How Monterey County is advancing health equity using a Health in All Policies framework

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June 14, 2018

About this case study

This case study is part of a series developed by the Berkeley Media Studies Group and supported by The California Endowment (TCE) that highlights the innovative work local health departments in California are doing to advance health equity. The Monterey County Health Department was one of three groups in the state recognized at "Advancing Health Equity Awards 2017: Highlighting Health Equity Practice in California Public Health Departments," a ceremony and set of awards created by The California Endowment and administered by a planning committee representing leaders in the field, to elevate promising practices among local health departments. The awardees received grants of $25,000, and MCHD was selected for the prestigious Arnold X. Perkins award of $100,000, given to the most compelling example of work to boost health equity. The awards and case studies, along with a suite of companion videos, were created to inform and inspire other health departments looking to engage in similar efforts.

To access the series on BMSG's website, visit: http://www.bmsg.org/resources/publications/advancing-health-equity-awards-2017-highlighting-innovative-practice

To access the series on The California Endowment's website, visit: http://www.calendow.org/wp-content/uploads/Health-Equity-Case-Studies-2018-web-optimized.pdf

To see the award-winning health departments in action, visit: https://www.youtube.com/playlist?list=PLLwLn83VLbvxIzuUc28CM2xLQ2GcdeUU1

Introduction

Ramona Villagrana, a resident of King City in Monterey County, works nights harvesting spinach. During her 28 years of gathering produce for the agricultural industry, she has often endured extreme temperatures and harsh conditions, but she presses on because she needs the job.

Like most residents in Monterey County, Villagrana is Latina. She is also a monolingual Spanish speaker, and without robust social supports, it would be easy for her and others like her to become isolated and unable to weigh in on issues affecting her family and community.

enlace logoTo keep that from happening, the Monterey County Health Department (MCHD) is investing in programs like enLACE (Leadership and Civic Engagement Academy), which means "to connect" in Spanish. The eight-week program, offered by the health department, is designed to help residents become more engaged and better understand the link between civic participation and community health. It is part of a larger health department strategy aimed at advancing health equity, or the ability of all people, regardless of their race/ethnicity, gender, age, ability, or income, to be healthy.

Through enLACE, residents can learn about everything from safety and prevention to budgeting and policymaking. They also gain insight into the health implications of policies, such as housing ordinances, which may determine how many homes in residential developments are affordable to low-income households, and transportation policies, which can influence how easy or difficult it is for people to walk and bike within their neighborhoods.

Villagrana, who joined an enLACE cohort in King City, said she learned about nutrition and health, how government funds are distributed, and where to go to make requests on behalf of her community.

"My participation in enLACE has helped me work in a different way, to communicate in a different way, to know where to find information," Villagrana said, through a translator. "enLACE makes you see life in a different way," she added.

Although the program is transformative for many of its participants, health department leaders are modest about their role in supporting enLACE, which they say is one of MCHD's responsibilities to the community.

"Working in the fields is very hard labor," County Health Director Elsa Jimenez said. "I feel that it's our obligation to help those individuals achieve positive health outcomes and be able to obtain their fullest potential."

That Villagrana could participate in enLACE is largely a credit to its locations. Unlike many programs and services, which are concentrated in cities such as Monterey and Salinas, enLACE meets residents where they are.

"If all the services come here, people will be there to attend them," Villagrana said. "Many people don't attend programs because it's too far away; they don't have a way to get there. And even if they take the bus, it stops in every location, so if you have an appointment, you sometimes can't make it in time. … I would really like [more services] to be in our community. They shouldn't forget us."

Keeping in mind the county's demographics — according to U.S. Census Bureau data, about 58 percent of residents are Latino, and more than half speak a language other than English at home — MCHD offers its enLACE sessions in Spanish, when needed.

"It's been a huge success to be able to offer it in Spanish with people who aren't traditionally at the table," said Carmen Gil, a Health in All Policies manager at MCHD. "They're the ones that are being impacted by these policies, so they should have a say in them."

