Share Public Health Transcript: Tackling Equity, the Social Determinants of Health

Season 1 Episode 18

Hannah Shultz Welcome to Share Public Health, the Midwestern Public Health Training Center’s podcast connecting you to public health topics, issues, and colleagues throughout our region and the country, highlighting that we all share in public health. Thank you for tuning into this 10-part series on health equity. Over the course of this series, we will discuss a broad range of topics connected to health equity. For additional resources and information, be sure to check the podcast notes or visit mphtc.org/healthequity.

Paul Gilbert Hello, this is Paul Gilbert. I’m an assistant professor in the department of Community and Behavioral Health at the University of Iowa College of Public Health. I’ll be serving as your host for this podcast episode. And today’s topic—the social determinants of health—is one that I’m very familiar with. Every year I teach a course on health equity, disparities, and social justice in public health, and as the head of training for the Prevention Research Center I often lead workshops on health equity and the social determinants of health. For this episode, I had conversations with two people who I thought would have unique perspectives and could shed light on this topic. First, I spoke with Dr. Georges Benjamin, who is the Executive Director of the American Public Health Association. And second, I spoke with Dr. Nalo Johnson, who until very recently served as Director of the Community Health Division at the Johnson County, Iowa, Department of Public Health and is now the Division Director for Health Promotion and Chronic Disease Prevention at the Iowa Department of Public Health. Before we get to those conversations, I’d like to take a moment to talk about a couple of key concepts. In essence, this is laying the foundation for the conversations to come. First off, let’s consider what we mean by the word “health.” The World Health Organization has a very useful definition, which I and my colleagues teach to our students. The WHO says that health is not just the absence of disease. Health is actually a state of complete physical, mental, and social wellbeing. I like that definition because it’s well rounded. It reflects all the ways that we might be well or not well, including different domains of health that often get overlooked, like the mental health and social connections. In addition, the definition says that “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Now this definition was adopted in 1946 as the WHO was being organized, and it aligns very well with the current notion of the social determinants of health. So okay, what about this second term? What do we mean by the social determinants of health? I like to tell people that, yes, there are some things that we name as a social determinant of health, like the access to good quality schools, but I prefer to explain it as a way of seeing the world. It’s a framework or a lens that we use when we consider health in a community or a population. Once a person understands the framework or way of seeing things, they’ll be able to identify the social determinants of health that are most relevant. This is important because different social determinants will be more or less salient in different communities, at different times and in different places. And simply put, the framework is ecological. It means looking at all the contexts that people find themselves in and the ways—either directly or indirectly—that various contexts shape health status. Let’s turn to Healthy People 2020, which serves as the national blueprint for health objectives for the United States, for a good concise definition. Healthy People says that the social determinants of health are the “conditions…in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” Now that’s a lot packed into this simple statement. But I particularly like the life course element, the recognition that there are different phases of our life, from birth to childhood through adulthood and later ages, and that at these different times in our lives there are contexts that matter. There are social and physical, environmental, political, economic and other factors that influence health and that we should pay attention to. Now I think that’s enough from me alone. Let’s get to the conversations that I had, as I think they’ll help illustrate these ideas even more. In October 2019 I reached out for a perspective from the American Public Health Association, and here is a recording of that conversation.

Paul Gilbert Alright well joining me today is Dr. Georges Benjamin, who is executive director of the American Public Health Association and I’m really glad to have the opportunity to talk with him about health equity and the social determinants of health. Especially to get his perspective as one of our national leaders and a longtime leader in public health. Benjamin, thank you very much for taking the time today. I’d like to start with a question about the Association itself. Health equity has been an important topic. It’s been a theme of some of the recent annual meetings, and in fact on the Association’s web page there’s a whole page devoted to health equity. How did it come to hold such a prominent place in the American Public Health Association?

Georges Benjamin Well you know the APHA has been around since 1872. And since its founding um we have um saw ourselves in many ways as the champion of improving the health for everyone–

Paul Gilbert Uhuh.

Georges Benjamin And if everyone doesn’t have equal opportunity for health then nobody has it. We believe very strongly in the World Health Organization’s definition of health which is a very broad concept that health is not just the absence of disease but it’s about wellbeing.

Paul Gilbert So a holistic approach to health.

Georges Benjamin Very much so. Yeah. You know one of the– I’m an emergency doc and one of the painful revelations for me, through all the years of practice, was that 80% of what makes you health occurs outside of a doctors office. So then those are the determinants.

Paul Gilbert You know and that is a great lead in to this topic of the social determinants of health and I often this of them– and ill explain them to folks– as the mechanisms that are responsible for health equity or inequities and they’ve been getting more and more attention, especially in academic circles and professional circles. But I wonder what your thoughts are about broadening the interest. How do we get folks, say legislators, or the lay public, the general public more interested in this notion of the social determinants of health or even simply to understand what we’re talking about, us professionals use this term?

