The Effect of Modern Day Racial and Social Stratification on African Americans

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This is a final research paper, it should be 7 pages long with a citations page, 12 pt font, double spaced. Please integrate all the provided papers whether it's a direct quote or paraphrase (Please no more than one or two direct quotes, paraphrasing is okay)

The paper is about how African American individuals suffer from class and racial inequality in the United States.

It should include the following aspects:

1. Power: How African American individuals lack power in the United States in comparison to the upper white class who control the corporates, economy, and the government in a way to help their business growth (An example would be how some large corporates avoid paying federal taxes)

2. Wealth: The unequal distribution of wealth when comparing the upper white class with lower class African Americans.

3. Inequality: How this racial and social stratification affects black individuals in the health and education systems.

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BETTER HEALTH THROUGH EQUITY Case Studies in Reframing Public Health Work MARCH 2015 Healthy People 2020, the nation’s health objectives for the current decade, defines health equity as the “attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.” Such goals aren’t unfamiliar to public health practitioners—the field has a long and storied tradition of serving the most vulnerable and bringing life-saving care to communities that would have otherwise gone without. And while the nation has come a long way in identifying, acknowledging and addressing disparities1 in health and health care access, it is clear that eliminating disparities cannot be accomplished without seriously addressing the underlying social determinants of health2, many of which are shaped and perpetuated by bias, injustice and inequality. Across the country, state and local public health agencies are taking up this call to action in earnest, integrating a health equity framework at an organizational level and using equity values to drive community health work. The following are five case studies exploring the experience of public health departments as they make a concentrated shift toward achieving health equity. 1. What’s the difference between health disparities and health inequities? According to Paula Braveman in an article published in Public Health Reports, “Health equity means social justice in health (i.e., no one is denied the possibility to be healthy for belonging to a group that has historically been economically/socially disadvantaged). Health disparities are the metrics we use to measure progress toward achieving health equity. A reduction in health disparities (in absolute and relative terms) is evidence that we are moving toward greater health equity.” (Source: www.publichealthreports.org/issueopen.cfm?articleID=3074) 2. The social determinants of health are the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at the global, national, and local levels. Examples of resources include employment, housing, education, health care, public safety, and food access. (Source: www.who.int/social_determinants/sdh_definition/en/index.html) THE VALUE OF INVESTING IN HEALTH EQUITY The efforts chronicled in this series of case studies are not only designed to improve health outcomes, they are also poised to save the country billions in health care spending. According to one study published in 2009, more than 30 percent of direct medical costs faced by African Americans, Hispanics and Asian Americans can be tied to health inequities. Because of inequitable access to care, these populations are sicker when they do find a source of care and incur higher medical costs. That 30 percent translates to more than $230 billion over a four-year period. If health disparities among minorities had not existed between 2003 and 2006, direct medical care spending would have been reduced by a whopping $229.4 billion. Source: https://www.ndhealth.gov/heo/publications/The%20Economic%20Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf ACKNOWLEDGEMENTS With support through CDC Cooperative Agreement#5U38HM000459-05, the American Public Health Association (APHA) contracted with Kim Krisberg to conduct a series of 5 case studies of state, local and tribal health agency efforts to create health equity. We would like to acknowledge the staff at the health agencies that provided the information essential to this report. We are grateful for their participation and willingness to share their stories. The contents of this report are solely the responsibility of the authors and do not represent any official views or endorsement by CDC. CDC funds were not used to fund the work described in the report. This report is not designed to support or defeat enactment of any legislation, pending before Congress or any state or local legislature. Federal, state, tribal and local jurisdictions apply differing rules regarding engagement with legislative bodies and other policy-related activities. Jurisdictions considering legal or other policy initiatives should seek the assistance of state or local legal counsel. Additional guidance for CDC funded recipients may be found at www.cdc.gov/od/pgo/funding/grants/foamain.shtm. TABLE OF CONTENTS ACHIEVING HEALTH EQUITY: LESSONS LEARNED.................................. Page IV SHIFTING THE DISCUSSION, APPLYING A NEW LENS (MULTNOMAH COUNTY, OREGON).........................................................Page 1 EQUITY IN ACTION: Multnomah County..................................................Page 5 HARNESSING THE POWER OF CROSS-SECTOR COLLABORATION (MENOMINEE INDIAN TRIBE, WISCONSIN).............................................Page 9 EQUITY IN ACTION: Menominee Indian Tribe.........................................Page 13 MAKING HEALTH EQUITY A COMMUNITY AFFAIR (VIRGINIA).......Page 16 EQUITY IN ACTION: Virginia Department of Health................................Page 21 INTEGRATE AND OPERATIONALIZE: RECOGNIZING EQUITY EVERY DAY (COLORADO) .....................................................................Page 24 EQUITY IN ACTION: Colorado Department of Public Health and Environment ..................................................................................Page 30 TRANSFORMING THE WORK OF COMMUNITY HEALTH (TEXAS) .....Page 32 EQUITY IN ACTION: Texas Department of State Health Services ............Page 36 About APHA APHA champions the health of all people and all communities. We strengthen the public health profession. We speak out for public health issues and policies backed by science. We are the only organization that influences federal policy, has a 140-plus year perspective and brings together members from all fields of public health. BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page III ACHIEVING HEALTH EQUITY: LESSONS LEARNED A number of lessons learned identified as essential to successfully implementing a health equity framework were gathered during APHA’s Better Health Through Equity project. The following are the most salient. WITHIN YOUR ORGANIZATION: Achieving health equity first begins with building knowledge, understanding and capacity within your organization or agency. listen and learn about the lives of the people you serve. This may throw a wrench into all of your preconceived plans and force you to go back to the drawing board. But that’s okay—achieving health equity may mean taking as many steps backward as we do forward. 1 ACKNOWLEGE THAT EQUITY IS MORE THAN ANY ONE, SINGLE INTERVENTION: Health equity truly is a state of mind. It’s a framework within which public health practitioners from all disciplines can work. Making a purposeful shift toward achieving health equity forces us to consistently view health status within the larger context of society and history and will ultimately bring public health farther upstream than it’s ever been before. 2 6 BUILD TRUST: Trust is the foundation of all health equity work. In fact, it may be the only starting point that will lead to sustainable progress. Building trust requires having an open mind, being flexible, listening to people’s stories, respecting and integrating traditional ways, engaging community leaders and empowering people with the means to seek change for themselves and their communities. WITHIN YOUR PRACTICE: Achieving health equity means allowing community values and priorities to shape and inform interventions. Science-based evidence is always important to measuring needs and progress, but gaining community buy-in is critical to sustainability. HAVE AN OPEN AND HONEST DIALOGUE: Start a conversation in your health agency—and ideally across fellow public agencies—about racism, bias and inequality and how they contribute to disparate health outcomes. Use an icebreaker such as the documentary “Unnatural Causes: Is Inequality Making Us Sick?” and make sure you tailor the event to fit your audience and create a respectful environment. Talking about inequity is not always a comfortable exercise—in fact, it can put some people on the defensive—but it is vital to gaining buy-in and shifting the focus from traditional disease prevention to tackling the social determinants of health. 7 PARTNER, PARTNER, PARTNER: Moving toward health equity means zeroing in on the social determinants of health, which also means that the public health sector can’t achieve health equity on its own. Transportation, housing, health care, employment, environmental quality, working conditions, education, child care, law enforcement—all of these sectors and many more have a role in creating the conditions that enable all people and communities to attain and sustain good health. Public health workers are uniquely skilled at convening players across sectors, and this skill will be invaluable in achieving health equity. 