2004 Model Practice Application (Public)

Bay Area Regional Health Inequities Initiative (BAHRII)

Contra Costa Health Services

The mission of BARHII is “to transform public health practice for the purpose of eliminating health inequities using a broad spectrum of approaches that improve community health.” Consistent with that mission, BARHII has set the following objectives:

• Train staff on broad spectrum of strategies to improve nutrition and physical activity, and reduce health inequities.
  
  
• Develop regional collaborations of public health departments, organizations, coalitions and communities to participate in a comprehensive approach to improve nutrition and physical activity.
  
  
• Develop a media advocacy campaign to raise awareness among policy makers and the general public about key issues of nutrition and physical activity, and their link to chronic disease and health inequities.
  
  
• Use the regional platform to achieve changes in institutional practices and public policies, and increase support for public health.

Outcomes of practice include:

• A transformation of local public health department practice.
  
  
• Development of a collaborative regional mode.
  
  
• Creation of a regional media advocacy campaign.
  
  
• Changes in institutional practices and public policies.
  
  
• Increased public and official support for public health.

Key elements needed to replicate the practice include an expanded concept of public health practice, senior public health leadership committed to working collaboratively, and an understanding of the value of a regional approach.

The focus of BARHII’s mission is on the convergence of: 1) chronic disease burden and health inequities, and 2) the transformation of public health practice that will be required to make a substantial difference in both. Local public health departments on the whole are not well prepared to address chronic disease or health inequities in all their dimensions. Even with dedicated, typically short-term grant funds, much of the programmatic response to chronic disease focuses on specific diseases and/or populations. Reductions in chronic disease or health inequities will be limited without a comprehensive prevention framework that can address social and environmental conditions, as well as individual knowledge and behavior. The formation of BARHII represents a concerted effort to build organizational capacity in the public health department and redefine a standard of practice in order to rise to the challenge of chronic disease and health inequities.

Two elements combine to recommend the importance of a regional approach that can simultaneously take advantage of the most promising developments in individual public health departments and turn them into a pool of experience that can inform public health practice more generally These elements are 1) the relative absence of a strong state leadership role on health inequities in California and 2) the extraordinary focus on bio-terrorism preparedness that has occupied much of the attention of senior public health officials throughout the state. Especially during a time when public health department budgets are being cut, a collaborative approach can both help reaffirm a vision for public health practice and devise a strategy for creating the capacity to follow through with the departments’ objectives.

Senior leadership from six bay area public health departments came together, motivated by a common desire to significantly contributed toward reducing the burden of chronic disease and eliminating health inequities. They recognized that the required transformation of public health practice could best be achieved through a regional approach. While there are many examples across the nation of regionalization, most are for the purpose of sharing resources to carry out existing public health mandates. It is rare to have a regional approach to expand the scope of public health practice, especially to take on the scale of activities inherent in a comprehensive prevention campaign to reduce the burden of chronic disease and eliminate health inequities. The experience of BARHII can help inform an enlarged understanding of the functions and strategies that can be carried out at a regional level.

BARHII was formed as a collaboration among six public health departments. The public health directors, health officers, and senior managers of the participating public health departments meet monthly to initiate and oversee the work of BARHII, including development of the long-term strategic vision. Work groups have been formed to define priorities for policies and alliances, a process for expanding the collaboration, and a financing and support strategy. The scope of public health practice BARHII envisions requires a broader collaboration with other organizations, coalitions, and communities. The role of the public health departments is both to define the contributions they can make to those collaborations and to serve as the convener for organizations and activities that might otherwise proceed on parallel paths, so they can take full advantage of the potential benefits of a thoughtful division of labor. The process for clarifying the role of the public health departments and for broadening the collaboration is as follows:

• Define a specific focus for BARHII activities that have a reasonable chance of being carried out effectively but reveal the full scope of public health practice required to contribute substantially to reducing the burden of chronic disease and eliminating health inequities.
  
  
• Begin an organizational development strategy that encourages and supports public health department staff to embrace an expanded scope of public health practice that includes the importance of collaborations with other organizations and communities.
  
  
• Begin a process that systematically courts the organizational and community partners who will be essential allies in the campaigns to address chronic disease and health inequities.
  
  
• In conjunction with the organizational and community partners, define a project(s) that can meet the standard of substantially contributing to reducing the burden of chronic disease and eliminating health inequities.
  
  
• Secure funding to support the project.
  
  

BARHII has developed a four-fold strategy for funding and resources. Support for BARHII and work group meetings is now provided in-kind by participating public health departments and by a staff person from the Public Health Institute. Notes are recorded, summarized and distributed to all participants to keep track of issues raised and decisions made. The written record has significantly improved BARHII’s ability to accomplish tasks and stay on course.