Georges Benjamin Well you know um neither one of us lives in an environment in which we work live play pray um there are things in the environment that allow us to easily live our lives and there are things in that environment that make it more difficult for us to live our lives. SO if you just think about a community which was built without any sidewalks and people go out and exercise. You can do that, but it means you have to walk in the street. You have to get in the car and go somewhere to actually walk. And the challenge in many of our communities is that you can’t walk in the street because it’s too busy. Or it’s too dangerous. You wouldn’t let your kids do it. Um and if you don’t have an automobile or it’s too far away or the walking path in your community is too inconvenient you’re much more likely not to walk. So if you really want people to walk then you need to make those communities walkable which means you need sidewalks. Those sidewalks have to lead somewhere, otherwise it’s a very boring walk. Um If you think about access to food. The fact that there are many parts in our community that have robust access to grocery stores. You go to the grocery store and you can find what you want. It’s at an affordable price, the food is fresh, it’s safe to eat. Far too many of our communities, you have to take two bus rides, um carrying loads of bags. So where are you more likely to shop if that happens? You’re more likely to go to the little corner store where the food is more expensive, where it’s maybe less fresh- not always, but the selection is very narrow. So what ends up in those places? High fat, high salt, low nutritious foods. And so if you just think about the way we’ve constructed our communities, either on purpose or by accident. It’s easier to do things of normal living. And our goal in terms of addressing the social determinants is to make communities so that everyone has the opportunity for a grocery store with lots of opportunities to buy you know fresh affordable foods. To make sure every community is walkable. To make sure that the school is such that the kids can get to it. You know far too many of our kids have to be bussed to school. [inaudible] to school, but it’s not safe for them to walk to school. So they’re not going to get the physical activity they need, and you know they’re going to be on a bus- and they also have to get up very early to get on the bus. So it impacts our community the way we’ve actually designed it.

Paul Gilbert So it almost sounds like some of the key ways to explain this to folks is some of the concrete experiences or day-to-day experiences and how they are either promoting or hindering good health.

Georges Benjamin Oh absolutely. And then, you know, if you just look from a historical perspective just residential segregation. That uh we’ve designed those communities. I’ve talked about the fact that every community has a railroad track that goes through the community and you can visually see it. On one side there’s affluence. On the other side there’s poverty. But, in addition to the economic differences in those communities, the negative health outcomes track with the lower income communities as well.

Paul Gilbert Right.

Georges Benjamin And the truth is, if you go back and look at some of the original zoning laws, we designed those communities to be just like that. That may not have been the original intent, although I must admit, in some cases, that was the original intent. And so if you want to fix that you can fix it. Zoning, the fact that we know that high density communities with lots of liquor stores have a higher incidence of alcoholism, higher incidence of violence. If you want to fix that, change the zoning laws.

Paul Gilbert Well that gives us hope too that we… that these situations aren’t set in stone that we could change it that there are tools that we could use to design healthier communities. And I think that actually leads me into another question I wanted to ask you, this is maybe a two part-er: What do you see as the biggest successes of late in health equity and addressing social determinants and what are the biggest barriers that we still have to contend with?

Georges Benjamin Well you know we’ve begun to look at health in communities at the zip code level. So now more and more we have the county health rankings as a great example. Where we have counties right close to one another that demonstrate those communities that you just described. You can visually see the difference. We now have maps which show that you know 5 mile, 10 mile differences huge differences in health outcomes so it gives us an opportunity to measure progress, to measure baseline and to measure progress as we change things. So for policy purposes they can say look: you know health outcomes in my community aren’t what they ought to be, I’m looking at the community next door. Here’s what they have here’s what they’ve done from a policy perspective. That seems to benefit their community, now how can I do that in my community to improve that health. It’s both a benchmark and it gives us some tools on a policy framework that we can make changes. The other thing is it takes away this argument that you know the people that are unhealthy are bad people. They have somehow misused their bodies.

Paul Gilbert They brought it on themselves, or something.

Georges Benjamin Yeah, they brought it on themselves. Behavior is a big issue here, but some of those behaviors are driven by the environment in which they’re in. And we can work on both the individual behavior aspects at the same time work on the structural aspects which, at the same time, enhance the behavioral aspects of it.

Paul Gilbert All right. And the county health rankings that you’re referring to is the Robert Wood Johnson Foundation funded project that provides some really incredibly detailed information. Essentially a detailed health profile of all these individual counties so we’ve got a really tremendous amount of information at our disposal now.

Georges Benjamin We do, we do. And if we want to be data driven that’s important. Now, by the way, this is not a secret. Anyone who has worked in governmental public health or in a social service organization or in a housing organization providing services knows what communities we’re talking about. The economic development people know exactly what communities we’re talking about because all those problems overlap. While the problems may be a little different in each community, each of those communities have challenges. Now, by the way, all those communities also have strengths that we can build on. So we should acknowledge the strengths in those communities; build on them. And then try to remove the negative influences that dissuade our help.

Paul Gilbert Right. Right. I think that’s important to remember the resilience and the strengths that are inherent. We can’t always be looking at things as the problem, the deficit, the lack of something, but there’s also, at the same time, something going on that keeps these communities going. There may be some things that we can leverage, positive aspects that we can build on. So, as I told you, our podcast series is really geared toward local public health professionals in the spirit of continuing professional development. Do you have any thoughts on what the local workforce needs to know to understand health equity, to grapple with social determinants of health or maybe how we train up our local public health workforce better?