8 3 WITHIN YOUR COMMUNITY: Achieving health equity requires an empathetic approach that acknowledges a community’s history, respects its traditions, listens to its stories and actively engages its members as leaders in any health equity intervention. 4 COMMUNITY OWNERSHIP IS PARAMOUNT: Community participation is intrinsic to health equity work. This is probably a nobrainer for most practitioners, as community engagement is a fundamental component of public health work. However, ensuring that the community is involved in every aspect of health equity work—from data gathering to implementation to evaluation—is key. 9 10 BE MINDFUL OF HISTORY: Government and public policy played enormous roles in perpetuating the very biases, injustices and inequalities that created the health disparities and inequities we seek to address today. Be mindful that many communities are still very much experiencing and facing the effects of historical trauma. As a public official, coming into such a community with a predetermined plan and top-down approach only perpetuates that trauma. 5 FOLLOW THE DATA, BUT…: Data are essential to the work of public health. We need data to pinpoint problems, deploy resources, track progress, evaluate effectiveness and justify continued support. But in the work toward health equity, data can’t be the only driver. For example, worrisome data on prenatal care may lead you to initiate contact with a community. However, residents might have more pressing concerns, such as few employment opportunities, difficulties affording enough food and unsafe housing conditions. These are the issues you have to tackle first if you want to positively impact infant health in the long term. LET GO OF YOUR AGENDA: Avoid going into a community that has a long history of experiencing health and social inequities with a predetermined agenda. Instead, go in with an open mind and simply PAY ATTENTION TO PROCESS: The process of developing strategies to create health equity is as important as—and sometimes even more important than—the actual initiatives. If you can create a process for developing interventions that is truly community-driven and founded on trust, you have a better chance of sustaining momentum on the long journey toward health equity. KNOW WHEN TO STEP ASIDE: Despite your skills, experience, education and competencies as a public health practitioner, you might not be the best person to implement a strategy to create health equity on the ground. Many successful health equity efforts recruit and train workers from the community who have the same lived experience as the residents you are hoping to reach. Keeping this in mind will help build trust, community ownership and sustainability. Page IV | BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK SHIFTING THE DISCUSSION, APPLYING A NEW LENS Multnomah County Health Department, Oregon “When we talked about disparities it was simply reflecting the data. We weren’t telling the whole story, we weren’t talking about the structural pieces. …Until we started looking through a lens of race, power and poverty, we really weren’t moving upstream. Now we’re focusing on the conditions that lead to the outcomes we see.” — BEN DUNCAN FORMER PROGRAM MANAGER OF THE MULTNOMAH COUNTY HEALTH DEPARTMENT HEALTH EQUITY INITIATIVE AND CURRENT DIRECTOR OF THE COUNTYWIDE OFFICE OF DIVERSITY AND EQUITY I n 2008 and in the wake of a report on racial and ethnic health disparities in Multnomah County, Ore., local officials launched the Health Equity Initiative, a countywide effort to raise community awareness of the root causes of health inequities and put forth real solutions. The effort—led by the Multnomah County Health Department with strong support and participation from county leadership—began with the seemingly simple but critical step of encouraging honest, reflective and often challenging conversations about the connections between racism, injustice and health disparities. Those community conversations eventually led to the creation of the Equity and Empowerment Lens: Racial Justice Focus, a health equity tool that is slowly transforming the everyday work of public health in Multnomah County. BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page 1 VISUALIZING INEQUITY Tackling health equity in a meaningful way means confronting the social determinants at the root of poor health and engaging the officials and community stakeholders who are well positioned to drive change. But first, organizers in Multnomah County needed a way to jumpstart cross-sector collaborations, community conversations, and the slow, sustained drive toward systemic change. Taking on the social determinants of health would mean talking openly about oppression, racism and personal bias—topics that can make people uncomfortable or even defensive—and organizers needed an inclusive conversation starter. Health Inequity by the Numbers Out of 33 counties in Oregon, Multnomah ranks 15 in health outcomes. Some examples of health inequities in Oregon and Multnomah County include: In 2011, 26 percent of Multnomah County children younger than 18 were living in poverty, as compared with a statewide rate of 23 percent and a national rate of 14 percent. 26% Multnomah County 23% 14% USA Oregon An estimated 108,000 of Oregon’s children ages 0–6 are at risk of not being ready for kindergarten as a result of poverty, adverse childhood experiences, and other risk factors that are highly associated with or most often predicted by race and ethnicity. 108,000 In 2010–2011, only 63 percent of Multnomah County ninth-graders graduated from high school within four years, as compared with 68 percent statewide. Multnomah County Oregon 63% 68% Source: www.countyhealthrankings.org 3 http://www.unnaturalcauses.org/ To do that, staff from the Health Equity Initiative turned to film, specifically the four-hour PBS documentary Unnatural Causes: Is Inequality Making Us Sick?  3 In 2008, they began hosting local screenings of the documentary, using the film to develop a shared understanding of the social determinants that contribute to poor and disparate health outcomes. In all, the initiative hosted 57 screenings open to both county officials and community members, eventually reaching more than 500 people. The screenings had three main goals: raising community awareness, building the capacity to address inequity, and advancing relevant policy solutions. During the screening events, trained volunteers from county agencies and the community facilitated open and honest discussions on the topic. According to Ben Duncan, former program manager of the Multnomah County Health Department Health Equity Initiative and current director of the countywide Office of Diversity and Equity, Unnatural Causes “gave us new ways to talk about equity…the concepts and values weren’t new, but all of a sudden we had a language to talk about it.” “Unnatural Causes created a platform to shift the conversation from disparities to inequities—it was Page 2 | BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK a very intentional shift,” Duncan says. “We used the screenings as catalysts to start having conversations about what people were experiencing, but also to start thinking about the types of needed policies to address [health inequities] and the root causes that actually lead to lifelong negative health impacts. We went from a typical public health approach…and we created a vision for building partnerships, addressing issues like education, and getting engaged in activities that were traditionally out of the purview of public health.” “FINDING OUR TRUE NORTH”: APPLYING A HEALTH EQUITY LENS In the fall of 2012, the Multnomah County Office of Diversity and Equity launched the Equity and Empowerment Lens (E&E Lens, link on page 8) to address inequities in services, policies, practices, and procedures across the county. Based on the health department’s pilot equity framework, the E&E Lens was developed to help county agencies integrate key questions rooted in justice and inclusion into their decision making. The new movement was a priority—the county’s Office of Diversity and Equity had even created a new position dedicated to institutionalizing the lens countywide. In an introductory letter outlining the new equity lens, then health department Director Lillian Shirley wrote: “This work takes stepping into an unknown space, a space that makes us vulnerable. Answering the Lens questions and institutionalizing clear, systemically-based recommendations based on equity and empowerment requires us to be brave, courageous, and persistent in our efforts. Focusing specifically on racial justice is essential for the health of all of our communities, because racial and ethnic inequities are the most prevalent and pronounced according to our data.” The E&E Lens also benefits organizations by driving quality improvements, providing a more accurate assessment of client needs, and offering an enhanced ability to explain how the work and role of an agency contribute to the community. The E&E Lens leads agencies through nine questions that “seek to uncover patterns of inequities, separate symptoms from [the] actual causes of such inequities, and maintain the visibility of impacts on communities of color, immigrants, and refugees.” For example, questions urge agency officials