Place Matters: Eliminating Health Disparities by Addressing the Social Determinants of Health

Place Matters: Eliminating Health Disparities by Addressing the Social Determinants of Health Webcast Thursday, March 19, 2009 3:00 4:30 pm (Eastern) Sponsored by Health Resources and Services Administration Maternal and Child Health Bureau & CDC National Center on Birth Defects and Developmental Disabilities Prevention

Disclosure Statement CDC, our planners, and our presenters wish to disclose they have no financial interest or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. Presentations will not include any discussion of the unlabeled use of a product or a product under investigational use.

Learning Objectives Define social determinants of health, health disparities and the impact of place or location/environment on health. Describe interventions used by Place Matters to eliminate health disparities by addressing the social determinants of health. Describe local health department strategies in eliminating health disparities and local-level policies that can improve social determinants of health. Identify at least two resources for local health departments to eliminate health disparities by addressing the social determinants of health.

Continuing Medical Education (CME) This activity was planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the CDC, NACCHO, and CityMatCH. CDC is accredited by the ACCME to provide continuing medical education for Physicians. The CDC designates this activity for a maximum of 1.5Category 1 credits toward the AMA Physician's Recognition Award. Continuing Nursing Education (CNE) This activity for 1.5contact hours is provided by the CDC, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditations. Continuing Education Contact Hours (CECH) The CDC is a designated provider of continuing education contact hours in health education by the National Commission for Health Education Credentialing, Inc. This program is a designated event to receive 1.5Category 1 contact hours in health education. The CDC provider number is GA0082. Continuing Education Units (CEU) The CDC was reviewed and approved as an Authorized Provider by the International Association for Continuing Education and Training (IACET). The CDC will award.15ceus to participants who successfully complete this program.

If you are interested in receiving continuing education units: - Go to the CDC Training and Continuing Education Online at http://www.cdc.gov/tceonline. If you have not registered as a participant, click on New Participant to create a user ID and password; otherwise click on Participant Login and login. You will need to enter the following verification code: NACCITYIPV1 - Once logged on to the CDC Training and Continuing Education Online website, you will be on the Participant Services page. Click on Search and Register. Use one of the 3 search options. Search for Course Number (EV1237) Click on View. - Scroll down and click on the program title. Select the type of CE credit you would like to receive and then click on Submit. Three demographic questions will come up. Complete the questions and then Submit. A message will come up thanking you for registering for the course. - If you have already completed the course you may choose to go right to the evaluation/posttest. Complete the evaluation/posttest and Submit. A record of your course completion and your CE certificate will be located in the Transcript and Certificate section of your record. If you have any questions or problems please contact: CDC Training and Continuing Education Online 800-41TRAIN or 404-639-1292 or Email at ce@cdc.gov

EXPANDING A FAIR HEALTH MOVEMENT: ISSUES AND OPPORTUNITIES HEALTH POLICY INSTITUTE JOINT CENTER FOR POLITICAL AND ECONOMIC STUDIES

Our Mission To ignite a Fair Health movement that gives people of color the inalienable right to equal opportunity for healthy lives

How Will We Build This Movement? Increase the capacity of local and national leaders to elevate health equity in the public discourse Conduct research to continue to build the evidence base to compel action Harness new tools, such as internet based mapping, social networking, and advocacy platforms Proactively engage key stakeholders and constituencies Promote new ideas for action to eliminate health disparities

Place Matters is a nationwide initiative designed to improve the health outcomes of participating communities through shared learning experiences. The program assists participating teams in developing and implementing community-based strategies to address the social factors that determine health. Scientific research indicates that changing the social determinants of health is crucial to promoting health equity and reducing disparities. Unfortunately, conversion of this knowledge into policy and practice has been limited, particularly at the local level. The Place Matters initiative aims to address this gap by cultivating new leadership and advancing the Fair Health Movement one community at a time.

