SE PTE M B E R 20 19 Culture of Health Sentinel Community Insights Health Equity Table of Introduction About This Report 1 2 Contents H E ALTH E QU I T Y Three Broad Perspectives in Addressing Health Equity 3 AD D RE SSI N G H I STO RI CAL AN D SYSTE M S‑ L E V E L BARRIER S I N C RE ASI N G E CO N O M I C AN D/O R E D U CATI O N AL O PPORTUNITIES RE D U C I N G H E ALTH D I SPARI TI E S Approaches in Addressing Health Equity 5 C RE ATI N G N E W G OV E RN M E N T STRU CTU RE S E STAB L I SH I N G CO L L AB O RATI V E S E N H AN C I N G E N GAG E M E N T O F TRAD I TI O N AL LY M ARG I N AL I Z E D P O P U L ATI O N S TARG E TI N G H I G H ‑ N E E D P O P U L ATI O N S TO RE D U C E H E ALTH D I SPARI TI E S B ROAD ‑ BASE D C H AN G E S W I TH U N SP E C I F I E D E QU I T Y G OAL S Sentinel Community Changes in Enhancing Health Equity 9 C H AN G E S TO LO CAL P O L I CY C H AN G E S I N CO M M U N I T Y D E SI G N C H AN G E S I N WO RK FO RC E TRAI N I N G AN D E D U CATI ON Facilitators and Barriers to Effectively Address Health Equity 12 P O L I TI CAL SU P P O RT AN D TH E N ARRATI V E AM O N G CO M M U N I T Y L E AD E R SH I P CO M M U N I T Y AN D P H I L AN TH RO P I C I N V E STM E N T S TO ENHA NC E H E ALTH E QU I T Y AVAILABILITY OF DATA TO INFORM HEALTH EQUITY STRATEGIES Conclusions and Insights 14 Cover photos, top to bottom from left: Kali Nine LLC, iStock; Annabel Clark/Redux for the Robert Wood Johnson Foundation; Matt Moyer; Sze Fei Wong, Moving Forward 15 iStock; monkeybusinessimages, iStock; Tyrone Turner, tyrone@tyronefoto.com; Davel5957, iStock; Fly View References 15 Productions, iStock; Annabel Clark/Redux for the Robert Wood Johnson Foundation Appendix: Discussion Guide for Communities 16 C U LT U R E O F H E A LT H H E A LT H E Q U I T Y SENTINEL COMMUNITY INSIGHTS SEPTEMBER 2019 Introduction The Robert Wood Johnson Foundation (RWJF) Sentinel The concept of health equity cuts across the Action Areas of Communities Surveillance project, which began in 2016, monitors the Framework. Through the lens of health equity, communities activities related to how a Culture of Health is developing in each shape and form values about who has access to health‑promoting of 30 diverse communities around the country. In the Snapshot resources and how health is prioritized for population subgroups. and Community Portrait reports for each community, developed Equity drives how organizations and sectors work together to between 2017 and 2018, we described Sentinel Community make sure practices, policies, and investments are both equitable efforts to promote the health and well‑being of their residents. and effective. Achieving healthier, more equitable communities This report on Health Equity is the first in a set of three requires a focus on historical and structural conditions that reports that provide insights and themes drawn from all Sentinel have led to economic, social, and physical barriers to positive Communities. The collection focuses on key topics that may be of health outcomes. Finally, health equity shapes access to services; value to stakeholders working to build a Culture of Health in their influences consumer experience with health care; and ensures own communities. The other reports focus on the role of anchor balanced resource allocation across health and social services. institutions and the unique experiences of small communities. This report provides insight into how 11 communities Health equity underpins RWJF’s vision of a society in which conceptualize health equity and how those perspectives influence everyone has a fair and just opportunity to live the healthiest strategies and approaches to promote health equity. While this life possible. This vision is articulated in the Culture of Health report presents three broad ways of thinking about health equity, Action Framework—depicting a holistic, integrated approach to this summary is meant to be a springboard for deeper discussions population‑level health, well‑being and equity. The Framework within and across communities about how perspectives of equity includes four Action Areas: 1) Making Health a Shared Value; shape approaches and actions. By sharing existing strategies 2) Fostering Cross‑Sector Collaboration to Improve Well‑Being; being employed as communities work toward health equity— 3) Creating Healthier, More Equitable Communities; and 4) others can gain insight on ways to address and overcome Strengthening Integration of Health Services and Systems. systemic and long‑standing barriers to health and well‑being. F i g u r e 1 : C U LT U R E O F H E A LT H AC T I O N F R A M E WO R K EQUIT Y ACTION AREA ACTION AREA 1 2 MAKING FOSTERING HEALTH A CROSS-SECTOR SHARED VALUE COLLABORATION TO IMPROVE WELL-BEING OUTCOME IMPROVED POPULATION HEALTH, WELL-BEING, AND EQUITY ACTION AREA ACTION AREA 3 4 CREATING HEALTHIER, STRENGTHENING MORE EQUITABLE INTERGRATION OF COMMUNITIES HEALTH SERVICES AND SYSTEMS EQUIT Y © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 1 C U LT U R E O F H E A LT H H E A LT H E Q U I T Y SENTINEL COMMUNITY INSIGHTS SEPTEMBER 2019 About This Report Information in this report was obtained from the Sentinel H E ALTH E QU I T Y Communities Surveillance Project. For each community, project Definitions of equity and health equity emphasize social and staff conducted an environmental scan of online and published distributive justice, making them distinct from notions of equality community‑specific materials; a review of existing population and disparities. RWJF defines health equity as follows: ”Health surveillance and monitoring data; and collection of local data equity means that everyone has a fair and just opportunity to be or resources provided by community contacts or interview as healthy as possible. This requires removing obstacles to health respondents. Phone interviews were conducted with individuals such as poverty, discrimination, and their consequences, including representing community organizations working in a variety of powerlessness and lack of access to good jobs with fair pay, sectors (e.g., health, business, education, human services, youth quality education and housing, safe environments, and health development, environment). Information from a total of 201 care.” (Braveman et. al, 2017). interviews was used for this report from 11 Sentinel Communities. Inequities are avoidable, systemic differences between Key themes discussed in this report emerged through a groups that are created by barriers to health, education, housing, qualitative analysis of the Sentinel Community data noted above, and other systems, as well as challenges in the distribution of examining common themes and patterns. power. These barriers give rise to the inequitable distribution and quality of community resources (e.g., education, income, housing, quality of neighborhoods), resulting in differences in SENTINEL COMMUNITIES INTERVIEWED FOR THIS REPORT social and economic opportunities. Braveman and colleagues Allegheny County, Pa. San Diego (2017) discussed the value of an ethical approach to health Finney County, Kan. Stockton, Calif. equity. Even beyond the health disparities that may result from Harris County, Texas Tacoma, Wash. social disadvantage, the authors suggest that acting upon the Louisville, Ky. Tampa, Fla. unjust social conditions that disproportionately affect certain Maricopa County, Ariz. Tennessee communities should be a human rights priority for communities. Mobile, Ala. Using this lens, racial and economic equity—although often discussed outside of a health context—is an important part of health equity. For the purposes