Health Equity Alliance Advancing Community Health

Transcription

1 Health Equity Alliance Advancing Community Health FINAL EVALUATION REPORT The goal of the Health Equity Alliance (HEA) project is to enhance the capacity of local health departments, in partnership with community residents, organizations and leaders, to achieve health equity through a focus on the social, political, economic and environmental conditions that affect health. SAN JOSE OFFICE 1871 The Alameda, Suite 180 San Jose, CA P: F: WATSONVILLE OFFICE P.O. Box 1927 Watsonville, CA P: F: CLAREMONT OFFICE P.O. Box 1845 Claremont, CA P: F: W W W. A P P L I E D S U R V E Y R E S E A R C H. O R G

2 Health Equity Alliance Project Final Evaluation Report Table of Contents Table of Contents EXECUTIVE SUMMARY... 3 EVALUATION METHODOLOGY... 7 Evaluation Plan... 7 Evaluation Questions... 8 Measurement... 8 INTRODUCTION Introduction to the Pilot Sites and the Sequence of the HEA Project FINDINGS Summary The Social Determinants of Health (SDOH) Health Disparities and Health Inequities Policy Makers Collective Social Justice Movement Community Engagement CADH Support to Pilot Sites The Health Equity Index Next Steps with the Index A Summary of Key Findings: Final Takeaways Evaluation Findings Applied Survey Research,

3 Executive Summary Executive Summary Health Equity Alliance Project Final Evaluation Report The Health Equity Alliance (HEA) project is a pioneering effort designed to support local public health departments in Connecticut by providing specific localized data. The purpose is to improve health equity by targeting the community conditions that impact health. Health equity is related to access to resources. For example, in general poor people die at a younger age than wealthier people. Local public health directors in Connecticut reported in a 2003 survey, that they wanted to improve health outcomes by addressing inequities in their communities, but lacked reliable local data with which to make public health decisions. The Connecticut Association of Directors of Health (CADH) developed a Health Equity Index (the Index) that provides data ranking community conditions and health outcomes for every city and town in Connecticut. 1 The Index displays a profile of measures related to housing, education, safety, employment, environmental quality, economic stability, and civic engagement, considered as social determinants of health (SDOH) within a community. CADH created a learning collaborative to see how three local public health departments in Hartford (Hartford Health & Human Services Department), New Haven (New Haven Health Department) and Groton (Ledge Light Health District) would benefit from the Index. Each health department provided training sessions to their staff about community conditions that impact health, and reached out to community members to share data. The expectation is that as community members are increasingly involved in the analysis and decision making, they will begin to create strategic action plans to address issues of priority. The ultimate goal is to promote health equity and better health outcomes at the local and state level in Connecticut. Findings from the Pilot Project The Index Provides a Comprehensive Source of Reliable Data The Index has been a consistent go to tool for us; one we can depend upon to give us concise information on specific social determinants of health A local public health director Among the three local health departments, the Health Equity Index was used to: Highlight specific inequities in health outcomes such as asthma, emergency room visits, prenatal care, and cardiovascular disease Write and receive grants Stimulate strategic data discussions within the local health departments Enable the community to have a sharper focus on the use of local data Prompt internal reviews of how data are collected/managed/displayed Develop reports, briefing papers, and fact sheets on health disparities, public safety, and obesity Stimulate neighborhood discussions Initiate discussions with elected leaders and municipal representatives Strengthen collaborative efforts through using/sharing Index data. 1 CADH received funding from the W.K. Kellogg Foundation to pilot test the Index with three local health department community sites. Applied Survey Research (ASR) conducted an independent external evaluation of the project. 3 Applied Survey Research, 2011

4 Health Equity Alliance Project Final Evaluation Report Executive Summary The Index Enhances Understanding of Community Conditions That Impact Health Employees are more comfortable talking about the social determinants of health (SDOH), and I m hearing more of the SDOH language in the office. A local public health director Public health employees at the three local health departments were given a survey in fall 2009 at the beginning of the HEA project. They then received employee training on health equity and the survey was repeated in the spring of Only half (53%) of employees responding to the survey in 2009 understood what health inequity was, but this increased to 87% in 2011 at the end of the project (p < 0.05). Figure 1: I have a clear understanding of the meaning of the term health inequity. 100% 80% 60% 40% 20% 0% 53% 36% 12% Source: Local Health Department Employee Survey, 2009 and % 11% Agree Not Sure Disagree 3% There was a statistically significant difference in knowledge between employees who received training about health inequities and employees who didn t receive the training (p< 0.05). Less than half of untrained employees (48%) were familiar with the major health inequities impacting residents in their local communities, as compared to 89% of employees who received training. Figure 2: I am familiar with the major health inequities affecting residents in the community we serve. 100% 80% 60% 40% 20% 0% 48% 39% Untrained employees 13% Source: Local Health Department Employee Survey, 2011 (Trained employees, n =129, Untrained employees, n=25) 89% Agree Not Sure Disagree 7% Trained employees 4% The Index Promotes Community Conversations and Collaboration on Health Issues I have the mayor e mailing me back, I have doctors and lawyers e mailing me back it started from this project. A community member involved with the HEA project Local health department (LHD) employees reported that the project contributed to their departments becoming more active in their communities, improving relationships with community members, and contributing to more communication with the broader community on the conditions impacting community health. Applied Survey Research,

