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Over the past decade, public health research and practice sectors have shifted their focus away from identifying health disparities and toward addressing the social, environmental, and economic determinants of health equity. Given the complex and interrelated nature of these determinants, developing policies that will advance health equity requires collaboration across sectors outside of health. However, engaging various stakeholder groups, tapping into their unique knowledge systems, and identifying common objectives across sectors is difficult and time consuming and can impede collaborative efforts.
The Southwest Health Equity Research Collaborative at Northern Arizona University, in partnership with an 11-member community advisory council, is addressing this need with a joint community-campus effort to develop and implement a Regional Health Equity Survey (RHES) designed to generate an interdisciplinary body of knowledge, which will be used to guide future multisectoral action for improving community health and well-being.
Researchers and community partners used facilitated discussions and free listing techniques to generate survey items. The community partners pilot tested the survey instrument to evaluate its feasibility and duration before survey administration. Respondent-driven sampling was used to ensure that participants included leadership from across all sectors and regions of northern Arizona.
Over the course of 6 months, 206 participants representing 13 sectors across the 5 counties of northern Arizona were recruited to participate in an RHES. Survey response rates, completion percentage, and sector representation were used to assess the effectiveness and feasibility of using a community-engaged apporach for survey development and participant recruitment. The findings describe the current capacity to impact health equity by using a multisectoral approach in northern Arizona.
The Southwest Health Equity Research Collaborative effectively engaged community members to assist with the development and implementation of an RHES aimed at understanding and promoting multisectoral action on the root causes of health inequity. The results will help to build research and evaluation capacity to address the social, economic, and environmental conditions of health inequity in the region.
Over recent decades, eliminating health disparities has been a major focus of public health efforts in the United States [
In 2013, the Robert Wood Johnson Foundation launched a nationwide health equity effort called the
The barriers to effective action on health equity may be due, in part, to a lack of intersectoral collaboration and consensus on how to identify and overcome the root causes of health inequity, which is defined as the underlying social, economic, and environmental inequalities that create different living conditions among and between populations. A multisectoral approach (MSA) to addressing health equity refers to “deliberate collaboration among various stakeholder groups and sectors (eg, public health, transportation, education, criminal justice) to jointly achieve a policy outcome” [
A major contributor to the lack of successful cross-sectoral collaboration is the problematic perception that addressing issues related to health equity is the sole responsibility of those working in health-related fields [
To address this fundamental issue, we describe the community-engaged development and implementation of the Northern Arizona University (NAU), Southwest Health Equity Research Collaborative’s (SHERC) Regional Health Equity Survey (RHES) [
The SHERC is a National Institute of Health–funded Research Centers in Minority Institution (RCMI) initiative of the Center for Health Equity Research (CHER) at NAU. The overall goal of the SHERC is to increase basic biomedical, clinical, and behavioral research at NAU to address health disparities among diverse populations of the southwestern United States. The SHERC consists of 5 cores that interact synergistically: administration, investigator development, recruitment, research infrastructure, and community engagement. This paper focuses on the community engagement core’s (CEC) efforts to address collaborative engagement in health equity in northern Arizona.
The CEC endeavors to cultivate and sustain productive collaborations and partnerships with community-based organizations and leaders in meaningful ways that foster awareness and participation in health equity research. Broadly, the CEC is guided by the
The main objective of the CEC is to engage community-based organizations, community leaders, policy experts, and researchers from various sectors, including childhood development, education, criminal justice, public health, and policy, to (1) identify commonalities in health trends and social, structural, and environmental factors that contribute to health inequity and (2) understand and strengthen organizational capacity to address locally identified health equity issues using an MSA. A primary step in defining public health priorities and understanding the community’s current capacity to impact health inequities is through the systematic collection of information [
As a newly established research center, CHER took the first step to better understand public health priorities in 2017 through a collaboration with regional partners, which produced the groundbreaking Regional Health Equity Assessment (RHEA) [
Geographically positioned atop the Colorado Plateau, the northern Arizona region covers more than 6000 square miles of land; is home to 12 federally recognized American Indian tribes; and comprises the following 5 counties: Apache, Coconino, Mohave, Navajo, and Yavapai (
Map of northern Arizona counties.
