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Health Equity Scholars Academy

State: CA Type: Promising Practice Year: 2019

Monterey County, California, has a population of 437,907. Agriculture in Monterey County has an estimated $8 billion annual impact on the local economy, and the surrounding Salinas Valley is known as the Salad Bowl of the World.” Overall, 55% of the population is Hispanic/Latino, 33% are White (not Hispanic), 6% are Asian, 3% are Black/African American, and the remaining 3% are Other with 53% of the population not speaking English at home. Monterey County has a 17% poverty rate, 1 in 3 residents are on Medi-Cal, and 1 in 10 of the county's public school children are homeless. Monterey County Health Department (MCHD) tackles diverse health issues reflective of its diverse population. 

Health equity is a guiding priority and core value of the American Public Health Association.  Health equity means everyone has the opportunity to attain their highest level of health. Inequities have led to disparities in key outcomes (from infant mortality to life expectancy) in the United States and these differences in health status by social and demographic factors have tended to grow larger over the past several decades rather than diminish. Health departments are at the forefront of work to reduce health inequitities. Yet often staff have not had opportunities to consider the history of health inequities in their jurisdiction, learn methods for reducing health inequities as part of their daily work, or provide input on how their health department addresses health inequities. A knowledgeable and engaged workforce is one that can shift systems thinking and work strategically with other sectors to address factors that influence health, from housing to food access.

MCHD's Health Equity Scholars Academy (HESA) seeks to help achieve health equity in Monterey County by transforming MCHD culture. HESA's goal is to build understanding and capacity to advance equity across MCHD's workforce and in the community. Objectives include enhancing the safety and quality of services through training staff in health equity principles; creating collaborative relationships across department sectors to address inequities; and improving staff leadership and their work done in the community at a systemic level to address health inequities. Through a learning environment, staff gain an awareness of one's culture and lived experience and how that affects health.

HESA was implemented in 2014 by the Health Director as part of the 2011-2016 Strategic Plan. HESA supports internal transformative processes through guided classroom dialogue about issues including social determinants of health, cultural inclusion, and structuralized racialization. HESA participants meet once a month over five months to learn about these issues in relation to Monterey County and discuss how to better serve in a culturally sensitive manner. Most importantly, participants brainstorm steps MCHD can take to reduce such inequities and build community capacity.

Given the goals and objectives, the HESA program has been quite successful.  It is a voluntary training, resulting in 105 staff to date participating in a comprehensive five-module course of 20 hours total. Twenty-one percent of participating staff have been managers or supervisors and 79% have been front line staff. Over half of the participants come from MCHD's Public Health Bureau and there has been representation from all seven Bureaus over the four years that the training has been offered. Staff have appreciated the opportunity for dialogues and learning around equity, power, and oppression. HESA's goal of 80% of participants gaining knowledge in health equity has been surpassed for each cohort. In addition, knowledge gained by staff has disseminated across all staff. In a 2017 all staff survey, nearly 75% of MCHD staff members indicated that MCHD is committed to addressing upstream issues, including environmental, social, and economic conditions that affect health. Additionally, approximately three out of four respondents agreed that MCHD has expectations for how staff should work with community members.


In addition, this program at MCHD has facilitated more discussions around racial equity across county departments and HESA components have been incorporated into a new mandatory countywide training on implicit bias. 


A number of factors have led to the success of the HESA program. These include championing of transformative change by senior leadership, building internal infrastructure to develop the training, allocating resources to advance equity, engaging with the community and truly committing to addressing the issues they raised around equity, and building alliances both within and outside the department to protect against naysayers and ensuring accountability. 


HESA has impacted MCHD's public health practice as the majority of staff understand the importance of health equity as part of the department's work and department efforts have begun to impact systems change across the county.


Website for your program, or LHD

MCHD: www.mtyhd.org

HESA website: http://www.co.monterey.ca.us/government/departments-a-h/health/planning-evaluation-and-policy-pep/health-equity-scholars-academy

HESA was developed due to a lack of health and racial equity-specific training at the local level for health department staff. It grew out of discussions between a core group of staff in the health department with other county health departments in California around Health in All Policies and health equity. At the same time, community assessments indicated significant health inequities and the desire by communities for MCHD to work more intentionally on the social determinants of health. Across the United States, there is varying awareness and understanding of how health departments can play a role in improving health inequities, while at the same time there is a need for staff to have a safe space to explore and develop skills to make a greater impact. MCHD leadership saw a need to provide opportunities for staff to engage in dialogue and learning to understand their role and the impacts of power imbalances in how the health department has operated in the past and continues to operate and how to change those power dynamics through a health-focused approach to address health inequities in Monterey County.