of this report, we use “health While not every stakeholder interviewed had health equity equity” to capture dimensions of equity that relate to health explicitly at the forefront of their agenda—and community and well‑being, which includes racial and economic equity. approaches to addressing health equity varied considerably— every Sentinel Community identified efforts that they viewed as addressing health equity in some form. The 11 communities selected for this report represent a diverse mix of approaches and challenges to discussing and addressing health equity in the context of building a Culture of Health. These communities represent diversity in context, history, community strategy, and types of efforts pursued to improve health equity. Looking across these diverse communities, patterns and themes emerge that generate learnings and insights for other communities reflecting on their own approaches to building health equity. © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 2 C U LT U R E O F H E A LT H H E A LT H E Q U I T Y SENTINEL COMMUNITY INSIGHTS SEPTEMBER 2019 Three Broad Perspectives in Addressing Historical and Perspective Addressing Health Equity Systems-Level Barriers Perspectives of health equity varied significantly across Stakeholders with this perspective espouse a more explicit stakeholders within and across communities, shaped by both the conceptualization of health equity that stems from racial respondent’s own personal experiences and the context of the inequity and economic injustice. They also consider the community in which they lived or worked. While orientations to historical context as well as the current social and political health equity could be grouped in numerous ways, our analysis climate of the community to be key drivers of health and identified three broad, but distinct perspectives. These different well‑being. Stakeholders also recognize that multi‑faceted perspectives led to variability in how communities approached solutions are required to address upstream, and in many cases, health equity and the community changes they ultimately long‑standing barriers, that have led to inequities in health and adopted (Figure 7). The color‑coding used in this report (shown well‑being. Examples of communities where this perspective is below) is intended to help the reader easily identify approaches common include: and related community changes that align with one or more of these perspectives: ●● Tacoma, Washington. Stakeholders in Tacoma have a long history of activism for social justice causes, and city leaders | Those that acknowledge and explicitly discuss health equity in the context of historical and systems‑level barriers; regularly discuss equity as a strategy and a long‑range goal for the city. This perspective is championed by city government focused on reducing inequity in housing, | Those that discuss their efforts as increasing economic and/ or educational opportunities, but do not make the explicit ●● representation in leadership, and public safety. Allegheny County, Pennsylvania. Public conversations are connection to health equity; and taking place in many sectors with a focus on how historical, | Those that prioritize and frame their work as reducing health disparities, but do not explicitly discuss health equity as structural inequities have resulted in housing discrimination, exclusion of black residents from higher paying jobs, and defined in this report. ultimately poor health outcomes. ●● Stockton, California. Stockton’s new executive leadership In the sections that follow, we provide examples of how rose from the grassroots level by noting how the structure of these perspectives are operationalized. It is important to note various city systems contribute to the city’s equity challenge. that while we aligned Sentinel Communities to each of the ●● Louisville, Kentucky. Many low‑income, majority‑black three perspectives—based on the most prevalent view offered neighborhoods are prone to flooding, poor air quality, by stakeholders within the community—not every stakeholder and a lack of health care and food outlets, and there is an in that community aligned with that prevailing perspective of acknowledgement that the city’s history of segregation health equity. This inconsistency sheds light on key barriers for and racism have given rise to inequitable health outcomes addressing health equity (described in more detail at the end precipitated by these risk factors. of this report). It also helps to explain some of the variability in approaches to addressing health equity that was observed within communities. F i g u r e 2 : T H R E E P E R S P E C T I V E S I N A D D R E S S I N G H E A LT H E Q U I T Y Addressing Historical and Increasing Economic and/or Systems-Level Barriers Educational Opportunities Perspective Reducing Health Disparities © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 3 C U LT U R E O F H E A LT H H E A LT H E Q U I T Y SENTINEL COMMUNITY INSIGHTS SEPTEMBER 2019 Across these communities, while work to enhance economic Increasing Economic and/or and educational outcomes may contribute to equitable Perspective Educational Opportunities opportunities to achieve health and well‑being, there is a reluctance to calling out this health equity connection due to As noted above, the RWJF definition of health equity includes concerns for political and stakeholder reprisal. racial and economic equity as key influencers of health and well‑being. However, not all communities we observed make this link explicit. Communities that focus on broader equity frame their approach as promoting equitable opportunities for Perspective Reducing Health Disparities education and jobs within their community, with the goal of improving the economy and reducing disparities in economic outcomes. They stop short, however, of talking about such Stakeholders with this perspective did not draw a clear distinction opportunities in the context of health and well‑being specifically. between health equity as defined in this report and health In many cases, this perspective was presented as a deliberate disparities. The emphasis of this health equity perspective is framing based on the political climate of the region where health on closing the gaps between groups and supporting those is not a priority. This broad equity perspective may result in of greatest need in order to reduce inequality, rather than paternalistic and incomplete approaches to health equity—that do addressing inequity. Stakeholders with this perspective typically not address the creation of fair and just opportunities for health do not incorporate the historical causes of inequity in their and well‑being beyond those tied to the economy. Examples of conceptualizations, and address their impacts largely through communities where this perspective is common include: downstream, targeted efforts. As such, these communities do not truly embrace the definition of health equity underlying this ●● Maricopa County, Ariz. In Maricopa, the narrative focuses report. This perspective is more common among stakeholders almost exclusively on economic inequities, driven in large in very diverse communities experiencing large or rapid part by the realization that such disparities are a barrier demographic shifts as a result of an influx of immigrants not only to opportunities afforded to individuals, but to the or refugees with unique language and cultural needs. This economic prosperity of the entire region. perspective was also more common among stakeholders in ●● Harris County, Texas. In this diverse community, stakeholders communities