and staff to consider which particular group will be affected by a policy or decision or to think about how certain processes contribute to the exclusion of populations that disproportionately experience inequities. At the county health department, according to Duncan, an administrative policy dictates that all programs use the E&E Lens. “You’ll see the language of equity within almost every program within the agency,” he says. T he lens can help workers realize that regardless of their competencies and professional education, they might not be best positioned to effectively deliver public health services within every cultural context. BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page 3 “There is no doubt that if you asked what a core value of the health department was, all staff would talk about equity.” H OUSIN CRIMIN A JUS T IC L E G TRANSP ORATIO N PU HE BL IC AL TH N ow, because of the deeper understanding of social deter- minants brought about by the equity initiative, public health is regularly at the table with officials from transportation, criminal justice, education, and housing. All agencies better understand their role in improving people’s health, and public health officials realize they can’t do it alone. As of late 2013, the health department was still in the process of fully integrating the E&E Lens. The department has dedicated equity staff and administrative policies in support of the lens, and achieving equity is part of the health agency’s strategic plan. “We’ve created the environment to move this work forward, and now it’s just about doing it,” Duncan says. Now the question is: What does using an equity framework look like in everyday public health work? One example is that the lens can help workers realize that regardless of their competencies and professional education, they might not be best positioned to effectively deliver public health services within every cultural context. It can be a difficult realization to have—and one that can put people on the defensive—but it “helps hold us accountable when we’re working with communities,” Duncan says. Five years after the Health Equity Initiative began, the health department released “Five Year Reflection: The Policy Crosswalk,” (link on Page 8) a report that served as a showcase for an equity framework in action. Among the many outcomes of looking through a new lens, the health department has formed new partnerships to shore up addiction and mental health services, has applied for grant support to engage in chronic disease management for people transitioning from correctional institutions, and is using its own position as a contractor of services to promote economic development via micro-enterprise projects, which are typically carried out by small businesses and entrepreneurs. The lens also makes it clear just how important policy is to both perpetuating and eliminating inequities. Now, because of the deeper understanding of social determinants brought about by the equity initiative, public health is regularly at the table with officials from transportation, criminal justice, education, and housing. All agencies better understand their role in improving people’s health, and public health officials realize they can’t do it alone. In fact, one of the health department’s biggest equity-related successes, Duncan says, is building the internal capacity to effectively partner across agencies. “There’s been a shift in direction; we’re finding our true north,” Duncan says. “What the lens symbolizes to the community is a commitment to do our work better, a commitment to good government, a commitment to values and principles. This work is coming from the research…but it’s the same thing communities have been demanding for years.” Page 4 | BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK EQUITY IN ACTION: Multnomah County T he following are examples of what a health equity framework looks like when it’s applied to traditional public health programs, which often involves a complete transformation in agenda setting, community engagement, collaboration and implementation. 1. FUTURE GENERATIONS COLLABORATIVE In Multnomah County, rates of poor birth outcomes, including preterm deliveries and infant mortality, are disproportionately high among women in Native communities, as is the prevalence of substance use before, during, and after pregnancy. Health department workers sought out a technical assistance grant to build the agency’s capacity to address these disparities in both traditional and nontraditional health settings. Photo by eyecrave, courtesy iStockphoto According to the Future Generations Collaborative, “historical and intergenerational traumas are emotional and psychological injuries that accumulate over time and across generations as a result of cultural genocide inflicted on Native peoples. …Historically and today, public health planning and actions in Native communities are often implemented without regard to the effect of historical trauma in these communities.” They took all of the steps typical to such work—collecting data, seeking buyin from the local Indian Health Board, and initiating the process of finding community partners. But as public health staff began engaging with stakeholders in the Native American and Alaska Native communities, all of their preconceived ideas about how to develop and implement an effective public health intervention began to fall apart. While they had set out with the best of intentions, they had overlooked a key foundational starting point: trust. “[The community] said we don’t trust you, we have no working relationship with you,” says Heather Heater, MPH, health educator at the Multnomah County Health Department. “We had to take 10 steps back. …Our organization had no institutional knowledge of how to partner effectively with Native communities.” It was a huge wake-up call for Heater and her colleagues, who then approached leaders at two local Native American service organizations on how to move forward. They began to engage in critical discussions about the role of government in creating and perpetuating inequities within Native communities. They shifted their focus from getting a service model in place to forming collaboration with the community. While healthy pregnancies were still the ultimate goal, the health department’s focus had dramatically shifted from programmatic to process. The outcome of that shift, the Future Generations Collaborative, was launched in 2011 with the aims of mending the relationships between Native communities and government entities and developing genuine community-driven solutions. As with most health equity efforts, however, it had to begin with open and honest dialogue. BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page 5 To facilitate that dialogue and build the Future Generations Collaborative, health workers and community members engaged in a trauma-informed collaborative process that acknowledged the government’s role in the health and social inequities experienced by Native communities and was rooted in the traditional ways of knowing and doing within Native cultures. This collaborative strategy, developed in response to community demand, recognized that trauma is the root cause of health disparities among Native peoples. According to Heater, the process isn’t set in stone or even based on the literature—instead, it’s constantly evolving to meet the community’s needs. I “We’re still really struggling with managing and institutionalizing our learning,” says Heater, who serves as the collaborative’s project manager. “We realized that this is what needs to happen—they need us to listen. We’ve heard stories about grandmothers and mothers being removed from their homes, forced sterilization, tribes being stripped of their status…what’s important is for people to teach us through their stories so we can learn. They’re taking a huge leap of faith in us.” f we really want to get to a place of health equity, we have to dismantle the systems that are preventing communities from reaching their full potential. Consistent with the collaborative’s health equity framework, the community is involved every step of the way, from identifying possible interventions to overseeing how data can be used. The collaborative is now entrenched in the community engagement phase, working to mobilize community members to identify the root causes of poor pregnancy health, the impact of historical trauma on prenatal health, and the strengths and aspects of Native communities that support women and families. As of fall 2013, eight key organizations were involved—such as the county’s Native American Rehabilitation Association and Native American Youth and Family Center—and about 20 elders and natural helpers had been trained as community organizers and facilitators. And many more community members want to join the effort: “We’ve never seen this kind of engagement before,” Heater says. “If we really want to get to a place of health equity, we have to dismantle the systems that are preventing communities from reaching their full potential,” Heater says. “That means examining how our systems perpetuate inequality…. The first day I was able to completely abandon my own agenda was the day I became a transformed professional.” 