5 Executive Summary Health Equity Alliance Project Final Evaluation Report Seventy nine percent of the HEA leadership staff at the three health departments said that their departments became somewhat or a lot more active in their community because of the project. The three sites reported not being able to place as much attention on community engagement as they had initially hoped, due to time constraints. Although the pilot sites became more active in the community and communicated more with the broader public, more time was needed to begin the community action planning steps to confront health inequities. Reversing or changing long standing policies and practices requires adequate time for strategic planning, community organizing, and consensus building. The Index Provides Data for Decision Making and Policy Change Each of the three health departments reported making inroads with policy makers about health equity. Over 71% of HEA leadership staff at the departments reported that their sites had communicated somewhat/a lot with policy makers (including mayors, city council members, and state legislators) about the social determinants of health. Several high profile state leaders also expressed support for the project. 2 Seventy nine percent of HEA leadership staff from the three departments said that the HEA initiative contributed to a local and to a statewide conversation in support of a collective movement to advance health equity. Figure 3: How useful has the Index been in showing the connection between the Social Determinants of Health (SDOH) and health outcomes for Local Health Department Staff, the General Public, and Policy Makers? Local Health Department Staff? 57% 43% 0% The General Public? 43% 50% 7% Policy Makers? Source: HEA Pilot Leadership Staff Survey, Moving Forward With the Index 33% 50% 17% Somewhat/very A little Not at all Although the grant period has been completed, each of the three departments reported that they will continue the HEA project. Groton used Index data to apply for and receive a community transformation grant. The Hartford Health & Human Services Department used Index data for grant writing and received awards of $3.9 million for lead poisoning and $4.5 million for teen pregnancy prevention. New Haven used Index data to develop a proposal to examine low weight births. CADH is working to make the Index available to all Connecticut local health departments and is also working with hospitals to see how the Index can support their federally mandated community health assessments. 2 Supporters include the executive director of the State of Connecticut Commission on Health Equity, the former Commissioner of the Connecticut State Department of Public Health, and the senate chair of the appropriations committee in the state legislature. 5 Applied Survey Research, 2011

6 Health Equity Alliance Project Final Evaluation Report Executive Summary Evaluation Findings Evaluation findings suggest that there are some key factors that may have contributed to the success of the HEA Project including: Leadership Characteristics A public health director committed to the HEA project, willing to set department priorities related to health equity, who encourages widespread workforce development training on health equity, and is a public advocate for health equity with elected officials, municipal employees and residents. Workforce Capacity and Development A committed LHD staff, some of whom are drawn from the LHD leadership team, who have public health experience with a history of working within the department, and are familiar with the neighborhoods in which the LHD focuses it health equity efforts. Implementation of a comprehensive workforce development training program focused on SDOH at the beginning of the project, prior to community engagement. Employees need to feel confident in their capacity and skills to engage with their community, using the Index. Willingness from some LHD staff members to work closely with the Index and to encourage a data rich environment for the HEA project team, the department, and the community. Applied Survey Research,

7 Evaluation Methodology Evaluation Methodology Health Equity Alliance Project Final Evaluation Report CADH hired Applied Survey Research (ASR) in June 2010 as a neutral external evaluator. ASR is a non profit social research firm based in California, with a 30 year history of evaluation, assessment and strategic planning. ASR has worked with public health departments throughout its 30 year history and has expertise in large scale federal, state and local evaluations with dozens of grantees. ASR specializes in working with at risk populations such as young children, seniors, low income families, immigrant families, families who have experienced domestic violence and child maltreatment, the homeless, and children and families with disabilities. ASR has conducted dozens of community assessments and community health assessments and has received national and international awards for their work. ASR staff members have published several articles about their work in international journals including Applied Research Quality of Life; Community Quality of Life Indicators: Best Practices; Diversity and Community Development: An Intercultural Approach; and publications of the Organization for Economic Cooperation and Development (OECD). ASR was hired to evaluate the overall HEA effort, while each pilot site developed their own local evaluations. The following section outlines CADH s theory of change, the primary evaluation questions, and the primary tools for evaluating the HEA Project. EVALUATION PLAN The HEA project was expected to initiate change through three major components: 1. Development and testing of the HEA Index, 2. Training the local health department (LHD) staff on SDOH and beginning to impact the policies and procedures of the LHD, and 3. Providing outreach to the community on SDOH and encouraging community members to develop action plans to impact SDOH and health outcomes. At the same time, CADH was both supporting the local public health departments in their efforts and attempting to change opinion leaders in the state to have a greater focus on health equity to improve health outcomes. As a result of the three steps for the pilot sites, and the work of CADH to encourage HEA champions, the HEA Project hoped to foster a local and statewide social justice movement to improve health outcomes. CADH Theory of Change Develop and test the Index Outreach to communities re: SDOH LHD sites change practices re: Index, Workforce, and SDOH Create and implement local and statewide action plans re: SDOH Create a local and state wide social justice movement re: SDOH CADH Support to Pilot Sites CADH Leadership/Advocacy Improve local and state wide health outcomes 7 Applied Survey Research, 2011