Given the diversity of the northern Arizona region, it is crucial that any initiatives addressing health inequity be community driven. Community advisory councils (CACs) can benefit research institutions by ensuring that the research agenda aligns with priorities that are salient within the community. In addition to providing their unique perspectives and expertise to guide the development of research projects, CAC members can help to bridge gaps and build trust between the community and the research institution [
The initial stage of the survey development occurred in April 2018 with a half-day, in-person survey workshop between personally, professionally, and geographically diverse members of the CAC and the CEC. The RHES workshop was guided by meaningful learning theory and popular education techniques, which acknowledge that adult learners integrate new knowledge into what is already known and create a cognitive structure to make sense of their surroundings and situations [
Community advisory council free-listing activity.
The survey questions underwent 2 rounds of edits by CAC members, SHERC project staff, and SHERC research leadership. The final RHES is composed of 48 open- and closed-ended questions covering topics including, but not limited to, the extent and focus of the current cross-sectoral partnerships, priority areas for future research, and the use of data in decision making. To aid participants in completing the survey, the CEC added a glossary of definitions and examples of major public health concepts such as
The population of interest for the RHES included community, organizational, and grassroots leaders from the 5 aforementioned northern Arizona counties. In line with the Vitalyst Health Foundation’s elements of a healthy community [
A 3-pronged approach was used to identify potential participants for the RHES. First, extensive internet searches were conducted to identify individuals in positions of leadership across sectors and counties of northern Arizona. Second, the CAC members nominated leaders from their regions and sectors. Finally, the CEC staff presented the RHES and circulated RHES sign-up sheets at county-level leadership meetings attended by the target population. Attendees were encouraged to add the names of sector leaders who were not present at the meeting. All potential participants’ names were compiled, duplicate names were removed, and county-level participant lists were generated for each sector. Before administering the RHES, at least two county champions (eg, assistant county manager and local public health director) vetted each county’s list, removing names of individuals who were no longer in their positions and filing in gaps in sectors where there was no representation.
Once participant lists were finalized, introductory emails were sent by the county champions, alerting all potential participants of the RHES, followed by a personalized email with links to the survey 1 day after the introductory emails were sent. Participants received 2 reminder emails 2 and 4 weeks after the initial invitation. All respondents were offered a US $25 gift card as compensation for their participation.
Regional Health Equity Survey development and implementation flow chart. CAC: community advisory council.
All descriptive statistics were analyzed using IBM SPSS (version 26). Depending on the responses, qualitative data from open-ended questions were analyzed using either a priori coding or emergent coding and a thematic analysis approach (ATLAS.ti 8, Scientific Software Development GmbH). The Vitalyst Health Foundation’s elements of a healthy community [
The development and implementation of the RHES were reviewed and deemed nonhuman subjects research by the NAU’s institutional review board (project number: 1198096-1).
A total of 206 of the 560 invited multisectoral representatives (response rate 37%) from northern Arizona participated in the RHES. Of those who participated, 64.1% (132/206) completed the entire survey, whereas 27.6% (57/206) answered 30% or less of the survey questions.
Although there was a relatively equal distribution across genders with all counties combined (female: 69/129, 53.4%; male 56/129, 43.4%), there was very little ethno-racial diversity, as most of the respondents identified as White (108/129, 83.7%). Survey results indicated that respondents were well established in their sectors (
Half of the participants (102/204, 50%) held government positions at the federal, state, county, and municipality levels, and approximately one-third of respondents (45/135, 33%) said that they had an active role or were the primary decision maker within their organization. The reported leadership positions of participants included, but were not limited to, county managers and department directors, chief of police, superintendents, presidents, chief executive officers, and executive directors. Most participants reported either working directly with community members (154/192, 80%) or supervising staff who worked directly with community members (140/192, 73%).
Participant demographics by county.