Now, thanks to enLACE and other health department-supported efforts, residents like Villagrana are gaining a voice in local decision-making and becoming self-assured, powerful advocates.

"We really recognize residents and the power that residents have to make change," Jimenez said. "We recognize that it's our responsibility as local policymakers, as decision-makers, to really prioritize those communities that are most disenfranchised, most underserved, and allocate our resources to provide services to them."

This case study explores how MCHD is doing just that. It examines the local context for the health department's work, the framework MCHD is using to collaborate with partners and elevate the role of health in policymaking, the challenges they have overcome along the way, and lessons learned.

agriculture in Monterey

A tale of two Montereys

Located along the Pacific Coast, Monterey County has become known for its rugged shoreline, sweeping ocean views, and majestic mountain landscapes. It is home to scenic Big Sur, the Monterey Bay Aquarium, and a variety of other tourist attractions. But the health department's Jimenez wants to shine a light on an important aspect of the county that often gets overlooked.

"Many people, when they think of Monterey County, they think of Pebble Beach, they think of Carmel Beach. Many times, they think of the wine industry," Jimenez said. "I would hope that they would think of agriculture because we are known as the salad bowl of the world."

Monterey County attracts immigrants from Mexico and other parts of Latin America who bring their knowledge of agriculture to form the backbone of the area's food production.

Many of the farmworkers "are really here doing the work that most Americans will not want to do," Jimenez said.

Jimenez explained that many immigrant households are financially insecure, despite the great wealth that surrounds them: "We have, I guess I could say, both ends of the spectrum, in terms of having families with very low income struggling to make ends meet, yet are feeding the world in terms of produce. And, on the other end, we have individuals with lots of money that have summer homes in Pebble Beach."

In addition to income inequality, many residents lack safe, affordable housing, access to employment opportunities, and access to preventive care. "Monterey County still has anywhere between 30,000 and 60,000 residents that are not able to have health care coverage because of their documentation status," Jimenez said.

This combination has fueled poor health outcomes and health inequities.

According to Jimenez, Monterey County faces disproportionately high rates of diabetes and other chronic conditions among the county's communities of color. Countywide, heart disease is the number one cause of death, and the county's Latina population has a high teen birth rate.

For Jimenez, who grew up on a cattle ranch in King City, eliminating these and other health inequities is more than a professional interest; it is a personal mission. "Being a person of this community, it brings me great pride to be able to come back after I pursued my education and be able to provide my public service," she said.

"I feel that it is my obligation to make sure that individuals do have access to opportunities that will help them have a healthy life and achieve positive health outcomes," Jimenez added. "I take my responsibility very seriously … and am surrounded by individuals that will really help to serve the most disenfranchised in our community."

A framework for advancing health equity

community members

In 2011, during the process of developing their strategic plan, pursuing accreditation, and completing a community health assessment, MCHD staff discovered from conversations with residents and analyses of county health data that they needed to address the county's health issues by focusing on systemic and structural causes of poor health, rather than looking primarily at services and individual lifestyle changes.

To better understand what residents' most immediate needs were and what barriers were keeping them from leading healthy lifestyles, MCHD organized several community dialogues.

"We brought out residents, businesses, [and] community-based organization representatives to really begin to kind of tell us what their challenges were with respect to achieving positive health outcomes," Jimenez said. "The community was really very vocal about how the environment that they lived in was preventing them from being able to practice healthier lifestyles," she added.

For example, Jimenez recalled, residents who lived in areas plagued by violence could not provide safe places for their children to play, even if they had parks nearby; people without grocery stores within walking distance were hard-pressed to find fresh produce at affordable prices; and people without transportation access said they had trouble making it to medical appointments.

After hearing these and other stories from residents, Jimenez said that the health department discussed how they could "help to marry that information with health statistics to be able to put forward strategies that would help to begin to address those gaps."

They identified three areas of focus: helping to empower the community so that they could advocate for policies to improve health; enhancing health and safety through prevention, with a particular focus on addressing violence — especially among youth; and ensuring that health department services were culturally and linguistically appropriate.