The target population was MCHD staff. Staffing at MCHD has grown from 820 in 2014 to over 1,100 in 2018. Currently, the demographics of the county are 56% Latino as are MCHD employees. Eighty-six percent of MCHD staff are non-management.  Non-management staff have different capacities and are tasked to work in community settings, whether home visits from public health nurses to food safety checks by environmental technicians or social group therapy sessions by a behavioral health social worker.  Although, the variety of skills will vary from position to position, the ability to connect and build a sense of trust with community will be similar across settings.  HESA supports staff's learning and processing historical inequities in a setting with other MCHD staff.  This process can support staff's interactions in settings and communities they are not familiar with and be empathetic to inherent barriers individuals in the community have to obtain services.  It is MCHD's goal that the greater  awareness staff have about how culture and lived experience affects health will only improve the work done in our diverse communities.

The goal is for eventually all MCHD staff to be trained through HESA. As of the end of 2018, five cohorts totaling 11% of staff have been trained in HESA. In the past there was no training across the county or within MCHD on racial inequities or health equity. HESA is not mandatory, and interest in taking it is encouraged through relationship building across the Bureaus and incorporating health equity in to other MCHD efforts, including performance measures, quality improvement training, the strategic plan, and all staff surveys. HESA is innovative with a mission training public health workforce leaders to transform the culture of our department to be more intentional in our work around health equity.” The vision of HESA is The Health Equity Scholars Academy explores being active within the context of a systems-oriented approach to enhancing people's status to address health inequalities and injustices in our local communities.” This training is a creative way to help MCHD staff prepare for what they are not familiar with and what is not physically apparent about the individuals in the community they serve. It will only improve the work done in this diverse community when the staff have more awareness about how one's culture and lived experience affects their health. Because the training is open to all employees of the MCHD, participants also expand their understanding other bureaus and how everyone contributes to health equity. Although it covers theoretical concepts, HESA also teaches practical skills to participants to better educate their peers and address local injustices. Overall, HESA aims to empower all Monterey County Health Department employees to affect change in Monterey County.

Recently, in 2018, HESA components were incorporated in to an implicit bias training mandatory for all county staff, into a leadership training classes for MCHD Behavioral Health and Environmental Health Bureaus as further opportunities to gain knowledge in racial and health equity.

Development of the curricula focused on a learning environment and included adapting some modules from two other California counties trainings on the history of public health and application of some online training tools on racial inequities in the United States. Tools used included video segments and learning from Unnatural Causes and Race: The Power of Illusion, and CommonHealth ACTION's Equity Competencies, and Government Alliance on Race and Equity racial equity tools. In addition, the curriculum incorporates learning to support the National Standards for Linguistically Appropriate Services in Health and Health Care, and training tools developed by some of the key leaders in racial inequities and implicit bias.

The goal of Monterey County Health Department's Health Equity Scholars Academy (HESA) is to build understanding and capacity to advance equity across the department and workforce. Objectives include enhancing the safety and quality of services through training staff in health equity principles, through a learning environment whereby staff gain an awareness of one's culture and lived experience and how that affects health; creating collaborative relationships across department sectors to address inequities; and improving staff leadership and their work done in the community at a systemic level to address health inequities. This training helps MCHD staff prepare for what they are not familiar with and what is not physically apparent about the individuals in the community they serve. It will only improve the work done in this diverse community when the staff have more awareness about how one's culture and lived experience affects their health. Because the training is open to all employees of the MCHD, participants also expand their understanding other bureaus and how everyone contributes to health equity. Although it covers theoretical concepts, HESA also teaches practical skills to participants to better educate their peers and address local injustices. Overall, HESA aims to empower all Monterey County Health Department employees to affect change in Monterey County.

Supported by the MCHD's 2011-2015 Strategic Plan, HESA was implemented 2014 by the MCHD's Director of Health. HESA is a five module, four hours per module, class series based on the cohort learning model. Research on racial and health equity theory and practice and components of complimentary trainings was conducted for six months and informed the first offering of HESA. Since implementation, HESA has been offered approximately every eight to ten months.