Place Matters Our national learning community consists of 16 PLACE MATTERS Teams responsible for designing and implementing health strategies for residents in 21 counties and three cities. HPI, CommonHealth ACTION, and other consultants provide technical assistance to participating Teams in the form of facilitation, Design Lab meetings (including national-level experts and peer-to-peer learning opportunities), technical assistance grants, and access to data. Members of the Place Matters teams have been chosen from various sectors including local government, public health organizations, business entities, educational systems, faith-based groups, and community-based organizations.

Place Matters teams are seeking to improve an array of health outcomes, including: Chronic Diseases (Asthma, Cardiovascular Disease, Hypertension) Cancer (Breast, Cervical) Mental Health Maternal and Child Health Injury

Place Matters teams are addressing a broad array of social determinants of health, including: Social Inequity (e.g., institutional racism, inequitable power arrangements and educational opportunities) Economic inequity (e.g., economic insecurity and poor job opportunities) Infrastructure inequity (e.g., inequities in built environment, housing, land use, transportation, parks and recreation) Inequitable Access to Resources (e.g., services, healthy foods)

Core functions/strategies of Place Matters teams: Identification of social determinants of health Collection and integration of data to inform practical interventions Development and dissemination of tools to catalyze community leadership in implementing these interventions Strategic leadership to inform and influence policymakers, public officials, and legislators about strategies to eliminate health disparities.

Future Directions: Harnessing New Media and Web 2.0 Tools to Support Policy and Advocacy Efforts Utilize Web 2.0 and social networking tools to translate and disseminate findings (e.g., blogs, discussion forums) Harness new tools, such as interactive web based mapping platforms to illustrate the spatial dimensions of health inequality and point to place based solutions Generate and promote the use of New Media (e.g., YouTube video)

Promoting New Ideas for Action Race, Place and Regionalism Place Based and People Based strategies to reduce concentrated poverty Health Impact Assessment as a tool to evaluate the health consequences of policies in criminal justice, housing, transportation, education, and other areas Health Empowerment Zones to improve community conditions for health, such as improving the retail food environment

Taking Action to Eliminate Health Inequities in Boston Barbara Ferrer, Ph.D., MPH, M.Ed Executive Director Boston Public Health Commission

Who lives in Boston? Slightly over 600,000 residents Increasingly diverse community: 50% White, 23% Black, 17% Latino, 9% Asian/PI; 28% of residents are foreign born 20% of residents are living with income below poverty level; 31% of children live in households with income below poverty level

What health care resources are available in Boston? 26 Community Health Centers 12 Teaching Hospitals 3 Medical Schools, 4 Schools of Public Health, 5 Nursing Schools, 8 Allied Health Programs 95% of residents have health insurance through 2007 health reform law

Racial Disparities in Boston Health Indicator Black White Asthma (< 5, hosp) 11.4 per 1000 3.4 Birth Weight (Less than 3.3lbs) 3.0% of births 1.6% Body Weight (Overweight or Obese) 68% 41% Breast Cancer (Morality) 29.7 per 100,000 25.9 Cervical Cancer (Mortality) 5.6 per 100,000 2.3 Death Rate (Mortality) 959.7 per 100,000 750.0 Diabetes (Mortality) 41.8 per 100,000 16.6 Drug Related Mortality 35 per 100,000 39.6 Heart Disease (Mortality) 157.1 per 100,000 151.6 High Blood Pressure 30.4% 17.2% HIV / AIDS (Mortality) 28.1 per 100,000 6.8 Homicide 27.2 per 100,000 2.2 Hospitalization 163.8 per 1000 108.9 Infant Mortality (Mortality) 13.2 per 1000 3.6 Lung Cancer (Mortality) 61.6 per 100,000 66.2 Prostate Cancer (Mortality) 68.3 per 100,000 31.2 Smoking during pregnancy 6.3% 5.1% Suicide (Mortality) 3.6 6.2 Teen Birth Rate (15-17) 14.1 per 1,000 6 Uninsured 9.2% 6.5%