working on revitalization efforts, where the goal is to acknowledge that economic disparities fall along racial/ethnic not only improve the health and well‑being of current residents, lines. Stakeholders note that this inequity has potentially but to promote health and well‑being in order to draw potential damaging economic consequences for the county as the residents and businesses into the area. proportion of non‑white residents continues to grow. ●● Tennessee. Tennessee’s equity narrative has been shaped ●● Finney County, Kan. Stakeholders in Finney county define around education reform, educational attainment, and health equity as ensuring that language, cultural and other education‑to‑work strategies. Because of a deep historical barriers are removed so that subpopulations of refugees and context of racism in the state, some stakeholders view other immigrants can gain access to health care. Stakeholders racial equity as particularly challenging to address given also focus on meeting the immediate needs of distressed political sensitivities. Within Tennessee there is also a strong residents, but have not yet turned to addressing the root reluctance to link education efforts to health or health causes of inequity in the community. equity explicitly. Doing so is viewed as potentially alienating ●● Tampa, Fla. Stakeholders in Tampa recognize the linkage of partner agencies, which do not consider themselves among built environment influences and differences in to lead health‑related work. A health equity focus is also health outcomes. While they have worked to revitalize the politically risky in an environment where spending on health downtown and waterfront areas with a focus on health is not seen as a priority. and well‑being, the focus of these efforts has been to draw ●● Mobile, Ala. Here, stakeholders acknowledge the profound new residents to the downtown areas. Less attention has education and economic inequities that exist by race. been paid to addressing root causes of health inequity Discussions focus on ways to improve equitable access to new that residents, many of whom were displaced as part of jobs entering the local market. revitalization, continue to face. © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 4 C U LT U R E O F H E A LT H H E A LT H E Q U I T Y SENTINEL COMMUNITY INSIGHTS SEPTEMBER 2019 Approaches in Addressing Health Equity In this section, we describe how a prevailing perspective of ●● San Diego integrated their health and social services into a health equity within a community can shape its approaches in single government agency in San Diego County [the Health moving toward health equity. Through our analysis, we identified and Human Services Agency (HHSA)], which includes public several approaches that communities are using to address health health services; housing services; community development; equity, including: integrated service delivery for vulnerable residents; and other services. The integrated HHSA resulted from a ●● creating new government structures recognition that these diverse systems play a critical role ●● establishing collaboratives in producing inequitable outcomes in the community. It ●● enhancing engagement of traditionally marginalized was established to help the agency better meet its goals of populations improving health and well‑being in the community. ●● The Louisville Metro Government (LMG) also created several We also identified differences in whether communities new offices within the past decade that are instrumental pursued targeted health equity efforts or broad‑based changes to its core strategy of supporting equity and creating with the potential to benefit the entire community. While some healthier, more resilient neighborhoods. The Office of Safe approaches were more common in communities having a specific and Healthy Neighborhoods; Center for Health Equity (part prevailing perspective of health equity, several approaches for of Department for Public Health and Wellness); Office of addressing health equity were engaged by communities across all Sustainability; and Office of Resilience and Community three perspectives. In these cases of mixed approaches, however, Services all consider enhancing equity, including health implementation of the approach often varied in level of intensity, equity, to be part of their work. breadth or depth due to the mix of perspectives. Below, we describe these approaches in more detail and provide examples F i g u r e 3 : E X A M P L E O F H OW ‘A D D R E S S I N G H I STO R I C A L A N D from the Sentinel Communities. Again, the color coding highlights SYST E M S‑ L E V E L BA R R I E R S’ P E R S P E C T I V E C A N R E L AT E TO A T Y P E the perspective commonly associated with each approach. O F A P P R OAC H | CREAT I NG NEW G OVER NM ENT ST R U CT U R ES Creating New Government Some communities that recognized historical and structural Approach Structures barriers to health equity created new government structures or re‑aligned service provision to address root causes of health Addressing Historical and Perspective Systems-Level Barriers inequity. In some communities, this resulted in the development of city or county offices and government‑level positions that work with the community to address health equity. ●● Tacoma, for example, created two separate offices dedicated to equity: the Office of Equity and Human Rights at the city, and the Department of Health Equity at Tacoma‑Pierce County Health Department. © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 5 C U LT U R E O F H E A LT H H E A LT H E Q U I T Y SENTINEL COMMUNITY INSIGHTS SEPTEMBER 2019 ||| ESTABLI SH I NG COLL A BOR AT IVE S increase awareness of equity issues. TBHC was developed 15 years ago to more effectively coordinate services and Collaboratives develop a shared purpose to align their resources existing resources and build provider capacity around three and efforts in order to produce tangible outcomes for their areas: advocacy, health equity, and wellness. TBHC partners community. Across the Sentinel Communities, we reported report increased understanding of health equity and culturally numerous examples of collaboratives addressing health and and linguistically competent care, as well as a greater well‑being. Some collaboratives are more narrowly focused with understanding of public policies and advocacy opportunities a smaller set of stakeholders, while others are uniting diverse to affect health in Tampa. However, they stop short of stakeholders in a multisector strategy to address health inequities working with other stakeholders to address long‑standing and in their communities. Some examples include: upstream systemic barriers that give rise to health inequity. ●● Equity‑oriented collaboratives exploring systemic barriers to health and well‑being. This type sometimes arose in response to specific incidents or the release of key health and ||| E N H AN C I N G E N GAG E M E N T O F TRAD I TI O N AL LY M ARG I N AL I Z E D P O P U L ATI O N S well‑being indicators in communities. One example of this One of the historical and structural barriers to achieving health comes from Stockton, Calif., where the Stockton Educational equity in communities has been a lack of civic involvement Equity Coalition (a consortium of community and civil rights from those negatively impacted by the policies, systems, and advocacy groups, including Fathers & Families and the ACLU) procedures that lead to inequitable outcomes. Stakeholders issued a “report card” on excessive police activity in Stockton in the Sentinel Communities are increasingly prioritizing schools. This