Health Departments’ Role in Addressing Social Determinants of Health in Collaboration with Multisector Community Partnerships

Abstract

Multisector community partnerships (MCPs) are key component of the public health strategy for addressing social determinants of health (SDOH) and promoting health equity. Governmental public health agencies are often members or leaders of MCPs, but few studies have examined the role of health departments in supporting MCPs’ SDOH initiatives. We engaged 42 established MCPs in a rapid retrospective evaluation to better understand how MCPs’ SDOH initiatives contribute to community changes that promote healthy living and improved health outcomes. As part of this work, we gained insights on how health departments support MCPs’ SDOH initiatives, as well as opportunities for enhanced collaboration. Results indicate that health departments can support MCPs’ SDOH initiatives through the provision of funding and technical assistance, data sharing, and connecting community organizations with shared missions, for example. Findings can be used to inform the development of funding opportunities and technical assistance for MCPs and health department partners.

Introduction

Chronic diseases, such as heart disease, stroke, cancer, and diabetes, are leading causes of morbidity, mortality, and health care costs in the United States.^1,2,3 Social determinants of health (SDOH)—the conditions in the places people are born, live, learn, work, and play—contribute to disparities in chronic disease health outcomes and risks. Addressing these determinants is a critical strategy for advancing health equity.^4,5,6,7

Multisector Community Partnerships (MCPs) consist of a wide range of organizations, such as health departments; hospitals and health clinics; education, house, and transportation agencies; and faith-based organizations, that collaborate on interventions designed to improve health in their communities.⁸ By leveraging shared resources and diverse expertise, including the lived experience of underserved community members, these partnerships are key agents for addressing SDOH and promoting health equity.^8,9 Governmental public health agencies are often members or leaders of MCPs, but few studies have examined the role and value of public health in facilitating community changes to address SDOH.^10,11,12,13

As part of the Improving Social Determinants of Health—Getting Further Faster (GFF) evaluation, the Center for Disease Control and Prevention’s (CDC’s) National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) partnered with the Association of State and Territorial Health Officials (ASTHO), National Association of County and City Health Officials (NACCHO), 42 established MCPs, and evaluation contractor, RTI International, to strengthen the evidence base for MCP-driven SDOH initiatives. The Getting Further Faster evaluation retrospectively assessed SDOH initiatives implemented by the 42 MCPs in one or more of five SDOH focus areas: (1) built environment (BE), (2) community-clinical linkages (CCL), (3) food and nutrition security (FNS), (4) social connectedness (SC), and (5) tobacco-free policies (TFP). These SDOH focus areas were selected based on their links to chronic disease and NCCDPHP’s unique position to address them.⁴ Our rapid retrospective evaluation work involved characterizing the role of state and local health departments in leading or supporting MCP-driven SDOH initiatives. Findings can help inform public health practice, including the provision of resources and technical assistance to MCPs working to address SDOH and advance health equity.

Methods

GFF partnerships participated in the rapid retrospective evaluation from February through July 2021. The evaluation studied SDOH initiatives implemented within the past 3 years by GFF partnerships across 26 states. Nineteen GFF partnerships focused on one of the five SDOH focus areas (BE-2, CCL-7, FNS-4, SC-1, TFP-5), and 23 partnerships focused on multiple SDOH focus areas. Priority populations for the partnerships’ SDOH initiatives included people from racial and ethnic minority groups, older adults, and people living in rural areas.

Our evaluation work was guided by CDC’s Framework for Program Evaluation in Public Health and culturally responsive evaluation principles (e.g., we engaged GFF partnerships in evaluation priority-setting to ensure work was responsive to their information needs).^14,15 We also integrated implementation research constructs (e.g., inner setting and intervention characteristics) to help focus the evaluation design (CDC Framework step 3), inform data collection, analysis, and synthesis (CDC Evaluation Framework steps 4–6), and ensure our work yielded meaningful practice-based evidence.^14,16 The GFF retrospective evaluation involved review of implementation and outcomes-related data abstracted from partnerships’ GFF applications and program documents (e.g., progress reports to funders, evaluation reports, and publications and presentations) to better understand how MCPs’ efforts contributed to community changes that promote healthy living and improved health outcomes. We also held discussions with representatives from each of the 42 GFF partnerships to aid in our interpretation of abstracted data and gather insights on factors that facilitated and hindered their SDOH work. Additional details regarding the rapid retrospective evaluation methods will be published in a separate paper. Evaluation plans were reviewed by the RTI Institutional Review Board (IRB) and determined to not be human subjects research.

