Addressing the Social Determinants of Health through the Alameda County, California, Place Matters Policy Initiative

Abstract

In Alameda County, California, significant health inequities by race/ethnicity, income, and place persist. Many of the county's low-income residents and residents of color live in communities that have faced historical and current disinvestment through public policies. This disinvestment affects community conditions such as access to economic opportunities, well-maintained and affordable housing, high-quality schools, healthy food, safe parks, and clean water and air. These community conditions greatly affect health. At the invitation of the Joint Center for Political and Economic Studies' national Place Matters initiative, Alameda County Supervisor Keith Carson's Office and the Alameda County Public Health Department launched Alameda County Place Matters, an initiative that addresses community conditions through local policy change. We describe the initiative's creation, activities, policy successes, and best practices.

Many low-income residents and people of color in Alameda County (AC), California, face barriers to good health, such as poor air quality, dilapidated housing, limited access to healthy food and parks, underfunded schools, and few economic opportunities. These community conditions are linked to higher rates of asthma attacks, obesity, diabetes, heart disease, and mortality.^1,2 For instance, an African American born in West Oakland, California, can expect to die almost 15 years earlier than a white child born in the Oakland Hills area of California.² Across the country, discriminatory policies and practices tied to race/ethnicity and socioeconomic status have resulted in disinvestment in low-income communities and communities of color.^3–6 For example, redlining, a “government condoned practice where banks refused to grant home-purchase loans in certain areas based on their ethnic/racial composition,” prevented people of color from buying homes in certain neighborhoods.⁷ This practice limited their ability to accumulate wealth, leading to a reduced tax base and decreased capital investment in critical community infrastructure (e.g., schools, parks, and businesses).⁸ Other policies have similarly diverted critical resources away from low-income communities of color.⁶ To foster greater health equity, the public health field must address underlying policies that shape community conditions and opportunities for good health.^5,9–11

In 2006, the Joint Center for Political and Economic Studies (hereafter, Joint Center) invited AC Supervisor Keith Carson to create one of the national Place Matters initiative teams. The goal of the Place Matters initiative is to improve the health of participating communities by “addressing social conditions that lead to poor health” through “identifying the complex root causes of health disparities and defining strategies to address them.”¹² Supervisor Carson reached out to the AC Public Health Department (ACPHD) to create and implement an initiative focused on multisector partnerships, public health department and community capacity building, and policy and systems change to advance health equity. The initiative is currently housed within ACPHD and supported by ACPHD staff, and Supervisor Carson remains a critical partner of the AC Place Matters team.

Three fundamental factors helped provide a strong foundation for the AC Place Matters initiative at the time of its launch. First, senior leaders within ACPHD and its parent agency, the AC Healthcare Services Agency, were dedicated to ensuring strong government-community partnerships and building employee capacity to advance health equity. This dedication included a willingness to devote staff to the initiative and resulted in strong ties with other governmental sectors and community groups. Second, ACPHD's research unit used advanced methods to identify social and health inequities at neighborhood levels. This innovative use of data to understand stark inequities created a sense of urgency for staff and partners that helped advance the work. Finally, ACPHD was developing a strategic plan to achieve health equity, and policy change emerged as a key focus area.

AC PLACE MATTERS ACTIVITIES

AC Place Matters started with a small group of ACPHD senior leadership and staff, a representative from Supervisor Carson's office, and local partners. Together, they developed AC Place Matters' goal of advancing health equity through community-centered local policy and systems change that addresses six specific social determinants of health (SDH): criminal justice, economics, education, housing, land use, and transportation.¹³ Initially, all ACPHD staff involved continued working on other health department programs, leaving little time for AC Place Matters. In 2007, ACPHD hired a full-time AC Place Matters coordinator, providing the necessary structure, continuity, and vision for the planning team to advance the initiative.

The planning team conducted a needs assessment that included a literature review on links between each issue area and health outcomes, local data on each issue area, and key informant interviews with local government, community-based, and business leaders. As part of the needs assessment, staff researched historical and current policies and practices at the root of inequitable community conditions. Key informant interviews were a critical aspect of the needs assessment. As team members worked with new partners from sectors such as housing and economics to understand policy needs, barriers, and opportunities, they developed and strengthened relationships and trust, which helped establish a framework to advance solutions collaboratively.

Responding to emerging policy issues

As a result of the relationships AC Place Matters staff developed through the needs assessment, local leaders began requesting that AC Place Matters analyze and comment on local policy issues from a health equity perspective. For example, a local environmental and economic justice organization asked AC Place Matters to testify on the relationship between affordable housing and health. After testifying, AC Place Matters received feedback that their introduction of a health equity lens allowed decision makers to rise above competing political agendas to support affordable housing.