report card summarized concerns particularly community engagement as a strategy to enhance health equity. affecting black students, who were arrested twice as often as This is especially true in those communities recognizing that white or Hispanic students, and often for minor infractions. marginalization has degraded the power of residents to influence decision‑making over time. However, there remains significant Other collaboratives have formed around regional variation in how communities engage marginalized populations, development plans, part of the perspective around economic which is tied in part to the prevailing health equity perspective. and educational equity, where stakeholder approaches to health For example, some engagement strategies are limited to equity are explicitly or implicitly tied to discussions of how seeking input from residents (e.g., through focus groups), which is communities are physically designed. In San Diego, for example, then used by those in power to shape solutions. Other strategies, the pursuit of equitable development and healthy and livable however, look to embed marginalized populations into the teams communities for all has been tackled through integration of the designing and implementing the solutions. Engaging historically community perspective into San Diego Forward, the county’s vulnerable communities as advocates for systems reform can regional development plan. In order to reach traditionally create shared leadership opportunities and give voice to often underrepresented communities, planners partnered with 12 disenfranchised populations. This can serve the ultimate goal community‑based organizations that serve these populations of building community capacity and addressing the underlying to act as liaisons. By drawing on the partners’ leadership and processes of marginalization and power dynamics that create knowledge of their communities, the goal is to put more focus inequities. Some examples of various approaches include: on social equity and environmental justice in the transportation planning process. ●● In Tacoma, Wash., Neighborhood Councils (independent, nonprofit, citizen‑led organizations) lead neighborhood ●● Some collaboratives help to promote and disseminate improvement projects and advise the city on neighborhood information about health equity, but stop short of actively issues. They are considered the primary tool of civic working to address root causes of health inequity. engagement in Tacoma. Each of the Councils receives a Collaboratives of this type are more common in communities modest budget from the city for discretionary spending where health equity is perceived as being equivalent to on local initiatives. Councils employ various methods of reducing health disparities. The Tampa Bay Healthcare engaging constituents, including neighborhood surveys Collaborative (TBHC) is a long‑standing example of and door‑to‑door canvassing. Despite the integration of collaboration across health and wellness professionals to Neighborhood Councils into the decision‑making process, © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 6 C U LT U R E O F H E A LT H H E A LT H E Q U I T Y SENTINEL COMMUNITY INSIGHTS SEPTEMBER 2019 some local stakeholders recognize that the councils have not kept up with demographic changes in Tacoma neighborhoods, | TARG E TI N G H I G H ‑ N E E D P O P U L ATI O N S TO RE D UC E H E ALTH D I SPARI TI E S and do not fully represent the current constituents. Thus, Stakeholders who perceive health equity as synonymous even in more socially activated communities, challenges to with reducing health disparities between populations often truly have representative engagement remain. take downstream approaches to improving the health and ●● Harris County, Texas, leverages the Neighborhood well‑being of populations. While these activities focusing on Centers’ 60‑plus sites, using an established approach high‑risk populations are critical to meeting the immediate called “appreciative community‑building” to ask residents needs of vulnerable populations, this tends to be a more general questions about what parts of their neighborhood reactive approach to reducing health disparities rather than a matter most, what they aspire to do, and what they want for long‑range strategy toward health equity. themselves, their family, and their community. This approach has been used to inform equity‑based strategies, such as ●● New Hope Together, an initiative started in an apartment the development of a new center to address economic and complex in Finney County, Kan., is designed to specifically health equity concerns together—e.g., the challenge of poor meet the health care needs of refugees and to serve as infrastructure and business instability. a resource for English language instruction. The sizable ●● Other communities are working to engage traditionally immigrant population is particularly high‑need, and New marginalized populations through top‑down approaches. Hope Together has had success creating linkages to health Louisville, Ky., for example, has created several new offices and related social services. to work closely with community‑based organizations with the goal of increasing participation and the decision‑making F i g u r e 4 : EXAMPLE OF HOW ‘REDUCING HEALTH DISPARITIES’ power of historically underrepresented residents. PERSPECTIVE CAN RELATE TO A TYPE OF APPROACH ●● In San Diego, the HHSA and other agencies are critical to establishing health as a community priority. However, such financial and organizational strength does not always Targeting High-Need support equitable and community‑based activities to Approach Populations for Intervention reach residents who are missed by government systems, or those who avoid them out of mistrust or confusion. County Perspective Reducing Health Disparities stakeholders, who recognize this barrier, are now working to find solutions that encourage more input from residents. Exemplifying this approach, San Diego County’s regional Community Health Improvement Plans (CHIPs) are vehicles Although the prevailing perspective of health equity in used by HHSA and its partners to promote community Mobile, Ala., is focused on economic and education equity, engagement and data sharing among residents. HHSA there are numerous stakeholders who align more with divides the county into six regions, each of which develops the disparities‑reduction perspective of health equity. In its own CHIP, goals, and programming based on data collaboration with Providence Hospital and the Mobile County furnished by HHSA. Health Department—the Mobile United task force is taking a geographic approach to identifying and addressing high‑need groups. The task force is piloting a program to increase cancer and diabetes screenings in areas of the city with the largest health disparities. © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 7 C U LT U R E O F H E A LT H H E A LT H E Q U I T Y SENTINEL COMMUNITY INSIGHTS SEPTEMBER 2019 | B ROAD ‑BASED CH A NGE S WIT H U NS P E C IF IED EQ U IT Y G OAL S Tennessee’s Drive to 55 works toward the goal of 55 ●● percent of residents having a college degree or certificate In communities that think about equity from the perspective of by year 2025. Initiatives within Drive to 55 include, among economic or educational outcomes but not with health equity others: the Tennessee Promise scholarship for eligible high at the forefront, it is common for efforts to have sweeping school students; the tnAchieves mentorship program; and goals related to improving conditions for everyone in the Tennessee Reconnect for