HESA is open to all MCHD staff. Participants are encouraged to apply through emails out to all staff with applications and deadlines for application provided in the email. An application is utilized in order to communicate with and obtain attendance approval from a participant's supervisor.

During the five-part module training, participants connect with each other to learn about historical context of public health, develop a common language around racial and health equity, discuss privilege and oppression, practice using an equity lens, and develop a commitment to ongoing learning through engagement in a culture of inquiry and discussion.  The five modules cover the following topics (including their associated goals): Module I:  Public Health History, Public Health Systems, Core Functions and 10 Essential Services (define public health, know public health history, describe public health system, list the bureaus of MCHD and their functions, describe and understand three core functions and ten essential services of public health); Module II:  Cultural Competency and Inclusion (increase awareness/appreciation for Monterey County's and MCHD staff's diversity, understand cultural competence and cultural humility); Module III:  Racing to Health (underlying social, economic, and political conditions that disproportionately privilege some groups while disadvantaging others,  structural racialization, safe environment for discussion, identify possible next steps to address structural racialization at the department level); Module IV:  Social and Health Equity (historical and current policies link to social inequities, which link to health inequities, learn how MCHD is taking action and finding solutions); and Module V:  Community Capacity Building (MCHD Community Capacity Building (CCB) projects). The last module of the five-part series focuses on MCHD community capacity building projects and how staff can become more involved in them. For this module, community partners that work specifically on racial equity are brought in to engage with staff about their community projects. Currently, 5 cohorts have taken the HESA training (approximately one cohort every eight months) with over 100 staff participating from across all MCHD Bureaus.  Snacks and breaks are provided during each module, with follow-up readings and encouraging emails keeping participants connected and engaged with each other and the training.  For example, HESA alumni were invited to provide key feedback on pilot sessions for the implicit bias training developed before countywide distribution.    

Also, there was wide cooperation, and subsequent participation, across the MCHD. HESA trainers received input from MCHD leadership and coordinated cohort times with MCHD leadership and staff. The program has been advertised and supported across MCHD's different bureaus. From 2014-2017 77.1% of participants have been line staff and 22.8% have been managers or supervisors. During that same time, the bureau representation has been: 49% Public Health, 21% Behavioral Health, 13% Administration, 8% Clinic Services, 5% Environmental Health, 2% Human Resources, and 2% Public Guardians. These staffing patterns generally match those of MCHD and are process measures that support the goals of the program.

Startup costs and staff time to do ongoing training and module improvements are covered by 0.20 FTE funded through cost allocations to all Bureaus. An MCHD's Planning, Evaluation, and Policy Unit employee implements and coordinates the HESA program. This reflects the County's commitment to the program, its staff, and achieving health equity.

HESA objectives include: enhancing the safety and quality of services through training staff in health equity principles, whereby staff gain an awareness of one's culture and lived experience and how that affects health; creating collaborative relationships across department sectors to address inequities; and improving staff leadership and their work done in the community at a systemic level to address health inequities. Evaluation consists primarily of tracking process measure of attendance by Bureau and staffing level (line staff or manager/supervisor), student satisfaction with the modules through individual module surveys, and outcome measures of numbers of staff completing HESA and a pre/post survey that explores participant's learning. Participant attendance is tracked with an Excel spreadsheet. The HESA coordinator collects and analyzes the data. An MCHD Evaluator has provided input on evaluation design. Data from the surveys are entered into Excel spreadsheets and simple descriptive statistics calculated for each cohort as well as across cohorts.

Participation has generally matched MCHD demographics. From 2014-2017, over 11% of staff have participated and 77.1% of participants have been line staff and 22.8% have been managers or supervisors. During that same time, the bureau representation has been: 49% Public Health, 21% Behavioral Health, 13% Administration, 8% Clinic Services, 5% Environmental Health, 2% Human Resources, and 2% Public Guardians.

