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Health Equity Training

State: MO Type: Promising Practice Year: 2020

St. Louis County is the 45th largest county in the United States, and the most populous county in Missouri.  St. Louis County has a population of just over 1 million residents and represents 16.2% of Missouri's total population.  St. Louis County's racial demographics are made up of White: 69%; Black/African American: 24%; Asian: 4.2%; Hispanic or Latino: 2.8%. The poverty rate in St. Louis County is 9.8%.

The St. Louis County Department of Public Health (DPH) is a key resource for residents, as it provides the following services: medical, dental, health education, immunizations, lead screening and treatment, nutrition counseling, prescription savings program, sexually transmitted infections services, social services, substance use disorder treatment, Women, Infants & Children Nutrition Program, women's health, and X-Ray services.

DPH provides services to a racially, culturally and socioeconomically diverse population.  Due to its diverse nature, St. Louis County has many social determinants that impact health inequities.   St. Louis County's poverty is concentrated geographically and disproportionately affects African-Americans.  Historically, poverty in St. Louis County has been concentrated in the inner-ring communities of North County.  St. Louis County has identified a 12 year gap in life expectancy between census tracts in North County.  In addition, the Missouri Department of Health and Human Services reported that there are 7.2 asthma emergency department visits per 1,000 population.  Also, 17.57% of Black residents are uninsured compared to 7.18% of White residents (American Community Survey, 2010-2012).

DPH is committed to being a public health leader in the community, and has recognized the need to take steps to address health disparities and inequities.  In an effort to serve County residents with a racially and culturally approach, DPH formed a Health Equity Committee (HEC) and developed a health equity training plan.  One of the HEC initiatives was to develop a department-wide health equity training plan that educates employees about social and demographic factors that affect health including, but not limited to racial equity, LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex and Asexual), cultural competency and health literacy.  This plan seeks to serve as a training guide on creating a culture of health equity.  The training plan is made up of 5 modules, and a separate Managers Module was created and implemented at the launch of the HEC Training Plan.  The Manager's Module is provided to managers and supervisors as an educational tool on the training plan, what to expect, and how to support staff who participate in the HEC Training Plan. 

The two goals for Health Equity training are: 1.) increase new hire and existing staff awareness and understanding of health equity and, 2.) incorporate health equity awareness into job functions to better serve County residents.  The objectives for goal 1 are:  1.) employees will complete health equity training and gain awareness of the health equity definition; 2.) creation of a health equity training curriculum; and 3.) provide ongoing communication to share health equity training materials with DPH staff.  The objectives of goal 2 are: 1.) develop and implement a manager specific training to guide managers to incorporate health equity awareness and language into their programs; and 2. develop all health equity training to ensure Problem Solving” component. 

All training plan objectives have been met, although the committee is still in the progress of launching modules 4 and 5.  After the launch of modules 4 and 5, staff will have had the opportunity to complete all health equity modules.

The factors that have led to the success of the HEC training plan initiative has been ongoing support from DPH leadership, and encouragement of staff to attend the training sessions.  The Manager's Module was a key step in the implementation of the HEC training plan.  This module offers an understanding to the goal of the training plan and why it is necessary.  Managers and supervisors are empowered to support staff in attending the training opportunities and provide follow up support.

The HEC and training plan is a cross-collaboration of DPH staff and divisions.  HEC members provide support for implementation of the modules and to ensure that goals and objectives are being achieved. Regular communication via email has informs staff of upcoming modules and to complete trainings.

In 2017, the HEC Training Plan was recognized as one of NACCHO's Promising Practices.

http://www.stlouisco.com/Health-and-Wellness/About-Your-Department-of-Public-Health

DPH provides services to a racially, culturally and socioeconomically diverse population. Due to its diverse nature, St. Louis County has many social determinants that impact health inequities.   St. Louis County's poverty is concentrated geographically and disproportionately affects African-Americans. Historically, poverty in St. Louis County has been concentrated in the inner-ring communities of North County. St. Louis County has identified a 12 year gap in life expectancy between census tracts in North St. Louis County. In addition, the Missouri Department of Health and Human Services reported that there are 7.2 asthma emergency department visits per 1,000 population. Also, 17.57% of Black residents are uninsured compared to 7.18% of White residents (American Community Survey, 2010-2012).

