Challenges and Supports for Implementing Health Equity During National Accreditation Among Small Local Health Departments in the United States

Abstract

Objective:

This article focuses on supports and challenges to health equity that small local health departments (LHDs) experienced while working toward national reaccreditation or Pathways Recognition with the Public Health Accreditation Board’s Standards & Measures Version 2022 (PHAB S&M v2022).

Design:

The study team conducted 22 qualitative interview sessions with members of health department leadership teams.

Setting:

In the spring of 2024, participants from 4 small LHDs in the western and midwestern regions of the United States participated in individual remote interview sessions.

Participants:

Participants were members of leadership teams in LHDs with population jurisdictions less than 50 000.

Main Outcome Measure(s):

Common challenges relating to the health equity measures in the PHAB S&M v2022 included external influences on equity language; lack of small population data; and racially and ethnically homogeneous populations and staff. The main support was the national equity standards provided justification for pursuing equity work.

Results:

Strategies to overcome challenges associated with the equity measures included staff training, seeking alternative equity language, and examining socioeconomic inequities in addition to race and ethnicity. Internal workforce understanding of health equity was improved through department-wide training initiatives. When working under restrictive language requirements for state agencies, grants, and other funding sources, staff suggested using alternative phrases and keywords such as level playing field and equal access. When addressing racially and ethnically homogenous populations, staff pursued equity in terms of income and focused on those living with pre-existing conditions (ie, diabetes).

Conclusions:

Ensuring that LHDs can work toward health equity is crucial for reducing health inequities. While the equity focus of PHAB S&M v2022 proved challenging, for this selection of LHDs, participants affirmed that PHAB accreditation allowed them to solidify their equity work to better serve their communities.

Local health departments (LHDs) in the United States provide fundamental and crucial public health services to their local communities.1 LHDs often serve as the backbone of the US public health infrastructure, providing a range of community services, including health screenings, vaccinations, health inspections, and disease surveillance.2 Despite the wide variety of geographic, demographic, and cultural settings for the more than 2500 LHDs in the United States, consistency in and accountability for LHD functions and services came to fruition with establishing a national accreditation program. Originally established in 2011, the Public Health Accreditation Board (PHAB), a 501(c)(3) nonprofit organization, provides a voluntary national accreditation process for governmental public health entities within the United States – including local, state, territorial, and Tribal health departments – and globally. In 2022, PHAB released a new set of Standards & Measures, Version 2022, which was informed by the 2020 revised 10 Essential Services of Public Health Framework3 and the Foundational Public Health Services Framework, both of which emphasize the concept that health equity should be a central theme in all governmental public health practice. In addition to the national accreditation process, PHAB administers the recently established Pathways Recognition program, which supports performance improvement efforts, strengthens infrastructure, and facilitates public health system transformation and can be used as a step toward national accreditation.4 Pathways Recognition program participants use a subset of the PHAB Standards & Measures Version 2022 (PHAB S&M v2022), focused on the Foundational Capabilities. Public Health 3.0, a new era of public health focuses on interventions serving the whole population and emphasizes the importance of local leadership in improving health outcomes.5 In alignment with Public Health 3.0, PHAB strives to ensure that the entire US population is served by an accredited health department.

As of March 2023, more than 90% of the US population was served by an accredited public health department.6 State and large municipal health departments have more often sought accreditation, and the benefits of accreditation for these larger health departments are far-reaching7-11 on the other hand, PHAB accreditation has been pursued proportionately less by small LHDs (covering < 50 000 population).12,13 Regardless of population jurisdiction, challenges and barriers are common when pursuing accreditation; however, small non-metropolitan LHDs often face challenges related to staff size and competing priorities, given that they are typically understaffed and receive less funding than their metropolitan counterparts. These challenges could result in small LHDs developing the perception that the time and effort needed for accreditation may outweigh the anticipated benefits.14