8 Health Equity Alliance Project Final Evaluation Report Evaluation Methodology EVALUATION QUESTIONS The following table shows the different aspects of the Health Equity Alliance Project, and the corresponding 7 primary evaluation questions that were created to guide the evaluation. Figure 4: Validity of the Index Internal Agency Practice changes Local Outreach Support to Pilot Sites CADH Leadership/ Advocacy Action Plans, Advocacy and Influence CADH Evaluation Questions Questions about validation of data with other valid measures, availability of neighborhood data, inclusion of supplementary data, etc (parts of Q 1 and 2) How does the use of the INDEX support the LHD in its efforts to incorporate the consideration of SDOH in reducing health disparities and improving community health outcomes? (Q1) How did the HEA approach change the internal practices of the LHD, shift its role in the community, and build each site s information and communication capacity specific to the SDOH? (Q3) How does the use of the Index support the LHD in its efforts to communicate the connection between social determinants and health outcomes to the broader community? (Q2) How well did CADH support pilot sites in the use of the INDEX, workforce development, community engagement and communications? What was the relative significance of each of these components to the overall success of the initiative? (Q4) How effectively did CADH work with HEA champions, the State Health Equity Commission and others to increase knowledge of SDOH? How did CADH help to identify and establish policies, practices, or infrastructures that work to improve health outcomes by addressing the social determinants of health? What role did the use of the INDEX play in these efforts? (Q5) How did the HEA initiative build a collective social justice movement, locally and statewide focused on health equity among HEA partners and the pilot sites? Which communication efforts were most effective in establishing linkages among pilot sites, CADH, HEA champions, the State Health Equity Commission, and HEA Team? (Q6) Overall, has the INDEX proven to be a useful tool for engaging the general public and policy makers in addressing social determinants of health as a way to improve community health? (Q7) MEASUREMENT ASR used a wide range of qualitative and quantitative methods with which to evaluate each of CADH s evaluation questions. The major methods included: site visits with CADH and each of the three public health departments, key informant interviews with CADH staff members, HEA staff at each of the sites, HEA state champions, residents, and policy makers. ASR also conducted on line surveys with public health department employees and members of the leadership teams of the HEA Project at each site. ASR conducted extensive analysis of administrative and secondary data. Details about each method are included below. Customized primary data collection tools were developed as a main source of data: An employee pre project survey was created and administered by CADH staff in September 2009 for employees of each of the three public health departments. A total of 149 employees took the survey: 25 from LLHD, 50 from Hartford HHS, and 74 from New Haven. An employee post survey of each of the three public health departments was created by ASR and conducted in May 2011, using survey monkey. The post survey shared many of the pre survey questions, but had additional questions that conformed to the evaluation plan. The survey was sent to all employees in Groton (25) and New Haven ( ), and 115 full time employees in Hartford HHS (the part time and temporary employees were not included). A total of 173 employees took the survey: 25 Applied Survey Research,

9 Evaluation Methodology Health Equity Alliance Project Final Evaluation Report from Ledge Light Health District, 91 from Hartford HHS, and 57 from New Haven Public Health Department. The majority of respondents (83%) had been trained in the Health Equity Alliance curriculum in ASR analyzed the statistical significance between employee respondents to the pre survey in 2009 and the post survey in 2011 using the Z proportion test of significance where p<0.05. The report will include an asterisk (*) where there is significance. ASR conducted key informant interviews of Health Equity Alliance Pilot Leadership staff of each of the three health departments, staff of CADH, and Green River staff in September 2010 and again in March and April Key informant interviews were also conducted in April 2011 with HEA champions that had been working with CADH staff. ASR created and implemented a self administered survey of the Health Equity Alliance Pilot Leadership staff of each of the three health departments in March Leadership staff included the Health Directors, Deputy Health Directors, Project Directors/Co directors, epidemiologists, community relations, and other staff with leadership responsibilities in the HEA Project. The survey was completed by 14 staff members on survey monkey. ASR conducted on site visits in June and October of 2010, and March There were several secondary data sources utilized including: Grantee applications of the pilot sites to CADH at the start of the project. Annual work plans from each of the pilot sites. Annual and semi annual reports of each of the pilot sites to CADH. Annual reports of CADH to the Kellogg Foundation. Background documents from CADH in regards to the Index and the pre survey findings. Public relations and communication documents from each of the pilot sites to their local communities. Evaluation plans and evaluation data for each of the pilot sites, where available. Pilot site internal evaluation reports. Minutes from meetings between CADH and pilot sites. 9 Applied Survey Research, 2011

