The public health accreditation process, guidance, and structure have been instrumental in assisting the Public Health Services (PHS) department in the County of San Diego (CoSD) Health and Human Services Agency (HHSA) to integrate health equity throughout the agency. Since 2008, actions to incorporate health equity principles and conduct upstream policy work to address the social determinants of health have occurred in HHSA. However, it was when PHS embarked on the accreditation process that the division was able to elevate health equity across HHSA. In 2010, that elevation and coordination began when PHS served as one of the beta-test sites for national public health accreditation. Also, that same year, the health officer developed a health equity framework for the California Conference of Local Health Officers (Table 1). By this point, HHSA also had already acknowledged health equity as an agency priority, and PHS included health equity language in its annual county budget narrative.1 The concept was further operationalized with the formation of the PHS Health Equity Committee in August 2012. The committee includes representatives from all PHS branches and is led by the PHS health equity coordinator. Its purpose is to implement the annual Health Equity Committee Work Plan and to provide regular updates to branches on committee activities, opportunities for education and training, and progress on health equity activities, as well as support the CoSD Diversity and Inclusion initiative and Climate Action Plan.
One of the first tasks of the committee was to develop a Health Equity Strategic Plan and Policy, both requirements of the accreditation process. The effort of shaping these documents as a department assured buy-in and engagement from all PHS branches. Once the new Health Equity Strategic Plan2 and Policy were completed, the department effectively had a blueprint for actions over the ensuing 5 years. Each year, the Health Equity Committee draws from the Strategic Plan to create an annual health equity work plan directing activities of the committee. All health equity efforts fit within goals, strategies, and objectives that align with the vision of the health equity strategic plan—“health equity for all San Diego County residents.” These efforts also align with the PHS Strategic Plan,3 the County of San Diego Strategic Plan, and the Live Well San Diego action framework, which is a regionwide wellness vision.
A number of times, in the years leading up to the accreditation site visit, public health accreditation standards and measures were reviewed by staff and management to ensure that PHS was effectively satisfying all Public Health Accreditation Board (PHAB) requirements. In a landscape of competing public health priorities, it is helpful to refer to accreditation standards to validate and confirm why staff and management should consistently maintain this effort. Public health demands are constantly expanding with competing mandates, emergencies, and emerging issues. Utilizing PHAB standards and measures to ensure there is a health equity focus reinforces a continuing commitment and accountability toward achieving a collective vision.
In 2015, the PHS Office of Health Equity, consisting of 1 staff member—the health equity coordinator, was established and housed in the administrative office of PHS. Up until this time, health equity activities were conducted by the PHAB coordinator and one other part-time support staff member. From this point forward, the health equity coordinator has conducted health equity activities, as well as coordinated PHS responsibilities for other related countywide initiatives—diversity and inclusion, trauma-informed services, customer service, and climate change.
The health equity coordinator and the Health Equity Committee have been able to achieve a number of key activities in recent years. These activities are to (1) build capacity and integrate health equity into public health operations, (2) develop training and tools to build understanding, and (3) sponsor and support events that raise awareness (Table 2).
These efforts were made possible through the PHS structure and organization established, which was guided, in part, by the accreditation standards. All County of San Diego efforts to improve the experience and outcome for the customer, internal and external, are cross-threaded for optimal integration.
In addition, the health equity coordinator and several other committee members are points of contact to relay messages to vulnerable populations in the event of a major disaster or emergency. The Office of Emergency Services and PHS work together to facilitate the Partner Relay Program, where community partners assist in translating messages to disseminate to special populations for emergency preparation and response. The program garnered a National Association of County & City Health Officials (NACCHO) Model Practice Award at the 2017 NACCHO Annual Conference.
The health officer has initiated a comprehensive review of performance measures by individual branches, with attention to disparities and disproportionality. Health Equity and Metrics Workshops were scheduled with each branch from October 10, 2016, to August 28, 2017. Metrics identified are being used to build branch performance dashboards that will be incorporated into the new 3-year PHS Strategic Plan for FY (fiscal year) 2018-2020. In each of the workshops, PHS staff had the opportunity for thoughtful discussion on health disparities, disproportionality, potential actions, and measurements.
Many exciting PHS programs are addressing health equity. One such project underway is the Healthy Cities, Healthy Residents (HCHR) initiative, addressing health equity by targeting cities with large numbers of low-income residents eligible for food assistance. Community-based organizations (CBOs) are working in neighborhoods within 3 cities and receive technical assistance in active transportation/living, healthy food environments, place-making, and media advocacy. The HCHR initiative builds on successes of Communities for Excellence in Nutrition, Physical Activity and Obesity Prevention (CX3), a concept borrowed from tobacco health promotion efforts, in which residents and CBOs in 6 communities pursue strategies to increase urban agriculture production and improve walkability (2012-2016).
Giving residents the training and tools to effectively advocate for community change is an innovative and empowering approach reflected in all of these efforts. It was first developed in 2011 with the Resident Leadership Academies (RLAs). With RLAs, community residents attend a training program, led by a facilitator, and learn practical ways to promote community change. The county now has a network of more than 135 RLA graduates who attend RLA Council meetings, a number of whom have attained public positions—a 2011 graduate was elected the mayor of Lemon Grove in 2016.
PHS periodically provides health equity technical assistance support to various internal and external stakeholders. The methodology for the Health Equity and Metrics Workshops, described earlier, was shared externally with students in a public health undergraduate program. On October 31, 2016, a training workshop on “Health Equity in Action,” with a focus on developing metrics for a performance dashboard, was conducted for Texas A & M public health undergraduate students.
The aforementioned workshops, for employees and graduate students, demonstrated that PHS has been able to institutionalize and operationalize the guidance in the PHAB standards and measures. The workshops also demonstrate how PHS is dedicated to sharing best practices with the current and next generation of public health professionals. PHS leadership believes it is important to train and educate public health practitioners and students to take action on health equity. These skills are important for the current, as well as the next, leaders of public health to understand and address the challenges and barriers (eg, social determinants of health) experienced by specific populations in achieving optimal health. Mastering these concepts and principles will help develop public leaders of today and tomorrow to become chief public health strategists in training.
Since 2004, PHS has reviewed local data with HHSA regional communities. PHAB requirements, to develop a community health assessment and improvement plan, amplified the PHS annual data review process by also identifying community health priorities, generating community strategic plans, and implementing strategic actions to improve regional health. The resulting Live Well San Diego Community Health Assessment7 and Community Health Improvement Plan8 were developed utilizing the Mobilizing for Action through Planning and Partnerships process. This community engagement method created 5 energetic community leadership teams that reviewed local data though the health equity lens. HHSA began to look at areas of inequity, work with the community to identify and address priorities, allocate resources for identified needs, and select interventions that made the most sense.
All of the aforementioned programs and activities support the regionwide Live Well San Diego vision to create healthy, safe, and thriving communities. Evaluating data through the health equity lens is one of the guiding principles for determining the success of Live Well San Diego. Contributing to the Live Well San Diego vision, PHS seeks to identify and address the root causes of priority health issues to achieve health equity among all San Diego County residents. This would not be possible without public health accreditation, which requires jurisdictions to conduct community assessments, implement community improvement plans, and complete the strategic planning process, all including a focus on health equity.