Each participating public health department has also contributed $5,000 to a pool, which will be used to plan and sponsor the regional forum in the summer of 2004. The pool of funds is administered through the Alameda Public Health Department’s non-profit foundation. Funding for core infrastructure is being sought from a collaboration of San Francisco Bay Area community foundations, which coincide with the jurisdictions represented by the public health departments. One foundation has awarded funds, and two foundation CEOs have expressed their commitment to fund BARHII and to help recruit their colleagues.

The total budget for infrastructure is $250,000-$300,000, which will pay for a director, program coordinator, administrative assistant, basic operating expenses, and consultation on media advocacy. The value of seeking the funding from local community foundations is not only for the budget support, but also for the potential advantage of engaging leaders from public health departments and charitable organizations to jointly develop strategies to reduce health inequities in the region. Finally, at regional forum in the summer of 2004, a large-scale project will be defined and a funding strategy to support it will be developed. The intention is to seek substantial, long-term funding from a major foundation and/or government agency to carry out the work over a multi-year period.

1) BARHII concluded that it would focus initially on nutrition, physical activity and obesity because:

• They now rival tobacco as a leading cause of preventable disability and death.
  
  
• Their effects fall disproportionately on low-income communities of color.
  
  
• The substantial attention and concerted activity targeting them provide an important opportunity to achieve results on a significant scale.
  
  
• The approaches required for effective work on nutrition, physical activity, and obesity will be instructive for approaches to other dimensions of health inequities.

2) To help build a constituency for this work within the respective public health departments, BARHII hosted a forum on Food, Health, and Justice that involved over 80 staff from the six participating public health departments. Each department summarized its work on food and nutrition within the framework of the Spectrum of Prevention, which enabled staff not only to see the scope of work being done by their colleagues in other departments, but also to evaluate their work collectively against a standard of what they should be doing.

3) A BARHII work group that was established to plan the follow-up forum created a matrix of all the organizations and coalitions engaged in activities related to nutrition, physical activity, and obesity in the Bay area. A second matrix of all the neighborhood-organizing activities in the region was completed. It was decided, that before hosting another forum, a series of one-on-one meetings should be held with each major group to discuss that group’s work and how that group could contribute to a larger division of labor.

4) A jointly sponsored regional forum is tentatively planned for the summer of 2004. The regional forum will be convened to report the results of the one-on-one meetings and to reach consensus on the goals and objectives for the broad collaboration. The forum itself will provide the outlines of a specific project that the group as a whole will undertake over the next three to five years.

5)The regional forum will also provide the outlines of a strategy to secure funding for the project.

While the overall funding strategy outlines the ideal, culminating in a significant commitment of funds for a project of substantial scope, BARHII’s continuation, its collaborations, and its work is not contingent on funding. For over three years, senior public health leadership in six public health departments have met at least monthly to keep this work moving forward. If there is not enough money to cover all the costs of the infrastructure, the public health departments will contribute it in-kind. Moreover, the relationships that have been cultivated with other organizations, coalitions, and communities will not dissolve for lack of money. The general strategy envisions a substantial scope of work adequately funded, but the fallback option is to continue the work at a slower pace, with borrowed staff and resources and a network of partners who share a common resolve.

There is as yet no formal evaluation of BARHII, although evaluation will be written into the proposal that emerges from the summer regional forum. Nonetheless, directors of epidemiology and evaluation units from two public health departments are active participants in BARHII, and a draft evaluation framework has been developed.

The nature of the work being undertaken does not lend itself to significant population health outcomes in the short run. However, incremental accomplishments measured as process evaluation can describe important practice objectives that can mark the path to longer-term health outcomes. Those measures include staff working on nutrition and physical activity in all six participating public health departments will have been trained on the broad spectrum of strategies, including social and environmental changes, necessary to make significant improvement in nutrition and physical activity; a regional forum consolidating partnerships among key organizations and coalitions will have been held, resulting in agreement on a collaborative project(s) that can make substantial contributions to improvement in nutrition and physical activity and a reduction in health inequities; funding will have been secured for that collaborative project; a regional media advocacy strategy will have been developed and implemented, using regional media and more targeted ethnic media to convey not only the importance of improved nutrition and physical activity, but their links to health inequities and the importance of social justice as a premise for large-scale success; and the collaboration will have achieved important changes in institutional practices and public policies that promote improved nutrition and physical activity and a reduction in health inequities.

The evaluation design will also have a formative component so that assessments of activities undertaken can help determine their value to the overall direction.