Tuesday Breakout Session Options

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1 Tuesday Breakout Session Options A. and F. Expanding the Boundaries: Health Equity and Public Health Practice Tuesday, November 17, 2015, 1:00 and 2:10 pm session options Arbor Lakes Room The emphasis of this session is on identifying core practices necessary to assure the conditions in which all people can be healthy. Participants will develop an expanded understanding of health, will recognize the roots of health disparities including structural inequities and structural racism and will identify elements of an emerging health equity practice. Participants will be introduced to a framework for action including use of a health in all policies approach and strategies to strengthen communities to create their own healthy futures. Learning objectives 1. Identify core elements of an emerging practice to advance health equity. 2. Identify a new framework designed to generate action on the factors that create health. 3. Develop a broader understanding of what creates health and health disparities including structural inequities and structural racism. 4. Recognize the essential nature of a health in all policies approach to health and health equity. 5. Will learn concrete ways to strengthen communities to create their own healthy future. Jeanne F. Ayers, RN, MPH Assistant Commissioner of Health, Minnesota Department of Health Jeanne F. Ayers, RN, MPH, currently serves as assistant commissioner for the Minnesota Department of Health. Prior positions include director of nursing and preventive services at the University of Minnesota Boynton Health Service and executive director of the Center for Public Health Education and Outreach at the School of Public Health, University of Minnesota. Ayers served as the chief architect of ISAIAH s faith-based health equity and healthy communities work and launched and directed the Healthy Heartland Initiative a partnership of community organizations in five Midwestern states dedicated to building organizing capacity for health and racial equity. She was selected as the 2010 University of Minnesota Josie R. Johnson Human Rights and Social Justice Award winner for her work on health and racial equity. Ayers earned a master s degree in public health from the University of Minnesota and a bachelor s degree in nursing from Marquette University in Milwaukee, Wisconsin. Minneapolis Heart Institute Foundation

2 EXPANDING THE BOUNDARIES: HEALTH EQUITY AND PUBLIC HEALTH PRACTICE Jeanne Ayers Assistant Commissioner, Minnesota Department of Health Connecting to Transform Communities 2015 November 17, 2015 Presentation: Part One Part One Introduce/Expand our understanding of what creates health and health disparities including structural inequities and structural racism. Part Two: Share a framework designed to generate action on the factors that create health and introduce core elements (Triple Aim of Health Equity) of an emerging practice to advance health equity. Part Three: Describe practices, tools and examples of Triple Aim of Health Equity Expanding the understanding of health Implement Health in All Policies with Equity as the Aim Strengthen community capacity 1

3 Public Health Public health is what we, as a society, do collectively to assure the conditions in which (all) people can be healthy. Institute of Medicine (1988), Future of Public Health What is Health? From WHO 1948 and Ottawa Charter for Health 1986 "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Health is a resource for everyday life, not the objective of living. 2

4 What is required for health? Prerequisite conditions for health Peace Shelter Education Food Income Stable eco-system Sustainable resources Social justice and equity World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, Accessed July 12, 2002 at < 3

5 Factors that determine health Tarlov AR. Public policy frameworks for improving population health. Ann N Y Acad Sci 1999; 896: Health Is Community Community Conditions for Health and Quality of Life 4

6 Minnesota is doing well overall Second highest life expectancy at birth Lowest infant mortality rate Six highest life expectancy after age 65 Highest rated health of seniors Highest rated health care system Access, quality, cost, outcomes Health Equity Report Advancing Health Equity February 1, 2014 in Minnesota the opportunity to be healthy is not equally available everywhere or for everyone in the state. 5

7 Health inequities in Minnesota are significant and persistent, especially by race: In Minnesota, an African American or Native American infant has more than twice the chance of dying in the first year of life as a white baby. Disparities in Birth Outcomes are the tip of the health disparities iceberg Disparities in Birth Outcomes Heart disease Hypertension Obesity Renal failure Cancer Asthma Alcoholism Stroke Cirrhosis Nephritis STDs Dementia COPD Unwanted pregnancies Diabetes Drug abuse Homicide HIV Substance Use Injuries Suicide Influenza Depression Anxiety Tuberculosis Malnutrition 6

8 Predictors of Health by Race The connection between systemic disadvantage and health inequities by race is clear and predictive of the future health of our community. What does health equity mean? Health equity means achieving the conditions in which all people have the opportunity to realize their health potential the highest level of health possible for that person without limits imposed by structural inequities. 7

