience for us; is to, again, not go in with our public health hats and act as though we have the answers, but to really allow the community to feel empowered to come up with the solutions themselves.

So again, I really—I'm such a believer this place-based model, and ensuring that the community has the space and the time to think through what their needs are, and for us to come along beside them and help support them in that.

JOHNSON:
Thanks for listening to Public Health Review.

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For Public Health Review, I'm Robert Johnson. Be well.