Life Expectancy in Years 100 Life Expectancy of Black and White Boston Residents, 2004 2006 90 80 70 60 50 40 30 20 10 0 74.8 69.6 Males 75.5 81.1 77.4 Female DATA SOURCE: Boston resident deaths and live births, Massachusetts Department of Public Health Data ANALYSIS: Boston Public Health Commission Research Office 81.6 Boston Black White

16.0 Infant Mortality Rates by Race/Ethnicity and Year, Boston, 1993-2006 Deaths per 1,000 Live Births Within Race/Ethnicity 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Black 15.0 12.5 11.9 9.9 12.8 12.0 13.5 13.6 13.5 12.4 14.2 12.1 8.7 13.2 Latino 8.9 8.2 3.0 5.2 3.6 4.5 4.1 5.1 5.6 6.5 4.0 9.4 3.1 2.9 White 5.9 7.2 4.7 6.7 9.5 4.0 5.6 2.8 5.1 4.6 3.1 n<5 4.1 3.6 BOSTON 9.8 9.2 6.8 7.0 8.4 6.3 7.4 6.7 7.4 7.0 6.3 6.0 5.2 5.8 DATA SOURCE: Boston resident linked birth/death files, Massachusetts Department of Public Health DATA ANALYSIS: Boston Public Health Commission Research Office

Model of Social Determinants of Health Inequities Socioeconomic Status Environmental Exposure Stress Racism Health Behaviors Health Outcomes Access To Health Services Access to Testing and Screening

If racism was constructed, it can be undone. It can be undone if people understand when it was constructed, why it was constructed, how it functions, and how it is maintained. ---People s Institute For Survival and Beyond

Boston s efforts to address racial and ethnic inequities in health www.bphc.org/disparities

Guiding Principles Evidence based foundation: data collection, analysis and dissemination of relevant information Community capacity building and coalition development are the pillars of the work Inequities considered as a central issue and elimination strategies are integrated into core public health functions Working upstream with non-traditional partners is required to address root causes of inequities Funding is directed to support efforts to eliminate inequities

Mayor s Task Force Blueprint Report Released: June 23, 2005 Mayor invited leaders from health & human services, business, academia and community coalitions Review of history, research, and underlying causes Recommendations for action Focus on health care and on larger societal & environmental factors Balance of broad and specific recommendations linked to action steps

Mayor s Hospital Working Group Report Released: June 23, 2005 Mayor invited senior personnel from all Boston hospitals to participate Hospital specific recommendations developed across 5 areas: Collecting Information on Race & Ethnicity Measuring Health Disparities Diversifying the Health Care Workforce Improving Cultural Competence at Your Hospital Including the Community in Institutional Decision Making Processes

Framework for Promoting Health Equity Develop institutional competency to engage in sustained efforts to eliminate inequities Support/build community capacity to lead and engage in efforts to eliminate inequities Identify partnership opportunities to enhance and promote efforts to eliminate inequities

Building BPHC Institutional Capacity Providing employee education and training opportunities (core competencies and leadership development) Integrating elimination of inequities in every program (logic models, goals, objectives, activities and evaluation) Identifying and changing policies that may perpetuate inequities (ARAC)

Regulatory Example: Boston Data Collection Regulation Passed by the Public Health Board in June 2006 Requires all hospitals and community health centers to: Collect race, ethnicity, preferred language and highest level of education Report individual patient data to BPHC Report on quality measures by race, ethnicity, language and education Requires that the Commission convene a Health Equity Committee, with representatives from hospitals and health centers to: Review and establish system for integrating and reporting quality measures by race, ethnicity, preferred language and education to target quality improvement efforts

Regulatory Example: Regulations for Container Lots, Junkyards, & Recycling Facilities Regulation created permitting and inspection process: 1. Site Suitability 2. Operations must not be too close to property boundary. 3. Must have adequate operating area. 4. Must not adversely impact sensitive receptors. 5. Must not create: Noise Litter Rodent, insect, and avian infestation Odors Nuisances

