Four Years of Supporting Health in All Policies Initiatives at the Local Level: 2018-2022

Introduction Policies and practices in sectors that historically operate outside of the public health space, including environmental health, transportation, and housing, often impact health outcomes. Collaborating across sectors is key to improving the health of all people—particularly those most impacted by health inequities and environmental injustices. As public health seeks to address current and emerging trends that impact communities, meeting individual social needs is not enough to truly address social determinants of health and the structural conditions that produce these inequities. Health in All Policies (HiAP) is a framework to support public health in its work to center health in decision-making and policy development. The National Association of County and City Health Officials (NACCHO) defines HiAP as changes in systems that determine how decisions are made and implemented by local, state, and federal governments to ensure that policy decisions have neutral or beneficial impacts on the determinants of health.1 An additional goal of NACCHO’s HiAP work is to build the capacity of local health departments (LHDs) to champion cross-sector work and improve community and environmental public health. From 2018 to 2022, partner organizations provided funding or technical assistance to 11 LHDs, 2 state health agencies, and 2 territorial health departments to use a HiAP approach to advance their efforts to reduce lead exposure and its impacts on health. Lead exposure was the subject matter area for this project, considering it is a complex public health challenge involving multiple sectors. Additionally, many of the homes within the jurisdictions of the health departments that participated in these grant periods were built prior to 1978, the year in which lead was banned from paint. As such, these homes are likely to have lead-based paint, which can result in early exposure to lead. Health departments were the primary implementors, as they have the legal authority to protect and promote the public’s health and can work alongside government agencies and community members to ensure policies have a positive health impact. They are natural leaders for HiAP efforts. This article discusses the implementation of the HiAP grant periods, the benefits of implementing HiAP, the challenges LHDs encountered, and key takeaways from using a HiAP approach. The national partners that supported this HiAP work included the National Center for Healthy Housing (NCHH), NACCHO, the Association of State and Territorial Health Organizations (ASTHO), the Centers for Disease Control and Prevention’s National Center for Environmental Health/Agency for Toxic Substance and Disease Registry (NCEH/ATSDR), and the National Environmental Health Association (NEHA). Health in All Policies strategies According to Gase et al, there are 7 strategies that communities in the United States use to implement HiAP: (1) developing and structuring cross-sector relationships; (2) enhancing workforce capacity; (3) incorporating health into decision-making; (4) integrating data, research, and evaluation systems; (5) coordinating investments and funding streams; (6) implementing accountability structures; and (7) synchronizing communications and messaging (Figure).2 For more information on the 7 strategies, view NACCHO’s Local Health Department Strategies for Implementing Health in All Policies.1 Each of the teams involved in the grant periods focused on specific HiAP strategies to embed health considerations into their policies and practices to achieve a variety of goals. Health in All Policies projects: HiAP + Lead Collaborative & Evaluating Health in All Policies initiatives The HiAP + Lead Collaborative was a 2-year partnership of national organizations, NCEH/ATSDR, NCHH, NACCHO, NEHA, and ASTHO, which supported health departments in their efforts to address lead exposure through a HiAP approach. It concluded in 2020 due to the impact of COVID-19 on participating health department capacity; however, an iteration of the collaborative took place from 2021 to 2022. The first year of the collaborative, 2018-2019, involved 3 LHDs that received up to $20 000 in funding and 6 months of technical assistance to implement HiAP activities to address lead exposure in their jurisdictions. Activities included creating a countywide coalition of partners to track and advocate for statewide lead hazard regulations, engaging community groups to work across sectors, building cohesive messaging and communication on lead prevention, streamlining data collection and integration, using integrated data systems to identify neighborhood areas at a high risk of lead exposure, developing new data systems for case management, and holding educational and outreach campaigns to raise awareness of the effects of lead exposure.3-5 From 2019 to 2020, the original 3 LHDs were offered continued funding up to $25 000. An additional 5 local, 2 state, and 2 territorial health departments were selected through a competitive application process and received up to $25 000 over 6 months. The second year of the collaborative was structured in a way so that each national organization provided technical assistance to those in its cohort, compared to the first year in which all 3 LHDs received technical assistance from all national organizations. NACCHO provided technical assistance to 4 additional LHDs, of which 2 did not complete the project period. ASTHO provided technical assistance to 1 territorial health department and 1 state health agency. NEHA provided technical assistance to 1 LHD, 1 state health agency, and 1 territorial health department. See