9 Definitions Health Disparity: A population-based difference in health outcomes. Health Inequity: A health disparity based in inequitable, socially-determined circumstances. Structural Inequity: Structures or systems of society such as finance, housing, education, social opportunities, etc. that are structured in such a way that they benefit one population unfairly (whether intended or not) Disparities in health are the tip of the societal disparities iceberg Disparities in Health Unemployment Social exclusion Poverty Poor housing Racism Violent neighborhoods School suspensions Bad schools Liquor stores Homicide Drug abuse Crime Food deserts Red lining Incarceration Substance Use Lack of wealth Environmental Contamination Injuries Suicide Immobility Disrupted families Segregation Blight Lack of hope 8

10 Roots of Inequities-how did we get here? Disparities are not simply because of lack of access to health care or to poor individual choices. Disparities are mostly the result of policy decisions that systematically disadvantage some populations over others. Especially, populations of color and American Indians, GLBT, and low income Structural Racism Structural/Institutional Racism Structural racism is the normalization of an array of dynamics historical, cultural, institutional and interpersonal that routinely advantage white people while producing cumulative and chronic adverse outcomes for people of color and American Indians. 9

11 Structural Inequity: Housing 75% of white population in Minnesota owns their own home, compared to: 21% of African Americans 45% of Hispanic/Latinos 47% of American Indians 54% Asian Pacific Islanders Source: Advancing Health Equity Report 2014 Structural/Institutional Racism Ignores differential impacts on racial populations Ignores differences among racial populations (e.g. accumulated wealth, homeownership, transit dependence, employment, education, geography) Focuses on efficiency, cost, numbers to the exclusion of other criteria such as community impact Raises barriers to resources, such as grants or contracts Is based in dominant culture norms, experiences, approaches or expertise Reflects lack of cultural knowledge/background/awareness 10

12 Conditions that create opportunities for health Parks & trails Affordable, healthy food supply Job opportunities, fair wages, benefits and safe work practice Thriving small businesses and entrepreneurs Financial institutions Better performing schools Good transportation options and infrastructure Sufficient healthy affordable housing Home ownership Social inclusion/civic engagement Availability of family support and social networks Strong local governance Good Health Status Poor Health Status Contributes to health disparities: Obesity Diabetes Cancer Asthma Injury Conditions that limit opportunities for health Unsafe/limited parks Lack of affordable, healthy food Lack of job opportunities, fair wages, benefits and safe work practices Payday lenders Few small businesses Poor performing schools Few transportation options Poor and limited housing stock Rental housing/foreclosure Social exclusion Lack of family support and social networks Weak local governance Legislation: Health Equity Report Things are the way they are because we designed them that way. The roots are deep in historical policies Structural Racism Greatest potential for change is effective policy development. Not a new program but a commitment, a commitment to fundamental shifts in paradigms about what constitutes evidence, who is involved in decision-making, and what creates health Laws of Minnesota 2013, Chapter 108, Article 12, Section

13 Asking Questions as a Path to Action Inquiry Questions: What is working? What policies, practices, processes create inequities within our organizations and more broadly? Identify areas where structural inequities and structural racism are creating inequitable health outcomes. Develop the practice of examining Policies, Processes and Assumptions. Presentation: Part Two Part One Introduce/Expand our understanding of what creates health and health disparities including structural inequities and structural racism. Part Two: Share a framework designed to generate action on the factors that create health and introduce core elements (Triple Aim of Health Equity) of an emerging practice to advance health equity. Part Three: Describe practices, tools and examples of Triple Aim of Health Equity Expanding the understanding of health Implement Health in All Policies with Equity as the Aim Strengthen community capacity 12

14 Public Health Public health is what we, as a society, do collectively to assure the conditions in which (all) people can be healthy. Institute of Medicine (1988), Future of Public Health Assuring Conditions requires Seeing a Wider Set of Relationships Health Living Conditions 13

15 FRAMEWORK ALERT! Social Determinants of Health Have the Largest Impact on Equity in Health and Well-Being Commission on Social Determinants of Health. (2010). A conceptual framework for action on the social determinants of health. Geneva: World Health Organization. 14