adults seeking a post‑secondary community. Many of these communities elect to invest in degree. However, independent evaluators have determined broad‑based changes without a clear tie‑in to improving health that while overall college‑going and completion rates are equity, believing that “a rising tide lifts all boats.” While diverse rising in Tennessee, educational disparities are actually stakeholders within Sentinel Communities are able to unify worsening, with students of color attending college at lower around shared goals of improving educational and economic rates. From 2011 to 2015, black students’ six‑year graduation outcomes—in some communities, there are also common rates at public four‑year institutions fell four percentage assumptions that improvements for all will equate to equity points (down to 41% from 45%). gains. Moreover, specific connections between educational and ●● In Maricopa County, Ariz., the need to address gaps in economic outcomes and the goals of health equity are rarely education funding has emerged as a shared priority across made in these communities. other sectors. Stakeholders hope that an increase in education funding will close race‑based educational gaps. Greater Phoenix Leadership—including business leaders— F i g u r e 5 : E X A M P L E O F H OW ‘ I N C R E A S I N G E C O N O M I C A N D/O R has partnered with the Phoenix Chamber of Commerce, as E D U C AT I O N A L O P P O RT U N I T I E S’ P E R S P E C T I V E C A N R E L AT E TO A well as the Arizona Chamber, and other groups to advocate T Y P E O F A P P R OAC H for additional investment intoHistorical and system. Addressing the education Increasing Economic and/or Systems-Level Barriers ●● Mobile’s Map for Mobile was adopted in 2015 as a Educational Opportunities Perspective Reducing Health Disparities comprehensive plan to guide current and future development Broad-Based Changes With Approach Unspecified Equity Goals in the city. While the approach engaged diverse sectors and incorporated resident input, it takes a broad view of Increasing Economic and/or investments and activities in the community, emphasizing Perspective Educational Opportunities “widespread access” to physical activity, neighborhood amenities, and tourist attractions to improve economic opportunity without tying the benefits realized to specific health equity goals. F i g u r e 6 : P E R S P E C T I V E S I N A D D R E S S I N G H E A LT H E Q U I T Y A N D E X A M P L E S O F R E L AT E D A P P R OAC H E S Creating New Government Structures Broad-Based Changes With Targeting High-Need Unspecified Equity Goals Approach Addressing Historical and Populations for Intervention Systems-Level Barriers Increasing Economic and/or Perspective Reducing Health Disparities Educational Opportunities © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 8 C U LT U R E O F H E A LT H H E A LT H E Q U I T Y SENTINEL COMMUNITY INSIGHTS SEPTEMBER 2019 Sentinel Community Changes in Enhancing Health Equity While health equity perspectives may shape the approaches by Addressing Historical and and creating affordable housing (Allegheny County, Pa.; Tampa, Systems-Level Barriers Increasing Economic and/or criminal justice reform (Louisville, Ky.) on health equity, which communities work to address health equity, they also Fla.) and Educational Opportunities Perspective influence the types of changesHealth Disparities decide to Reducing that communities proximally or at least distally. Some communities have taken implement. Not surprisingly, our analysis of Sentinel Communities steps toward strategic planning to address these issues, though identified numerous examples of how they’re using programs and very few have implemented specific policies to help ensure equity interventions to reduce health disparities and address downstream at the time of this report writing. and immediate barriers to achieving health and well‑being. While Policies that have been implemented primarily affect the the importance of these efforts cannot be underestimated, they ways that local governments operate in the context of racial fall short of being true health equity solutions. Less commonly equity, some with a tenuous link to health equity. As noted identified were changes to the community that addressed upstream earlier, Tacoma has two separate offices dedicated to equity, both drivers of health and well‑being. Although there are numerous of which have institutionalized their commitment to promoting potential changes that communities could deploy to address health equity. Racial equity is an important part of their vision—and equity, we identified three types that serve as helpful examples of city policies, including those to improve health—require that large‑scale strategies and changes within communities: 1) changes decision‑makers consider age, income, and gender both in to local policy; 2) changes in targeted community interventions; and communities and in the governments and agencies serving 3) changes in workforce training and education (Figure 7). them. They are using an “equity Government Creating New lens” for assessing the potential impacts of policies. Structures Equity training is also a requirement for all Broad-Based Changes With ||| Targeting High-Need CH ANGES TO LO CA L P OLICY Approach Unspecified Equity organizations that receive funding from the city. Populations for Intervention Goals Increasing Economic and/or Addressing Historical and Systems-Level Barriers Public policy has been a long‑standing driver of social and racial Educational Opportunities 2016, Louisville was selected by Living Cities and the ●● In Perspective Reducing Health Disparities inequities, with impacts ranging from housing discrimination Government Alliance for Race and Equity as one of five cities and segregation (e.g., redlining)—to criminal justice policies that to participate in Racial Equity Here, a two‑year initiative disproportionately affect communities of color. Communities to facilitate efforts to understand government’s role in that focus on the importance of policy for shaping structures improving equity, particularly for young people of color. and context as a part of their equity narrative recognize that Since then, the metro government has used the initiative’s taking policy action is required to create a more equitable guidelines to refine its equity strategy through in‑depth society. In the Sentinel Communities, stakeholders from across all trainings for all city employees. By fall 2017, the LMG three health equity perspectives are increasingly recognizing the completed equity training for 2,000 employees, including value of policy changes. Examples include the areas of preserving most 24‑hour and public safety departments. F i g u r e 7: P E R S P E C T I V E S I N A D D R E S S I N G H E A LT H E Q U I T Y, S O M E E X A M P L E A P P R OAC H E S A N D C O M M U N I T Y C H A N G E S Institute Office of Equity to Impact Local Decision-Making Job-Skill Matching for Improved Employment Creating New Government Community Change Cancer Screening for At-Risk Populations Structures Broad-Based Changes With Targeting High-Need Unspecified Equity Goals Approach Addressing Historical and Populations for Intervention Increasing Economic and/or Systems-Level Barriers Perspective Reducing Health Disparities Educational Opportunities © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 9 C U LT U R E O F H E A LT H H E A LT H E Q U I T Y SENTINEL COMMUNITY INSIGHTS SEPTEMBER 2019 ●● Other initiatives have focused on policies that could enhance improving the built environment in one specific area has not economic