10 Health Equity Alliance Project Final Evaluation Report Introduction Introduction Overview The Health Equity Alliance Project (HEA) is a pioneering effort designed to support local public health departments in Connecticut to improve health equity by focusing on the social determinants of health (SDOH) such as the social, political, economic, and environmental conditions that impact health. The short term goal of the pilot project was to create a learning collaborative to see how three local public health departments would benefit from access to new data about SDOH and health outcomes in their regions, how they could train their own staff about SDOH, and reach out effectively to community members to share data about health equity. The longer term goal is to promote health equity and better health outcomes at the local and state levels in Connecticut. The three year HEA pilot effort is a testing ground to observe changes in public health practice, the relationship between local public health departments and the community members that they serve, and community conditions that promote health equity and better health outcomes. The project is under the direction of the Connecticut Association of Directors of Health (CADH), and funded by the W.K. Kellogg Foundation. Theory of Change There are three major components to the first phase of the HEA Project: 1. The creation and testing of a Health Equity Index that shows the correlations between the social determinants of health and health outcomes. 2. Workforce development within local health departments such that staff members become more aware of the social determinants of health and their links to health outcomes. 3. Outreach to local community members to increase awareness about the SDOH, to share Index data, and for communities to establish priorities and action plans to improve the SDOH. The expectation was that these three major steps would be key in promoting local collective social justice movements focused on health equity. The first phase of the HEA pilot project was to focus efforts in the three cities of Hartford, New Haven and Groton. CADH provided extensive support to these three cities as well as promoting the HEA Project at the state wide level with champions who could forward a health equity agenda at the state and local levels. The second phase of the project is to focus efforts on additional local health departments in seven towns and cities including Stratford, Trumbull Monroe, West Hartford Bloomfield, Uncas, Torrington Area, Stamford and Norwalk. This evaluation report focuses on the first phase of the project in the first three cities with data collected up to May 31, However, it is important to note that although the foundation funding officially ended at the end of May 2011, the cities of Hartford, New Haven and Groton have reported that they will continue the HEA project in various forms in their local health departments. Further, the seven additional towns and cities are continuing to work with the Health Equity Index and the Index continues to be refined to meet the needs of local health departments. Background In 2003, CADH joined with the National Association of County and City Health Officials (NACCHO) and a diverse group of stakeholders to launch an initiative focused on making health equity principles integral to the practice of public health. CADH surveyed its membership and found a widespread belief that health directors at Local Health Departments (LHDs) should direct their attention to improving the SDOH as a form of primary Applied Survey Research,

11 Introduction Health Equity Alliance Project Final Evaluation Report prevention. CADH also found that health directors lacked good quality local and reliable data with which to confront health inequities. According to CADH, health departments had little or no ready access to health outcome data or data about SDOH. CADH helped to establish a state wide coalition of stakeholders, known as the Health Equity Action Team (HEAT) and funded with seed money from the Universal Health Care Foundation of Connecticut. HEAT members come from state agencies, universities, health care organizations, community based organizations, and foundations. A primary focus of HEAT became the creation of a datagenerating tool that would provide local health departments with current reliable data about SDOH and health outcomes. The tool was called the Connecticut Health Equity Index (Index). Additional grants from the Connecticut Health Foundation and the Joint Center for Political and Economic Studies provided funding for the development of the Index. The primary function of the Index was to quantify the social determinants that led to health disparities between different population groups. Another goal was for the Index to help stimulate community discussions and community action to help improve health outcomes. CADH did a wide literature search and analysis of indices in the United States and across the globe and decided on the necessary components of the Index. In 2008, CADH received funding from the W.K. Kellogg Foundation to test the Index in several communities. 3 One of the goals of testing the Index in a range of communities was to document the different approaches of each of the health departments and the contextual factors that impacted the project, such as leadership, staffing, size of communities, workforce development training tools, and methods of community engagement. CADH began the HEA Project by expanding the Index into a statewide database with the help of Green River, a consultant group with expertise in data collection, web based application development, and data base display. The Index contains data from a vast range of local, state and federal data sources, including data for all 169 towns and cities in Connecticut and all 800 census tracts. Data sources include US Census data, hospital discharge records, CT Department of Public Health Vital Statistics, CT Department of Social Service Caseload Records, CT Department of Education Data and Research, CT Housing Finance Authority, Municipal Voter Registration and Voting Records, Home Mortgage Disclosure Act, and county real estate information. The Index functions as an electronic database with GIS maps of health and community indicators. The Index uses standardized indicators for every city and town. It is organized by showing a range of social determinants of health such as economic security, education, environmental quality, housing, employment, civic involvement, and community safety, and the correlations between those SDOH and health outcomes such as life expectancy, cancer, diabetes, childhood illnesses, cardiovascular disease, and infectious diseases. Each SDOH is made up of multiple indicators; for example, economic security is made up of 14 separate indicators such as measures of the poverty level, TANF participation, foreclosures, mortgages approved, household income, sale price of homes, value of homes, and mortgages initiated. Each SDOH and each health outcome has a score, on a scale from 1 10, and the scores are color coded to be seen on GIS maps. The expectation is that health department staff, municipal leaders and community members can look at a map of their city, town or neighborhood and grasp the status of that SDOH based on its color and score as well as a score and a color for health outcomes. The Index provides statistically calculated correlations at the neighborhood and town level, and allows comparisons to other cities and towns in the state. While CADH and Green River were constructing the Index, CADH sent out a Request for Proposals to local health departments to pilot the project. In order to be selected as a potential pilot site, health departments had to identify health disparities in their communities, provide examples of community collaborations, a work 3 Connecticut Association of Directors of Health (CADH), HEA Project Summary Draft, May 2011 and; CADH, The Health Equity Index: Background and Initial Literature Review, Applied Survey Research, 2011