To make progress in these and other cross-cutting areas, MCHD decided to adopt a framework called Health in All Policies (HiAP), which they learned about while participating in the California Leadership Academy for the Public's Health, a group that helps leaders across the state develop the skills and build the capacity they need to address the social determinants of health.

Through the HiAP framework, now embedded within the health department's strategic plan, MCHD fosters collaboration among multiple sectors and engages with a wide variety of partners, many of them nontraditional, to make sure that all government decision-making considers the influence its policies, programs, and practices will have on health. These partners include staff from other government agencies, community leaders, educators, advocates, and residents.

"Health in All Policies is really a framework for looking through a health lens at all potential intended or unintended consequences and impacts to health as we move recommendations forward, whether it be policy changes or program changes," Jimenez explained.

After adopting the framework, MCHD created a Planning, Evaluation and Policy Unit (PEP), as well as a HiAP manager position to implement Health in All Policies. To maximize its effectiveness, MCHD uses HiAP together with what is known as a collective impact approach, which means all partners share a common agenda and measures of progress as they work toward solutions, even though their individual roles vary. In MCHD's case, they provide "backbone support" through funding and staffing to coordinate the various partners involved in the initiative.

Additionally, achieving health equity is now a strategic priority for the County Board of Supervisors. After gathering best practices from early practitioners of HiAP and from the HiAP Guide for State and Local Governments, MCHD staff began making presentations on HiAP to the board. Once the board approved it, the stage was set for MCHD to start reaching out to other nontraditional partners, such as affordable housing developers and community-based organizations.

"Our elected Board of Supervisors are pretty progressive," Jimenez said, noting that the group is also quite representative of the community, with two Latinos and two women sitting on the board. "They definitely see the connection between the environment and individuals' opportunities for achieving positive health outcomes, for obtaining college degrees, for finishing high school, for obtaining employment," she added.

Though it has only been in place since 2012, HiAP has already opened the door for MCHD to look at county planning agency documents through a health equity lens and provide feedback. Now, Jimenez explained, MCHD is at the decision-making table for any new environmental projects.

For example, when a local agricultural company was planning to build a new housing site for farm workers, the health department not only reviewed the application, provided recommendations, and shared best practices, but staff and HiAP committee members also met with the architect and project manager to provide feedback on the design and use of the facility. For instance, they requested a community room, which provides opportunities through partnership with local community institutions and nonprofits for dissemination of health information to the workers. Additionally, vaccines can be administered, and institutions like the local community college can provide English and GED classes.

MCHD has also leveraged HiAP to create a collaborative process for incorporating health equity assessments into the County Planning Department's land use reviews. Health equity has since become a part of the decision-making process for everything from wind turbine projects to groundwater extraction to transportation projects. As the result of one such review, considerations for the location of a wind turbine included an analysis of noise impacts and proximity to people's homes.

Another success is MCHD's collaboration, in 2013, with The California Endowment-funded Building Healthy Communities East Salinas. Together, the groups made the case for getting a "quality of life" section added to the economic development plans for the city of Salinas. As a result, Salinas now more actively engages community members in its planning processes.

To further support efforts to advance health equity, the Board of Supervisors is also encouraging decision-makers to look at health through a racial lens. Through the Government Alliance on Race & Equity, "they are now supporting a group of county employees to participate in a statewide cohort that is providing them the tools and the promising strategies that have worked in other communities to help transform government and really, truly govern for racial equity and health equity," Jimenez said.

While MCHD is increasingly focused on addressing the underlying social and environmental causes of poor health, those efforts are in addition to, not in place of, more traditional health department work, such as connecting people to health services. For example, to reduce the number of people without access to preventive care, MCHD has worked together with California Rural Legal Assistance, Central Coast Center for Independent Living, and Communities Organized for Relational Power in Action to get the County Board of Supervisors to fund a $500,000 pilot project that will provide critical medical services to the uninsured, including undocumented immigrants.

The goal is to "get individuals into primary prevention services so that hopefully we can identify conditions before they develop," Jimenez said.