DPH formed the HEC to cultivate a culture within the department that supports the growth of employees' understanding of health equity in a manner that raises consciousness, stimulates action and improves health outcomes for the community at large.  The department-wide health equity training plan educates employees about social and/or demographic factors that affect health outcomes.  The target population for the training plan are DPH employees, which is approximately 500 people.  To date, more than 70% of DPH employees have attended multiple HEC training modules. 

This was a new initiative within DPH to address health equity and continues to be evaluated for improvements and updates.  The development of the health equity training was creative in that the modules were designed, built and tailored from evidence based curriculums, materials and modules, including: PRIMER, Cultural Competency and Health Literacy guide for health professionals; The Development, Implementation and Assessment of Health Equity Action Training (HEAT): Implications for Local Health Departments; Unnatural Causes: Is Inequality Making Us Sick; and Race: The Power of Illusion.  

The HEC conducted a Health Equity Organizational Assessment for DPH prior to launching the training plan.  The purpose of the assessment was to provide information to guide the process of developing and implementing strategies that: improve awareness of health inequities in St. Louis County; improve skills to address the underlying causes of health inequities in St. Louis County; and cultivate a culture of health equity at DPH.  The HEC discussed preliminary survey results and determined key priority areas in the assessment report.  The report also informed the HEC on strategic priorities and objectives.

The goals and objectives of the training plan are as follows: 1.) increase new hire and existing staff awareness and understanding of Health Equity, and 2.) incorporate Health Equity awareness into our job functions to better serve Saint Louis County.  The following are objectives for goal 1 are: 1.) employees will complete health equity training and gain awareness of the health equity definition; 2.) creation of a Health Equity training plan; and 3.) provide ongoing communication to share health equity training materials with DPH staff.  The objectives for goal 2 are: 1.) develop and implement a manager-specific training to guide managers to incorporate Health Equity awareness and language into their programs; and 2.) develop all Health Equity training to ensure a solutions focused approach.  Revise health Equity training based on trainee and trainer feedback as needed in order to better apply Health Equity concepts on the job. 

To achieve the goals outlined above a subcommittee was formed to develop a training plan. During the planning phase, training modules were developed and reviewed, along with a training plan calendar and recruitment for Health Equity committee members to become trainers to train staff on designated modules.  Meetings were held with external organizations for community collaboration on designated modules.  Staff from the external organizations provided resources and guidance on how HEC members can be trained to in order to provide effective training for DPH staff.  

HEC continues to engage with and cultivate relationships with community partners.  In October and November 2017, PROMO gave the presentation LGBTQIA – Letters and Words- What Do They Mean?”. In May 2018, St. Louis Public Radio hosts of the podcast We Live Here” held a discussion with staff on equity and race in the St. Louis region.  In addition, Alive and Well has been a supporting partner of the Health Equity Initiative. 

The training plan is composed of five separate modules with each module having a different focus on health equity.  The HEC launched the first of five modules in April 2017.   Within the first few months of implementation of module 1, the majority of DPH staff had completed the training.  Module 1: Intro to Health Equity” focuses on becoming familiar with health equity, health inequities; learning the social determinants of health, and at least one place to find data related to them; being able to identify at least three social determinants of health; learning how to think about the relationship between public health and social justice; and increase data literacy.  Training is offered throughout the year.  

In early 2017, an all-staff email was sent about the upcoming health equity training modules and purpose.  Staff received a training plan flyer that included a brief description of the 5 modules.  The email gave instructions on how to sign up for trainings.  To highlight the launch of the training plan, module 1 was implemented during National Public Health Week.  The five modules were delivered in a mixed-method training approach with both classroom and self-study modules.  Modules include discussions, role-play, activities, and videos.  Staff receive emails about upcoming trainings, and additional information about training implementation.