12 Health Equity Alliance Project Final Evaluation Report Introduction plan, potential partners, measurable outcomes, organizational capacity, how they would evaluate their progress, and a detailed budget. Proposals were scored by an independent review panel and ultimately three local health departments were chosen: the Hartford Health and Human Services Department (Hartford HHS), the New Haven Public Health Department Health Department and the Town of Groton, as part of the Ledge Light Health District (LLHD). The pilot sites were announced in April 2009 and sites began their work in the summer of INTRODUCTION TO THE PILOT SITES AND THE SEQUENCE OF THE HEA PROJECT Each of the three pilot sites was quite different from one another in size and structure, and in the way that they implemented and sequenced the HEA Project, as well as the number of staff hours dedicated to the project. The following chart outlines some of the differences between the three sites, followed by a brief introduction to the three sites, and a table outlining the sequencing of activities for each site including workforce development, working with the Index and community engagement. Figure 5: Characteristics of Pilot Sites City Town/City population Overall LHD Staff Number of Staff Trained on HEA Project and SDOH Groton 39, All staff trained to some degree Groton/Ledge Light Health District Primary LHD Staff on HEA Project Approx. 7 9 and 11 high school student interns Estimated LHD Staff Neighborhoods Hours on Chosen HEA Project 4 neighborhoods 13,887 hours Hartford 125, Approx. 130 Approx. 7 City wide 9,464 hours New Haven 125, Approx. 100 Approx. 2 3 City wide 5,514 hours LLHD began their work with staff trainings on SDOH by their public health director who had helped to create the HEA Project. The staff trainings began even before the site was chosen as a pilot. According to the HEA Project Director, all LHD staff were trained to some degree on SDOH and the HEA project. Trainings in SDOH were also offered to other municipal leaders in the region including town and city department heads and program managers. The HEA Project was also introduced at several schools. In the spring and summer of 2010, the LLHD epidemiologist utilized the Index and provided extensive feedback on the Index to CADH and Green River staff. The epidemiologist also gathered Index data to share at community roll outs in the summer of Four neighborhoods were chosen for the community outreach component from four different socioeconomic levels from very poor to very wealthy. Student interns conducted door to door outreach to the four neighborhoods to announce the roll outs. LHD staff members were assigned to neighborhoods where they had prior connections, including both personal and professional experience. At the roll outs, community members were introduced to Index data, the HEA Project, a photo voice exhibit about health that was created by local youth, and residents were asked to complete evaluations and indicate whether they wanted to participate in later focus groups. Focus groups were launched in March of 2011, with the help of staff and a team of 11 high school student interns. The epidemiologist also provided trainings on the Index to health department staff. Other staff members spent limited time using the Index on the website, but more commonly reached out to the epidemiologist for data requests. Applied Survey Research,