Building Community Capacity $2 million investment to 54 community and health institutions to address health inequities Key Project Areas: Data Collection, Health Systems, Raising Public Awareness, Workforce Diversity, Patient Education, Violence Prevention and Trauma Response, and Food Access/Obesity Prevention

Example: Workforce Diversity GOAL: Increase resources to recruit, train, retain and graduate persons from underrepresented groups of color in the healthcare field Activities: Support dual enrollment Provide admissions advisement Conduct field trips Provide exposure to health careers Offer CNA certification course Provide medical interpreter instruction Mentoring by students of color Provide tutoring Offer life coaching

Example: Food Access and Obesity Prevention GOAL: Promote healthier neighborhoods by increasing access to healthy food options and involving youth in the response to disparities in obesity Activities: Include youth leadership development Champion healthy school breakfast/lunch Promote local food production and marketing Construct community gardens Provide nutrition and physical activity education Develop food cooperatives in Boston Public Housing

Building Partnerships --Underlying Principles Create a common understanding, shared vision and strategy Share leadership Share resources Share information/evidence-based foundation Acknowledge and affirm wide-range of skills and expertise Respect and make room for differences Operate with transparency Build community capacity

Example: BPHC CEED: A New England Center of Excellence US Centers for Disease Control and Prevention designated the Boston Public Health Commission as one of 18 national Centers of Excellence in the Elimination of Disparities The CEED will facilitate regional efforts to eliminate disparities in breast and cervical cancer and CVD in Black communities across New England BPHC will receive $4.5M between 2007 and 2012 to work across six New England states: MA, Rhode Island, Vermont, Maine, Connecticut, New Hampshire.

Example: Policy and Advocacy Legislative advocacy and voter education: - Violence Prevention Bill - Chronic Disease and Overweight Prevention Bill - Re-entry Bill Active engagement with State efforts such as Disparities Council, Governor Patrick administration, and Executive Office of Health and Human Services, and the MA Department of Public Health Joining with community coalitions organizing around education, health care reform, economic security, environmental justice, and dismantling racism

Example: Building Neighborhood Peace Councils Peace Councils Purpose: Opportunity for residents and local agencies to work together to build a safe and vibrant neighborhood by ensuring the provision of city services, supporting civic engagement, and ensuring accountability. Goals: Define a neighborhood vision Build relationships Construct solutions Create opportunities for youth involvement

Strategies Resident Engagement start with door knocking and listening; use participatory processes On-going Communication use a variety of mediums, create feedback loops, strive for information sharing and communication of vision Roles, Responsibility, and Accountability share leadership, create opportunities for distributing the work, and record assignments Assessment and Re-alignment establish tracking system and measurable objectives;

Partnership Success Reduction of violent crime in first 4 months in each neighborhood with Peace Council Visible improvements in each neighborhood (street signage, cleanliness, lighting) Resident leadership established Peace Council sponsored neighborhood activities

Where to start.. Promote a skilled, diverse workforce and leadership team Identify root causes of health inequities Build and sustain diverse partnerships Collect appropriate data to understand the challenge, measure progress and establish accountability

Refocus Activities Focus on policies that are good for health, not just health policies Fund efforts promoting community health Build strategic partnerships

Work Upstream Strongly oppose discrimination and racism in all settings Support affordable, healthy housing Promote local opportunities for safe exercise and recreational activities Promote local opportunities for healthy, quality affordable foods Invest in public education

Let America be America again. Let it be the dream it used to be. O, let America be America again The land that never has been yet And yet must be the land where everyman is free. Langston Hughes

Addressing the Root Causes of Health Inequities through a Local Policy Agenda CityMatCH NACCHO Alameda County Public Health Department Place Matters Webinar March 19, 2009

Presentation Overview Background Reactive Policy Work Responding to community requests Getting Proactive: Building a Local Policy Agenda Process goals Steps Policy workgroups, decision making tools, stakeholder engagement Implementing a policy agenda Activities, structure, guidelines