Georges Benjamin I think there’s several tips for our local practitioners who are trying to grapple with these problems. Recognize, of course, that every community now has to do a community health needs assessment either the hospital has to do it as part of their nonprofit status or the health department, which has historically done these kind of community health needs assessments, and I think every community ought to look at the data. Second thing you ought to do is recognize that we in the health world cannot do this by ourselves. The way we’ve made the most progress is by pulling together multi-sectorial, multi-disciplinary teams. And come together and say ok: here’s the problems we’re trying to solve, here’s the team that can help us do it and then work together and leverage what we all bring to the table. Because it often doesn’t require a lot of new money. Sometimes no new money. It simply requires us to make sure that we’re all going in the same direction. That our policies are coherent, that they make sense together. That one agency of government isn’t undoing something that another agency of government is trying to do. Sequence activities in such a way that we leverage each other’s strengths. And in doing that you’ll find that you have enormous success. And also don’t, you know– recognize what the problems are, fix the problems that are most important, but realize that what I, as a health official, may think is the most important problem may not be what the community thinks is the most important problem, and I would let the community lead on that. My idea that yeah we’ve got an obesity problem is important, and I go in and talk to the community and what the community says is no, no, no. What we need is we need the streets fixed, the lights fixed so that we can go out at night, because you want us to walk. You can’t address the obesity problem until you fix some of those structural issues.

Paul Gilbert Right.

Georges Benjamin You want us to walk safely in our community. So that might be what they need to have done first, and then we can do a much more comprehensive look at the obesity problem in a community, as an example.

Paul Gilbert Right. I think what you said about, you know, making sure everybody is aligned and maximizing the resources available– that’s so important for a lot of our smaller health departments where you have limited personnel, limited budgets… And also that alignment with what the community wants that nothing, you know our programs aren’t going to succeed if we go in trying to do something that nobody has prioritized. That the folks in the community see a different need, or it’s somewhere else in their rankings that something else is a priority.

Georges Benjamin That’s right.

Paul Gilbert Absolutely.

Georges Benjamin It also helps build trust and, and, until you build trust with those communities then you are just government coming in.

Paul Gilbert Mm-hmm, mm-hmm. I think I have one final question for you. I just wonder is there anything else that you’d like to share with me and with our listeners about health equity and working on the social determinants of health?

Georges Benjamin Sometimes these programs seem like, and the problems seem like they’re too large to solve, and they’re not. They are big problems, they are complex problems, but I would encourage people to take a piece of the problem work on it diligently show, that you can improve it and then go on. Recognize that if you do it that way and don’t get hung up with the what I call the paralysis of analysis…

Paul Gilbert Mm-hmm.

Georges Benjamin We will accomplish and improve our and health of our communities it’s it’s a is a task you always take four steps forward three steps back. You know, two steps forward half a step back, but as long as you’re continually going forward, you’ll have progress.

Paul Gilbert Right. Those are some, some good advice right there. They’re good words of wisdom. Well I want to thank you again for taking the time to chat with me, Dr. Benjamin I really appreciate it and we’ll look forward to seeing what, what else comes out of the annual meeting and from the Association.

Georges Benjamin I thank you and I’m pleased that I had the opportunity to talk with you today.

Paul Gilbert I really appreciated talking with Dr. Benjamin and I appreciate how the American Public Health Association has emphasized health equity and the social determinants of health. The Association even has a web page devoted to the topic at APHA.org and it includes fact sheets that you can download I’ll make sure that there’s a link to it in the podcast notes. Now a couple of things came up in our conversation that I’d like to revisit. Dr. Benjamin mentioned the County Health Rankings as a source of information about the social determinants of health. This is a great resource. It’s funded by the Robert Wood Johnson Foundation, maintained at the University of Wisconsin, and there’s a searchable website online. I’ll make sure that the link is also included in the podcast notes. You can look up any county in the US and get a summary of its key health outcomes and the key factors that contribute to those health outcomes. Now there’s nothing labeled as social determinants of health per se, but you’d recognize that some of the categories are absolutely about the social determinants of health. Take for example the category of social and economic factors which includes things like high school graduation levels and unemployment rate.Now I’m also plugging the County Health Rankings because I’m a great believer in working efficiently, especially by using the data that have already been collected. The County Health Rankings are a great place to start if you’re looking for information about your community. Say trying to get a sense of its health profile and areas that need strengthening. Dr. Benjamin also referred to the process of doing a community health needs assessment. I imagine that many listeners know that this is a planning review that’s required every 3 or 5 years depending on whether it comes from a hospital or a health department. But without knowing it, Dr. Benjamin set up my next conversation very nicely. I wanted to move from thinking broadly about the issue to specific ways that local folks might address the social determinants of health and I was thinking about folks in local health departments and what they might do to take action on the social determinants of health. And, in fact, I thought that my own local health department here in Johnson County Iowa might offer some good examples. Johnson County has made health equity and the social determinants of health a priority in their latest health improvement plan which is the action plan that follows the data gathering of a community health needs assessment. So I asked Dr. Nalo Johnson to chat with me and we’ll get to that conversation in just a moment, but I should also make a confession. Full disclosure: I’m a member of the Community Advisory Board for the Johnson County Health Department. Maybe this gives me a little more of an insider’s perspective, but I don’t think it biases my judgment. Anyway, let’s move on to my second conversation. This is our local health department and I’m really eager to speak with you about some of the local efforts that you have done that you’ve led here about health equity, the social determinants of health, and some of the data collection and planning. So first off Dr. Johnson thank you very much for coming and chatting with us. I’d like to start with a very general question: What do the social determinants of health mean to you?

Nalo Johnson Excellent question. When I think about social determinants of health I’m thinking about those social, those economic, those environmental barriers that impact health outcomes. I think people have a broad understanding of health in terms of one’s physical health and healthcare access but then we also want to move and think more broadly about understanding what other barriers may exist that also have an impact on people’s health outcomes.

