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News From NACCHO

Fostering Agency Through Local Public Health

Grenadier, Andrea BA; Holtgrave, Peter MPH, MA; Aldridge, Chris MSW

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Journal of Public Health Management and Practice: September/October 2018 - Volume 24 - Issue 5 - p 499-501
doi: 10.1097/PHH.0000000000000864
  • Free

When public health departments support all aspects of the public's well-being—beginning with striking at the roots of health inequity—it can create transformational change. Part of this process is encouraging people in communities to determine their own futures, to express agency; something that is rooted in action and power. So, how does local public health get there?

We already have examples of success. For instance, local health departments have been at the forefront of health equity work by building internal capacity and infrastructure, fostering strategic community partnerships to build power and engage in social justice work, and working across government agencies to develop shared ownership for health equity.

However, although these examples exist, all too often public health's efforts fail to improve population health—often because of the fear of failure.

There is fear of trying new initiatives that might not work out. There is fear of running out of time, will, allies, and money. There is fear of not meeting funders' expectations, even when their expectations do not align with the community's needs. There is fear of going against the governing bodies, such as mayors and other officials, even when their agendas may conflict with the community's needs. And underlying all of this is the fear of losing ever-dwindling vital resources.

Addressing the roots of health inequity requires operating out of a social justice—and not just a medical—framework. In their role as scientists, public health practitioners can no longer shy away from addressing issues of unequal power and structural bias, such as racism.

The Seattle-based Bridging Health and Community is dedicated to exploring health from the perspective of communities. Its Creating Health Collaborative comprises innovators exploring health from the perspective of people and communities and how that perspective influences local efforts to create it. The Collaborative came to focus on the importance of agency to health and developed 12 Principles1 that describe inclusive, participatory, and responsive process to holistically shift how healthy communities might be developed. The principles are:

  1. Include in a community's collective effort, those who live there, those who work there, and those who deliver or support services provided there.
  2. Spend time understanding differences in context, goals, and power.
  3. Appreciate the arc of local history as part of the story of a place.
  4. Elicit, value, and respond to what matters to community residents.
  5. Facilitate and support the sharing of power, including building the capacity to use it and acknowledging existing imbalances.
  6. Operate at 4 levels at the same time: individual, community, institutional, and policy.
  7. Accept that this is long-term, iterative work.
  8. Embrace uncertainty, tension, and missteps as sources of success.
  9. Measure what matters, including the process and experience of the work.
  10. Build a vehicle buffered from the constraints of existing systems and able to respond to what happens, as it happens.
  11. Build a team capable of working in a collaborative, iterative way, including being able to navigate the tensions inherent in this work.
  12. Pursue sustainability creatively; it is as much about narrative, process, and relationships as it is about resources.

MAPP and the 12 Principles: Multnomah County Health Department

As a framework for overcoming this narrowness, the 12 Principles resonate strongly with how the National Association of County and City Health Officials (NACCHO) and local health departments should—and often do—engage the communities we serve. For example, the 12 Principles directly correspond with NACCHO's Mobilizing for Action through the Planning and Partnerships2 (MAPP) approach for guiding health departments and their cross-sectoral partners in working collaboratively to improve community health through health assessment and planning. How do MAPP and the 12 Principles dovetail to create a practical framework, and what does the work look like in practice?

A successful example resembles the efforts of the Multnomah County Health Department (MCHD), which used the MAPP tool to find out what issues were being faced by those with disabilities within the community and what the community could do about those concerns. Heightened community involvement and engagement created an initiative in which all were equal partners at the table. They developed a vision and mission, assessed the community, identified problems and potential strategies, and created an action plan. The partnership members are currently still working on the action cycle phase of the process, but have made progress in providing health services and health promotion programming for community members with disabilities.

People with disabilities make up 16% of the total population of Multnomah County, Oregon. The MCHD and its community partners were interested in promoting health and well-being for these 115,000 county residents with disabilities. Working with NACCHO, the partners conducted the MAPP process to begin working toward this community goal. The range of partners included Oregon Health & Science University's Center of Excellence in Women's Health, Vocational Rehabilitation, Multnomah County Aging & Disability Services, Portland State University, Disability Arts and Cultural Program, and the City of Portland.

The partnership began by brainstorming and deciding upon a common vision: health and well-being for those with disabilities in Multnomah County; their purpose, to “help the health department begin to address the health promotion needs of people with disabilities in their clinics and community.” A steering committee was then divided into three subcommittees to conduct surveys based on stakeholder feedback and the existing literature on health promotion programming for people with disabilities. They were conducted in the waiting rooms of six primary care clinics operated by the MCHD, and surveys in Spanish were available at all locations.

Of the total 144 surveys completed by individuals seeking healthcare in one of the health department's primary care clinics, 69 identified themselves as having a disability based on inclusion criteria. Summaries made from the findings included that respondents wanted more information from their healthcare providers about treatments for specific conditions and about prevention and general health; respondents were interested in a wide array of health promotion activities and supports, including help with stress reduction, cooking classes, finding employment, and resource information; lack of money was the most commonly cited barrier to taking care of one's health.

The results of the survey were incorporated into the health promotion summit, the product of the second subcommittee. The summit focused on the notion that people with disabilities constitute a community and that public health professionals should relate to them as a community. The committees decided to focus on these strategies:

  • Identify and survey health department clients with disabilities to support the planning and implementation of health promotion programming for this community.
  • Develop a voluntary registry of people with disabilities in order to be able to provide appropriate services in the event of an emergency.
  • Convene a summit for people with disabilities and providers of services for people with disabilities to establish a long-term agenda for health promotion programming.

The third subcommittee is working to develop a voluntary registry to alert emergency response workers to community members with disabilities. The success of this project is dependent on approaching health promotion in the disability community in the same way it approaches health promotion in other communities: by working in partnership with leaders and members of the disability community and focusing on the underlying social determinants of health.

Human Impact Partners' Health Equity Guide

Echoing the 12 Principles, one of NACCHO's partners, Human Impact Partners, has developed a full range of strategic practices rooted in the theory that to systematically dismantle the patterns of “othering” and exclusion in government practice, we must pursue wall-to-wall transformation of how local health departments work—internally, with communities, and alongside other government agencies. This inside/outside approach requires health departments to build internal capacity and a will to act on the social determinants of health and health equity.

These practices clearly align with the 12 Principles and are articulated in Human Impact Partners' HealthEquityGuide.org3 website, a remarkable resource with inspiring examples of how health departments have advanced health equity, both internally within their departments and externally with communities and other government agencies. Of particular note are more than 25 detailed case studies from departments that describe how they advanced their practice, as well as more than 150 resources from allied organizations and others to advance the strategic practices. The Health Equity Guide clearly documents how the 12 Principles are made real in communities.

A local health official once commented that the role of local public health is to be the mirror and conscience of the communities they serve, bringing the health and health disparities data to the community to raise awareness of what needs to be addressed. For local health departments to truly support community agency, this consciousness-raising needs to be done in coalition with the communities they serve, respecting not just professional knowledge but also community knowledge. By acknowledging that communities have agency, we can contribute to some of the key elements that cultivate community agency: transparency, full participation, and accountability for decisionmaking.

For more information, contact Andrea Grenadier


1. Bridging Health and Community. 12 Principles. Accessed July 5, 2018.
2. NACCHO. Mobilizing for Action Through Planning and Partnerships. Accessed July 5, 2018.
3. Human Impact Partners. Local health departments are building power for health equity. Accessed July 5, 2018.
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