Document Review and Abstraction

Analysts reviewed and abstracted relevant data from the applications and program documents submitted by GFF partnerships. Abstracted data included partnership characteristics: type of lead organization (i.e., community-based organization, health care organization, health department, university, or other); whether the partnership included a state or local health department; and type of outcome(s) reported (i.e., capacity building, community changes, health behaviors, clinical outcomes, general health, or health care utilization/costs). Analysts abstracted and categorized relevant data using an Excel database, and a senior scientist reviewed and synthesized abstracted data using pivot tables.

Discussions with Partnerships

The study team developed a discussion guide, which was tailored to each partnership’s work based on information gathered through document review. Questions to clarify a partnership’s relationship with state and local health departments were included in the guide, with probes for detail about the perceived contributions and benefits of working with state and local health departments. One 60-minute virtual discussion was held with each partnership, and discussions were conducted by four teams of two analysts in May and June 2021. Key staff and partners from all 42 GFF partnerships participated in the discussions. Partnerships selected participants with knowledge about core discussion topics. Types of participants varied across partnerships and included community-based organization, health department, community development, and health care organization representatives. With participants’ consent, discussions were recorded, and recordings were transcribed by a third-party vendor. Text about the role and contributions of state and local health departments were coded and organized using qualitative data software (NVivo 12.0). Analysts double coded 10% of the transcripts and met to adjudicate differences, then independently coded the remaining transcripts.

Results

Among the 42 GFF partnerships, almost all (N = 41, 98%) had health department members. Based on document review and discussions, 10 (22%) GFF partnerships partnered with both state and local health departments, nine (21%) partnered with only state health departments, and 22 (52%) partnered with only local health departments. Eight (19%) GFF partnerships were led or co-led by state or local health departments. Of the 22 (52%) GFF partnerships reporting health outcomes data, 21 included health departments, including two partnerships that had health department leads.

Table 1 highlights key themes that emerged from partnership discussions about the benefits and challenges of working with health departments. Discussion participants reported that health departments provided their partnerships with funding, key resources, and championed partnerships’ SDOH initiatives. Participants also perceived that health departments gave legitimacy to partnerships at local, state, and federal levels. However, some partnerships faced challenges working with health departments due to competing priorities within the health department, limited funding available to health departments, and government bureaucracy.

Table 1.

Key Themes: GFF Partnerships’ Experience Working with Health Departments

Key Theme	Theme Description	Exemplar Quotes
Benefit: State and local health departments were an essential source of funding and resources for many partnerships.	Health departments provided funding support through grants, tangible resources (e.g., vans, tobacco signage, clinical spaces, and campaign materials), planning and coordination assistance, and technical assistance and training. Some local health departments provided evaluation support, including data collection and data sharing, to measure community and health impacts. Partnerships often benefited from local health departments’ community health needs assessments and understanding of local needs, including SDOH.	“One of the main benefits is the access to funding because [health departments] have a little more leverage than we do when it comes to reaching those federal dollars.” –CCL partnership (1) “It [the health department] has provided a lot of capacity…four working groups … had been facilitated by people from the health department, just volunteering their time. There’s a lot of overlap with what they want to accomplish as health educators in their job, and so it was a good marriage that way. So we have heavily relied on the health department in getting work in the health arena going. We’ve utilized the three-year analysis that they do for a community assessment. So, we utilized all of their data as a foundation for our work.” –BE, CCL, FNS, SC, TFP partnership
Benefit: State and local health departments increased credibility with decision-makers and helped advance community changes to promote healthy living.	State health departments supported partnership initiatives through various forms of promotion at both federal and state levels—for example, through the provision of letters of support for federal grants. Collaborating with health departments also helped to increase partnerships’ credibility with local decision-makers.	“Being with the Health Department increases our credibility and allows us to present ourselves as a resource rather than solicitors upon initial contact with local decision-makers.” –TFP partnership (1) “Many public health employees share expertise in the topics that we work to address in the community (e.g., tobacco policy), which also allows for their staff time to be committed to lead committees …which is extremely helpful when volunteers cannot commit time. It is also helpful in having a more direct connection to community leadership, such as the county commissioners. It also allows for more community well-being projects to be tackled at once (e.g., community health improvement plans and blue zones projects).” –BE, FNS,TFP partnership
Benefit: Local health departments helped build relationships among community organizations.	Local health departments leveraged their relationships to facilitate partnerships among community organizations with similar missions and priority populations.	“One of the biggest things I’m thinking is relationship building…. I realized that a lot of [community organizations] come to [county health department] just about general questions, or other resources they may need, and it’s just opened up that door for me to make other connections to the community ambassadors to address whatever needs they may have.” –BE, CCL, FNS partnership
Challenge: State and local health departments’ competing priorities can limit their contributions to partnerships’ work.	In some cases, partnerships reported challenges aligning their work to health department priorities and timelines. Additionally, partnerships’ work sometimes took a backseat to public health emergencies, such as COVID-19.	“COVID-19 has presented a challenge for us in enhancing our partnership with our local health department.” –TFP partnership (2)
Challenge: State and local health departments’ limited resources can pose challenges for partnering.	Limited funding impeded health departments’ involvement in some partnerships. Staffing shortages or turnover at both the state and local levels also posed challenges for some partnerships, because they had to develop relationships to re-establish communication protocols with new staff.	“I think that their challenge is their funding. They want to participate, they’ve got programs, they have the data, they know what the need is, but they’ve got limited resources, like you would expect from any health department. And that’s probably one of the biggest issues.” –CCL partnership (2)