Paul Gilbert So I know that Johnson County has done a lot of work recently emphasizing health equity and trying to address the social determinants of health in the local work here so I’d like to hear some about that. I want to start off by asking you to describe a little bit a recent project, healthy JoCo or Healthy Johnson County, but I want to start by telling our listeners that you are the recipient of the Henrik L. Blume award for Excellence in Health Planning. This is given out by the Community Health Planning and Policy Development section of the American Public Health Association, so it’s a great honor to be recognized for this work, congratulations.

Nalo Johnson Thank you, thank you.

Paul Gilbert But maybe we can start with just: What is Healthy JoCo?

Nalo Johnson Well, Healthy JoCo is our community health needs assessment and health improvement planning process and we’re very excited about this effort so it was wonderful to be able to be recognized by our peers for the ways in which we have constructed this methodology around how to do assessment work and planning work with your community. What we desired to do with Healthy JoCo was, well our main goal was really around broad community engagement. So when you look at the models that are out there around assessment oftentimes you’ll see convenience surveys or you’ll see focus groups with a small number of people representing this larger idea of who your community is. And we really wanted to push ourselves further to say: who isn’t traditionally at the table and being asked their opinion about their community health needs? And incorporated not only that idea around broad community engagement but also how we could then marry these more robust public health evidence-based best practice research methods in data collection efforts. So we’ve done things like deploy intercept surveys, deploy CASPER Community Rapid Needs Assessment Tool, conduct a community asset mapping exercise with a local youth serving agency. All of these different touch points with community members using these evidence-based practices, but also being very mindful and intentional about targeting the breadth of the community in order to gather that information.

Paul Gilbert That’s really interesting, and I was going to ask you a follow-up question about what exactly, what strategies, what ways you’ve been able to bring community members more into this process but this, this is the process to set priorities or goals for the health department activities in bringing the community in more, more directly into setting those priorities or giving you the information to set those priorities.

Nalo Johnson Absolutely. And are another you know byproduct of this process was really to change people’s mindset or maybe make them think differently about their relationship with the health department. So we spent a lot of time cultivating relationships with community members on an individual level but also with our partner organizations on a more, I guess, a systemic level and understanding what we what we mean when we say Healthy JoCo as a methodology for assessment and health planning and it’s really shaping, we looked at it as a professional development opportunity. So not just for the staff in the Community Health Division but across the department from our public health nurses who are normally giving immunizations or providing nutrition information to our environmental health specialists who are normally doing food operator inspections and that type of work. We’ve exposed them all to this understanding of things like community-based participatory research methods and the specific CASPER methodology so that it’s really as well as relied on a student group of undergraduate and masters of Public Health students so they could be a part of this experience and understanding what it means to do work in the field as a local public health practitioner. So all of these touch points really allowed community members to have a relationship to the health department and a way that they couldn’t experienced before and so it really seemed like this ability to co-create with the community around this new concept of Healthy JoCo.

Paul Gilbert Mmm-hmm. And it sounds like it’s almost breaking open the, the health department. Something that may be a bit inscrutable or invisible to a lot of people unless maybe you went to the immunization clinic or you went to the WIC clinic or you had some, some interaction otherwise but you know bringing people in more than normally they would have.

Nalo Johnson Absolutely.

Paul Gilbert So let me just ask a quick follow-up. You talked about some of these specific strategies, things like intercept surveys and CASPER methodology. Can you tell me what, what that is? Break that down a little bit more for me and the listeners who may not be familiar?

Nalo Johnson Yeah, so as we, again, part of our desire to have this broad community engagement was the desire to rebrand what we were doing. People couldn’t necessarily understand and find accessible the concept of a community health needs assessment and health improvement plan or a CHINA/HIP. Some of us in the field call it or a CHA/CHIP some folks in the field call it. So instead, again working with community members, with our staff, what is something that could encompass what we mean and our purpose around doing assessment and planning and prioritization. Well, we’re, we’re looking at a Healthy Johnson County. A Healthy JoCo, right so we subsequently then branded all of our data collection efforts to follow that nomenclature. So our intercept survey we refer to as healthy Joko chats. We recognize this would be a convenience sample type of survey but again from a relationship building standpoint it had that dual role of helping us understand at a very basic level what people are identifying as community health needs but also allowed us to be out in the field with our Healthy JoCo t-shirts and our literature. We also created a website so we can share this information out that we’re collecting so, HealthyJoCo.com I will plug and so we could provide people with little business cards where they could find the website and read for themselves about some of these community health and public health practices. So this was all part of that larger engagement strategy. So our strategy for the Healthy JoCo chats was to identify key community events throughout the summer so we were at your traditional places like Iowa City pride or Juneteenth or Hills Fourth of July Fest but we also selected key locations in the communities. So we were at the Center for Worker Justice and the North Liberty Rec Center Senior Meal, and the Iowa City Johnson County Senior Center. So we very much wanted to be intentional about where we were showing up as well to make sure we were able to speak to a breadth of community members. So that’s how Healthy JoCo chats, our intercept surveys work.

Paul Gilbert And those are just having your workers go up and talk to people and ask them, you know can I ask you about you know . . .