As requests for testimonies, letters to decision makers, coalition partnerships, and other opportunities increased, AC Place Matters staff developed internal tools, including a health equity analysis tool, and protocols to ensure all community requests would be analyzed using clear criteria and there would be a process to ensure that all actions would be approved by ACPHD leadership.¹⁴

Creating a local policy agenda

After establishing a strong system for responding to emerging issues, the AC Place Matters planning team decided to create a local policy agenda to identify issues that staff would tackle in more depth in partnership with local organizations. The planning team developed a process for creating and implementing the local policy agenda that identified key opportunities for advancing health equity. This process also helped prioritize resources for activities with the greatest impact and increased staff and community engagement.

Staff engagement.

AC Place Matters launched five staff workgroups to create and implement the local policy agenda, which focused on criminal justice, economics, education, housing, land use, and transportation. The planning team reached out to approximately 600 health department employees to recruit members for the workgroups. Since launching the workgroups, more than 50 staff members have participated in monthly workgroup meetings, and another 50 have signed up for e-mail updates. Two factors contributed to the successful launch of the workgroups: (1) having a clear goal of developing the policy agenda and (2) having a clear process for achieving this goal with manageable steps that used a range of staff skills.

Community engagement.

The AC Place Matters team worked with consultants, funded through the Joint Center and the W.K. Kellogg Foundation, and AC's Public Health Commission to design a public engagement plan that was flexible and prioritized community-identified issues. This approach supported existing community-driven policy change activities and ensured that all partners, regardless of time and resources, could be engaged in AC Place Matters.¹⁵

In April 2010, Supervisor Carson and the AC Place Matters team invited more than 200 local residents and representatives from community-based and government organizations to four community engagement gatherings. The gatherings included (1) discussing the root causes of health inequity, such as structural racism and potential policy solutions; (2) viewing and discussing the film “Unnatural Causes;” (3) an orientation to policy change and discussion of possible policies to consider for the policy agenda; and (4) a process to determine community priorities for the local policy agenda. More than 125 people participated in at least one gathering. AC Place Matters invited all participants to stay connected to and drive the work through multiple methods, including AC Place Matters workgroup meetings, trainings, Facebook, listserv updates, and AC Place Matters staff attending other groups' meetings.

Based on the insights from community leaders and the workgroups' background research, the AC Place Matters workgroups developed concrete, achievable local policy goals. To ensure a focus on health equity, the AC Place Matters planning team developed several decision-making tools that weighted policies deemed to be community priorities and addressed health inequities. The local policy agenda was officially launched in September 2010, and every policy included in the agenda was a top priority from the community engagement process. The workgroups are currently partnering with community and government organizations to advance these policy goals.

HEALTH IMPACTS

Measuring the health impact of policy changes is a long-term endeavor; thus, AC Place Matters is currently tracking short-term impacts, including policy successes, new community-based and cross-sector partnerships, indicators of increased staff and partner capacity, and responsiveness to emerging policy issues. Examples of each are detailed hereafter. AC Place Matters monitors these short-term impacts because they are critical to achieving long-term health gains.^5,16–19 ACPHD's research unit continues to monitor numerous health indicators as well, although it is difficult to directly link policy change to distal health outcomes. Finally, to help assess health impacts of policy and systems change over time, AC Place Matters is working with ACPHD programs and partners to increase tracking of SDH related to the policy work, such as the number of truancy cases related to chronic disease.

Policy successes

Foreclosures and health.

In 2009, tenants living in foreclosed rental housing faced water shutoffs as landlords and banks stopped making water payments. Causa Justa :: Just Cause (CJJC), a grassroots social justice organization, mobilized its members to address the issue and asked AC Place Matters staff to testify on the health impacts of water shutoffs. This partnership helped CJJC secure a water shutoff moratorium.

Building on this success, AC Place Matters, other ACPHD staff, and CJJC developed a report that combined the results of data collection and analysis with personal stories on the link between foreclosure and health, and provided policy recommendations.⁶ The report received widespread media attention, and ACPHD and CJJC presented the report to the U.S. Departments of Housing and Urban Development and Health and Human Services. Community groups, including CJJC, used the report to support the City of Oakland's Vacant Property Registration Ordinance,²⁰ which has netted the city more than $1.6 million through fees assessed to banks that own vacant foreclosed properties. The funds are used to reduce blight, preventing deterioration of neighborhood conditions and associated health threats.

Code enforcement.

Fear of landlord retaliation, displacement, and deportation, as well as a lack of affordable housing, constricts choice and forces people—often low-income people of color—to accept unsafe housing conditions, such as mold, lead, and rodents, which can significantly impact physical and mental health.^21–25

The AC Place Matters Housing Workgroup is partnering with government and community organizations to advance the widespread adoption of a proactive approach to rental inspection. This adoption entails regularly scheduled inspections of all rental properties to ensure that substandard housing issues are addressed earlier, preventing negative impacts on tenant health. The Housing Workgroup provided information about the connections between housing and health and the benefits of proactive rental inspection to a task force charged with improving Oakland's code enforcement practices. The task force passed the recommendation for piloting this approach to Oakland elected officials, who in turn approved it.