The HEC launched the second module in December 2017, titled Module 2: Seeking Racial Equity.”  Module focuses on how racism relates to public health; identify the differences between institutional/structural racism and interpersonal racism; a discussion on a practice or policy that historically benefitted one race over another; and a candid conversation about race.  Training continues to be offered periodically throughout the year.

The HEC launched the third module in July 2017, titled Module 3: Health Equity & Diversity Self-Study.”  Staff are asked to complete 4 activities in different categories.

The fourth module, titled Module 4: Health Equity & Communication” is expected to launch in February 2020 and will focus on defining intersectionality, acknowledgement of our own bias, and will discuss three strategies to show openness and inclusion of others.

The last module, titled Module 5: Community Strategies” will focus on identifying community based interventions and collaborations, defining and identifying three community strategies to improve health outcomes, and becoming familiar with a causal loop.  The HEC anticipates implementing this training session in the summer of 2020.

The HEC has made great strides since its formation in 2015, including being named a 2017 Promising Practice by NACCHO.  The HEC has accomplished the following within the 2018-2019 year:

  • Created and distributed 2 newsletter issues of Health Watch: Our Journey Towards Equity
  • Planned and implemented activities as part of National Public Health Week, which included a panel discussion that featured community partners and staff, as well as holding Health Equity training.  A Health Equity Open House was held as a way for staff to learn about the HEC, DPH committees, programs and services.
  • In collaboration with the County Executive's Office a focus group was facilitated.
  • As part of the DPH Quality Summit, an Interactive Health Equity Potluck was offered; 47 participants attended.
  • 36 meetings were held in 2018 and 2019, and new staff joined the HEC.
  • Sustained implementation of health equity training modules 1 & 2
  • Introduction of health equity at New Employee Orientation; 48 participants attended.
  • Developed health equity training module 4

There has been no start up or in-kind costs and funding services associated with this practice.




The HEC training plan has been implemented for the past 3 years with a target deadline of December 2020 to complete all 5 training modules.

The following provides the number of staff that have attended each module:

Module 1-Intro to Health Equity

  • 2017-24 sessions with 364 staff completing
  • 2018- 3 sessions with 35 staff completing

Module 2-Seeking Racial Equity

  • 2017-1 session with 26 staff completing
  • 2018-19 sessions and 235 staff completing

Module 3-Health Equity and Diversity

  • 2017-2018 219 staff completed self-study activities

The HEC has implemented a training evaluation in order to quantitatively and qualitatively assess training components, identify aspects in need of improvement, and gather participant feedback. The evaluation reinforces DPH's commitment to creating a culture where health equity is valued.  As part of the evaluation process, participants completed a pre-survey before the training and a post-survey after the training.  The surveys included content based questions to assess participants' baseline knowledge of health equity, as well as knowledge gained after the training; questions about views on the importance of health equity; and opinions on the value of the training.  All responses were anonymous.  Once the surveys were collected, a HEC member analyzed, reported and disseminated the data and survey results.

205 completed pre-surveys and 204 completed post-surveys were collected. 90% of participants found that viewing projects and services through a HE lens, for DPH as a whole, is Extremely Important. 64% of participants found the training to be engaging and informative, and 78% of participants believe that training will have a dramatic or moderate impact on their job.  Survey results did show that there is room for improvement in conveying key concepts regarding terminology, social determinants, and predictors of one's health.

DPH has learned that continuous evaluation of the training modules is key to having a robust health equity training program.   Although there has not been a cost/benefit analysis, there are no current costs to implement the training.   The HEC plans to offer refresher/update sessions for staff on an annual basis to keep staff abreast of current and relevant information regarding health equity.   In addition, the HEC will continue to recruit staff to participate in the HE training, with the support of DPH Leadership.  The training plan is also written up in detail so that the responsibility for implementing and facilitating the trainings does not fall solely on one individual. Currently, there are also multiple individuals able to facilitate the training across multiple DPH sites, creating a broad base for sustainability.

There has been interest from other St. Louis County departments regarding the HEC, and the training plan, to gain a full understanding on the benefits of implementation.   The HEC will continue to engage with other internal and external stakeholders to provide guidance, as they may seek to replicate this model.

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