equity in the community, with some connection improved access to multimodal transportation or other built to health. Tacoma, for example, has instituted an increase environment assets outside of downtown Tampa. in minimum wage across the city and established paid leave ●● Allegheny County has also made changes in community for city employees. And Stockton has instituted a universal design across the county. Examples include the UPMC basic income pilot program, which may inform future policy health system’s Center for Engagement and Inclusion, which approaches to improve the role that economic safety nets facilitates neighborhood‑based screenings and preventive can have in promoting equity. care through its Community Health Partnership Initiative. The Heinz Endowments have funded efforts to revitalize || CH ANGES I N COM M U NIT Y DES IGN Pittsburgh’s Hazelwood neighborhood with a focus on equity and sustainability; and a new Eco‑Innovation District is in Community design strategies often consider the importance development in Pittsburgh to promote equity, sustainability, of place for promoting health and well‑being. However, the and job growth in the city’s Uptown neighborhood. As variability in narrative around such change reflects differences with Tampa, there is a concern in Allegheny that design in the driving factors behind these changes. Some communities approaches may still ignore or underestimate the larger think about the structural factors at play in a particular social, health, and policy context. There is also concern about geographic place that suggests such changes are being made scalability to realize broader health equity benefits given to help address upstream drivers of health equity. Others that such efforts are often tailored to the unique needs of the think about such changes solely through a lens of economic specific implementation site. revitalization, and an opportunity to attract new businesses and residents to the area. The challenge with this latter framing, however, is that changes in community design without explicit | C H AN G E S I N WO RK FO RC E TRAI N I N G AN D E D U CATION attention to health equity can actually contribute to health Early educational inequities and differential access to workforce inequities if residents are displaced. and training opportunities result in skills gaps, and consequently, Changes in community design range in scale from improving a lack of quality employment prospects for traditionally specific sites such as a housing development—to focusing disadvantaged populations. A small number of Sentinel on entire neighborhoods or city blocks. Most of the efforts to Communities have made changes in this area and created address health equity through community design are relatively workforce training opportunities for traditionally disadvantaged new. Hence, their positive impacts—as well as any remaining gaps populations. The vast majority of these efforts were developed in or unintended consequences arising as a result of these efforts— communities where a perspective of health equity is focused on are currently unclear and warrant ongoing monitoring. Examples increasing broad economic and educational opportunities. of two communities that made changes through community design include Tampa, Fla., and Allegheny County, Pa.: ●● In Harris County, Texas, there are large income and employment inequalities across racial and ethnic groups. ●● In 2010, Tampa received funding from the U.S. Department The UpSkill Houston program was developed to reduce of Housing and Urban Development (HUD) to develop a unemployment, and consequently poverty, by enhancing master plan and shared vision of downtown Tampa as a job‑skill matching. UpSkill tracks industry trends and community of mixed‑income, diverse, safe neighborhoods partners with community‑based organizations to identify connected by walking and biking paths. The Water Street under‑ and unemployed residents and to train them in the Tampa development prioritizes building and community skills needed to fill the jobs of the future in their community. design to enhance health and well‑being across 10 concepts ●● Similarly, Maricopa County agencies are working together (e.g., “water,” “movement,” “mind”). As a result of these to address the disparities in educational attainment that redevelopment efforts and resident relocation, Tampa subsequently affect access to higher‑paying jobs. Leaders today has one of the lowest levels of poverty segregation in contend that Hispanic student success is not just important Florida. However, unintended consequences of these design for educational equity but is also a major factor in the initiatives were demonstrated in Tampa during this period. economic prosperity of the region. Recognizing that Hispanic Many residents were displaced, and an intense focus on students make up 44 percent of the population in Arizona © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 10 C U LT U R E O F H E A LT H H E A LT H E Q U I T Y SENTINEL COMMUNITY INSIGHTS SEPTEMBER 2019 public schools, the Helios Education Foundation is working with ASU, the Greater Phoenix Economic Council, Maricopa Community College District, Phoenix Union High School District, and other partners on Latino Student Success. This program is focused on early grade success; college and career readiness; and postsecondary completion among Hispanic students. In both Harris and Maricopa Counties, stakeholders are increasingly recognizing the impact of the U.S. demographic transition on future workforce composition and are able to make an economic well‑being argument for supporting the employability of these populations. ●● In Mobile, significant racial disparities in educational outcomes are the focus of the Mobile Area Education Foundation, which partners with Mobile County Public Schools to take a highly individualized approach to improve educational outcomes in Mobile’s most vulnerable neighborhoods. Strategies include flexible school schedules and linkages to social services in the school setting. © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 11 C U LT U R E O F H E A LT H H E A LT H E Q U I T Y SENTINEL COMMUNITY INSIGHTS SEPTEMBER 2019 Facilitators and Barriers to Effectively Address Health Equity In the sections above, we describe findings from interactions prioritize or spend money on health, poses significant barriers with Sentinel Community stakeholders related to perspectives to addressing health equity. While Tennessee is working to of health equity; how these perspectives shape the approaches address inequities in educational attainment and workforce communities use to address health equity; and the types of development, stakeholders rarely discuss these efforts through changes communities have made to address health equity. a health equity lens. However, the prevailing health equity perspective is not the only factor driving the success (or challenge) of community CO M M U N I T Y AN D P H I L AN TH RO P I C I N V E STM E N T S TO ENHA NC E efforts in addressing health equity. Our analysis identified three H E ALTH E QU I T Y additional factors that were raised by stakeholders as facilitators, Communities that more directly describe their efforts as and sometimes barriers, to addressing health equity in their addressing health equity are more likely to report broader community. These include political support and the narrative community and philanthropic investments to support this among community leadership; community and philanthropic work. Some communities, like Tacoma and Louisville are able investments to enhance health