2. HEALTHY BIRTH INITIATIVE In Multnomah County, where African Americans make up approximately 6 percent of the population, African American babies are more likely than white babies to be born prematurely and at low birth weights. In addition, they’re more than twice as likely to die before their first birthday. Such disparate birth outcomes were the impetus for the health department’s Healthy Birth Initiative, which began nearly two decades ago and is still going strong. Page 6 | BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK In conjunction with direct public health services, such as in-home visits, health education and support groups, the initiative is tackling the social determinants that often lay the groundwork for poor maternal and infant health outcomes, such as lower educational attainment, underemployment and poor housing conditions. To successfully address those factors, the initiative has grown into a genuine partnership among program participants, stakeholder organizations, social service agencies and health providers. Program participants, all of whom are African American, are screened to determine their health and social service needs and linked with appropriate agencies and resources. In particular, the initiative is governed by a client-driven consortium that provides programmatic direction and assists with evaluation. The initiative also uses a culturally specific approach that reflects the needs and experiences of African American women and families, notes Rachael Banks, MPA, program director of the Healthy Birth Initiative. “The staff I work with reflect the communities we serve,” she says. “We’re very aware of the impact of racism on birth outcomes…and our success speaks to the value of hiring people who have a lived experience.” The initiative’s primary goals are to prevent premature birth and low birth weight, and to ensure that every baby sees his or her first birthday. But a bigger question, according to Banks, is how to get there. Indeed, a 2013 study that examined the perspectives of African American women who were seeking pregnancy care showed that their experiences “fit within a definition of institutionalized racism—in which the system was designed in a way that worked against their attempts to get quality prenatal care.” For example, study participants felt they were treated differently based on whether they had public or private health insurance and that the stigma they faced affected the quality of available care. An earlier study published in the American Journal of Public Health determined that lifelong experiences of racism were an independent risk factor for preterm delivery. I n conjunction with direct public health services, such as in-home visits, health education and support groups, the initiative is tackling the social determinants that often lay the groundwork for poor maternal and infant health outcomes, such as lower educational attainment, underemployment and poor housing conditions. Banks—who highlights the impact of racism by noting that college-educated African American women still tend to have poorer health outcomes than white women who have dropped out of high school—says that it’s essential for public health workers to address issues of systemic bias if they hope to improve health status. “For us, health equity means working on social connections, addressing institutional racism in the health care system, paying attention to insurance discrimination, addressing educational and economic needs and making sure the environments families live in are supportive and healthy,” she says. “It’s really hard to talk about racism—it’s not as tangible as talking about the dangers of BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page 7 smoking to birth outcomes…but the [health department’s overall] Health Equity Initiative has made it a lot easier.” Hand in hand with the communities it serves, the Healthy Birth Initiative has achieved some impressive outcomes, as follows. 88% of participants initiate early prenatal care; a rate that’s among the highest in the county. Birth weight: In 2010, 4.3 percent of infants born to mothers participating in the Healthy Birth Initiative had a low birth weight, in comparison with 6.3 percent among African American women living in the initiative’s service area but not enrolled in the initiative. The low birth weight rate among white women was 3.8 percent. Prenatal care: Eighty-eight percent of the participants initiate early prenatal care—that’s more than Multnomah County’s white population and higher than the county’s overall prenatal care entry rate. Also, about a third of Healthy Birth Initiative participants are self-referred, which is an indication of how well known the program is within the community. Housing and employment: Between 2008 and 2012, the percentage of participants who were linked to housing resources rose from 75 percent to 85 percent, and the percentage initiating use of employment services increased from 67 percent to 80 percent. The initiative aims to have 95 percent of women who have identified housing, employment and education needs linked with the necessary resources to make a difference. Banks says that while the Healthy Birth Initiative began many years before the Health Equity Initiative, the maternal and child health effort helped “lay the foundation and groundwork for the department really being intentional about addressing health equity.” “I feel really optimistic,” Banks says. “I think we now have a better understanding of health equity, and now the challenge is to make sure it’s an authentic understanding and not just a buzzword.” RESOURCES Equity & Empowerment Lens https://multco.us/diversity-equity/equity-and-empowerment-lens “Five Year Reflection: The Policy Crosswalk” https://multco.us/health/public-health-practice/health-equity-initiative Future Generations Collaborative http://multnomah.granicus.com/MetaViewer.php?view_id=3&clip_id=616&meta_id=39353 Healthy Birth Initiative https://multco.us/services/healthy-birth-initiative Cover photo children eating: Photo by Michael DeLeon, courtesy iStockphoto. Page 8 | BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK HARNESSING THE POWER OF CROSS-SECTOR COLLABORATION Menominee Indian Tribe, Keshena, Wis. “If we’re all trying to fight this battle, we should try to fight it together. I’m not getting anywhere by myself.” — JERRY WAUKAU, HEALTH ADMINISTRATOR, MENOMINEE TRIBAL CLINIC M enominee County, which is more than 85 percent American Indian, is the poorest county in Wisconsin and home to the state’s highest unemployment rate and worst health indicators. This is a recipe for adversity that even those with the best resources would have difficulty overcoming. For years, county and tribal officials witnessed and tackled the outcomes of social disadvantage and injustice within their own separate silos, addressing the same social determinants but from their different clinical, educational and social services perspectives. Then in 2003–2004, state education officials tapped the Menominee Indian School District as a “School Identified for Improvement.” At the same time, the Menominee Nation was struggling with significant health issues: the county scores higher than the state average on just about every negative health outcome for which there are available data. It was the proverbial “perfect storm” needed to jumpstart a community-wide transformation. BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page 9 AN EDUCATION IN COLLABORATION Health Inequity by the Numbers Out of 72counties in Wisconsin, Menominee ranks 72 in health outcomes. Some examples of health inequities in Wisconsin and Menominee County include: In 2012, 47 percent of Menominee County children younger than 18 were living in poverty, as compared with a statewide rate of 18 percent and a national rate of 22 percent. 47% Menominee County 18% 22% USA Wisconsin More than 15 percent of Menominee County residents 16 years or older were unemployed but seeking work in 2012; the overall rate in Wisconsin was about 7 percent. 15% unemployed Menominee County 7% unemployed Wisconsin In 2009–2011, 20.4 percent of low-income preschoolers in Menominee County were obese; in contrast, Wisconsin’s bestperforming county had a rate of 5.6 percent. Menominee County Wisconsin 20.4% 5.6% Sources: http://www.countyhealthrankings.org; http://www.ers.usda.gov/data-products/food-environment-atlas/go-to-the-atlas.aspx When the state singled out the Menominee Indian School District for improvement, local officials began digging deeper into the reasons behind the district’s poor academic achievement and high dropout rates. What became clearer to officials was that students faced significant challenges in the larger community—challenges that stayed with them during the school day and handicapped their academic ability, says Wendell Waukau, superintendent of the school district. In other words, in addressing the state’s evaluation of the Menominee Indian School District, W. Waukau and his colleagues began to readjust their contextual frame to view students within a larger social context. And what they saw turned the usual way of doing business on its head. “It was a paradigm shift of thinking about this as a dropout crisis to a public health crisis,” W. Waukau says. “Previously, we had thought the County Health Rankings were someone else’s report card, but we realized that those rankings apply to everybody. I don’t think anyone can hide from that.” Poor health outcomes and risky health behaviors, such as teen pregnancy, obesity and alcohol use, were making it difficult for Menominee youth to excel and stay in school. On the flip side, not having a high school diploma dramatically increased tribal members’ chances of a lifetime of disease and disability as well as premature mortality. In fact, the scientific literature is increasingly pointing to educational attainment as a key factor in good health across