13 Introduction Health Equity Alliance Project Final Evaluation Report The director of the LLHD took a very active role in the HEA project and assigned different duties of the project to a wide range of staff members, including the deputy director, the supervisor of community relations, the evaluator, epidemiologist, and several interns. The HEA Project director was a senior member of the LLHD staff. In the second year of the project, a team of two co directors led the project, under the direction of the health director. The Department calculated that they spent a total of 13,887 staff hours on the HEA Project over two years. Hartford HHS Department Hartford followed a different sequence when implementing their HEA effort. Their epidemiologist also began to work closely with the Index over the spring and summer of 2010 and provided trainings on the Index to health department staff. Some staff spent a brief amount of time using the Index on the website, but more commonly reached out to the epidemiologist for data requests. In the fall of 2010, the Hartford department worked with the Hispanic Health Council to refine a workforce development training curriculum and began trainings of their employees. The curriculum included information about SDOH, and had a strong focus on cultural competency. There were three distinct modules in the curriculum that were taught over five trainings: Social and Health Equity, Undoing Racism, and Stereotyping and Bias. Ultimately, the goal of the health director was to train the entire staff, and approximately 130 staff members were trained by the end of May Meanwhile, in the fall of 2010, the Hartford Health & Human Services Department started to participate in community meetings, especially in two neighborhoods, where they shared the concept of the HEA Project. However, staff was reluctant to show the Index or actual data, as they felt that the Index data might be too complicated and they were concerned with the political consequences of sharing data that showed poor health outcomes. Nearly 300 community members were reached through neighborhood meetings including block parties, the opening of a recreation center, and a men s health gathering. The department also featured HEA information on a local community television show, in public service announcements, op eds, newsletters and on their website prior to and after the launch of their community meetings. In April 2011, the Hartford Health Department created a series of three meetings at the city s main public library to unveil the Index to an audience of municipal employees, community leaders, and residents. As of spring 2011, the epidemiologist was using Index data to write a health disparities report for the department; an introduction to SDOH was also included in the city s Critical Health Indicators Report, an assessment of health in Hartford. Index data were used to apply for several large grants and the department received funding in two areas including $3.9 million for lead poisoning and $4.5 million for teen pregnancy prevention. The Hartford HHS Department assigned different elements of the HEA Project to a wide range of staff members including the deputy health director, the HEA project director, the health education manager, epidemiologist, the public health nursing supervisor, and two additional team members with expertise in outreach and communications. The project director was hired from outside the health department for this project, while the co leader of the project came from within the department, and had a long history of working in public health and media. The Department calculated that they spent a total of 9,464 staff hours on the HEA Project over two years. 4 4 The final report from the Hartford Health Department calculates staff hours at 88 hours each week for the first year and 94 hours each week for the second year (multiplied by 52 weeks a year=9,464 hours). 13 Applied Survey Research, 2011

14 Health Equity Alliance Project Final Evaluation Report Introduction New Haven Public Health Department The New Haven Public Health Department faced some challenges in implementing the HEA Project in that they experienced three different health directors over the course of the project: the health director who applied for the grant, an interim health director, and a permanent health director who assumed leadership during the last few months of the project. The project was assigned to a smaller number of staff than that of LLHD or Hartford and had active participation from the HEA project director and to a lesser extent from the epidemiologist. The New Haven Health Department hired the project director as a consultant external to the health department, so the project director did not have experience working within the health department. Workforce development training started with SDOH learning sessions called Lunch and Learns in the fall of 2010 (for a total of 8 sessions with approximately 8 10 people per session). Sessions included showing the video modules from Unnatural Causes documentary, discussing the content of the videos and how it applied to the staff s work. The department also used and refined a curriculum from the Hispanic Health Council, similar to the Hartford HHS department with the same 3 modules. The curriculum had a focus on cultural competency, as a pathway to the SDOH. That curriculum was launched near the end of the project period in March/April 2011, and finished by the end of May Nearly 100 of the staff members were trained in the curriculum. The department linked their HEA Project with another city project effort known as Health Matters. Health Matters has a wide and diverse leadership drawn from well placed municipal leaders and the mayor s office. The mayor helped to set the priorities of Health Matters to include three subject areas: public safety, obesity and tobacco. The HEA Project embraced those same topic areas for their work. Health Matters and HEA launched a one day conference in March 2011 with over 100 participants, including participation from the mayor and a key state senator, Toni Harp, a champion of the HEA Project. At the conference, HEA team members unveiled a briefing paper on public safety and a fact sheet on obesity. Some data for the briefing paper on public safety came from the HEA Index, supplemented with local police data. The conference also featured a video that was produced for the HEA Project about people s perceptions of what would make a healthier New Haven. The video drew from hundreds of hours of interviews with a wide variety of community members and local leaders. Shorter videos were also created to be distributed to a range of outlets. The Department calculated that they spent a total of 5,514 staff hours on the HEA Project over two years. 5 Sequencing The following table summarizes some of the major steps at each of the pilot sites and provides color coding for similar activities including Workforce Development Trainings (WFD), Testing of the Index, and Community Engagement (CE). The table shows that Groton started with WFD prior to the start of the project, followed by testing of the Index (spring/summer 2010), and community engagement in 4 neighborhoods (starting summer 2010); Hartford began with testing the Index (summer 2010), and then conducted WFD at the same time as they began community engagement in two neighborhoods (fall 2010). New Haven started by testing the Index (summer 2010) followed by limited workforce training (fall 2010), then community engagement (the Health Matters Conference in March 2011), ending with comprehensive workforce development (spring 2011). Comprehensive workforce development training started prior to the start of the project in Groton, and near the end of the project in New Haven. 5 The final report from New Haven Health Department calculates staff hours at 1,354 hours; the project director estimates spending and additional 40 hours each week for each of two years (40 hours multiplied by 52 weeks=2,080 multiplied by 2 years=4,160 hours). Applied Survey Research,