Alameda County Place Matters Team Sandra Witt Pam Willow Kimi Watkins-Tartt Diane Woloshin Katherine Schaff Mona Mena Sarah Martin-Anderson Jessica Luginbuhl Karie Gaska Amy De Reyes Alexandra Desautels

Infant Mortality Trend Infant Mortality, Alameda County, 1991-2006 Infant deaths per 1,000 live births 8 7 6 5 4 3 2 1 0 91-92 93-94 95-96 97-98 99-00 01-02 03-04 05-06

Low Birth Weight Trend Low Birth Weight Alameda County, 1991-2006 8 7 Percent low birth weight 6 5 4 3 2 1 0 91-92 93-94 95-96 97-98 99-00 01-02 03-04 05-06

Infant Mortality by Race/Ethnicity Infant Mortality by Race/Ethnicity, Alameda County, 2004-2006 Infant deaths per 1,000 live births 16 14 12 10 8 6 4 2 0 10.8 7.2 4.9 3.5 3.4 All Races AfrAm API Latino White

Social Inequities: Root Causes of Health Inequities Health Inequities Segregation Income & Employment Education Housing Transportation Air Quality Food Access & Liquor Stores Physical Activity & Neighborhood Conditions Criminal Justice Access to Healthcare Social Relationships & Community Capacity Social Inequities

Organizational Context Leadership willing to take risks 1.5 FTE dedicated to local policy work Flexibility and responsiveness Strong relationships Strategic Plan Department-wide plan for achieving health equity Direction #5: Advocate for policies that address the social conditions impacting health. Part of a 3-pronged strategy for addressing health inequities (see next slide) Institutional Change

ACPHD s Approach to Achieving Health Equity Policy Change Institutional Change HEALTH EQUITY Data and Research Community Capacity Building

Organizational Context Report increases: ACPHD understanding of the issues ACPHD credibility Public awareness of the issues and ACPHD work Find it online: www.acphd.org

ACPHD s Place Matters Initiative The Alameda County Place Matters team promotes health equity through a community-centered local policy agenda focused on education, economic development, housing, incarceration, land use, and transportation. The ACPHD Place Matters Initiative is part of the Place Matters National Initiative of the Joint Center for Political and Economic Studies Health Policy Institute and funded by the W. K. Kellogg Foundation.

What we have done so far Completed needs assessments in each policy area Responded to community and staff requests for policy analysis Built relationships with community stakeholders and other government agencies Planned and implemented a process for institutionalizing the policy work in ACPHD

Needs Assessment Needs Assessment Literature Review Baseline Indicators Discussions with Experts One per policy area Mutually informing components Outputs: Full report & summary documents Preliminary Policy Assessment Tools Relationships!!! Policy analysis and testimony

Reactive Policy Work Process Receive a request Community groups Government agency Apply basic screening criteria, including: Is there a disproportionate impact on communities experiencing health inequities? Does this policy address the root causes of health inequities? Will working on this policy help build relationships? Complete analysis Examine potential health impacts of a given decision [Engage ACPHD and resident stakeholders] Oral and/or written testimony

Reactive Policy Work Examples Transportation AC Transit fare increase Metropolitan Transportation Commission Regional Transportation Plan 2035 Land Use Estuary Specific Plan Eastshore Power Plant Port of Oakland Affordable Housing Transit Oriented Development San Leandro Crossings

Reactive Policy Work Drawbacks Siloed Not connected to ACPHD s programs Lacked a unifying vision and goal Not sure if we were actually getting at root causes Not necessarily reacting to community priorities ACPHD lacked human capacity to meaningfully sustain the work

Moving to a Proactive Model: A Local Policy Agenda Process Goals Institutionalize policy work in ACPHD Ensure policy work is: Community driven Research driven Proactive Responsive Create and enhance stakeholder buy-in Build relationships Ensure service level interventions are connected with policy change efforts Outcome Goal Address the roots causes of health inequities through policy change