Within the field of public health, there is a renewed emphasis on addressing health equity due to various racial and ethnic inequities made prominent in the wake of the COVID-19 pandemic. In addition to addressing racial and ethnic health inequities, conversations expanded to include inequities associated with other historically marginalized identities, such as immigration status, gender, economic status, and sexual identity.15-17 Rural counties in the United States also experience extensive health inequities compared with metropolitan counties, with worsened social determinants of health (SDOH), overall mortality, self-reported health status and cancer mortality and risk factors.18,19 As noted by the Centers for Disease Control and Prevention (CDC), achieving health equity requires addressing injustices and improving economic and social opportunities for all people.15 This requires improving access to services, documenting inequities, advocating for change, and providing evidence-based practices to guide decisions.20 According to Lang et al., from 2015 to 2021, most (89.6%) accredited health departments reported working on issues pertaining to health equity; however, the extent of the equity work varied among health departments.16 A recent review of racial and ethnic health equity interventions conducted by or in collaboration with governmental public health agencies found interventions on improving access to care, cancer screening, health behavior, and infectious disease testing and control.21

Recognizing equity’s central role in local public health practice under Public Health 3.0, PHAB has pursued different ways to expand participation among small LHDs. PHAB’s efforts have included asking small LHDs about challenges experienced, receiving feedback from Tribal health departments, gathering recommendations from state health departments on how to support local accreditation efforts, and pursuing Public Health Infrastructure Grants to support health departments.14,22 In this paper, we describe the health equity-related experiences of the accreditation teams of 4 small LHDs within the western and midwestern regions of the contiguous United States as they pursued reaccreditation or Pathways Recognition utilizing PHAB S&M v2022.

Methods

This descriptive qualitative study examines equity-related participant experiences during reaccreditation or Pathways Recognition with the newly established PHAB S&M v2022 as part of a larger inquiry from 22 key informant interviews with leadership teams in 4 small LHDs. Eligible health departments included county, district, or Tribal health departments that were currently seeking reaccreditation or Pathways Recognition using the PHAB S&M v2022 and had jurisdiction populations under 50 000. As of December 12, 2023, health departments were eligible for participation. In collaboration with the PHAB coauthors, the study team selected and invited 7 LHDs to participate. Of the 7 LHDs contacted, one declined and 2 did not respond. Four LHDs agreed to participate, 3 of the LHDs were pursuing reaccreditation; the remaining LHD was completing the final requirements for the Pathways Recognition program. Two of the 4 health departments serve Tribal nations; one serves a single non-metropolitan area; and the fourth serves multiple non-metropolitan counties.

The staff size of the LHDs in this study ranged from 3 to 47 employees, with duties and responsibilities varying among health departments. Individual study participants were adults 18 years of age or older at the time of the interview who were involved in the health department’s accreditation process. LHD managers and staff were purposefully sampled and were identified after the PI met with each LHD director. Initially, 24 potential participants received an invitation to participate via email. Twenty-two agreed to participate and 2 did not respond to the invitation. Between January 2024 and March 2024, the study team conducted 22 key informant interviews. Interviews were conducted remotely by 2 members of the study team through a 60-minute semi-structured interview session. Interviews were audio-recorded via Zoom and transcribed verbatim by a third-party service. The interview guide utilized inquired about multiple topics regarding the PHAB S&M v2022 such as accreditation challenges, advice for other health departments, quality improvement and performance management, perceived benefits, and experiences with an equity focus. This article specifically focuses on the newly incorporated equity focus of the PHAB S&M v2022 and the associated successes and challenges in the reaccreditation or Pathways Recognition process.

During the equity section of the interview, follow-up questions were structured around the experience with the PHAB S&M v2022 and its emphasis on health equity, how inequities within the population were identified, governance of the LHD, and the equity language or framing that was used with the LHDs population. Table 1 outlines the interview questions utilized by researchers for participants. The following CDC definition of health equity was also provided to participants, “When we use the term equity, we mean everyone having a fair and just opportunity to be healthy and to thrive. We’re aware health departments may use different terms such as access or diversity.”15

TABLE 1.