Characteristics | County | ||||||
|
Apache (n=8) | Coconino (n=94) | Mohave (n=34) | Navajo (n=28) | Yavapai (n=42) | Total (N=206) | |
|
|||||||
|
Female | 1 (13) | 20 (21) | 16 (47) | 8 (29) | 24 (57) | 69 (53) |
|
Male | 4 (50) | 26 (28) | 7 (21) | 11 (39) | 8 (19) | 56 (43) |
|
Other | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 1 (2) | 1 (1) |
|
No answer | 0 (0) | 1 (1) | 0 (0) | 2 (7) | 0 (0) | 3 (2) |
|
|||||||
|
American Indian or Alaskan Native | 0 (0) | 2 (2) | 0 (0) | 1 (4) | 0 (0) | 3 (2) |
|
Asian or Pacific Islander | 0 (0) | 0 (0) | 1 (3) | 0 (0) | 0 (0) | 1 (1) |
|
Black or African American | 0 (0) | 3 (3) | 0 (0) | 0 (0) | 0 (0) | 3 (2) |
|
Hispanic or Latino | 0 (0) | 2 (2) | 0 (0) | 0 (0) | 4 (10) | 6 (5) |
|
White | 5 (62) | 40 (43) | 19 (56) | 17 (61) | 27 (64) | 108 (84) |
|
Other | 0 (0) | 0 (0) | 1 (3) | 0 (0) | 2 (5) | 3 (2) |
|
No answer | 0 (0) | 0 (0) | 2 (6) | 3 (11) | 0 (0) | 5 (4) |
Age (years), mean (SD) | 52.6 (5.9) | 45.8 (10.1) | 52.7 (11.1) | 50.9 (9.7) | 49.4 (14.4) | 49 (11.6) | |
Position time (months), mean (SD) | 21.1 (15.6) | 58.1 (71.9) | 79.8 (78.5) | 69.9 (59.2) | 65.4 (77.2) | 63.7 (71.7) | |
Sector time (months), mean (SD) | 91.1 (87) | 192.4 (116.2) | 233.6 (147.3) | 480 (199.6) | 204.2 (150.8) | 199.4 (133.3) |
In some of the less populated counties, individuals may be responsible for leading multiple departments; thus, participants could identify with more than one sector. Of the respondents, approximately 71.8% (148/206) identified with only 1 sector. Although there was representation from all 13 sectors, most participants identified in part with either
Distribution of participants by county and self-identified sector.
Participant self-identified sector | County | |||||
|
Apache (n=8), n (%) | Coconino (n=94), n (%) | Mohave (n=34), n (%) | Navajo (n=28), n (%) | Yavapai (n=42), n (%) | Total (N=206), n (%) |
Health and human services | 2 (25) | 42 (45) | 14 (41) | 11 (4) | 26 (62) | 95 (46) |
Education | 1 (13) | 18 (19) | 11 (32) | 7 (25) | 11 (26) | 48 (23) |
Community and economic development | 1 (13) | 13 (14) | 7 (21) | 6 (21) | 7 (17) | 34 (17) |
Law, justice, and public safety | 2 (25) | 21 (22) | 0 (0) | 5 (18) | 6 (14) | 34 (17) |
Policy | 1 (13) | 13 (14) | 3 (9) | 1 (4) | 7 (17) | 25 (12) |
Housing | 0 (0) | 11 (12) | 1 (3) | 2 (7) | 4 (10) | 18 (9) |
Transportation | 1 (13) | 6 (6) | 3 (9) | 3 (11) | 4 (10) | 17 (8) |
Food systems | 1 (13) | 1 (1) | 6 (18) | 1 (4) | 4 (10) | 13 (6) |
Early childhood development | 0 (0) | 4 (4) | 4 (12) | 1 (4) | 3 (7) | 12 (6) |
Parks and recreation | 1 (13) | 4 (4) | 2 (6) | 3 (11) | 1 (2) | 11 (5) |
Planning and zoning | 1 (13) | 6 (6) | 0 (0) | 1 (4) | 1 (2) | 9 (4) |
Arts, music, and culture | 1 (13) | 3 (3) | 1 (3) | 1 (4) | 0 (0) | 6 (3) |
Cultural resource management | 1 (13) | 1 (1) | 0 (0) | 2 (7) | 1 (2) | 5 (2) |
The most frequently cited characteristics for developing a successful multisectoral partnership were communication, shared vision, and trust
Extent of cross-sectoral collaborations on health equity issues.