Students have been highly satisfied with all modules and have provided input through comments boxes that have been used as part of continuous quality improvement for module delivery and refinement. = Learning has been consistently high across all cohorts.  For example in the last cohort (2017), participants experienced an 89% increase in knowledge about the history of public health and the core functions of public health, and all participants gained an improved understanding of the ten essential public health services. Eighty-nine percent gained an improved understanding of the social determinants of health, health inequities, and health inequities in Monterey County, and what MCHD is doing to address health inequities. And all learned more about the benefits and outcomes of community capacity building.  One participant summed it up by commenting This is an essential training anyone involved in public service should take. I went in not knowing anything about this topic and now I am leaving with a better understanding of the importance of community.”

Participants are asked to share one thing they will do different due to their learnings from each module.  These learnings are shared either in dyad pairs or to the entire group.  In subsequent sessions participants are asked to share their progress of any of their actions or something that they did different due to last sessions learnings.  This is a put it into practice” opportunity that highlights that as individuals staff can shift their personal and professional circles in helping their thinking and potentially work strategically with other units that will have broad impacts on communities they serve.

This learning is spreading across MCHD. The 2017 All Staff Survey showed nearly 75% of MCHD staff members indicated that MCHD is committed to addressing upstream issues, including environmental, social, and economic conditions that affect health. Fewer respondents but still more than half agreed that MCHD partners with community organizations to advance racial equity. Additionally, approximately three out of four respondents agreed that MCHD has expectations for how staff should work with community members.

Evaluation survey responses have been used after each cohort to continue to refine module content and facilitation. Adjustments have included how videos have been used as part of learning and guided questioning process used by the facilitator. As HESA continued from cohort to cohort, some modifications were also made in order to maintain currency and relevancy. For instance, as the national conversation surrounding race grew, the conversation surrounding race in HESA became more in-depth. New videos and items have been added based on student input as well.

The evaluations and ongoing guidance by leadership have contributed to lessons learned. The program was transferred between the developer and a new staff member and the input from participants after the first module with the new staff member led to development of a train-the-trainer approach by a senior staff member in order to support trainer growth and learning for subsequent modules.  Incorporation of health equity into MCHD's 2011-2016 and 2018-2022 strategic plans and the Community Health Improvement Plan has continued to underscore MCHD's commitment to advancing health equity in the county, both for staff and the community, and ensures sustainability of the practice. Further sustainability is supported by the fact that components of HESA have been recently incorporated into a county-wide implicit bias training. In addition, MCHD staff are participating as trainers in this county-wide training and modeling the train-the-trainer methods developed for HESA. Involvement of community partners in the last module of the HESA training also provides impetus for staff to maintain commitment to the process of incorporating a health equity lens in to their work.

Internal learnings have also supported staff completion of the modules.  Simple operational components to the training that contribute to success include providing snacks to help curb student distraction due to hunger. Also, bathroom breaks have been built into the schedule so students do not miss out on module content if they need to use the restroom. Finally, the HESA program manager has begun sending appointment reminders via the calendar function in MCHD's email system to ensure the attendance of all participants (as the month-long gap between module sessions can lead to forgetfulness) and to remind them to coordinate their absence with their supervisor. Community partners are kept engaged by supporting the HESA Coordinator's involvement with community at significant at community meetings HESA Coordinator or attendance at related learning events.

No cost-/benefit analysis of HESA has been conducted, however, using part of an FTE with costs shared across Bureaus is a method to keep training dollars with in the county system, contributing to a sustainability plan where costs and benefits are shared equitably across training recipients. Because of the all-encompassing benefit HESA provides to the MCHD, there is sufficient stakeholder commitment to continue HESA. MCHD leadership supports the rededication of staff's on-the-clock time from their normal duties to HESA training. The investment in MCHD staff members' professional and personal development and growth has been recognized as a factor in job satisfaction. Also, because it is the entire MCHD's goal to achieve health equity, it is cost effective and mutually beneficial to train all bureaus in one setting for the purpose of working towards that goal. The MCHD 2016-2020 Strategic Plan was expanded to include a goal specifically focused on engaging the MCHD workforce in order to improve operational functions to meet current and developing population needs. Also, it has been requested that HESA be expanded beyond the MCHD to include all County staff. This will be mutually beneficial, considering the interdependency of the County's functions and the effects other County operations, policies, and practices have on health equity. In the future, the MCHD hopes to include HESA in all new employee's onboarding and orientation.  County elected have passed a resolution supporting county-wide efforts towards health and racial equity and as such have provided written approval of efforts and thus approve sustainability plans. 

At a NACCHO conference