The value of partnerships

Health department staff know that to be successful in advancing health equity, they must collaborate with others, including groups that have not traditionally thought of their work as health-related.

"Through HiAP, we have been given the opportunity to work outside our field," said MCHD's Gil, who manages the department's HiAP efforts.

A prime example of MCHD's work with nontraditional partners is its involvement in the Active Transportation Program (ATP), which is a collaboration among five Salinas Valley cities, the health department, and the local Transportation Agency for Monterey County (TAMC). Gil described the city of Gonzales, a community where one of the ATP projects is taking place, as a "tight-knit" and "family-oriented" community — one with a lot of diversity but also a lot of poverty. The area's working-class families often hold multiple jobs and do not enjoy the same level of resources as some other communities in the county. Gil said smaller communities like Gonzales often get left behind because they do not have a large team able to pursue the grants needed to bring in critical services.

ATP projectTo help remedy this, in 2014, the health department coordinated a regional grant proposal to CalTrans, the state of California's transportation authority, for infrastructure to improve active transit — and health — in Gonzales and the four other partnering cities. The proposal was accepted, and CalTrans awarded $4.6 million to increase walking and biking in the Salinas Valley region. MCHD continues to convene the five cities regularly to discuss infrastructure disparities and upgrades.

Prior to the grant, the sidewalks surrounding one of Gonzales' most heavily trafficked routes — where its community pool and elementary school, which serves more than 900 kids, are located — lacked important safety features and were not fully ADA accessible. Now, thanks to the ATP grant, as well as other funding, the area has the appropriate ramps, which benefit people with disabilities, as well as parents and grandparents bringing children through the area in strollers. Several sidewalks have also been repaired or replaced, and the city has made access to its alleys much safer by pouring concrete and pavement into the crossings, which used to be made of dirt and gravel.

The grant also allowed the city to better identify how people travel throughout Gonzales, with a special focus on the west — and oldest — side of town, which has the greatest need for improvements.

"The major health component is [to] keep people out of their cars and get them walking and exer-cising when they don't even realize they're exercising," Gonzales City Manager Rene Mendez said.

So far, the community has reacted with support, despite interruptions to things like parking locations and street crossings. "I think the community's been very happy," Mendez said. "They've gone to the council and thanked the council for doing it and so forth, so it's been real positive."

The health department's Gil described this collaboration as one of MCHD's "aha projects." "Through this grant, we had the opportunity to really sit at the table with engineers. … I think it's been a learning experience for both them as well as for us," she said. "We're learning how to speak engineering language, and they're learning about health, and so it's two completely different disciplines coming to the table with people who haven't necessarily engaged in conversations before."

Mendez echoed the importance of cultivating such relationships. "We typically don't have the technical staff necessary to lead these efforts by ourselves and to go out and get that staff," he said, adding, "[This work] is very expensive, so the partnership with the County Health Department helps us leverage the experts in this area."

Mendez also emphasized that the partnership between the city of Gonzales and MCHD began years before this specific transportation grant. Rather than starting from zero, they were building on an already vibrant relationship. Gonzales had previously contracted with the health department to conduct a health assessment of their community to uncover some of its main challenges, including walkability and health care access.

According to Mendez, prior to the health assessment, Gonzales only had one doctor and one dentist. Now, because of the city's partnership with the health department and a local health nonprofit, they have a new health facility, four additional doctors, one additional dentist, and they have grown their local pharmacy.

Additionally, the city has partnered with the health department to fund a shared fellow whose goal is to improve health equity in Gonzales. The fellow is convening a group of residents to get input on what kinds of health improvements they would like to see and then using their feedback to write a health element into the city's general plan. The health element will make clear the need for healthy neighborhood conditions and will illuminate the connection between economic development and health.

"At the end of the day, we want to improve the quality of life for our residents, and … health equity is a very monumental thing to making you feel comfortable in your community," Mendez said.

