Health in All Policies (HiAP) is a framework to ensure that health and health equity are embedded throughout the creation, adoption, and implementation of policy and program development.

National Association of County and City Health Officials (NACCHO) strives to build the capacity of local health departments (LHDs) to champion HiAP and improve community and environmental public health. LHDs are natural champions for HiAP efforts 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.

Through 2021 – 2022, three LHDs, Franklin County Public Health, Kent County Health Department, and Minneapolis Health Department received funding and technical assistance from national organizations to advance their efforts to reduce lead exposure and its effects through a HiAP approach. The three LHDs were selected through a competitive application process. While the selection of LHDs was not based on geographic location, the regionality of the three LHDs did create a sense of camaraderie and strengthened their peer sharing. The national partners included the National Center for Healthy Housing, NACCHO, the Centers for Disease Control and Prevention’s National Center for Environmental Health, and the Agency for Toxic Substances and Disease Registry.

According to Gase et al., there are seven 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. For more information on the seven strategies, view NACCHO’s Local Health Department Strategies for Implementing Health in All Policies.

The three LHDs selected a combination of strategies to embed health considerations into their policies and practices and achieved a variety of goals. This post includes a brief overview of the work of each LHD as well as highlights testimonials from each community on the benefits of implementing HiAP and key takeaways. Additional information on the project year and LHDs can be found in this blog post developed by NCHH.

Franklin County Public Health (FCPH)

Background

FCPH is the sixth largest health district in Ohio and serves approximately 500,000 people. The mission of FCPH is to improve the health of the surrounding communities by preventing disease, promoting healthy living, and protecting against public health threats through education, policies, and partnerships.

FCPH works to encourage lead safety in homes through remediation efforts; however, one of the larger local home repair services do not allow for landlords to apply for, and receive, remediation. Often, those who are most impacted by lead-based paint and lead housing issues are those who are currently renting. Within the boundaries of Franklin County, there are 113,371 rental properties built before 1978 (the year when lead was banned from paint) —21,686 of which were built before 1940.

FCPH used a HiAP approach to ensure the safety of residents who may be at increased risk of lead exposure, such as families renting homes who experience lower incomes.

HiAP Strategies Used & Activities

• Develop and structure cross-sector relationships
  • Collaborate with legal team and regional planning committee partner to create a streamlined process by which landlords and property owners can register for the home repair services with local partners.
  • Foster a continual partnership with landlords and decisionmakers to ensure the health and well-being of all residents

• Incorporate health into decision-making process
  • Change the procedure and policy for whomsoever may enroll in lead-safe housing funding and remediation

• Coordinate funding and investments
  • Coordinate with fiscal team to ensure funding streams support the work

• Synchronize communications and messaging
  • Increased participation of landlords in lead-safe programming and campaigns

Achievements

The team created a draft tool for landlords and property owners to apply for lead remediation efforts while cementing significant relationships and streamlining future collaborations through the development process. The team also developed a full list of all registered landlords in Franklin County as well as agency contacts. These are crucial pieces of information needed to increase the participation of landlords and homeowners in lead-safe programming.

Next Steps

FCPH’s next steps include continuing to meet with community partners to maintain momentum and collaborate on additional Healthy Homes activities. FCPH will also continue outreach to Community Health Action Teams to connect community members with the grant application information. Ultimately, FCPH hopes to avoid a litigious and mandatory policy for landlords to enroll, and instead create a collaborative and beneficial partnership, which will also lead to improved health outcomes in the community and a decrease in children exposed to lead.

Lessons The Team Learned

Since the nature of different public health grants requires and expects LHDs to leverage multiple funding sources in their work, it is important to loop in the fiscal team early in the project period to ensure that the various funding streams are compliant with funder’s requirements. Additionally, partnership development takes time, consistency, and repeated “asks.” Teams implementing a HiAP approach should build back-up plans should a key partner need to step away from the project.

Key Takeaways on Using a HiAP Approach

This project provided the opportunity to engage a diverse range of partners and agencies in tackling one large problem. Each partner brought their own area of expertise, contextual knowledge, and funding to ensure that a person’s whole health was addressed. This approach is favorable compared to working in siloes which can create duplicative programming. The technical assistance provided an opportunity to discuss a variety of action plans, learn about best practices, and discuss a variety of strategies to support the project goals.

Minneapolis Health Department

Background

The Minneapolis Health Department (MHD) has a proud history of working within a dual status of city department and community health board to advance Health in All Policies by leveraging cross-sector collaboration and collective impact work. This project builds on two and a half decades of lead prevention policy and programming by evaluating the lead poisoning prevention work as it intersects with city housing work, county lead poisoning prevention work, and state policy that allows enforcement of lead reduction measures by MHD.

HiAP Strategies Used & Activities

• Incorporate health into decision making process
  • Understand how well existing city policies and interventions are occurring and provide evidence base to strengthen policies when necessary

• Coordinate funding and investments
  • Conduct a cost-benefit analysis for community health interventions

• Integrate research, evaluation, and data systems
  • Understand and localize the CDC’s recommended reference level for elevated blood lead levels in Minneapolis

• Synchronize communications and messaging
  • Community analysis findings to non-health partners to advocate for HiAP approach

“This work is foundational for our ability to create the evaluation and policy structures that are most effective, and we would advocate for continuing to teach and dedicate time to do it.”