the lifespan and one of the most promising levers available to public health professionals and their community partners (see textbox on page 11). Page 10 | BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK EDUCATION: A LIFELONG ‘ELIXIR’ A 2013 study1 of thousands of young people in Norway showed that high school dropout was linked to long-term illness and disability, even after adjustment for factors such as family income and health-related risk behaviors. In 2007, the Centers for Disease Control and Prevention published an article2 calling on health professionals to reframe the dropout rate as a public health issue. The article’s authors wrote that “if medical researchers were to discover an elixir that could increase life expectancy, reduce the burden of illness, delay the consequences of aging, decrease risky health behavior, and shrink disparities in health, we would celebrate such a remarkable discovery. Robust epidemiological evidence suggests that education is such an elixir.” To tackle the school dropout problem, Superintendent Waukau turned to the Bridges Out of Poverty3 framework, a strategy and training program designed to bring together leaders from different sectors to address sustainable solutions to social and economic issues. According to W. Waukau, Bridges Out of Poverty helped him and his colleagues view students’ academic challenges within a larger, more holistic context and shifted the issue from a individual/family problem to a systemic/community problem. It also gave school and community officials a new way of understanding how historical trauma continues to shape the factors that lead to health and educational disparities. A trauma-informed framework recognizes the role that historical oppression and inequity play in shaping the social determinants that perpetuate poor health outcomes and low academic achievement. But perhaps most important, according to W. Waukau, the Bridges framework helped connect the dots between education and health and acted as a stepping stone for community-wide collaboration and engagement. “You can’t punish the behavior out of them,” he says, referring to students who act out in school or who are repeatedly truant. “You have to look at what’s going on in their lives so these kids can start to become resilient. …We’re out knocking on doors, we’re listening and asking what it will take to get kids back to school and connecting families with resources and assistance.” Among the community collaborators who participated in Bridges Out of Poverty was the Menominee Tribal Clinic, which serves more than 8,000 local residents. At the time the Menominee Indian School District was facing a significant truancy problem, the clinic was trying to address the community’s poor health rankings and outcomes, says Jerry Waukau, health administrator at the clinic. Clinic staff were beginning to realize that no matter how good the clinic was, no matter how many doctors it hired, patients would continue to face barriers to attaining and managing good health outside the clinic’s walls. The Bridges Out of Poverty training was made available to all clinic staff and changed not only how T he Bridges Out of Poverty framework and training program educates participants on topics that include intergenerational poverty and effective client communication, and teaches stakeholders how to use that knowledge to redesign programs and policies toward building a sustainable path out of poverty. 1 Source: http://www.biomedcentral. com/1471-2458/13/941 2 Source: http://www.cdc.gov/pcd/issues/2007/oct/07_0063.htm 3 Source: http://www.ahaprocess.com/solutions/community/ BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page 11 Courtesy Menominee Tribal Clinic Dental Clinic. clinic providers worked with patients, but also how they delivered services. And the focus on community collaboration remained key. “You don’t always see where a patient who lives in poverty is coming from,” J. Waukau says. “You think you have this great clinic, but if people aren’t accessing it then something is wrong.” T he Bridges training put the problem in better perspective and led to cross-sector collaborations between the clinic and education system that brought dental hygienists and oral health services into the schools. Health officials also integrated preventive dental care into local Head Start efforts and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Here’s just one example: If a patient misses three dental appointments, he or she is at risk of losing access to the clinic’s dental services; to maintain access, the patient has to appeal to the clinic’s Health Committee. This process meant both the clinic and patients were spending a great deal of time and resources reinstating people’s access to dental care without addressing the behaviors that led to missed appointments in the first place. According to J. Waukau, the Bridges training put the problem in better perspective and led to cross-sector collaborations between the clinic and education system that brought dental hygienists and oral health services into the schools. Health officials also integrated preventive dental care into local Head Start efforts and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Instead of waiting for residents to access care, the Menominee Tribal dental clinic brought care to the community. Because of such efforts, active tooth decay among Menominee children declined by 22 percent between 2001 and 2008. Also, the percentage of children with no history of tooth decay increased from 12 percent to 41 percent over that period. Bridges Out of Poverty not only compelled health workers to view patients in a more holistic sense but also pushed them to optimize existing community resources toward better health outcomes and, thus, better educational outcomes. “We’ve become more outcome focused and patient focused,”J. Waukau says. “First we have to create healthy individuals, then healthy families and then your community can heal.” Page 12 | BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK EQUITY IN ACTION: Menominee Indian Tribe T he following is an example of what a health equity framework looks like when it’s applied to traditional public health programs, which often involves a complete transformation in agenda setting, community engagement, collaboration and implementation. COMMUNITY ENGAGEMENT WORKGROUP Students pick up their diplomas during the 2012 graduation ceremony at Menominee Indian High School. That year, the school achieved a 94 percent on-time graduation rate. (Photo courtesy Menominee Indian School District) According to 2005–2006 data, only 68 percent of Menominee County ninthgraders graduated within four years, as compared with the statewide rate of 88 percent. In a testament to the community’s collaborative success as detailed in this case study, that rate rose to 93 percent in 2010–2011, surpassing the statewide rate of 87 percent. Source: www.countyhealthrankings.org Building on the momentum and lessons learned from the Bridges Out of Poverty training, the Menominee school district and tribal clinic formally partnered to address the intersections among academic performance, health outcomes and social determinants, eventually launching the Community Engagement Workgroup in 2010 and quickly attracting the attention, support and participation of fellow community agencies. The importance of child and adolescent health and well-being was a closely held value throughout the community, J. Waukau says, and became a rallying point for gathering support, as was aligning the workgroup’s goals with existing local efforts and the tribe’s strategic plans. Led by the Menominee Indian School District and Menominee Tribal Clinic, the workgroup is dedicated to developing partnerships to improve community health, with an initial focus on increasing graduation rates and decreasing childhood obesity rates. Ron Corn, who served as administrative coordinator for Menominee County until 2014 and participated in the workgroup, says that obesity was chosen as a target because good data were already available and having reliable baseline data meant stakeholders could measure their progress and hold each other accountable. (Menominee County has the state’s highest obesity rate.) In addition, nearly every community organization and agency has a role to play in reducing childhood obesity, whether directly (serving healthier foods or providing nutrition education) or indirectly (modeling healthy behaviors). Obesity is also an issue with substantial social contributors, such as the affordability of healthy foods or the availability of safe places to be physically active, and so a purely medical model is insufficient. On the school front, the positive health outcomes that come with declining child obesity could tip the scales toward better academic achievement. To move the collaborative effort forward and promote accountability, the workgroup developed a “grid” that matches existing community resources and initiatives to health indicators listed in the County Health Rankings report. The local school district and tribal clinic were among the first organiBETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page 13 zations to place themselves on the grid, with many more quickly following their lead. The workgroup also adopted a framework for creating 90-day implementation plans, which J. Waukau says helped jumpstart community action and boost accountability. The workgroup’s efforts are based on seven principles: promoting patient- and client-centered care, self-management of health conditions or health