Nalo Johnson We had three questions. So we had set of demographics: your traditional zip code, how do you identify for gender, how do you identify for a race and ethnicity, what age range you fall in, and what is your primary language that you speak in your home so we could run some demographics on the data. And then we had three questions: what’s your primary health concern for you personally, what’s the primary health concern in your opinion for your neighborhood, so thinking about the space where you live in and then what’s the primary health concern in your opinion for the county or broader communities. So we could look at what the differences are between those three different responses.

Paul Gilbert Those are some interesting questions because you get a, you know, what is my individual concern but then what do I think is the concern my neighborhood, for my county.

Nalo Johnson Absolutely. And it’s you know being able to look at the analysis on those responses, which as a member of our steering committee, Dr. Gilbert, you’ll hear all of this. There are some similarities between the three different levels, but there’s also some differences. And so what does that tell us about what may be some important to someone personally but they think differently when it gets at that at that larger scale when they’re thinking of their community.

Paul Gilbert Was there any surprising results from these types, when you look across the different types of questions, anything that you could share now about that.

Nalo Johnson I guess if this airs in January [laughs] one of the things that surprised me and this isn’t my area of expertise, so maybe that’s part of my bias to why it surprised me. You know, I come from a health promotion and chronic disease prevention and communicable disease background. So water quality and air quality was most frequently mentioned concerned and all three levels.

Paul Gilbert Oh.

Nalo Johnson And that was unexpected for me.

Paul Gilbert That it was so consistent.

Nalo Johnson Yeah, absolutely. And so I think what we’re calling now based upon these findings from all our data collection areas of curiosity for me that rose to the top as one of these areas, one of the items that rose to the top as an area of curiosity and you know we can again, it was in the summertime, was there a lot of news stories on water quality issues… Oh I don’t know there’s a lot of factors that could have influenced people’s responses but that was something that, that surprised me that I wasn’t expecting to see as a most frequently mentioned concerned and especially at all three levels.

Paul Gilbert Yeah that seems especially striking that you know somebody would say it’s my individual personal concern and I also think it’s the neighborhood concern and a county concern.

Nalo Johnson Absolutely.

Paul Gilbert So, yeah, very striking.

Nalo Johnson So our second major data collection was our door-to-door survey and we utilized the CASPER methodology. And CASPER is a CDC-developed tool which, I’m going to do my best here, the Community Assessment for Public Health Emergency Response. It is a CDC developed tool that’s often deployed after times of disasters such as a flood or a hurricane.

Paul Gilbert Like a rapid needs assessment.

Nalo Johnson It’s a rapid needs assessment. So to understand, you know, what are the immediate needs within a community now that we’ve had this major incident occur. What we chose to do with the CASPER, because of the ways in which it allowed us to collect local-level data that had the potential to be scientifically valid data because it’s a survey of a randomized selection of households and then you weight that based upon population statistics. So they have their whole methodology. Again, we wanted to look at how do we move beyond the convenience survey, intercept survey sample and be able to have a more robust scientific, scientifically valid dataset along with that. So based upon their . . . We augmented the survey, let me step back, to be focused on the social determinants of health. So our tagline for Healthy JoCo is: “Live, Work, Learn, and Play”, which aligns with County Health Rankings and Roadmaps’ definition of what is health. It’s found in the places where you live, you work, you learn, and play.

Paul Gilbert Right, right.

Nalo Johnson We again, really subscribe to that idea around a broad understanding of community as well because we wanted to acknowledge the fact that we do have a large part of our population which is only with us for a short amount of time because they’re here at school. Or we do have a commuter population where people may live here but work elsewhere or they may come into our community because they work here but they live elsewhere. But they’re still a part of our community and we have people who come here to recreate, so they’re still here within our community participating even though they may not have that every day tie to our community as well. So along with this idea broad community engagement, also understanding, have taken a broad understanding of our definition of community.

Paul Gilbert Right.

Nalo Johnson So, utilizing this tool, we focused our questions around social cohesion, so connectedness to community, around some work and employment questions. We also deployed a health literacy tool. It’s a scientifically valid medical literacy tool to have an understanding of the rate of high or low literacy based upon the survey respondents and how that could impact our public health messaging. Then we also had questions around places of recreation. We were specifically interested in kind of the public versus paid admission percentages. So, how could we help decision-makers know where they should be investing their resources if people are choosing public spaces like parks and trails to recreate versus going to the mall or other downtown Iowa City activities, those kind of things.

Paul Gilbert Right.

Nalo Johnson So based upon the CASPER methodology, there are population thresholds. We were able to conduct the CASPER in Iowa City, North Liberty, and Coralville, which we did over two weeks in the summer. The goal was to speak, again based upon their methodology, with 210 households in each community and if we had an 80% response rate in each of those communities, we would have to meet their thresholds for weighting. Unfortunately we did not. In total we had . . . I believe it was about 244 surveys that were completed, which was still a valiant effort given that we also had a heat advisory where we couldn’t be out in the field, so we lost about four days of the two-week time period and that greatly impacted our efforts.

Paul Gilbert Right, yeah.

Nalo Johnson But what we were able to do was look at three communities in total and weighting in that way. So we’re not able to say yes, we conducted a CASPER, but we are able to say we used a CASPER methodology to be able to collect this data and analyze this data.

Paul Gilbert Right.

Nalo Johnson So looking across those three communities is how we’ve chosen to do analysis.

Paul Gilbert Well, it certainly sounds like a step up in terms of rigorous, you know, scientifically-based methods for gathering information. I’m curious, this sounds very intensive. Was there support for implementing this or say if any of the listeners are interested in using something like this. Yeah is there any resources that they could turn to?