15 Introduction Health Equity Alliance Project Final Evaluation Report Figure 6: Pilot Site Sequencing Pilot Sites Chosen Feb Groton March 2009 March 2010 On going Workforce Development training (WFD) of LHD and municipal employees Spring 2010 (Index released April 2010) Epidemiologist works with Index; Staff prepare for neighborhood roll outs Summer 2010 Community Engagement (CE):4 neighborhood roll outs Fall 2010 Intern training (WFD); Community Engagement (HEA introduced at several schools) Winter Community Engagement (Neighborhood Focus Groups) Spring 2011 Community Engagement (Neighborhood Focus Groups) Hartford New Haven Public TV show features SDOH topics HEA project linked to Health Matters Collaborative, Yale University and community organizations Epidemiologist works with Index Epidemiologist works with Index Planning of CE and WFD Refine work plan Community Engagement (Neighborhood meetings) and WFD trainings Limited WFD trainings (Launch Lunch and Learn sessions); Gather resident input about health for video Community Engagement WFD (on going) Refine WFD training curriculum Community Engagement and WFD (Library trainings on the Index) Community Engagement (Health Matters Conference); WFD trainings of full staff 15 Applied Survey Research, 2011

16 Health Equity Alliance Project Final Evaluation Report Findings Findings SUMMARY The following findings are divided into several focus areas including: the social determinants of health, health disparities and health inequities, workforce development training, how the HEA Project contributed to a collective social justice movement focused on health equity, the impact of the HEA Project on policy makers, HEA state champions, community engagement, the support of CADH to the pilot sites, the support of pilot sites to one another, and the Health Equity Index. After the findings are some suggestions for next steps and final takeaways. Each subject area includes overall data for the three pilot sites combined and sources of data will include the survey conducted with the HEA Project leaders at each of the pilot sites, data from the pre and post employee surveys, data from Key informant interviews, and secondary data. In some instances, details about one or more of the pilot sites will be included in footnotes to highlight particular successes or challenges of the project. THE SOCIAL DETERMINANTS OF HEALTH (SDOH) The workforce development process has been extremely beneficial for some of my long standing employees. It helped them understand the SDOH and helped them to realize their own stereotypes, prejudices and bias. There has been a gradual transformation of health department staff into equity junkies. Employees are more comfortable talking about the SDOH, and I m hearing more of the SDOH language in the office. Local public health directors One of the three major pillars of the HEA Project was to train the local health department staff about the social determinants of health and health disparities. According to the employee survey from all three pilot sites at the end of the project in spring 2011, 86% of employee respondents reported that they had a clear understanding of the meaning of SDOH; almost 70% reported that they could easily describe the concept of SDOH to other LHD staff members, and 73% said they could describe the concept to community members. Figure 7: SDOH I have a clear understanding of the meaning of the Social Determinants of Health. 86% 11% 3% Agree/strongly agree Not sure Disagree/strongly disagreee Source: LHD Employee Survey, 2011 Applied Survey Research,

17 Findings Health Equity Alliance Project Final Evaluation Report Employee respondents were given a list of four items (economic security, cardiovascular disease, civic involvement and community safety) and were asked to identify the one that was not a SDOH. 78% correctly chose cardiovascular disease, but 14% identified civic engagement. 93% of employee respondents agreed or strongly agreed that the health of their community was determined by things like access to affordable housing, transportation and an adequate living wage. HEA Pilot Leadership staff said that their employees gained knowledge of SDOH due to the HEA Project. Almost all HEA Pilot Leadership staff said that their staff had a lot or some knowledge of the Social Determinants of Health (93%) and that it was primarily due to the HEA initiative (79% said it had a lot to do with the HEA initiative). HEALTH DISPARITIES AND HEALTH INEQUITIES Another important aspect of the HEA Project was to educate local health department (LHD) staff about the concepts of health disparities and health inequities. A health disparity is a difference in health outcomes which is not due to a difference in one s access to resources. For example, women have more breast cancer as compared to men. Health inequities are related to one s access to resources. For example, poor people generally die at a younger age than wealthier people. Employees were given a survey in fall 2009 at the beginning of the HEA Project, and it was repeated again in the spring of According to the two surveys, there was a statistically significant gain (p< 0.05)* in employee knowledge of health disparities and inequities over the two years (* indicates statistical significance). 74% of employee respondents said they agreed/strongly agreed that they understood the meaning of health disparity in 2009, increasing to 89% in 2011, (p<0.05). * Figure 8: 100% 80% 60% 40% 20% 0% I have a clear understanding of the meaning of the term health disparity. 74% Source: LHD Employee Survey, % 89% 9% 8% 3% Agree Not Sure Disagree 53% of employee respondents said they agreed/strongly agreed that they understood the meaning of health inequity in 2009, increasing to 87% in 2011, (p<0.05). * 17 Applied Survey Research, 2011