equity; and the availability of data to use public dollars to fund offices, departments or centers to inform health equity strategies. for equity within the city or health department. In other communities, a challenging public funding environment has P O L ITI CAL SUPPORT A ND T HE NA R R AT IVE A M ONG placed philanthropy at the forefront of support for health CO MMUNI T Y LEADER S HIP equity and well‑being. In Maricopa County, one of the Vitalyst Influential community leaders, including politicians and Health Foundation’s most recent initiatives, the Year of well‑respected stakeholders can shape the narrative around Healthy Communities (YOHC), integrates 14 core elements of health equity based on how these leaders talk about differences a healthy community. Through YOHC, Vitalyst connects the in race, economic status, or health in their community and what is existing network of local chambers of commerce and various driving those differences. public‑private coalitions with Maricopa County Department of In Louisville, Ky., leaders in the LMG strategically use Health and the Health Improvement Partnership with the goal to metaphors to express the importance of health equity. “Identify, Connect, Shift, and Influence.” The current mayoral administration hopes to address In Allegheny County, Pa., a strong philanthropic community nonhealth‑related factors (such as employment, food scarcity, supports much of the activity on health equity and well‑being. transportation, educational opportunities, and air quality) that The Heinz Endowments, Pittsburgh Foundation, Richard King contribute to health outcomes—and not just treat the outcomes Mellon Foundation, Buhl Foundation, and Hillman Family as residual effects of inequitable systems. Leaders describe these Foundation encourage collaboration through funding and working diverse drivers as the “soil” and the health outcomes as the “tree” with other area stakeholders to improve the region. The Heinz that emerges. As a result of their efforts, the city has garnered Endowments’ concept of building a “Just Pittsburgh” includes attention and awards for improving health and community developing a framework to guide the city’s redevelopment that resilience. Similarly, the philosophy of the new executive embraces equity as a core principle and puts the concept of leadership in Stockton, Calif., led by a mayor with a background in equity at the core of the philanthropy’s grantmaking mission. community organizing, hinges on equitable development as the Launched in 2016 by the Pittsburgh Foundation, 100 Percent city emerges from bankruptcy. Pittsburgh explicitly targets inequality and the goal of helping Though communication about equity and strong leadership disenfranchised residents more fully participate in Pittsburgh’s alone are not sufficient to enhance equity, this cultural work economy. These examples illustrate the catalytic power of is perceived by many as a critical element of racial equity foundations to shift the conversation and to build community efforts. Lack of political support, however, can be a barrier to capacity to address the drivers of health equity, particularly when addressing health equity. In Tennessee, political sensitivities public dollars fall short of need. around racial equity coupled with a strong reluctance to © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 12 C U LT U R E O F H E A LT H H E A LT H E Q U I T Y SENTINEL COMMUNITY INSIGHTS SEPTEMBER 2019 AVAILABILITY OF DATA TO INFORM HEALTH EQUITY STRATEGIES In some communities, racial, economic, and health inequities are so pervasive or long‑standing that it has been difficult for stakeholders to decide where to begin to reverse those trends. Several Sentinel Communities draw upon formal and informal data collection activities to shape their strategies and approaches to addressing the impacts of systemic inequities. It is important to note, however, that the majority of these activities leverage data to better target programs that address disparities between particular populations or neighborhoods. Data use has grown in helping to improve access to health‑promoting resources. However, deep data gathering on the presence of structural barriers and systemic contributors to health inequities are largely not occurring in the Sentinel Communities. This remains a significant approach gap and barrier to addressing health equity across communities. © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 13 C U LT U R E O F H E A LT H H E A LT H E Q U I T Y SENTINEL COMMUNITY INSIGHTS SEPTEMBER 2019 Conclusions and Insights The analysis of health equity across a sampling of Sentinel ●● Making Health a Shared Value. Some communities are able Communities offers critical insights about how some communities to embed health equity in the value set of local governance are generally approaching this issue; what strategies/approaches structures and budgets. But this approach has been adopted they are employing; and what factors appear to support or by only a small number of communities. impede effective efforts to improve health equity. While these ●● Fostering Cross‑Sector Collaboration to Improve findings are based on a sample of 11 communities representing Well‑Being. Communities are using networks and diversity by geography, history, social, and political context—it is collaboratives to advance health equity. However, these clear that the broader issue of equity is a core challenge across collaboratives do not always include a fair and accurate all communities. What varies, however, are: the entry points for representation of the most disenfranchised community discussions about equity; how closely equity and health equity members/leaders. This lack of comprehensive engagement is are linked; which organizations and stakeholders are raising often shaped by historical and structural barriers precluding health equity as a concern; and how well these efforts are diversity among those in power. received and implemented in the broader community. ●● Creating Healthier, More Equitable Communities. Some Our analyses revealed three broad, but distinct perspectives communities are implementing activities and policies that in approaching health equity: address these structural barriers in order to create equity. In general, efforts tend to be site‑specific and the development | Some communities address underlying, systems‑level, and often long‑standing historical causes of inequity, ●● of equity‑based policy is not widespread. Strengthening Integration of Health Services and respond with longer‑term strategic approaches to Systems. Many communities are addressing the needs of engaging marginalized populations, and work to ensure underserved groups as part of their work to promote health representation and equitable power in decision‑making and well‑being. But most efforts described are focused on structures and policy. immediate gaps in access and general health disparities. There is less focus on other drivers key to this Action | Other communities find it difficult to discuss health equity specifically. They choose instead to frame conversations Area, such as consumer experience and balanced resource allocation across social and health services. and take action to increase economic and/or educational opportunities, with the hope that this will address a core underpinning of equity—fairness and justness of opportunity. | A final set of communities include health explicitly in their narrative but work primarily to reduce health disparities among subgroups rather than having an explicit tie or establishing policies and procedures to create