Building a local policy agenda Needs Assessment Literature Review Baseline Indicators Discussions with Experts Decision Making Tools Policy Platform Policy Criteria Policy Workgroups Stakeholder Engagement Residents Community and Government Agencies Staff Local Policy Agenda

Policy Workgroups Goal Create and advocate for ACPHD s local policy agenda Oakland focused at first Increase ACPHD staff capacity for policy analysis and advocacy Increase ACPHD capacity to partner with stakeholders around policy change 1 policy workgroup/policy area Department-wide participation Staff self-identify Structure Coordinator Liaison to ACPHD Legislative Council

Policy Workgroups Two Levels of Participation Key Members: Supervisor approval necessary Attend orientation & trainings 2-hour monthly meeting and follow-up Help plan engagement activities for residents, staff, and partners Participate in workgroup decision making Informed Members: (Optional) Attend orientation & trainings Receive policy updates via email (Optional) Attend a monthly meetings and complete follow-up

Policy Workgroups Phase I Understand the Issues Orientation Foundation: structural-level discrimination is the root of current inequities Policy helped get us here and it can help get us out Builds on our Public Health 101 training Module III: Undoing Racism Complete Discussions with Experts Collect information on current policy issues and community priorities Build relationships Phase II Policy Analysis Policy Analysis 101 Training Vetting process Place Matters Decision Making Tools Stakeholder engagement

Decision Making Tools Preliminary Policy Platform Vision statements for each policy area Communicates overall vision to the public Keeps workgroup activities focused on policy issues Policy Criteria Used to asses policies for inclusion in the Local Policy Agenda For internal use Core Criteria Ensure our values and goal is at the center of decision making Policy Area Specific Criteria Ensure problems reveled in the needs assessments are addressed Informed by: Needs Assessments Stakeholder Engagement process

Policy Assessment Tool Example Needs Assessment Overpayment on housing associated with poor nutrition, displacement, homelessness, community instability, etc. Increasing % of Oakland households overpaying for housing Policy Platform An adequate supply of housing is constructed and preserved in proportion to demand, maintaining cultural, racial, and class diversity of the community. All housing is safe, habitable, and supports good health. No household resides in overcrowded conditions, is homeless, or resorts to spending more than 30 percent of the income on housing costs. Policy Criteria Core: Is there evidence this policy will reduce inequities? Specific: Will this policy decrease the number of households overpaying for housing?

Stakeholder Engagement Engage existing groups Resident groups, CBOs, advocacy organizations Government partners and decision-makers People receiving services through ACPHD and partner agencies Goals: Provide opportunity for meaningful engagement Prioritize issues within each policy area Build relationships and buy-in Output informs policy assessment tools

Implementing the Local Policy Agenda Policy Workgroups Advocate for implementation of Local Policy Agenda Engage with stakeholders Communicate activities Coordinate with state and federal policy efforts Build capacity of other health professionals to engage in policy change Respond to requests for policy analysis and expert testimony

Implementing the Local Policy Agenda Place Matters Leadership Team Provides guidance on the boundaries of policy work Structure Representative from each of the policy area workgroups Key ACPHD decision makers Key partners (Board of Supervisors, School Board) Measure Impact! Changes in baseline indicators Assess the impact of using a health frame to influence policy decisions

Implementing the Local Policy Agenda Guidelines for Policy Activities Asses policy for health impacts Communicate health impacts clearly and strategically Offer criteria for evaluating alternative solutions Be strategic and politically minded

Thank you! For more information: Alexandra Desautels 510-208-1235 Alexandra_desautels@acgov.org www.acphd.org/healthequity/placematters.html

Questions?

Thank you for your participation! Please take a moment to submit the online evaluation form for this webcast using the link below: http://www.zoomerang.com/survey/?p=web228w5ds5ams To obtain continuing education credits, visit http://www.cdc.gov/tceonline Please join us for the next EMCH Webcast, April 16, Health Education in the 21st Century: Embracing Web-based and Emerging Technologies Thank you. You may now disconnect.