"There's no magic to this," he added. "I mean, if you have access to health care locally, you'll use it. If you have good parks and ability to walk around in your community and feel safe and secure, you'll stay in your community. You'll come out. You'll tend to exercise more. That's one of the things that we keep hearing is, 'We want a safe place just to exercise, to take our families.'"

In 2015, the health department staff applied for and are in the process of receiving another cycle of these funds that will continue to support their equity efforts in these communities. The new funds will bring in additional Safe Routes to Schools programming for Salinas Valley schools, more opportunities for residents to get civically engaged, and Ciclovía, or open streets events, for the five partnering communities.

Seeking out and elevating community voices

In addition to engaging with cities, MCHD has used HiAP to forge strategic partnerships with community-based organizations working on issues such as housing, transportation, and more. MCHD staff are part of many community coalitions and collaboratives working to advance health equity, including Impact Monterey County, Community Alliance for Safety and Peace, and the Coalition for the Prevention of Senior Homelessness. Each of these groups is cross-sector and includes a range of individuals, from elected officials to researchers and social workers.

With these and other collaborations, MCHD tailors its role based on the groups it is working with. For example, after staff from MCHD's Behavioral Health Bureau discovered a serious service gap in mental health and substance abuse treatment for residents in the southern part of the county, the health department became involved in a group of nonprofit providers, government officials, and community members working to increase services; however, rather than taking on a decision-making role, MCHD found that its staff members were most needed to handle the group's administrative duties, which freed others to take on leadership roles. At other times, MCHD fills a leadership position, as the department did when it co-sponsored several trainings to support the social equity work of the Nonprofit Alliance of Monterey County, which represents more than 100 nonprofit agencies.

According to MCHD, partner organizations tend to be highly responsive to health department requests for support or collaboration. This reflects the fact that MCHD has long valued community partnerships and has made them a priority in their work.

Like most health departments, MCHD also plays a traditional role of culling data from birth statistics, death statistics, and other sources to demonstrate what the community's health outcomes are, where the inequities are the greatest, and where resources need to be allocated. However, the health department's Jimenez stresses that data are no substitute for hearing directly from residents about the problems they face. That's why MCHD gathers input from community members and analyzes data with their feedback in mind.

"What's most critical is assessing the community, having the community voice at the table, and really starting where the community is," Jimenez said. "Until we can engage, gain their support and their trust, and begin to address what their immediate concerns are, we may not be successful in helping to address what the data is telling us that we should address. So, as a department, we always find that balance — between what we're hearing from the community and what statistics are telling us — to really help shape and provide direction for how we allocate our resources."

To further elevate community voices, MCHD urges residents to become personally involved in the civic process and offers programs and resources to provide them with the knowledge and resources they need to do so. The enLACE program that Villagrana joined embodies this aim.

While Villagrana focused mostly on learning about nutrition and government budgeting during her time in enLACE, other participants in the program use the opportunity to better understand local and state decision-making. Through enLACE, community members can go on field trips to council meetings and other gatherings, such as ENACT day (an annual day of advocacy in Sacramento), and learn ways to become involved as advocates.

"Some of those folks have never attended a city council meeting, and so they begin to feel empowered now that they have knowledge [about how] to contribute to the conversation," Gil said.

enLACE participants learn who their local leaders are, how decisions are made in their community, and when critical timelines are coming up. This gives them the knowledge they need to be part of the process and "actively voice their concerns and suggestions or solutions," Gil said, noting that once enLACE participants have established relationships with elected officials and other leaders, they are not afraid to pick up the phone later and alert them to a community concern.

A wide range of people participate in enLACE, from college professors to farmworkers, and MCHD offers the program mostly in underserved communities, such as rural King City, East Salinas, which is primarily Latino, and Seaside, a beach community with its own set of challenges. So far, about 100 residents have graduated from enLACE. Many of these participants remain in contact with their elected officials and with the Health Department long after the program ends.

"We've seen great transformation with this program," Gil said. "Once they graduate, we don't just leave them behind. We continue to follow up with the alumni and support their ideas and projects afterwards."