health equity. Each narrative appears to have some benefits in opening up access to health services and systems, as well as other social and economic supports. Yet, it is unclear whether the short‑term strategies to close health outcome gaps are able to fully integrate a range of stakeholders in health promotion in ways that are sustainable for population health and well‑being. At the outset of this report, we outlined the aspirations of each Action Area in a Culture of Health in integrating and promoting health equity. We summarize key findings in the context of the Action Framework here: © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 14 C U LT U R E O F H E A LT H H E A LT H E Q U I T Y SENTINEL COMMUNITY INSIGHTS SEPTEMBER 2019 Moving Forward This Sentinel Community Insights Report on Health Equity is a The Sentinel Community Insights Reports cover key topics first step in summarizing achievements toward health equity in that may be of value to stakeholders working to build a Culture the communities. This early analysis highlights several avenues for of Health in their own communities. This report on Health further investigation in health equity research and practice. For Equity offers insights into how communities perceive health instance, we are interested in how these perspectives influence equity, and what those perspectives mean for the strategies and health equity planning over time. Here are some paths forward: approaches that communities use to promote health equity. We hope that these themes may be of use to communities that are ●● Document and better assess narrative choices being made navigating ways to talk about and promote health equity locally. by community leaders in discussing health equity. This In the subsequent appendix, we offer a discussion guide to assist includes how leaders describe the drivers and influences of communities in their conversations about health equity. health equity in ways that can fully embrace diverse groups in a community. –– For instance, what terms and stories are used to explain health equity and to help argue for investment, References especially in communities where equity has not been a long‑standing priority? –– Does it matter which community leader (e.g., government, Braveman P, Arkin E, Orleans T, Proctor D, and Plough A. What nonprofit), is talking about health equity? Is Health Equity? And What Difference Does a Definition Make? ●● Learn more about how decision‑making bodies are Princeton, NJ: Robert Wood Johnson Foundation, 2017. making health equity investment choices. Understand how leaders are making resource allocations to advance health equity, designing options, and sustaining investments over a longer duration. ●● Understand whether and how communities that are not currently addressing health equity may evolve their approach over time. If these communities feel they cannot initially address health equity in a direct way, how can they evolve their approach over time? Or will they not discuss health equity explicitly as they build health strategies? It will be important to examine whether this indirect approach has positive impacts on health equity outcomes regardless, or to summarize the limitations of this strategy for long‑term improvements in health equity. ●● Strengthen the collection of equity‑based data. While communities appear to be leveraging many sources of data to describe health disparities and identify strategies based on those data, it is unclear how the health equity case is being made. How are improvements in health equity (i.e., improvements in systems and structural barriers) being monitored and tracked? We need to strengthen data gathering efforts related to the presence of structural barriers and systemic contributors to health inequities. © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 15 Creating New Government Structures Broad-Based Changes With R WJ F C U LT U R E O F H E A LTTargeting High-Need Unspecified Equity Goals Approach H Addressing Historical and H E A LT H E Q U I T Y Populations for Intervention Systems-Level Barriers SENTINEL COMMUNITY INSIGHTS Increasing Economic and/or SEPTEMBER 2019 Perspective Reducing Health Disparities Educational Opportunities Appendix: Discussion Guide for Communities After reading this report, think about how health equity is being defined and addressed in your community. How might some of the insights and examples from the Sentinel Communities inform your community’s efforts to address health equity? F i g u r e 8 : P E R S P E C T I V E S I N A D D R E S S I N G H E A LT H E Q U I T Y, S O M E E X A M P L E A P P R OAC H E S A N D C O M M U N I T Y C H A N G E S Institute Office of Equity to Impact Local Decision-Making Job-Skill Matching for Improved Employment Creating New Government Community Change Cancer Screening for At-Risk Populations Structures Broad-Based Changes With Targeting High-Need Unspecified Equity Goals Approach Addressing Historical and Populations for Intervention Increasing Economic and/or Systems-Level Barriers Perspective Reducing Health Disparities Educational Opportunities KEY THEMES IN THE CONTEXT O F C U LT U R E O F H E A LT H AC T I O N F R A M E W O R K ( R E F E R TO F I G U R E 1 ) Q U E S T I O N S F O R C O N S I D E R AT I O N TA L K I N G A B O U T E Q U I T Y A N D Which perspective reflects your view of health equity? C R E AT I N G S H A R E D VA LU E S Which perspective is most prevalent in your community? What other ways of defining health equity shape your community’s approach to addressing this issue? Why do you think these similarities or differences in perspective exist in your community? If your community stakeholders have a shared view of health equity, how did you get there? If you don’t yet have a shared perspective, how do you think you could get to that point? F O S T E R I N G A F O C U S O N H E A LT H If you work on health equity, which partners/sectors/systems are at the table? Which are not, but E Q U I T Y I N C R O S S ‑ S E C TO R should be? C O L L A B O R AT I V E S ●● Who leads efforts in your community to enhance health equity? Is it a health‑oriented organization, or another sector? ●● How do other cross‑sector collaborators exert influence in the conversation related to health equity? What are some examples in your community of how leaders from different sectors have worked collaboratively to address health equity? How is your community engaging marginalized or disadvantaged residents in these discussions? How could you work to ensure their voice is actively included in conversations and decision‑making? C R E AT I N G H E A LT H I E R A N D M O R E Which regions or populations of your community have experienced significant inequities related to E Q U I TA B L E C O M M U N I T I E S health? What gave rise to those inequities? How is, or could, your community work to address upstream causes of economic, social and physical barriers to opportunity? What opportunities exist for creating healthier, more equitable communities through place‑making? Is your community using policies or new government structures to address health equity? If so, what are these? A D D R E S S I N G E Q U I T Y A S PA R T Describe the integration of health care, public health and social services systems within your O F S T R E N G T H E N I N G H E A LT H community. Are there opportunities to strengthen the integration of these systems to address S E R V I C E S A N D SYS T E M S health equity? What role could data play in helping to shape your health equity approaches? © 2019 Robert Wood Johnson Foundation  |  Sentinel Community Insights: Health Equity 16