Nalo Johnson Absolutely. Before I answer that I’m going to just finish what we ended up doing after.

Paul Gilbert Sure.

Nalo Johnson So a part of what we’ve learned through the CASPER was now that we weren’t beholden to those population thresholds, how could we then take that CASPER methodology and implement it in our less populated communities. So we were able to use the same methodology for the randomized selection of households, use our same tool. I’ll also note we did this all on tablets using ArcGIS and Survey123, so from an efficiency and a sustainability standpoint, made a user-friendly experience for both our staff deploying the survey but as well as the participants. So we had the survey down to a six to seven minute time period when we were on somebody’s doorstep asking for their time which I think also greatly increased our participation rates.

Paul Gilbert That’s great. So it’s not gonna be a big burden to answer.

Nalo Johnson No, not at all. But we were able to do that in our seven remaining incorporated communities in the county. So that meant, again, under that goal of broad community engagement, we met that, and we chose to identify two census blocks within each of those communities. Out of a total of 98 attempted surveys, we were able to get 75 out of those communities, so that was a 75 percent response rate which – nearly – which was excellent, and so in terms of . . . when you say . . . like basically what’s the scalability of something like this . . .

Paul Gilbert Yeah, yeah.

Nalo Johnson I think it did take time and effort. So in the summer we had that student team, we called it our Healthy JoCo student team – I will note only half of that team of 13 were actual interns who are getting course credit for working with us. The rest were students who volunteered over 80 hours of their time working with us and being in the field. I think that really speaks to the value they found in the experience that they were that committed, as a volunteer, to say they were gaining something out of having this experience with us through the Healthy JoCo effort.

Paul Gilbert That’s really impressive!

Nalo Johnson I am [laughs] . . . that’s why we get awards!

Paul Gilbert It’s not only your drawing in the information, getting information from the whole community, but they’re also here as folks volunteering to be a part of this.

Nalo Johnson As an accredited public health department we take seriously our commitment to helping build the future public health workforce. So this was a professional development opportunity, not only for us internally, but also for our ability to make sure students also have that kind of exposure as well.

Paul Gilbert Very good, yeah.

Nalo Johnson But I do think that’s something that we will be able to help and share as we reflect on this experience is that scalability. So we had the student team in the summer for . . . We deployed the rural incorporated survey in over three weeks – so we also gave ourselves an extra cushion time given what we learned in the summer – over three weeks in September, and we utilized all of our staff, so Community Health Staff, some additional staff members out of the public health department, and a couple of additional members from the student team who agreed to help us out in the fall as well. So, it’s time intensive, but I think if you know your population size, that you’re able to determine the number of people, number of hours, what those expectations are, to be able to fit it to your department’s needs. So I wouldn’t… I guess my message is: if you don’t have a division of 10 staff like I do that you still have the potential if you know from the start what it might look like in terms of hours in the field or hours of preparation and that is part of . . . We are writing articles on our experience that we hope to publish so we hope to be able to provide that guidance to other local health departments who may want to attempt to do this later.

Paul Gilbert That would be really helpful. It’s helpful hearing what you did over the summer and then in September, but also if it’s written up, that folks can come back later and review it. Say like, okay, how would I take something like this and implement it in my community? I think that would be very helpful.

Nalo Johnson Absolutely, and I can’t underscore – yes, this is a more robust way in which to gather your assessment data, you know, hands-down – but I cannot underscore what it means to be in the field and have your team be able to have interactions with the community members that they serve. You know, anecdotally, in some of these communities, we have people who were so excited we showed up on their doorstep, and we had a strong communication strategy about this as well, which was very intentional.

Paul Gilbert They’re excited that they were there being asked for their opinion.

Nalo Johnson Exactly, exactly all the way to the other spectrum where people were: why did it take you this long to come to my community and have a conversation with me?

Paul Gilbert Ah-hah.

Nalo Johnson So it means something that, again, as you pointed out earlier, people may not have a reason to interact with the health department unless they have a specific service or question and instead the health department’s coming to them to know their opinion, to learn their story, or hear about their experience and have that inform our decision-making.

Paul Gilbert Right. Well you know what you’re just saying now reminds me so much of this definition of health that it’s not simply the absence of disease, that it’s well-being in all areas and this fits in really nicely. You’re not waiting for folks in the community to come because they have a problem, because there’s an emergency, because there’s something . . . a crisis, but going out almost proactively. What, what makes a healthy community, what is wellness, what do we need to do to ensure a healthy, well-functioning community?

Nalo Johnson Absolutely. Absolutely, and we also think that having those touch points, you know, on a very logistical standpoint, being out in the community allowed us to have exposure to different sites where, you know, for example, here’s a new community rec center that we didn’t know existed. So as we go out and share the findings with community members and conduct a prioritization process, here are these additional sites throughout the county that we know we can go to because these are the place of information for this particular community. So there are so many ways in which I am a proponent of the method that we’ve now undertaken.

Paul Gilbert Yeah. Was it– this is really great hearing about the details. I wonder if we could take a step back for a moment and I’d like to hear where the interest or the emphasis in things like equity and the social determinants of health came from. What’s driving that interest at the county health department?