behaviors, linking community resources, breaking down barriers to support and use of resources, improving access to community resources, promoting traditional beliefs and values, and integrating trauma-informed principles. “People were operating in their own silos; everyone was just doing their own thing,” Corn says. “We got to a point where we realized we’re all in this together, and when we started seeing things from that perspective we started gaining our successes.” Schoolchildren at the Menominee Indian School District Keshena Primary School take part in the Smart Sack Program, which sends healthy foods home with young students every week. (Photo courtesy Menominee Indian School District) O ther short-term achievements include a new apple orchard next to the primary school, healthier school snacks, more fresh fruits and vegetables at local groceries and new guidelines for providing healthy food and beverage choices at Menominee Nation events and seminars. While the workgroup initiative is still quite young, success has been achieved in a number of areas. As of 2013, more than 40 local and external agencies and departments were involved in the community engagement effort, including Menominee County, the local Head Start program and the Shawano/Menominee County Health Department. In fact, enabling organizations and agencies that don’t directly focus on health and education to see their work as supportive of children’s health and academic achievement was a success in itself, says J. Waukau. Other short-term achievements include a new apple orchard next to the primary school, healthier school snacks, more fresh fruits and vegetables at local groceries and new guidelines for providing healthy food and beverage choices at Menominee Nation events and seminars. W. Waukau says that since the Bridges Out of Poverty training, more of the district’s students are taking college entrance exams and more are going on to pursue a college degree. In fact, the percentage of Menominee County ninth-graders who graduate within four years rose from 68 percent in 2005–2006 to 93 percent in 2010–2011. The workgroup was also able to secure funding to support a population health fellow whose responsibilities include collecting and analyzing relevant data and creating new monitoring and evaluation methodologies. Among its latest efforts, the group is participating in the state-led Fostering Futures project, which supports the Menominee Indian Tribe in examining the consequences of adverse childhood experiences and in using trauma-informed care to reach at-risk children and families. At the end of the day, support among community leaders and members has been absolutely key, J. Waukau says. “Ten years ago, the community wasn’t ready for discussions about poverty, it was just too painful,” W. Waukau adds. “But now when we sit at the table as Page 14 | BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK agencies, as families, as educators, as leaders and to have those conversations without judgment, without blame or shame…we can help create the conditions that allow people to make changes.” RESOURCES Menominee Nation Community Collaboration http://uwphi.pophealth.wisc.edu/programs/match/healthiest-state/find-the-bright-spots/ menominee-nation-community-collaboration.pdf Menominee Tribal Clinic www.mtclinic.net County Health Rankings www.countyhealthrankings.org Bridges Out of Poverty www.ahaprocess.com/solutions/community BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page 15 MAKING HEALTH EQUITY A COMMUNITY AFFAIR Virginia Department of Health “People are not opposed to the idea of [health equity] if it’s presented in a way that they can receive it—in general, people are open to fairness. The key is to know your audience, so they can understand it and relate to W hen Michael Royster, MD, MPH, arrived at the Virginia Department of Health in 2007, he brought a passion for health equity along with him. While narrowing health disparity gaps was already a priority focus at the state public health department, his arrival coincided with what may seem on the surface to be a minor philosophical shift, but, in reality, radically transformed how the agency it and be open to receiving works toward better health and community engagement. Instead of your message.” primarily focusing on typical health disparity data, public health prac- — KAREN REED, MA, DIRECTOR OF THE DIVISION OF MULTICULTURAL HEALTH AND COMMUNITY ENGAGEMENT, VIRGINIA DEPARTMENT OF HEALTH titioners would begin to equally examine the characteristics of inequities—in other words, what were the social determinants that shaped a person’s opportunities to attain optimal health? The department’s newly named Office of Minority Health and Health Equity (formerly the Office of Minority Health and Health Policy), with Royster at its helm, had reset its course to head far upstream to uncover the very roots of poor health and disproportionate disease burden. Page 16 | BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK TRAINING THE TRAINERS Health Inequity by the Numbers According to the 2013 America’s Health Rankings, Virginia ranks 26th in the nation. Some examples of the social and health disparities that lead to health inequity in Virginia include: Black residents are more than twice as likely to live in poverty as white residents, and black children are more than three times as likely as white children to live in poverty. Black residents are also more likely to live in neighborhoods with higher concentrations of poverty. Adult residents who report worrying about having enough access to healthy and affordable food are twice as likely to report being unhealthy as adults who do not have such worries to report. Virginia residents who report experiencing racial discrimination are more than twice as likely to report being in fair or poor health. They are also more likely to report higher frequencies of mentally unhealthy days. MORE SICK DAYS Sources: www.americashealthrankings.org/VA and www.vdh.virginia.gov/ OMHHE/2012report.htm Implementing a health equity perspective within the state health department—what Royster described as seeing health challenges through a health equity lens—didn’t happen overnight. First, staff within the Office of Minority Health and Health Equity, which Royster directed from 2007 to 2013 and which houses the state’s Primary Care Office and Office of Rural Health, began educating themselves on equity using resources such as the documentary, “Unnatural Causes: Is Inequality Making Us Sick?” In fact, Karen Reed, MA, director of the office’s Division of Multicultural Health and Community Engagement, says that “we were reading whatever we could get our hands on.” Despite a long-standing focus on disparities and cultural competency, understanding health equity and how to apply its principles to traditional public health work required new skills and knowledge, Reed says. Royster adds that while work within the minority health office had been somewhat sectioned off into silos, the new health equity focus allowed the staff to unite across different projects with different grant-mandated requirements. “You really have to start internally with your staff and within your organization,” says Royster, who now serves as vice president at the Institute for Public Health Innovation. “There’s always going to be a learning and growth curve, and it takes a long time for change to become integrated and sustainable. This is long-term work.” Along with the new perspective, the office changed its vision and mission statement to pointedly include health equity as well: its current mission is “to identify health inequities and their root causes and promote equitable opportunities to be healthy,” and its vision describes the office as a “policy change agent.” The office also expanded its strategic plan to make room for health equity and a greater focus on the social determinants of health. BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page 17 After educating themselves, staff decided to grow the conversation statewide, developing a train-the-trainer toolkit that teaches interested residents, stakeholders and organizations how to facilitate community discussions about health equity. During a two-year period, the equity office led approximately 100 training sessions with diverse audiences such as churches, colleges and volunteer organizations, Reed says. The training curriculum educates participants on health equity as well as how to host and facilitate screenings of “Unnatural Causes” on their own and integrate health equity into organizational missions. Of particular note, the training explains how anyone can play a role in promoting better health for all Virginians and creating health opportunities. For example, according to Reed, a church or scouting group may feel compelled to reach out to homebound residents after learning about the negative health effects of social isolation. “They can take this knowledge and work it into their [missions] because the puzzle I is big when it comes to the social determinants of health,” Reed says. “I think ‘Un- nstead of presenting health equity to audiences from an academic perspec- tive, consider simply talking to residents about their priorities for the community and what they believe most affects their health and their ability to stay healthy. natural Causes’ is having an impact. People are looking for real solutions to health problems, and in order to do that you have to do something different.” So how does health equity manifest itself at a programmatic level? One way is through a stronger commitment to