Table 1 for a breakdown of participating health departments by year of participation, amount of grant funding received, and technical assistance provider. Please note that additional health departments were originally identified to be awarded, but due to COVID-19 and its related impacts, they were unable to accept funding. These funds were rescoped to support other health departments.FIGURE: Seven Strategies for Implementing Health in All Policies TABLE 1 - Health Department by Year of Participation, Amount of Grant Funding Received, and Technical Assistance Provider Local Health Department Year of Participation Grant Funding Received Technical Assistance Provider Allegheny County Health Department, Pennsylvania 2018-20192019-2020 $20 000$25 000 NACCHO, NEHA, and NCHH Louisville Metro Public Health and Wellness, Kentucky 2018-20192019-2020 $20 000$25 000 NACCHO, NEHA, and NCHH Houston Health Department, Texas 2018-20192019-2020 $20 000$25 000 NACCHO, NEHA, and NCHH Boston Public Health Commission, Massachusetts 2019-2020 $25 000 NACCHO City of Cleveland Department of Public Health, Ohioa 2019-2020 $25 000 NACCHO Camden County Department of Health and Human Services, New Jerseya 2019-2020 $25 000 NACCHO Milwaukee Health Department, Wisconsin 2019-2020 $25 000 NACCHO Puerto Rico Department of Health 2019-2020 $25 000 ASTHO Idaho Department of Health and Welfare 2019-2020 $25 000 ASTHO Boulder County Public Health, Coloradob 2019–2020 $32 500 NEHA Palau Department of Environmental Health 2019–2020 In-person training (valued at $10 000) NEHA Washington State Department of Healthb 2019–2020 $50 000 NEHA Kent County Health Department, Michigan 2021-2022 $30 000 NACCHO and NCHH Franklin County Public Health, Ohio 2021-2022 $30 000 NACCHO and NCHH Minneapolis Health Department, Minnesota 2021-2022 $30 000 NACCHO and NCHH Abbreviation: NACCHO, National Association of County and City Health Official; NCHH, National Center for Healthy Housing; NEHA, National Environmental Health Association.aDid not complete the grant period of performance.bReceived additional funding when other health departments were unable to accept grant due to COVID-19 and related impacts. Activities during the second year of the collaborative included creating a lead prevention working group to bridge the gap in coordination and provision of services between service providers and families, developing fact sheets and materials to raise awareness of the effects of lead, training community members to identify lead-related hazards in their communities, and updating data systems to integrate lead-related health data.6 The emergence of COVID-19 during the project period challenged teams’ capacity and ability to participate in the Collaborative. The HiAP + Lead Collaborative ended in 2020. In 2021, to expand the evidence base for HiAP, a new iteration of HiAP funding focused on implementing and evaluating HiAP initiatives with LHDs. LHD teams were asked to use NACCHO’s HiAP Evaluation Guidance Tool and at least 1 of the 7 HiAP strategies to implement innovative lead poisoning prevention strategies.7 Projects were scoped to take place over 6 months; however, due to changes in capacity and resources, teams received a 3-month extension with activities concluding in November 2022. Health departments adopted a variety of tactics and activities during the project period to address lead poisoning, including engaging property owners in lead-safe programming and creating a process by which they could apply for home repair services, conducting a community assessment to evaluate community-level knowledge of hazards of lead exposure and inform future community outreach and messaging, and integrating data systems for lead programs. Throughout the project years, the intent of the funding was to advance the implementation of HiAP at the local level and to encourage sustainable strategies for embedding health considerations into governmental structures, resulting in improved health outcomes. Each cohort participated in a project kick-off call where they met the technical assistance providers in addition to the other participating health departments. Each cohort also participated in a final convening in which they shared their achievements, lessons learned, and next steps. The national partners celebrated the achievements and accomplishments of each participating team. In addition to the kick-off and final convening, each team participated in a monthly call with the technical assistance providers and received support on a range of topics: connecting teams to peer health departments to share challenges and lessons learned and provide thought partnership; sharing existing HiAP resources to support implementation of HiAP activities; and engaging subject matter expertise on housing policy, housing regulations, community engagement, health equity, environmental justice, cross-sector partnership development, and lead poisoning prevention efforts. The core technical assistance team acted as a collaborative thought partner to ensure each team had what they needed to move their project forward. Teams were required to complete a benchmarking document that identified process and outcome measures, serving as a self-assessment of capacity and current level of engagement related to lead poisoning prevention and HiAP. The 2021-2022 cohort also completed a self-assessment of capacity related to health equity and environmental justice. Included in the benchmarking report was a narrative portion for the team to highlight the planned activities and additional context. Teams also completed an interim report that identified mid-point accomplishments, challenges and issues, supports used to address identified obstacles, lessons learned to