16 World Health Organization Commission on Social Determinants of Health IMPACT ON EQUITY IN HEALTH AND WELL- BEING Commission on Social Determinants of Health. (2010). A conceptual framework for action on the social determinants of health. Geneva: World Health Organization. World Health Organization Commission on Social Determinants of Health IMPACT ON EQUITY IN HEALTH AND WELL- BEING Health System INTERMEDIARY DETERMINANTS Social Determinants of Health Commission on Social Determinants of Health. (2010). A conceptual framework for action on the social determinants of health. Geneva: World Health Organization. 15

17 World Health Organization Commission on Social Determinants of Health IMPACT ON EQUITY IN HEALTH AND WELL- BEING Health System INTERMEDIARY DETERMINANTS Social Determinants of Health Commission on Social Determinants of Health. (2010). A conceptual framework for action on the social determinants of health. Geneva: World Health Organization. World Health Organization Commission on Social Determinants of Health IMPACT ON EQUITY IN HEALTH AND WELL- BEING Health System STRUCTURAL DETERMINANTS Social Determinants of Health Inequities INTERMEDIARY DETERMINANTS Social Determinants of Health Commission on Social Determinants of Health. (2010). A conceptual framework for action on the social determinants of health. Geneva: World Health Organization. 16

18 Social Determinants of Health Have the Largest Impact on Equity in Health and Well-Being Commission on Social Determinants of Health. (2010). A conceptual framework for action on the social determinants of health. Geneva: World Health Organization. Can use the WHO framework to: Develop hypotheses & explanatory pathways Explicitly articulate a theory of change Identify where you are working and the gaps Set reasonable expectations for outcomes 17

19 Implement Health in All Policies Approach with Health Equity as a Goal Determinants of Health and Health Inequities Commission on Social Determinants of Health. (2010). A conceptual framework for action on the social determinants of health. Geneva: World Health Organization. Reflection Placing our work in Context Think about your work. Where does it it falls on the WHO Model? What do you or your organization do? Provide services, Education, Research Policy Where are you/your work/ your organization situated? Health impacts? Intermediary determinants? Social or structural/political determinants? 18

20 Assuring Conditions requires Seeing a Wider Set of Relationships Health Living Conditions Social Determinants of Health The conditions and circumstances in which people are born, grow, live, work, and age. These circumstances are shaped by a set of forces beyond the control of the individual: economics and the distribution of money, power, social policies, and politics at the global, national, state, and local levels. WHO and CDC (adapted) 19

21 Assuring Conditions requires Seeing a Wider Set of Relationships Health Capacity to Act Living Conditions Centers for Disease Control and Prevention, Bobby Milstein Structure work to achieve our overall aim: Strengthen community capacity to act Organize the: Resources Narrative People Narrative: Align the narrative to build public understanding and public will. People: Directly impact decision makers, develop relationships, align interests. Resources: Identify/shift the resources-infrastructure-the way systems and processes are structured. 20

22 Essential Practices to Advance Health Equity Purposefully expand the understanding and conversation of what creates health to include the opportunity for health (narrative) Strengthen the capacity of communities to create their own healthy futures. Use public health tools: partnerships, engagement, convening ability, data, reports, education, policy, resources, legislation, bully pulpit (people) Implement a health in all policies approach with health equity as the goal in program and policymaking (resources) Social Cohesion 21

23 Presentation: Part Three Part One Introduce/Expand our understanding of what creates health and health disparities including structural inequities and structural racism. Part Two: Share a framework designed to generate action on the factors that create health and introduce core elements (Triple Aim of Health Equity) of an emerging practice to advance health equity. Part Three: Describe practices, tools and examples of Triple Aim of Health Equity Expanding the understanding of health Implement Health in All Policies with Equity as the Aim Strengthen community capacity Expand the understanding of what creates health Change the Narrative Health is not determined by just clinical care and personal choices Health is determined mostly by physical and social determinants affecting individuals and communities Determinants are created & enhanced by policies and systems that impact the physical and social environment 22

24 And The Real Narrative of What Creates Health Inequities? Disparities are mostly the result of policy decisions that systematically disadvantage some populations over others. Especially, populations of color and American Indians, GLBT, and low income Structural Racism Tools for Expanding our Understanding of Health Data Collection: include data on the opportunity for health-include indicators on the conditions necessary for health SDoH, as well as Demographics, SES, Race, Ethnicity, Language, Sexual Identify, Gender identification Data Analysis: incorporate an understanding of the social determinants of health, structural inequities, structural racism and the power of policy, system and environmental (PSE) approaches to prevention in the analysis Reports: Communication and dissemination Develop and share reports with an analysis of the inter-relationship between health outcomes and health opportunities or inequities. Partners: Partner with communities experiencing greatest health disparities and groups/agencies focused on improving the social determinants. 23