18 Health Equity Alliance Project Final Evaluation Report Findings Figure 9: 100% 80% 60% 40% 20% 0% I have a clear understanding of the meaning of the term health inequity. 53% Source: LHD Employee Survey, % 12% 87% 11% Agree Not Sure Disagree 3% Employee respondents were given a list of six items, and were asked to determine whether each one was a health disparity or a health inequity. Between 73% and 79% of respondents got the right answers for 5 of the 6 items. Applying a Health Equity Approach to LHD Work 83% of employee respondents in 2011 agreed or strongly agreed that they were familiar with the major health inequities affecting residents in the community they served. Over 68% of employee respondents reported that they were able to apply a health equity approach to their work since the beginning of the HEA Project in fall Figure 10: Applying a Health Equity Approach to Employees Work How much have you been able to apply a health equity approach to your work since the beginning of the HEA Project (fall 2009) Source: LHD Employee Survey, % 25% 20% 12% A lot/somewhat A little Not at all Don't know A Focus on Health Equity at the Pilot Sites LHD employee respondents from the three sites were asked in spring 2011 if they knew about the HEA Project, and 96% of them did, while 35% of them said they were directly involved with the project. 6 Employees were asked about the degree of focus on health inequities within their public health department; 46% said there was some, but not enough focus on health inequities, and 42% said there was about the right amount of focus on health inequities, 8% said there was too much focus and 5% said there was no focus on health inequities at all. 6 Ledge Light Heath District (LLHD) had a higher percentage of direct involvement of staff in the HEA project (46%, compared to 35% in Hartford and 30% in New Haven), but due perhaps to the low numbers of staff members at LLHD, the differences were not statistically significant. Applied Survey Research,

19 Findings Health Equity Alliance Project Final Evaluation Report Discrimination and Employees Comfort Level with Discussing Discrimination The majority of employee respondents agreed or strongly agreed that people in their community were discriminated against on the basis of their race (79%), followed by their job, financial status, and educational level (75%). 63% of employee respondents didn t think that men and women were treated equally in their community, while 37% were not sure or they believed that men and women were treated equally. Employees were asked about their comfort in talking with others about discrimination based on gender, social or economic class, and race. Between 77% 78% of employee respondents agreed or strongly agreed that they were comfortable talking about discrimination based on gender, social or economic class, and race. 7 The Impact of Training According to the employee survey in Spring 2011, 83% of overall employee respondents reported that they were being trained or had completed training in SDOH. Most employee respondents (74%) reported receiving 3 5 training sessions. Twenty eight employee respondents from the three departments reported not having been trained in the HEA curriculum including 9 at LLHD, 8 in New Haven and 11 in Hartford. When comparing respondents answers between those who were trained and those who were not trained, there were significant differences in several key areas (p<0.05). There was a significant difference between trained and untrained employee respondents in their understanding of the meaning of SDOH (92% versus 56%).* Figure 11: I have a clear understanding of the meaning of the Social Determinants of Health. 100% 92% 80% 56% 60% 40% 28% 8% 16% 20% 1% 0% Trained employees Untrained employees Agree Not Sure Disagree Source: LHD Employee Survey, 2011(Trained employees, n =129, untrained employees, n=25) There was a significant difference between trained and untrained employee respondents in their understanding of the meaning of the term health disparity (94% versus 63%)* and in their understanding of the term health inequity (92% versus 57%).* 7 New Haven and Hartford employee respondents tended to report more comfort than did LLHD respondents in discussing those subjects (although these were not statistically significant differences perhaps due to the low numbers of staff members at LLHD). For example, 84% of Hartford and 78% of New Haven employee respondents agreed or strongly agreed that they were comfortable talking about discrimination based on race, while only 52% of LLHD respondents were equally as comfortable. 19 Applied Survey Research, 2011

20 Health Equity Alliance Project Final Evaluation Report Findings Figure 12: I have a clear understanding of the meaning of the term health inequity. 100% 92% 80% 60% 57% 40% 30% 20% 7% 1% 13% 0% Trained employees Untrained employees Agree Not Sure Disagree Source: LHD Employee Survey, 2011(Trained employees, n =126, untrained employees, n=23) There was a significant difference between trained and untrained employee respondents in their understanding of the term social justice (88% versus 57%)* and how social justice applies to their work responsibilities (82% versus 52%).* There was a significant difference between trained and untrained employee respondents with their familiarity with the major health inequities affecting residents of the community they serve (89% versus 48%)*and in their belief that health is determined by housing, transportation, and a living wage (97% versus 70%).* Figure 13: I am familiar with the major health inequities affecting residents in the community we serve. 100% 89% 80% 60% 48% 40% 39% 20% 7% 4% 13% 0% Trained employees Untrained employees Agree Not Sure Disagree Source: LHD Employee Survey, 2011 (Trained employees, n =126, untrained employees, There was a significant difference between trained and untrained employee respondents in their understanding of the Health Equity Index (73% versus 38%).* Figure 14: I have a clear understanding of the Health Equity Index. 100% 80% 60% 40% 20% 0% 73% 18% 9% 38% 29% 33% Trained employees Untrained employees Agree Not Sure Disagree Source: LHD Employee Survey, 2011(Trained employees, n =127, untrained employees, n=24) Applied Survey Research,