community engagement, Royster says. The office uses a strategy known as the community-based participatory approach, in which community members are involved throughout a health promotion project or intervention and share in decision-making authority. Tenets of the approach include recognizing the community as a unit of identity, distributing relevant information and findings to all participants and building on a community’s existing strengths. The approach also requires going into a community with an open mind rather than a predetermined agenda. For instance, Royster says, instead of presenting health equity to audiences from an academic perspective, consider simply talking to residents about their priorities for the community and what they believe most affects their health and their ability to stay healthy. (To read about more about this approach, see the Equity in Action section on page 21.) To drive momentum, office staff and community stakeholders need to track their progress. One way to do so is to include equity and social determinants language in state health plans. For example, in the most recent version of the Virginia State Rural Health Plan, released in 2013, the authors call for increasing “awareness, engagement, and coordination among an expanded base of stakeholders to address the social determinants of health and promote healthy and equitable communities.” The plan also calls on local, regional and state policymakers to consider health equity in their day-to-day decision making. And instead of simply envisioning a future in which all rural residents have access Page 18 | BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK to quality health care, the plan envisions a future in which geographic distance, language and culture are no longer barriers to quality care. In other words, the plan directs energy toward leveling the playing field of health opportunities and targeting the conditions that make better health possible. MAPPING VULNERABILITY: THE HEALTH OPPORTUNITY INDEX The Virginia Department of Health’s “2012 Virginia Health Equity Report” served as a call to action on health inequities. The report introduced the new Health Opportunity Index (HOI), a tool designed to identify and analyze the social and economic factors associated with life expectancy and pinpoint policy levers that can be instrumental in expanding health opportunities and moving toward health equity. Royster says the idea for the HOI tool came from the department’s geographic information systems (GIS) staff, who assist public health practitioners in using the technology to map and predict disease trends. In essence, the HOI applies GIS technology to social and economic variables, using data at the census-tract level to map the distribution of determinants such as housing affordability, transportation availability and economic opportunity. When these geographic data are then viewed in conjunction with life expectancy data, the resulting maps make it easy to see that health-promoting opportunities are strongly correlated with how long people live, according to Royster, who notes that life expectancy in Virginia can vary by more than 25 years depending on where a person lives. At the end of the day, the tool underscores the notion that “place matters” when it comes to achieving health equity. B lack residents are most likely to live in areas with a low HOI score and least likely to live in areas with a high score—in fact, black residents are nearly four times as likely as white “It really does show the extent of inequity in Virginia,” he says. “Our goal is to raise awareness, to change the discussion around health and really broaden the strategies we use to promote equity.” The HOI consists of 10 indicators: education, environmental hazards (as designated by the U.S. Environmental Protection Agency), affordability of transportation and housing, household income diversity, job participation, population density, racial diversity, population churning (people moving in and out of a community), material deprivation, and local commuting patterns. The indicators are used to generate statewide color-coded maps that show the geographic distribution of communities with high health opportunities and those with low health opportunities. For instance, black residents are most likely to live in areas with a low HOI score and least likely to live in areas with a high score—in fact, black residents are nearly four times as likely as white residents to live in census tracts with a low HOI score. The color-coded maps make it easy to quickly pinpoint communities with low life expectancy—such as Richmond City, Danville, Pe- residents to live in census tracts with a low HOI score. The color-coded maps make it easy to quickly pinpoint communities with low life expectancy—such as Richmond City, Danville, Petersburg, Roanoke and Hampton Roads. BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page 19 tersburg, Roanoke and Hampton Roads—and see that they are also home to low HOI scores. The report concludes: “While race and poverty explain over 70% of the variation in life expectancy across Virginia, the HOI explains 87% of the variation in life expectancy at the state level. The HOI includes key socioeconomic, demographic and environmental processes that explain how race and class (and geography) influence health outcomes. In effect, the HOI helps answer the question ‘how do race and poverty (and geography) act to influence life expectancy?’” In addressing that question, the HOI succinctly illustrates the role policy can play in achieving health equity, and the tool can help guide effective policy development. It can also help communities and nontraditional public health partners, such as transportation and education officials, better understand their roles in improving people’s health, Royster says. He adds that public health staff throughout the health department are also using the HOI tool to prioritize their work and outreach. “It’s a powerful way to learn about equity,” he says. Page 20 | BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK EQUITY IN ACTION: Virginia Department of Health T he following is an example of what a health equity framework looks like when it’s applied to traditional public health programs, which often involves a complete transformation in agenda setting, community engagement, collaboration and implementation. MOSBY COMMUNITY HEALTH CONNECTION What does the community want? It’s a seemingly obvious question but one that, despite the best of intentions, even public health practitioners may neglect to ask. However, when it is posed to residents, it can have a powerful impact. Photo by monkeybusinessimages, courtesy iStockphoto. U sing the community-based participatory approach, the Connection first organized an asset mapping activity to identify community strengths as well as a “visioning” session to help residents “get excited about what Mosby could be and to help those who felt hopeless realize there was still hope for the community.” A few years ago, that very question came up in a meeting at Virginia Commonwealth University’s Center on Health Disparities, which was working to improve birth outcomes in Richmond. In response, staff decided to go into the community and find out. “We had been data driven and we decided it was time to see what would happen if we were community driven instead,” says Nannette Bailey, EdM, who at the time served as a program administrator at the disparities center. So in 2008, in partnership with the Office of Minority Health and Health Equity, Bailey and her colleagues reached out to nearby Mosby Court, a public housing complex east of downtown. They approached the Mosby Tenant Council to ask whether the community would be interested in forming a partnership aimed at improving residents’ health. According to Bailey, the council responded with serious hesitation. They were interested but noted that the university had come into Mosby Court before with promises of opportunity and improvement that had never materialized. Fortunately, Bailey and partners found a champion in Cynthia Newbille, a local city councilwoman who herself had grown up in public housing and spoke in support of the health project. And so the Mosby Community Health Connection was born. “It was really hard to hear, but we needed to be open to residents telling us why they had trust issues,” Bailey says. “We needed to listen to their stories to be able to address them.” Using the community-based participatory approach, the Connection first organized an asset mapping activity to identify community strengths as well BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page 21 as a “visioning” session to help residents “get excited about what Mosby could be and to help those who felt hopeless realize there was still hope for the community,” Bailey says. Soon after, work began on developing a survey to gather information on what residents believed to be the community’s priority health issues. Bailey notes that residents were initially concerned about who would have access to the survey data, “but we reassured them that this was their information and they would own it.” The survey was conducted in the fall of 2008 during a Mosby Court community day, and approximately 100 people took part. Interestingly, respondents tapped a number of social determinants as top issues. For instance, many residents said they wanted a medical facility in the Mosby community, as it was often difficult to obtain transportation to nearby health clinics or the hospital. They also called for a safe place for their children