The Interview Guide Questions Regarding the Equity-focused Standards & Measures

Category	Questions
Experience with equity focus	Tell me about your experiences with the equity-focused measures in the Standards & Measures. Have there been any challenges with the equity focus? Such as resources, skill sets needed, and terminology. Where are you in the process of addressing the new standards’ emphasis on equity? How is the national call for public health to address inequities and social needs affecting your health department? How has the accreditation process changed your relationship with the populations with the most significant health inequities?
Determining inequities	How do you determine priority subgroups for programs and services? Do you serve Tribal members exclusively or do you serve a wider set of people in your area?a How do you determine eligibility for services?a Which population groups served by your Tribal health department experience the most significant health inequities?a Which populations in your catchment area experience the most significant health inequities?
Governance and equity	As a sovereign nation health department serving a historically underserved population, how well or poorly do the equity measures fit your situation?a
Equity language and framing	Is there any framing or wording around equity that you have found particularly useful? How does your health department frame your equity work?

^aQuestion(s) specific to participants from Tribal health departments.

The 3 researchers who conducted the interview sessions independently coded the first 2 transcripts and then recoded the transcripts for consensus. Each interview transcript was coded independently by pairs of interviewers; these pairs later met to code for consensus, identify themes, and create theme reports. Thematic analysis was conducted among the 3 interviewers and included pairs independently identifying themes and meeting for consensus. The research team utilized NVivo 20 to code, sort, and manage portions of the transcripts (QSR International Pty. Ltd., Version 20). Content analysis from the transcripts followed the procedures laid out by Saldaña,23 allowing for recurring words and ideas to be extrapolated from the interview sessions. A structured codebook was developed by the 3 researchers and used to support deductive coding of participants’ experiences with PHAB S&M v2022. In addition to the procedures outlined by Saldaña, the research team followed the COnsolidated criteria for REporting Qualitative Research (COREQ) checklist24 and utilized multiple methods of verification (ie, peer debriefing, author reflexivity, and audit trails).25 Washington University in St Louis (IRB-202310219) received Institutional Review Board approval as an exempt study. Participants gave verbal or written informed consent.

Results

In this section, we review the supports and challenges LHDs encountered in addressing the health equity focus of the PHAB S&M v2022 and the strategies employed to address these challenges. Data analysis revealed 5 emergent themes: (1) determining health equity priorities in addition to race and ethnicity, (2) identifying population level needs, (3) balancing funding for population services with equity language, (4) addressing equity in the workforce, and (5) supporting equity work in LHDs using PHAB S&M v2022.

Determining health equity priorities in addition to race and ethnicity

One of the primary themes voiced by participants was difficulty in determining which programs or activities met the PHAB equity requirements. Part of this difficulty was based on the belief that inequities are primarily related to racial and ethnic demographics when compared with socioeconomic or other indicators (eg, age, education, employment status, income). This common misbelief among the jurisdiction population and staff proved particularly prevalent and challenging in both non-Tribal LHDs and Tribal nations where the jurisdiction populations are primarily racially and ethnically homogenous. An employee in a non-Tribal health department stated, “a lot of times people equate equity with a balance of race or gender or ethnicities or things like that and we are a predominantly white community, older community.”

However, challenges related to low racial and ethnic diversity were not only identified by non-Tribal health departments but also among Tribal health leaders. Tribal health departments reported challenges due to their jurisdictions comprising individuals and families in historically marginalized and underrepresented populations in which everyone is a priority. For instance, Tribal health department jurisdictions comprise primarily American Indians and Alaskan Natives (AI and AN), populations that have been historically underserved and underrepresented. Staff reported challenges labeling specific programs or services as equity work due to all services having an equity focus under the context of race and ethnicity.

Outside of the context of race and ethnicity, health department personnel aimed to address equity through other social and economic factors. For example, Tribal health departments sought priority populations established based on age, and addressed equity by providing additional services or programs to elders or children, increasing the focus on income inequities, and offering additional access to care for people with disabilities.

Identifying population level needs

When identifying priority populations, some participants identified resource allocation as a challenge in their equity work due to a lack of in-depth data on their population. Participants noted that, unlike larger municipal or state health departments, they could not access detailed population data, reducing their ability to allocate resources or identify specific demographic groups. When discussing the need for population-level data, one participant stated, “we don’t focus on stratification level or race or anything like that. We’re specifically focused on are you Tribal or are you non-Tribal?” There was a particular concern regarding language services and population data. One participant mentioned difficulty with expanding equity programs through languages other than English.