Nalo Johnson I think that, nationally, as I’m sure you’ve explored in many of your other conversations, that there’s been a growing interest in understanding the ways in which health equity is key to the work that we do in public health both from an academic point of view, but also from a practitioner point of view as well. And the social determinants of health . . . I guess let me back up. For me, health equity is understanding where health disparities exist amongst populations and then being able to target strategies specific to that health-disparate population. Because the goal is you see increased positive health outcomes, right? So hopefully that’s understood at this point – that a one-size-fits-all public health strategy is not going to give us the kind of outcomes across the board that we’re looking for.

Paul Gilbert Right.

Nalo Johnson There’s such an intrical way in which the social determinants of health impact health-disparate populations. So, you know, talking about those in combination with one another makes sense. So I feel like, as a local public health department, we’re really just following that national strategy, thought, embrace of this concept of health equity and social determinants of health. By far as a Community Health Division that I think we’ve embraced the ways in which we need to think differently about our work and the ways in which we built the Healthy JoCo methodology is an example of how we’re trying to attune to health equity and the ways in which we’re doing things.

Paul Gilbert You’ve told me a lot about the details of what you actually did and maybe alluded to some of the, the next question I have, but I’m really curious to hear about what worked well, what were the successes and then what were the challenges or obstacles that you encountered and how you worked through any of those challenges.

Nalo Johnson So I think the successes have been being able to communicate the importance of what we’re doing and thinking differently about the health department and its role in the community and its proactive nature versus reactive nature, being able to find support and buy-in for this methodology of bringing in broad community engagement in a very authentic way with the more robust research methods for data collection and analysis. I think people . . . From a leadership standpoint, we’ve had that support for investing in tools like the tablets to conduct the survey and bringing on new positions such as a full-time epidemiologist so that we can do the analysis ourselves and not necessarily have to rely on our friends at the College of Public Health to lend your expertise all the time.

Paul Gilbert So this is from the top leadership in the health department saying this is something that we’re gonna pursue and we’re gonna devote resources to it. We’ll make sure that this happens.

Nalo Johnson Right. Not just the health department but our board of supervisors as well. So, being cognizant that, yes, this is the Health Department leading this effort but we’re doing it under the auspices of the county and we’re doing it on behalf of the communities. So I think there’s also been a great buy-in from . . . we have a steering committee, which the steering committee consists of the cross sector of community leaders, and, from our nonprofit leaders, to folks who are at our health systems, to folks who are at the school district, so again representing those who are serving our community. So hearing that kind of feedback that they believe in the effort as well and see it as meaningful for us to be investing in this way to learn more about our community health needs, I think has also been very supportive. Challenges, I think with any effort it’s, that’s new and you don’t know how people will respond. So you know I was a part of conducting our first set of Healthy JoCo chats, which was at one of the summer arts festivals here in Iowa City and we went out we didn’t know what to expect, we didn’t know if people would talk to us or not.

Paul Gilbert Sure because you’ve never done something like this before and didn’t know what the reaction would be or would people stop and answer your questions.

Nalo Johnson Exactly.

Paul Gilbert Yeah.

Nalo Johnson But it was overwhelmingly positive. So the idea of trying something different was okay. We had a hunch that this would be something that people would engage with, we did our research to think about what methods would make sense, and people responded. The things that I would say challenge-wise is it was disappointing not to be able to hit our numbers so that we could call our door-to-door survey a CASPER.

Paul Gilbert Mm-hmm.

Nalo Johnson That was disappointing, but we also learned from the process to be able to structure it differently next time so maybe we could hit those numbers. And yet, we still have collected data that is meaningful and, as you mentioned, more robust than traditional methods and that, I feel, is moving us forward. So there’s, there’s a balance there between the successes and the challenges for sure.

Paul Gilbert Right, right. And speaking of the next time that you do this, will this be part of the next community health needs assessment process? For the health department, you do it every five years. Some organizations, especially when they’re part of a local hospital, they may be doing it every three years, but you’re planning to repeat this.

Nalo Johnson Our goal with this is Healthy JoCo is our assessment and planning methodology, so we will be deploying these efforts anytime we need to respond to an assessment. So if, for example, vaping is obviously touching all communities right now.

Paul Gilbert Right, right.

Nalo Johnson We currently have our tobacco health educator in the field with students educating on our new vaping prohibition that the county passed this summer to extend those prohibitions where all smoking is prohibited and utilizing the same strategies of a student team with a survey about education and deploying to businesses. So, this is our assessment method that we move forward with.

Paul Gilbert All right, excellent. Now, I just have a couple more questions for you. One is: are there any lessons or tips that you would have for other local health departments that may want to implement something similar, either doing another CASPER, using that specific methodology, or just doing more community engagement, anything that you’ve learned through the process that would be helpful for other health departments?