In King City, for example, enLACE graduates were active in creating district elections, and in Greenfield, they secured a grant to improve physical activity and now hold weekly Zumba classes for the community. Many other participants go on to join community coalitions and collaboratives that the health department works with so that they can provide input when MCHD makes decisions about programs or policies.

One enLACE graduate, Maria Martha Ramirez, became involved in what's known as the Alisal Vibrancy Plan in Salinas. While the city was working to revitalize its downtown — a more affluent part of Salinas — the health department, along with Building Healthy Communities East Salinas, residents, and other partners, talked with council members about the need for a similar revitalization plan in the Alisal neighborhood, one of Salinas' disenfranchised areas on the east side of town. The group succeeded, and the Alisal Vibrancy Plan is now being supported through the city's economic development element.

A native of Salinas, Ramirez moved away for her education but returned because she wanted to give back to her community. "I came back to do community service, volunteering — I wanted to see what kind of organizations were out there to make a difference, if there were like-minded people like me," she said.

Ramirez said she thought the Alisal Vibrancy Plan could help forge community bonds in parts of the city that did not seem united and explained that enLACE prepared her to participate in the plan by helping her understand how the city council works and how the area's environment affects the health of its residents.

"It's important for community members to be involved because it does give them a voice, and it helps them," Ramirez said, noting that this kind of engagement builds self-esteem and has the potential to lower stress and improve health.

Ramirez also participated in Adelante Con Orgullo Mujer Inmigrante (ACOMI), a health department-supported conference and community resource fair devoted to immigrant women. The day-long annual event, which began in 2012, provides participants with a series of educational workshops aimed at improving farmworkers' health. More than 100 community members from across Monterey and neighboring counties participate each year and are offered free transportation to attend through a partnership with Monterey-Salinas Transit.

ACOMI gathering

Tailored communications

To fully engage residents throughout the county and to make them aware of programs like enLACE and ACOMI, MCHD cannot take a one-size-fits-all approach to communication. Staff must understand where and how its residents access information.

For example, many low-income residents in Monterey do not have computers but do use internet-equipped smartphones, so MCHD is optimizing its communications for mobile channels. Staff have created an online marketing program using Constant Contact to ensure that their communications work is accessible across multiple platforms, including mobile.

To better serve rural patients who may not have easy access to transportation, MCHD has added telemedicine to its clinical practices. And to serve the county's many Latino households, MCHD regularly adds Spanish content to its social media channels, a practice that is not yet common among health departments in California.

MCHD also strives to communicate with community members using clear, nontechnical language.

"A lot of the times, we use the big language and the big lingo and the terms that don't resonate with [residents]," Gil said, explaining that MCHD works to reduce such jargon, as well as to discuss abstract public health issues in ways that help to make them more concrete.

"So, for example, we'll talk about [how] the housing element is really important to you because it's going to dictate where housing is going to go in your community, if your kids or friends or you are going to be able to afford housing, et cetera," Gil said. "And I think once you break it down to that level, it becomes real, and it shows the importance of [community members] being actively engaged in those decisions."

Gil stressed that the health department aims to help residents not only understand the impact that an issue will have on their daily lives and on the overall health of their communities, but also to envision solutions: "So, it's easy to complain about violence, but, really, what can we do to address some of that? Do we have more community centers available? Do we have prevention programs? Do we have green and open spaces that people can actively engage in?"

Applying HiAP using an "inside/outside" approach

According to the health department's Jimenez, MCHD's commitment to health equity and HiAP is both internal and external, and staff are applying it using what she calls an "inside/outside" approach.

"In order for us to be able to effectively help move the community along in Health in All Policies, we really looked internally first," Jimenez said, explaining that the health department has built a plan to educate and train staff on the social determinants of health and how environments affect how well people are — or aren't — able to practice healthy lifestyles.

Internally, MCHD offers staff an opportunity called the Health Equity Scholars Academy (HESA), which teaches employees about the basics of public health, as well as social determinants and health equity — and how those influence health outcomes.

"It creates a safe space where employees can converse about root causes and really begin to talk about some of the issues that they've seen out in the community and how we … can better serve our clients or customers," Gil said.