We’re a really rural [area], so it is a challenge to find those here as maybe opposed to a bigger city where there’s more options available. So, we use LanguageLine [Services] quite a bit. I’ve got some pocket talk devices, things like that, but to find a real person to person resource is a little bit more difficult for us up here.

Balancing funding for population services with equity language

In response to limited resources, LHDs often sought additional funding opportunities from state and federal entities to support their equity work. However, while some health departments in the United States are decentralized and retain certain authorities within their jurisdictions, their state or federal oversight entity is still the predominant funding source. Due to the homogenous populations that health departments served and/or the political landscape of their state or county, health departments frequently sought alternative language and phrases to incorporate health equity into their programs and services to maintain funding sources. For example, instead of using the term health equity, some health departments used the terms “disproportionately impacted populations,” “fairness or equal opportunity,” “access to care,” or “abilities and inabilities.” Yet others approached health equity by utilizing the Social Vulnerability Index or focusing on bias and gaps or differences in data between population groups.

Employees of non-Tribal health departments explained that the political climate of their state often determined whether they could include equity language in their programs and services. Despite some health departments operating under the control of local governing bodies, much of their funding still relied on the state government, limiting their autonomy. These individuals noted that their state government reflected a conservative political climate with restrictions on equity language for grant applications. One participant stated:

Particularly in [state] because [state] has taken a very strong stance right now, a conservative stance on shying away from the term equity. And so, institutions and agencies across [state] who receive state funding really have to be careful with the verbiage they use around equity for fear that the funding will be pulled.

Although Tribal health departments maintain sovereignty from state governments, participants also expressed challenges in balancing the funding of broader population equity programs with guidance and requirements received from federal entities within the United States, such as the Indian Health Service. These entities often provide funding and health care requirements and restrictions for only serving AI and AN populations, rather than the entire jurisdiction population, including non-Tribal family members.

Addressing equity in the workforce

Although these health departments had challenges incorporating equity language into their programs and services, participants stated that the PHAB S&M v2022 provided opportunities for health departments to revise internal policies to improve equity among their workforces. These policies sought to incorporate equity in official internal and external documents of the health department as well as the workplace culture of staff. Despite viewing equity as a priority, participants noted that there was difficulty in applying or creating equity policies in their jurisdictions due to “sheer lack of diversity in their own staff.”

In addition to revising internal policies, health departments utilized equity-related measures to implement new training for staff. One health department implemented trainings in health literacy, inclusive communities, and Immigration 101, while another trained staff on dementia recognition and interaction due to the high prevalence in their jurisdiction. Health departments also revised their hiring criteria to recognize experience outside of formal college education. One participant remarked, “We recognized that not everyone has the same advantages to be able to get an education that others do. And one of the first things when we’re hiring that we look at is do they meet the education requirements? And it was really limiting our talent pool…included on our job descriptions that we’d accept experience in lieu of education.” Another participant stated:

I think just educating people because everybody has their biases, their standards, whatever. But the more education you can get out there and the more voices that are heard, not the noisy voices, the nice voices. You know it is a political world out there.

Supporting equity work in LHDs using PHAB S&M v2022

Participants stated that while they had been pursuing equity in their programs for a long time, the PHAB S&M v2022 helped to solidify equity as a core concept in their programs and policies. When non-Tribal LHDs encountered politically divisive climates toward equity, staff were able to use the Standards & Measures to justify their equity work. Tribal LHDs benefitted from the Standards & Measures with the equity component guiding the LHD staff to produce culturally relevant programs to meet their community’s needs. Participants also suggested that the accreditation process allowed them to “dive deeper” and ensure they are working toward the equity goals they set forth in their programs and policies. Study participants emphasized that while many had been incorporating equity into their work before it had a name, the PHAB S&M v2022 served as a reference point for all their equity work moving forward. One participant stated:

I think the accreditation [process] really lent us to be able to say, we’re on the right path and we’re doing the right thing [around health equity], and here are the standards and measures that show this is what a health department should be doing.