25 Healthy 47 Minnesota 2020: Statewide Health Assessment and Statewide Health Improvement Framework Minnesota Department of Health and the Healthy Minnesota Partnership ership/hm2020/ Change the Narrative about What Creates Health Indicators in Statewide Health Assessment/Framework Themes Indicators Outcomes Social Determinants Vision 24

26 Health in All Policies Implement Health In All Policies-Equity Health in All Policies (HIAP) is a collaborative approach that integrates and articulates health considerations into policy making and programming across sectors, and at all levels, to improve the health of all communities and people. HIAP requires practitioners in all sectors to collaborate to define and achieve mutually beneficial goals. 25

27 Tools in Health in All Policies approach Data Reports Internal Policy Alignment White Papers Health Notes Health Impact Assessments Community Engagement--partners Asking Questions Health in All Policies: Questions to ask to advance health equity What do we know about who will benefit? What health impacts can we anticipate? Who will experience these impacts? What and whose values, beliefs and assumptions are guiding or influencing the decision? What do we know about impact(outcome) versus intent of the policy? Would the issue/policy benefit from further study or a health impact assessment(hia)? 26

28 Health in All Policies Work across policy arenas (health, transportation, education, housing, agriculture, safety, etc.) Cabinet-level Equity/Health in All Policies efforts Statewide Health Improvement Program (SHIP) Complete Streets-Safe Routes to School-Smoke-free campuses, housing-farm to School-Community Gardens. Interagency Council to End Homelessness Minnesota Food Charter Transportation Investments and Policy Policing, incarceration, school discipline policies Income and tax policy Parental, sick leave policies White Paper: Income and Health Life expectancy by median household income group of ZIP codes, Twin Cities Adults reporting "fair" or "poor" health status by income, Minnesota Life expecanty in Years Percent Less than $35,000 $35,000 to $44,999 $45,000 to $59,999 $60,000 to $75,000 or $74,999 more 0.0 Less $20,000 $20 to $34,999 $35 to $49,999 $50 to $79,999 $75,000 or more DK refused Source: The unequal distribution of health in the Twin Cities, Wilder Research Analyses were conducted by Wilder Research using mortality data from the Minnesota Department of Health and data from the U.S. Census Bureau (population, median household income, and poverty rate by ZIP code Source: 2011 Behavioral Risk Factor Surveillance System 27

29 Minimum Wage We all benefit from and have a role in creating healthier communities. It s time for us to come together to implement a minimum wage that further enhances the health benefits of employment It will be a great investment in the health of individuals, families, communities, and our state. Ehlinger Commentary in MinnPost Paid Parental and Sick Leave Linked to Improvements in: Infant mortality Health of infants and mothers Breastfeeding Vaccinations Well child check-ups Maternal depression Occupational injuries Routine cancer screenings Emergency room usage Days lost due to illness 28

30 Paid Leave Report: Those with lowest incomes least likely to have access to paid sick leave--mn Access to paid sick time for full-time workers in MN by annual income Percent eligible <$15 $15-<$35 $35-<$65 $65+ Health in All Policies Approach Helps Strengthen Community Capacity Information technology Recreation & Open Spaces Healthy Food Public transit & Active transportation Quality & Affordable Housing Green & Sustainable Development Community oriented media Healthcare Economic Opportunity Fair Justice System Complete Neighborhoods Quality Environment Safe Public Spaces 29

31 Strengthen Community Capacity to achieve our overall aim Our efforts to broaden and shift our relationships with community organizations is rooted in our understanding of the limitations of the approaches we have traditionally taken and their ability to advance health equity and assure optimal health for all How do we actually transform the distribution of money, power, social policies, and politics at the global, national, state, and local levels to assure the conditions for health are available to all? Community Partnerships-Where do we start? Conduct an analysis of our own power and networks and those of our partners are these relationships fit to purpose? What type of power is needed to achieve our aim of equity? Political will, sensitivity, complexity What relationships or alliances do you need to build? 30

32 Tool Kit for Strengthening the Capacity of Communities Community engagement plan Stakeholder identification including interests Community governance models Advisory and Community Leadership Teams Community input on grant criteria Community benefit accountability Participatory Budgeting Set of questions Community Partnerships-Where do we start? Who are you in relationship with? What interests do they represent? Do they have a base? (A source of authority, influence, or support? People they represent that they are accountable to?) Different groups play different roles all can bring value but not all the same depending upon the aim Be conscious of your power and impact 31