date, how the team was centering health equity and environmental justice, and partnership identification. At the end of the project period, teams submitted a final report that asked them to revisit the initial benchmarking report to identify progress on their goals. These tools highlighted how much each team accomplished in a relatively short period of time. Teams were also asked to assess the HiAP strategies that were used in the implementation of their projects, in comparison to those initially planned.7 Results of HiAP technical assistance and funding Previously published reports and the benchmarking, interim, and final reports completed by the health department teams provided robust information on the impact of the HiAP project period.3-5,7,8 Health departments advanced their project goals by using the 7 HiAP strategies as described in the subsequent sections. Eight teams partnered with community-based organizations, community members, local agencies, and local government agencies such as Departments of Education, Housing, Planning, and Environmental Health to form coalitions and collaboratives (Strategy 1) to advance efforts to address and prevent lead exposures. Five teams integrated their research, evaluation, and data systems (Strategy 5) to support their efforts. One site created maps of neighborhoods and homes most at risk for lead exposure. The maps were then used by the health department to target interventions. Another team connected lead program data across agencies, improving access and their ability to demonstrate the impact of the lead program. Additionally, one health department surveyed more than 900 community residents on knowledge of lead hazards and used the findings of their survey to develop and disseminate more relevant community resources. Several teams included education and outreach in their project (Strategy 6), centering community members and organizations most impacted by lead exposure in the program activities. One team created communications materials on lead hazards for public dissemination, which increased community awareness of lead hazards. In one county where most homes were built prior to 1978, the year in which lead was banned from paint, current home repair programs supported by the health department did not allow landlords to apply for and receive remediation, thus leaving a gap in services among those landlords who could not afford repairs to their rental properties. Through the project period, the team created a pathway for property owners and landlords to apply for lead remediation efforts, thus engaging a stakeholder that is usually left out of lead programming efforts. These project outputs represent not only the activities of these collaborative teams over a grant cycle but also the innovative approaches to a public health challenge—lead poisoning prevention—that involves multiple sectors. The project periods gave health departments the opportunity to take a step back from their day-to-day work and engage in strategic visioning with a diverse range of stakeholders around lead prevention policies. HiAP is an approach to thinking more creatively about how to engage partners, center those most at risk for lead exposure, and focus on preventative solutions. Teams were able to create a space in which different agencies, organizations, and community members came together to discuss and make informed decisions together. The cohort model and technical assistance worked to support each team in their efforts. Challenges Due to the COVID-19 pandemic at the start of the 2019-2020 project year, teams made many adjustments.4 Health departments prioritized COVID-19 response over other activities, including those in the HiAP + Lead Collaborative. Staff were reassigned from their lead-focused work to the COVID-19 response. Social distancing mandates forced health departments to limit or pause blood lead screenings, inspections, and community outreach efforts. Once project activities resumed, teams developed creative solutions to continue their efforts, including pivoting all meetings to virtual platforms, offering participants to complete virtual surveys on their own time if they could not attend meetings, and changing their process for lead inspections. The 2021-2022 cohort continued to experience the effects of the COVID-19 pandemic, including a decrease in workforce capacity as colleagues continued to respond to the pandemic, increased turnover in LHD staff, and the impact of misinformation and disinformation surrounding public health in the wake of COVID-19. Teams experienced additional challenges including partnership buy-in, funding restrictions, and troubleshooting online survey responses. Partnership development takes a significant amount of time, and teams highlighted the difficulty of conducting this activity as a lesson learned for future work. Since the project period provided short-term funding, teams sought to leverage multiple sources of funding to support their efforts. However, due to grant restrictions, teams were limited in their ability to use funding resources for purposes beyond their original intent. Impact of Project Periods The HiAP and lead poisoning prevention projects demonstrated the utility of implementing HiAP strategies to address complex public health challenges. Providing funding and technical assistance to LHDs as they implement HiAP activities gives LHDs the resources and space to create innovative solutions to pressing needs. Technical assistance included supporting the development of governance structures for the coalitions, providing thought partnership on goals and key strategies, and providing expertise on best practices in the field of housing, lead poisoning prevention, policy, and HiAP.