Discussion

In recent years, various inequities have emerged in societal discourse, at the local, state, and national levels, as a result of the COVID-19 pandemic and the reemergence of various social justice movements throughout the United States.15-17 This discourse, combined with the goals of Public Health 3.0,5 has subsequently led to a stronger health equity (solution-oriented) ideology than the previous focus on health inequities (problem identification) within public health.26 The advancement of evidence-based practice in health equity approaches is critical for LHDs.27 Among governmental public health entities, LHDs are the most engaged with their local communities, where health inequities may be most apparent; therefore, it is incumbent for LHDs to advance evidence-based practices to eliminate health inequities and promote health equity to achieve healthy populations.

Addressing health equity and social justice concerns requires attention to multiple political and social factors and support for LHDs to improve capacity building and accreditation planning.28,29 An evaluation report produced by PHAB identified that among health departments pursuing accreditation or reaccreditation, the process assisted them in implementing practices and policies that advanced health equity.30 Recognizing the public health urgency related to improving health equity to address health inequities throughout the country, PHAB incorporated equity as a central theme in their PHAB S&M v2022, for the accreditation, reaccreditation, and Pathways Recognition process for governmental health departments.31

As health inequities become more prominent at local levels, LHDs’ consistent and thorough efforts to build health equity will be vital in reducing health inequities.28 While previous literature has focused on identifying gaps in care, themes from this current investigation support other prior findings. For example, previous studies identified the need for alternative language when discussing equity, such as “equal opportunity and socially disadvantaged populations.”32 In addition to alternative language, challenges related to funding were also identified as restrictive, especially when working in multisector collaborations.32,33 Similar solutions to equity challenges faced by LHDs included identifying additional programming needs and implementing internal trainings and policies for staff.28

In this study, participants from 4 small LHDs currently pursuing reaccreditation or Pathways Recognition shared their experiences with the new equity focus in the PHAB S&M v2022. Participants highlighted various strategies with a focus on utilizing alternative language (eg, disproportionately impacted populations, fairness, equal opportunity, access) to continue equity work in divisive political climates and meet the requirements of funding sources, incorporating workforce training, and revising internal policies to promote equity in their workforce. Finally, participants indicated that although the emphasis on equity proved challenging, it was paramount to their health department as it served not only as a reference point for their commitment to internal and external equity, but also as justification to continue and expand their equity work even in politically divisive climates.

This qualitative study has several limitations. First, the study includes the perspectives of leadership teams from only 4 LHDs, 3 of which were working toward PHAB reaccreditation. With only a few small LHDs using the equity-centered PHAB S&M v2022 as of December 2023, it was not possible to include LHDs in a variety of phases of accreditation preparation. The 3 LHDs that were preparing for reaccreditation may have been better positioned to address health equity than LHDs seeking initial PHAB accreditation or Pathways Recognition. Second, the sample did not include any LHDs with shared state and local governance, further limiting the generalizability of the findings. Third, equity discussions were a subset of the larger study on small LHD accreditation preparation strategies and advice for others and so did not contain as much specific detail as desired.

Preparation for national accreditation, reaccreditation, or Pathways Recognition involves extensive capacity (eg, staff, partners) to conduct community assessments, strategic planning, performance management, and documentation of evidence-based approaches. Integrating health equity science in research and practice benefits all elements of public health, from community needs assessments to randomized control trials.34 In this study, the research team learned that LHDs must be deliberate about incorporating health equity into their plans and practice as some barriers and challenges require innovative approaches to overcome adversity. Despite the challenges in promoting equity in their respective settings, participants maintained that all health departments should pursue equity for their populations and that the PHAB S&M v2022 provides the framework to do this. While findings from this study only represent the experiences of 4 LHDs that were pursuing reaccreditation or Pathway Recognition, strategies used to overcome challenges faced when incorporating the new equity focus can be adapted by other Tribal and non-Tribal (and particularly small) LHDs throughout the United States that are pursuing health equity in their jurisdictions.

Implications for Policy & Practice

• Health departments can modify their language and use neutral terms to communicate their equity efforts.

• Health departments can justify efforts to improve health equity by referring to the PHAB’s emphasis on health equity in Version 2022.

• Health departments can incorporate health equity into their policies and programs even when working among racially and ethnically homogenous populations.

• State health departments or federal entities should increase funding and resources to small health departments to support PHAB accreditation and to better describe their jurisdictional populations’ needs.