"Once we felt that we were prepared internally to be able to effectively speak about this and help bring along community, then we started to have community meetings and gatherings with both traditional and nontraditional stakeholders," Jimenez said.

Since 2012, MCHD has trained more than 2,000 county staff and local residents on HiAP. These trainings have included a focus on institutional racism and implicit bias.

According to Gil, such education opportunities help to create a shared language and put everyone on the same page: "We all may [approach health equity] from different angles, but, ultimately, what's our end goal?"

In addition to conducting trainings, MCHD has linked its HiAP work to the accreditation process. While developing accreditation prerequisites, MCHD took the opportunity to educate health system partners about HiAP and incorporated the framework into several planning documents, including the health department strategic plan, community health assessment, and community health improvement plan, to encourage HiAP's use across agencies and partners. The function of the planning documents is complementary: While the community health assessment revealed the health inequities facing the county, the strategic plan provided a way to engage stakeholders in tackling these inequities through a HiAP approach, and the community health improvement plan helped bring county health initiatives into alignment so that different efforts, such as early childhood development initiatives and plans to reduce gang violence, operate in coordinated ways.

MCHD also has created a HiAP advisory committee, which meets monthly and tracks HiAP progress. The committee includes members from the Association of Monterey Bay Area Governments, city and county planning staff, and nonprofit organizations in the housing, transportation, and early childhood development spaces.

MCHD sign

Overcoming challenges

MCHD has been fortunate to have strong support from county elected officials. And with fewer than 500,000 residents, Monterey is a small county, which has made it easier for health department staff to have more in-person communication and stronger collaboration with partners.

Still, they have faced many challenges. These include coming to a consensus on what work to collectively prioritize, despite so many interests and areas of need; making sure all stakeholders feel that their perspectives are being heard and respected; and helping partners not traditionally associated with health to see how their work impacts health.

For example, it has been difficult at times for MCHD to help direct service providers, who deal one-on-one with individuals suffering from acute conditions like asthma, to look at their work through a different lens and see how it connects to the broader social determinants of health. To support this shift, the health department is intentionally linking collaborative activities with strategies as part of its annual review of its strategic plan.

"I think they're starting to recognize that when somebody comes in, they're also going to be talking about their lack of access to affordable housing, about their lack of access to food, their concerns about their children, and their afterschool activities," Jimenez said. "And I think they're starting to recognize that their role is not only to address the acute care need, but really [to] look at the person as a whole and begin to collaborate amongst other health department bureaus and with community to help to care for that person." Jimenez said.

Another hurdle has been keeping partners engaged. This can be particularly hard amid staff turnover. The health department often hires new employees and regularly brings new external partners into the HiAP work. New staff are provided an overview of HiAP, and it is discussed routinely at meetings of senior health department staff.

"People come and go, they change jobs, and so ensuring that they understand what we're trying to do with Health in All Policies is really important to us," Gil said, adding, "Developing that concise, consistent shared language and education around it is one of the constant challenges that we have."

Finally, like many groups in public health, MCHD must keep HiAP efforts funded. "Many times, our funding is categorical, meaning that we receive a pot of state or federal dollars to help address one issue, like reduction of teen births," Jimenez explained. "And so, we haven't really addressed comprehensively the root causes, which, regardless if you're looking at teen births, or you're looking at why kids are not completing high school, or you're looking at why kids are getting involved in the juvenile justice system, it really all boils back to what opportunities they had growing up. … Many times, they're limited based on where they live, how much income their family makes, who their social support systems are, or, if they don't have any social support systems, who their peer influences are."

Having to fulfill the obligations of those categorical grants, Jimenez continued, does not give MCHD the full flexibility that they want "to really push Health in All Policies across the organization."

Lessons learned

Since MCHD began implementing HiAP, health department staff and their partners have gleaned many insights that may be useful for other health departments interested in pursuing a Health in All Policies framework. These are some of their top tips:

Start building relationships and engaging partners as early as possible. It is important to make sure that all parties understand your goals from the beginning, Gonzales City Manager Rene Mendez explained. That way, he said, "if there's any difference of opinion or some political issues … you are able to identify them early. You don't want those to come up when you're asking for approval of an agreement or a contract."