Nalo Johnson Mm-hmm. Authentic community engagement is key and relationship-building is at the core of that. So I think you need to have a mindset that you’re willing to invest the time and energy to build those relationships. So, for example, our community asset mapping exercise that we conducted this summer, we conducted with an organization called the Dream Center. This is a largely African-American-serving organization that focuses on youth and families, and we worked with their summer youth leadership program. We spent three separate sessions with them, constructed a – or hosted a public health fair where we went in, met the students, brought in one of our environmental health specialists to talk about food inspection, our tobacco health educator to talk about tobacco control, our emergency preparedness planner to talk about your personal preparedness and people got to make personal preparedness kits with them, as well as some other community health strategies. And that was our first introduction to just say we want to expose you to this is the work that your public health department does. Our second session we conducted the community asset mapping or community resource mapping exercise with them, augmented it to talk about what do they see as resources for people, places, and things in their neighborhood, and then we did a photo voice exercise. So we provided them in the next session with disposable cameras. Their counselors went out into the community with them where they could take pictures and visually represent what they saw as resources and gaps. Now, we targeted this particular organization because we know that African-American population in Johnson County is a health-disparate population across a multitude of disease rates, as well as things like tobacco use and yet we don’t have significant relationships or programs targeted specifically towards this health-disparate population. So it was very intentional about building a relationship with a community organization for one of our health-disparate populations that we know we can continue to grow and build and therefore when we come to some other conclusions around our assessment strategies, can be more well-informed about how to approach interventions for that particular population.

Paul Gilbert Right. And what really strikes me there is this balance. Your assessment methodology may actually be one of these you know rapid quick, quick methods but you are investing a lot of time and effort into building those relationships, setting the stage so that you can do those either rapid assessments, or like you said, come back later. This is going to be an ongoing relationship, you’re going to develop whatever– a, a history or moving forward with them. All right.

Nalo Johnson It’s a “both and” for sure.

Paul Gilbert And, you know, one final question I have for you along the lines of lessons that we can take to other communities is: do you think . . .is there anything else that you think we should know?

Nalo Johnson So I’ve spent my career in mostly rural environments from a public health perspective and I think one of the things that we see both locally, but also at the state-level and the national scale, that there’s very much a difference in capacity depending upon where you’re at. So, here in Johnson County we have 48 FTE in our department. So, we have many different roles, like I said, having a full-time epi to be able to do data analysis is not something you’re going to find in a small, rural county health department.

Paul Gilbert Right.

Nalo Johnson Right? So recognizing that there are capacity differences.

Paul Gilbert And Johnson County has a lot of resources from the large health department, the University that’s right here, lots of community organizations.

Nalo Johnson Absolutely.

Paul Gilbert And you’re absolutely right the difference between urban and rural areas in resources, what you might have at your disposal– that can be quite stark sometimes.

Nalo Johnson Absolutely. And so I think, what I think my challenge is, is to say, don’t feel limited based upon where you may have some limited capacity. Instead think about ways in which you could grow that capacity. So whether that’s partnering with a larger local health department who may have some resources that they can share with you, like having an epidemiologist that can assist you with some of your data collection and analysis efforts, or whether you can reach out to your College of Public Health and have students who may be able to – either for course credit or through their own kind of personal growth and development – be able to assist with your efforts, or being able to look at the resources that are available through some of our leading national organizations, like the Robert Wood Johnson Foundation, or County Health Rankings and Roadmaps, or the Public Health Foundation. All of these resources that exist to be able to utilize some of the tools and templates that are out there so you’re not having to feel the burden of creating these on your own, but really just growing the kind of capacity that you have regardless at what level in order to do things in a more robust and meaningful way.

Paul Gilbert Mm-hmm. Alright. Well Dr. Johnson, thank you very much for sitting down to chat with me. This has been really fascinating to hear about all the details, all the activities that Johnson County Public Health has taken up, so thank you.

Nalo Johnson Thank you, it’s been a pleasure, and thank you for being a part of Healthy JoCo with us.

Paul Gilbert My pleasure.

Paul Gilbert It was a real pleasure talking with Dr. Johnson and hearing the details of a local health department’s efforts. If you want to see more of what Dr. Johnson was talking about go to HealthyJoCo.com and again, that link will be in the podcast notes. Now I have a few concluding thoughts to share. You know, one thing that came to mind as we’ve talked was that old saying “no data means no problem.” Dr. Johnson talked about how important it is to collect and use local information and I already mentioned the County Health Rankings, but in the spirit of leaving listeners with more resources, I’d like to mention a couple of other products from that website. Folks who are beginning to take action on the social determinants of health may be interested in two publications. One is called, “What Works: Social and Economic Opportunities to Improve Health for All”. As you can probably guess from the title, this short guide fits nicely under the heading of social determinants of health. It’s an 18-page booklet that has brief summaries of intervention strategies that have a good evidence base to support them. There are broad categories about improving educational outcomes, addressing income and employment, and strengthening families and social support. It’s a very good starting point as you plan action on the social determinants of health. And a second publication from the same website that I’ll draw your attention to is entitled “What Works: Strategies to Improve Rural Health”. It’s a very similar summary to the previous one, but as you’ll guess from the title, it focuses on rural disparities. It’s a 20-page booklet that includes details of health improvement strategies specifically in rural context. I think it’s important to call this out because we often neglect rural areas when we think of health disparities, but it’s a very important dimension to consider. In fact, every state in the nation has some rural areas. So I’ll make sure that the links to both of these resources are included in the podcast notes and with that I’d like to wrap up this episode. I hope that you found something that will help you in your work and thank you for listening.

Hannah Shultz Thank you for joining us today. Special thanks to Rima Afifi, Anne Crotty, Alejandra Escoto, Paul Gilbert, Kaci Ginn, Mike Hoenig, Kathleen May, Felicia Pieper, Melissa Richlen, Hannah Shultz, and Laurie Walkner. Theme music for Share Public Health is composed by Dave Hoing and Roger Hileman. Funding for this webinar is provided by the Health Resources and Services Administration. Please see the podcast notes for an evaluation and transcript.