to play and be outdoors as well as coordinated children’s activities. Birth outcomes— the original health topic the Center on Health Disparities had wanted to address—were a low priority for residents. “Residents talked about diabetes, asthma, violence, access to healthy foods, housing issues, transportation, general barriers to economic opportunity—their lived experience naturally leaned toward the social determinants of health,” Royster says. “We, as public health professionals, oftentimes think of health out of context…but someone living day to day in this environment can see these connections on a daily basis.” The Mosby Community Health Connection launched a “photovoice” project to address the issue of youth engagement. During the project, local middle school students took photos of what they believed to be barriers to good health. Their photos captured images such as a rundown house, a convenience store where the only healthy foods were canned vegetables and a recreational facility for young children that had little to offer to adolescents. The photovoice project was a success and eventually led to the launch of the Youth Health Equity Leadership Institute, which engages youth in developing leadership skills and in creating or improving health opportunities in Mosby Court. Its curriculum covers not only health equity and social determinants but racism, conflict resolution, advocacy, community organizing and assessment, critical thinking and much more. “The institute was an opportunity to really demonstrate the importance of community-based participatory work in which residents are involved as equal partners to help create change in the community,” Royster says. Around the time of the survey, the city was beginning to build health facilities back into public housing communities, but Mosby Court wasn’t being considPage 22 | BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK ered, Bailey says. With the help of the new Connection partnership and the support of Councilwoman Newbille, city officials put Mosby on the list. In 2011, the new Mosby Resource Center, a partnership among the university’s School of Nursing, the Mosby Tenant Council, the Richmond City Health District and the Richmond Redevelopment & Housing Authority, opened its doors to offer residents a range of health and social services. Bailey says that among the lessons learned from the experience is developing steps for action and keeping active, “as people will get discouraged with you if you do more talking and less moving.” She also notes that it was critical for residents to believe that better health was, indeed, within reach. The Mosby Community Health Connection continues to hold meetings every month. “Some residents had discounted themselves and their ability to achieve a level of health,” Bailey says. “It helped them to see that good health belongs to everybody, that we deserve good health just like everybody else and we have the ability to ask for it and go out and get it.” RESOURCES Virginia Office of Minority Health and Health Equity www.vdh.virginia.gov/OMHHE Health Equity Training of the Trainer Resources www.vdh.virginia.gov/OMHHE/healthequity/unnaturalcauses/resources.htm 2012 Virginia Health Equity Report www.vdh.virginia.gov/OMHHE/2012report.htm Mosby Community Health Connection www.slideshare.net/vahealthequity/community-connections-for-health-vcus-center-onhealth-disparities-community-engagement-initiative-with-mosby-court Youth Health Equity Leadership Institute www.facebook.com/pages/Youth-Health-Equity-Leadership-InstituteYHELI/183074925201961?ref=stream www.institutephi.org/our-work-in-action/research-evaluation/youth-health-equity-leadershipinstitute/? BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK | Page 23 INTEGRATE AND OPERATIONALIZE: RECOGNIZING EQUITY EVERY DAY Colorado Department of Public Health and Environment Environmental Justice L Collaborative’s mission is the agency began to ask: Why aren’t we making more profound progress “The Health Equity and to build an organizational ike most health departments, the Colorado Department of Public Health and Environment has long been working to address community disparities in health status, disease rates and access to care. Still, a few years ago, a group of public health practitioners within in closing disparity gaps? What are the social determinants of health that we need to address more comprehensively to truly make the elimination culture that empowers of health disparities a reality? The answer was shifting from a framework and supports staff in of disparities to one of health equity. With roots in the department’s Pre- addressing equity and environmental justice.” — MAURICIO PALACIO, MS, DIRECTOR, OFFICE OF HEALTH EQUITY, COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT vention Services Division, achieving health equity is now a cross-cutting priority goal for the state public health and environment department, which has cultivated support for equity not only in the department’s ranks but also among state policymakers. Today, at the Colorado Department of Public Health and Environment, health equity is much more than a goal—it’s a standard of everyday public health practice and the driving idea behind a new workplace culture. Page 24 | BETTER HEALTH THROUGH EQUITY: CASE STUDIES IN REFRAMING PUBLIC HEALTH WORK ROOTS OF CHANGE Health Inequity by the Numbers According to the 2013 America’s Health Rankings, Colorado ranks 8th in the nation. Some examples of the social and health disparities that lead to health inequity in Colorado include: The percentage of Colorado residents living below the poverty line increased from 12.6 percent in 2009 to 13.4 percent in 2011. In addition, the percentage of Colorado children younger than 18 living in poverty rose from 14.4 percent in 2008 to 17.7 percent in 2011. Overall, three in 10 Colorado residents live at or below 200 percent of the poverty level. Nine in 10 white Coloradans report that they can easily buy healthy food in their neighborhoods, as compared with eight in 10 Hispanic adults and seven in 10 black adults. 90% whites 80% hispanics 70%blacks In Colorado, the school dropout rate among American Indian, Alaska Native, Hispanic and black students is two to three times higher than the rate among white and Asian students. Overall, one in 10 Colorado residents do not have a high school diploma or equivalent diploma, and less than 64 percent of children 3 to 5 years old are enrolled in nursery school or kindergarten. 10% Colorado residents
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Running head: RACIAL AND SOCIAL STRATIFICATION

The Effect of Modern Day Racial and Social Stratification on African Americans
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RACIAL AND SOCIAL STRATIFICATION

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The Effect of Modern Day Racial and Social Stratification on African Americans
Racial and social stratification are still prominent in the United States in spite of the
measures which different stakeholders are adopting to contain the problem. While the country
has adopted a wide range of strategies to end discrimination of any form in the United States,
especially racial discrimination, it is important to note that the practice is still rampant in the
United States. The African Americans are some of the groups which are worst hit as a result of
the problem in the country. Since the era of the slave trade, African Americans in the United
States have faced a wide range of racial and social discriminations, and these have had adverse
effects on their life in the country. Racial and social stratification affect the social, economic, and
cultural aspect of the lives of African Americans. In areas such as education, healthcare and
access to the justice systems, the African Americans have always faced a tremendous level of
discrimination. These issues have in many cases had adverse effects on the status and quality of
life of the African Americans. The modern-day racial and social stratification has denied African
Americans an opportunity to have equal access to education, healthcare, and the justice systems
and that has had adverse effects on the status and conditions of their lives.
African Americans’ access to education in the United States
Access to education is an important factor which impacts the well-being of any
individuals in any county. Apart from access to the economic resources in the country, education
also plays an important role in helping individuals to fit into society. While examining the access
to education among African Americans, many people usefully forget about the discrimination
which African Americans faced in the education sector before the onset of the Civil Rights
Movement. During this period, African Americans did not attend the same schools as whites.

RACIAL AND SOCIAL STRATIFICATION

3

They schooled in separate environments where there was poor infrastructure as well as lowquality conditions of learning. The whites were determined to ensure that African Americans did
not receive the highest quality of education. After the Civil Rights Movement of the 1960s, there
was a change in the approach to the provision of education since it was no longer legal to
practice segregation in education. The period of the 1970s was a significant increase in
equalization funding, and that was evidenced by the increase in the performance between African
American and other minorities against the whites in major national tests such as the National
Assessment...


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