Discussion and Conclusion

There is a critical role for the public health field—and state and local health departments in particular—in addressing SDOH and advancing health equity. In alignment with the Bipartisan Policy Center (2021)’s recommendations in Public Health Forward,¹⁷ results from our evaluation indicate that public health departments can support MCPs’ work to intervene on SDOH and create healthier communities by providing funding, training, and technical assistance; sharing data; and connecting community organizations with shared missions. GFF partnerships described receiving tangible resources (e.g., clinical spaces, vehicles, and health communication campaign signage) from health departments to help offset the costs of SDOH initiatives, as well as direct funding from health departments and support for obtaining federal funding. GFF partnerships also described how collaborating with health departments boosted their credibility and connections with local decision-makers, which is important for advancing MCPs’ efforts to implement community changes, such as tobacco-free policies and built environment improvements, that promote healthy living. However, some GFF partnerships noted that underresourced health departments are limited in the support they can provide to MCPs. In order to fulfill their potential key roles as TA providers, funders, and partnering and data sharing facilitators, health departments need sufficient resources to provide long-term support to MCPs, in addition to managing their required health programs and responding to emergent public health crises.

Our work has limitations. The cohort of GFF partnerships is not representative of all MCPs. Also, this evaluation focused on the five GFF SDOH domains to improve chronic disease-related outcomes, so may not be applicable to other types of SDOH initiatives. Group discussions may have influenced participants’ remarks about benefits and challenges of collaborating with health departments. Because data collection was rapid and retrospective, our results are subject to recall and misclassification bias. We relied on partnerships’ ability to accurately recall activities that had occurred before our evaluation began, and discussions with partnerships relied on self-report. However, methods were appropriate for the purpose of this assessment, which was to rapidly gather practice-based insights to help inform future investments in MCPs’ SDOH initiatives.

The results from this rapid retrospective evaluation reinforce that, whether providing leadership or—more commonly and perhaps appropriately—much-needed support to community-based organizations leading MCPs, local and state health departments play an important role in addressing SDOH and advancing health equity. Future research regarding the role of public health departments as partners in addressing SDOH should quantify costs and resources needed to sustain public health’s involvement in these types of initiatives.

Implications for Policy and Practice

Health departments can fill an essential role in working with MCPs to address SDOH and advance health equity, including:

• Leveraging funding and other resources to support and sustain partnerships’ community health initiatives and streamlining the funding process for partnerships. Resources include products, such health education materials, as well as staff expertise and assistance with planning and coordinating partnership activities.

• Providing training and technical assistance to local partnerships on community needs and strengths assessments, evaluation, and acquiring external funding by introducing them to external grant opportunities and providing letters of support for responses to funding opportunities.

• Leveraging relationships to connect new community organizations to partnerships and serving on partnership boards or committees.

• Providing subject matter expertise and evaluation support, helping inform implementation and measurement of initiative impacts. Health departments can support data collection, share data, or help interpret evaluation findings to inform the partnerships’ implementation approach.

• Providing leadership to coordinate current and future initiatives to address SDOH. Health departments are uniquely positioned to provide the necessary leadership to connect and support community efforts.

More flexible funding may help address the challenges of competing priorities and limited resources. For example, health department funding that supports broad partnering or direct funding to MCPs that allows recipients to be responsive to emergent community priorities may help sustain capacity for community-level SDOH initiatives.