Achievements

The MHD team successfully gathered data from their lead program, coded it, and analyzed it to illustrate that the program is functioning well, and to tell a clear narrative of the state of lead prevention in Minneapolis. This information is key to demonstrating the risk of not acting on lead prevention efforts and to create a clear prioritization for housing inspections. This process took time and capacity and highlights the meaningful aspect of relationship building in cross-sector work. Ultimately, the teams produced work that will strengthen the evaluation support of the program moving forward.

Additionally, the team did an analysis of their own data that would allow the program to show that it is using best practices tailored to the community when prioritizing lead inspection and outreach. They were also able to support a vision of what the impact of capillary testing, when a finger-prick or heel-prick is used to take a small sample of blood, would look like.

Next Steps

The team is actively working to create a culture of evaluation within the health department through HiAP strategies which will strengthen the department across all activities and program areas. Their goal is to continue to create tools and resources so that they can offer a coherent evaluation experience for the department. They plan to conduct trainings on data and HiAP, as well as remind both evaluators and programmatic teams that HiAP is an approach that helps to communicate across departments.

Lessons The Team Learned

The team’s work was impacted by changes in capacity as well as the time necessary to meet with the program team. Additionally, there can be much accomplished by working with the data that a programmatic team does have rather than waiting for perfect data to be collected.

Key Takeaways on Using a HiAP Approach

The HiAP tools allow for adaptability to specific contexts which is so important for the nuance that exists in public health work. Additionally, a HiAP framework allows for teams to break down communication barriers, identify early wins, and create a story to highlight the important work going on. It is important to note that it is challenging to balance a potentially time intensive approach such as HiAP with a culture of urgency that exists in local public health with various public health crises happening at once. It takes time to develop strategic plans and relationships.

Check out the team discussing their HiAP work in this video:

Kent County Health Department

Background

Kent County Health Department (KCHD) serves Michigan’s 4th most populous county, with a population of roughly 650,000 people. Like other communities across the country, Kent County faces barriers to ideal health outcomes in the forms of systemic racism, the persistent rate of poverty, unmet basic needs, and social instability. Eighty percent of the homes in the city of Grand Rapids — the largest city in the county — and nearly 60% of homes in Kent County were built before 1978, the year in which lead was banned from paint. KCHD provides Childhood Lead Poisoning Prevention & Case Management services through its Environmental Health and Community Wellness Divisions.

KCHD seeks to establish better channels of communication in the community, develop baseline community knowledge data, and close the gap on health literacy inequities that contribute to the disproportionate rate of childhood lead poisoning on low-income children in Kent County. Through this project period, KCHD worked with community leaders to conduct a community survey to measure awareness of lead exposures, risks, and community resources among Kent County residents.

HiAP Strategies Used & Activities

• Integrating research, evaluation, and data systems
  • Develop and distribute an assessment driven by community members guidance to evaluate community-level knowledge of hazards of lead exposure, risks, and community resources to address lead issues.

• Synchronizing communications and messaging
  • Use community lead assessment results to create synchronized communications and messages for successful outreach and education of target communities.

Achievements

KCHD surpassed its goal of 300 responses and ended up with 997 responses from community residents. The team actively engaged and paid Community Connectors, community members who play a vital role in increasing community knowledge, awareness, resources around COVID-19, mental health, lead poisoning, sexually transmitted infections (STI) and HIV, and other identified adverse health outcomes of COVID-19, throughout the project period. The Community Connectors provide community members with timely updates and credible information in languages and formats that they best understand to maintain and improve community health. The KCHD team worked with Community Connectors for an inclusive data collection, analysis, sharing, and dissemination process. Collaborating with Community Connectors resulted in a more inclusive survey design representing several distinct languages, an equitable partnership, and greater trust between the health department and community residents. To make the survey accessible to residents, the team translated it into seven different languages. Additionally, the survey results revealed key insights for the KCHD team to address the most salient and pressing needs of the community, in addition to identifying key partners to engage in further lead efforts.

Next Steps

The KCHD will disseminate their report back to the 40 Community Connectors to ensure that those who participated in data collection receive the findings. Additionally, the results from the assessment will guide KCHD’s Lead Program to make policy changes to mitigate disproportionate exposure so that every community member can enjoy a safe living environment. KCHD will address gaps in educational and outreach programming that the survey highlighted, as well as engage additional community leaders in education and outreach efforts.

Lessons The Team Learned

Compensating respondents for their time and responses was important to a truly inclusive and equitable data collection approach. Early on in data collection, KCHD received 1200 fake responses from bots which made distributing the gift cards difficult. The team was able to troubleshoot, weed out the fake responses, and provide gift cards to the correct individuals. However, building in safeguards against bots early on would be beneficial next time.

Key Takeaways on Using a HiAP Approach

This project period allowed the team to advance their lead work with improved education and outreach initiatives. The HiAP approach allowed for representative community feedback and input, as well as inclusivity in survey design and languages offered. The HiAP framework allowed the team to think deeply about how they seek input and encourages continuous improvement of the team’s programming.

Acknowledgments

This publication was made possible through cooperative agreement #6NU38OT0003060301 from the Centers for Disease Control and Prevention. The content is solely the responsibility of the author and does not necessarily represent the official views of the CDC/ATSDR.

For more information, contact Rachel Siegel, Senior Program Analyst for Public Health Law & Policy.