Strive to understand the perspectives of other people and sectors. "There is more power in working together," said the health department's Gil. With that lesson in mind, MCHD staff approach their contributions to partnerships with humility. They recognize that they are one organization as part of a larger public health system and do not expect to be the sole authority in the room.

Equip community members to advocate on their own behalf. "Many times, the community feels that they don't have a voice, and we, as public health practitioners, need to help community residents find their voice by providing them the training, by providing them the language, by educating them about how to navigate [systems] — whether it's city government, county government, [or] the educational school system — so that then they can be the leaders that we need them to be to help make change," Jimenez said. "Policymakers, although they like to hear what the health department has to say, there's going to be more weight given if it's a community resident — one of their constituents — that is at the podium advocating for less liquor stores in their community or a grocery market in their community."

Remember that broad engagement benefits everyone. When community members are involved, they benefit because they are the ones who will feel the impact of policy decisions. But stakeholders gain support, too. "They may be thinking of implementing an action or a program or a policy, and if residents are on board with it, they can help [with] the implementation of it, which is even better, versus just putting a policy through, and then nobody ever does anything with it," Gil said, noting that such collaboration "brings more power into the community" and leads to greater success overall.

"It creates a healthier environment; it creates a healthier relationship with community residents and leaders and stakeholders. So, it really has a long-lasting impact," she said.

Know your audience. MCHD staff pay close attention to demographics and adjust their communication strategies accordingly. For example, they provide bilingual content and use different social platforms to reach different groups. They also work to make the intangible tangible by providing concrete examples of what policy changes will mean for people's day-to-day lives and try to minimize jargon when communicating with residents and partners who do not have backgrounds in public health.

Be flexible. Gil explains: "A lot of the times we say, 'This is our action plan; we have to stick to this.' However, if a new opportunity came up and it's not part of your action plan, it's not wise to let it fly by. We've seen major impact when we adjust course when needed to ensure that we're able to jump on some of those opportunities."

Dream big. "Don't think it's not achievable," said Mendez, noting that this is true both for systems-level changes in the community and for individuals wanting to make improvements in their lives. Mendez said that sometimes in communities like Gonzales, which are strapped for resources, people don't allow themselves to set aspirational goals. But, he said, "I think that we have a real unique position in this — trying to help our community [dream] big and see how we can get there."

MCHD's vision for the future

In the next five to 10 years, the health department plans to more closely consider where its dollars are spent to ensure that the areas with the most need are receiving enough support.

"I see our county moving forward and really intentionally looking at the services that we provide, how we fund them, and really reshifting or realigning the dollars that we have available to us to where we could have the potential greatest impact," Jimenez said.

Additionally, MCHD staff want to bring new partners into the work and continue conversations with the County Board of Supervisors, which has expressed interest in pursuing ways to govern for racial equity. "That is a huge step for a county the size of ours to really be intentional about how we're developing programs and policies and the language we use — and how we're being equitable in so many areas," Gil said.

Beyond that, she said, the possibilities are wide open: "I can only imagine that we are going to continue to progress in many ways."

To view video highlights from MCHD's health equity work, visit https://www.youtube.com/watch?v=3_O9geYB1NY&feature=youtu.be

Acknowledgments

This case study was written by Heather Gehlert. BMSG would like to thank Cookie Carosella for contributing reporting to this case study. We also thank the following reviewers for their insightful feedback: Carmen Gil, Monterey County Health Department; Krista Hanni, Monterey County Health Department; Jonathan Heller, Human Impact Partners; Elsa Jimenez, Monterey County Health Department; Rachel Poulain, The California Endowment; and, Bob Prentice, former director (retired) of the Bay Area Regional Health Inequities Initiative (BARHII).

This case study was funded by The California Endowment.

© 2018 Berkeley Media Studies Group, a project of the Public Health Institute, and The California Endowment

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