Truancy court partnership.

Chronic health conditions, especially asthma, often contribute to chronic absenteeism among students. The AC Place Matters Criminal Justice Workgroup, the ACPHD Chronic Disease Program, and the AC District Attorney's Office created a case management component for the AC truancy court—a court where a prosecutor, judge, and case managers work with parents of chronically absent children to improve school attendance. A process is now in place where the judge can refer families with chronic disease issues to the county's Chronic Disease Program for case management, which is improving attendance. The workgroup and partners are now exploring partnerships with local school districts to head off truancy problems related to chronic disease. This prevention will improve children's health, reduce absenteeism, and improve children's educational outcomes, which are directly linked to long-term health outcomes.^26,27

Additional policy successes.

In addition to these initial successes, work is underway to (1) make affordable consumer-focused banking services accessible to residents of low-income neighborhoods; (2) reduce pollution in areas that face high levels of exposure; (3) incorporate a health focus into land-use planning processes; (4) complete a health impact assessment on education funding models; (5) conduct a health impact assessment on funding for local public transportation; and (6) ensure supportive housing, employment, and health-care reentry services for people returning to communities from incarceration. AC Place Matters is also exploring ways to institutionalize equity in county decision-making processes.²⁸

From its inception as a new initiative, AC Place Matters has engaged 210 residents and community-based or cross-sector partners and has garnered 425 “likes” on Facebook. AC Place Matters has also sponsored six trainings and regularly hosts lunchtime learning sessions (Figure). More than 150 staff and community partners have attended at least one training session. In addition to implementing the policy agenda, AC Place Matters has responded to more than 130 requests for health equity impact analyses since it began tracking activities in 2009.

Figure.

Staff and community training sessions: Alameda County Place Matters initiative, Alameda County, California

BEST PRACTICES

Through internal planning and strategy sessions, AC Place Matters has identified several best practices that have contributed to the initiative's success. These best practices are foundational for the initiative and may be instructive to others engaging in local policy that addresses SDH.

1. Find and foster strong leadership. Having a policy maker, Supervisor Keith Carson, as a champion has been essential for the initiative's survival and success, as he and his staff have raised the visibility of the issue of health inequities and the potential for ACPHD to help advance solutions in partnership with local leaders. ACPHD senior leadership has been crucial in building new partnerships, increasing staffing levels, and providing vision for the initiative.

2. Dedicate staff resources to the work. Consistent, dedicated staffing is important, but a small staff is adequate, especially if others throughout the department, such as epidemiologists and case managers, contribute to the work when their expertise is needed.

3. Engage staff from across the local health department. In addition to advancing the policy agenda, the workgroups ensure AC Place Matters' policy priorities are linked to ACPHD's programs and services. Additionally, they institutionalize local policy efforts for health equity throughout the department rather than creating an isolated policy initiative.

4. Contribute to building grassroots power. Many AC Place Matters partners are base-building organizations that mobilize residents around policy issues. Their leadership is essential for building the grassroots power necessary to address root causes of health inequities.

5. Address root causes. Acknowledging the role of racism in health inequities and committing to addressing the root causes of health inequities is essential for establishing trust with community groups and helping other institutions understand why AC Place Matters is focused on equity across sectors.

6. Partner with community organizations and leaders. Local advocates and community organizations help determine AC Place Matters' policy priorities and activities. Being responsive to these partners demonstrates commitment to supporting their work, builds trust across sectors, and ensures that the work is grounded in the experiences and perspectives of local organizations and leaders. Additionally, flexible commitment structures increase long-term engagement and sustainability.

7. Partner with government institutions across sectors. Partnering with other government sectors also helps advance more equitable policies. AC Place Matters team members are now invited to bring a health equity focus to advisory boards such as the AC Transportation Commission's community and technical advisory working groups, the Oakland Unified School District strategic planning task forces, and the West Oakland Specific Plan Technical Advisory Committee.

8. Work reactively and proactively. It is important to be able to respond to emerging issues that are partners' priorities even while pursuing AC Place Matters' policy agenda.

9. Build capacity. Meaningfully engaging staff and partners in local policy and systems change requires preparing people for the opportunity to shape and drive changes for health equity. Additionally, trainings are a good way to build trust and share resources.

10. Use tools that ensure a focus on health equity. The creation and ongoing application of tools to analyze policies for health equity impacts ensures resources are appropriately targeted.

CONCLUSION

Policy and systems change is essential for reducing health inequities and creating communities of opportunity that support good health. Local policy work that is rooted in community partnerships and cross-sector collaborations is a key part of achieving this mission and ensuring that everyone has access to high-quality schools, housing, transportation, jobs, safe places to walk and play, and a fair criminal justice system. Developing a local policy initiative within a local health department has been a challenging but essential step in moving toward an AC where everyone, regardless of the color of their skin, the amount of money they make, or where they live, has the opportunity to lead a healthy, fulfilling, and productive life.