33 Asking the right questions helps strengthen community capacity to create their own healthy future Who is at the decision-making table, and who is not? Who has the power at the table? How should the decision-making table be set, and who should set it? Who is being held accountable and to whom or what are they accountable? How we set the table matters Reevaluate roles with eye to building power for change (Agreements on roles, Technical Expert panel, Decision-makers, 1 Consultant, Convener/Organizer, physical setting.) Healthy Minnesota Partnership (Organize narrative, broaden relationships invest in alignment of partners) Minimum Wage, Income and Health Report, Paid Sick and Family Leave, Pay Day Lending, Incarceration Justice: Ban the Box Advancing Health Equity in Minnesota Report (1000 people-- Built our capacity to deepen authentic engagement with communities experiencing greatest health inequities 32

34 Strengthen Community Capacity Clearly assess our skills and intentionally build our internal capacity-race, power, assets, differences, similarities Develop a set of guidelines-principles/practices regarding community engagement-convening to help shift practice-(iterative and with partners) Tension and partnership work together. Social Cohesion 33

35 Overall Lessons Organic must be interwoven with all other workrecognize it is iterative Must be intentional Commitment: Requires commitment to building our organizational and community capacity --skills Leadership Hold our selves and each other accountable-bring more people into decision-making Imperfect-incomplete work--navigating toward health equity -- permission to make course corrections Public health is the constant redefinition of the unacceptable Geoffrey Vickers Jeanne Ayers Assistant Commissioner, MDH P.O. Box St. Paul, MN

36 Tuesday Opening Keynote We Are What We Eat, and What We Build Tuesday, November 17, 2015, 8:10-9:30 am Northland Ballroom Humanity faces grave challenges in terms of environment, economy and health. Natural resources are becoming increasingly costly. Since the mid-century the carbon dioxide level of the planet has climbed from 300 ppm to 400 ppm, leading to more energy and moisture in the atmosphere, and thereby requiring more resilient places to live and work. Medical care costs will continue to escalate, not just because of population aging and new technology, but because of escalating rates of obesity and diabetes. Society needs solutions that solve problems across many challenges. Humans need places, especially green places homes, buildings, public areas that bring comfort and foster health at a personal and population level. The presentation will identify ways that support personal and community health will benefit by decreasing fossil fuel use and increasing healthy physical activity, access to daylight, healthy food and air. Learning objectives 1. Learn the importance and urgency of the health threats obesity, inactivity, diabetes and depression that demand places that allow and invite walking and biking, and actions steps they can take. 2. Develop strategy, lexicon and communications tools that will enable better dialog between the development and health worlds. 3. Learn from success stories from communities that have transformed themselves to become walkable and bikeable, and at the same time attracted creative energetic workers and smart investments. Richard Joseph Jackson, MD, MPH Professor, Fielding School of Public Health, University of California, Los Angeles. A pediatrician, Dr. Jackson he has served in many leadership positions with the California Health Department, including the highest as the State Health Officer. For nine years he was director of the Center for Disease Control s (CDC s) National Center for Environmental Health and received the Presidential Distinguished Service award. In October, 2011 he was elected to the Institute of Medicine of the National Academy of Sciences. Jackson was instrumental in establishing the California Birth Defects Monitoring Program and in the creation of state and national laws to reduce risks from pesticides, especially to farm workers and to children. While at CDC he established major environmental public health programs and instituted the federal effort to biomonitor chemical levels in the U.S. population. He has received a hero award from the Breast Cancer Fund, lifetime achievement awards from the Public Health Law Association and the New Partners for Smart Growth, the John Heinz Award for national leadership in the environment, and the Sedgwick Award, the highest award of the American Public Health Association. In 2015 he received the Henry Hope Reed Award for his contributions to architecture. Jackson lectures and speaks on many issues, particularly those related to built environment and health. He has co-authored three books: Urban Sprawl and Public Health; Making Healthy Places; and Designing Healthy Communities, for which he hosted a four-hour PBS series. He has served on many environmental and health boards, as well as the Board of Directors of the American Institute of Architects. He is an elected honorary member of the American Society of Landscape Architects as well as the American Institute of Architects. Jackson is married to Joan Guilford Jackson; they have three grown children and two grandchildren. Minneapolis Heart Institute Foundation