To examine how research can effectively influence health equity in northern Arizona, participants were asked, “What role do you think research has in addressing the environmental, social, and economic conditions that impact health in the community you serve?” Most leaders asserted that research plays a significant role in addressing the root causes of health inequity, whereas very few participants felt the role of research was
Economic opportunities: Poverty, disparities in income, job opportunity and lack of higher wage jobs, workforce development, economic development, and economic indicators
Health care: Access, affordability, and quality of health services and health plan coverage; long distances people must travel to seek care; and understaffing and difficulty attracting and retaining health care professionals, especially in rural areas
Behavioral health: Access to mental health and substance use services, including drug addiction, rehabilitation; addressing stigma related to mental health and substance use
Education: Educational opportunities from kindergarten through high school through higher education, affordability, and funding
Transportation: Access, affordability, and adequacy
Housing: Access, affordability, and homelessness
Food: Access, food security, and quality or healthy foods
Early childhood: Early childhood education and youth development
Social context: Social context around health inequities, understanding issues around culture, stigma related to health conditions, and social activities
Social justice: Effects of incarceration, historical trauma, and social justice in relation to other social determinants of health
Environment: Climate change
Tribal communities: Funding, focus and effectiveness of Indian Health Services, health care options on the reservation, and impact of native American culture on health maintenance
Rural communities: Access to services based on unique challenges experienced by rural communities
Aging and older people: Access to services
Data-informed health promotion is an emerging and ever-changing theme in public health research and practice. To examine the current data use across sectors, leaders were asked how often they used data to make decisions and what barriers they faced in the process. Across all leaders, 93.3% (126/135) reported having used data to make decisions; however, there exists a gap between how often data are currently used and how often leaders would ideally use data to guide their decision making (
Use of data for decision making.
In this paper, we describe how the SHERC at NAU effectively engaged community members to assist in the development and implementation of the RHES, with the goal of understanding and promoting multisectoral action on the root causes of health inequity in northern Arizona. Furthermore, we demonstrate how over 200 county-level leaders from various sectors, beyond public health and health care, were recruited to share their knowledge, attitudes, and actions to address the social, environmental, and economic conditions that impact health and well-being in the region.
Overall, our work revealed that using a community-engaged approach to survey local leadership can be an effective first step toward identifying and prioritizing areas of action on the root causes of health inequity. Specifically, using a community-engaged approach to develop and implement the RHES ensured that (1) survey questions resonated with community priorities and (2) respondents were recognized as representatives of their community. With participation across all sectors and counties of interest (
This study also exposes the benefits and challenges of developing and implementing cross-sectoral partnerships to address health inequities. Although collaboration with governmental and nongovernmental sectors outside of health is required to develop policies and programs to advance health equity, establishing and maintaining effective cross-sectoral partnerships is not an easy task [
Findings from this study suggest that county-level leaders in northern Arizona are currently working across sectors to address the root causes of health inequity; however, the extent to which they partner is limited, and the issues being addressed are bounded and unbalanced (
Results from the RHES further indicated that data-driven decision making is highly valued among participating leaders, but most found data to be outdated or unavailable or they worked in an environment in which expertise to analyze data was lacking. Lack of access to health-related data is particularly salient in rural areas, such as northern Arizona [
Finally, this study illustrated the potential utility of using a baseline assessment of organizational leaders to start a productive dialog on the various and unique ways in which each sector (eg, housing, transportation, justice, economic development, education, arts, and culture) can strengthen the health and well-being of their community. Following the Bay Area Regional Health Inequities Initiative framework [
Although a community-engaged approach to survey development for health disparities research has clear benefits [
Without a clear consensus on the root causes of health equity and greater cross-sectoral collaboration, the development of effective policy and practice objectives aimed at reducing health disparities and improving health equity will be limited [
community advisory council
community engagement core
Center for Health Equity Research
multisectoral approach
Northern Arizona University
Research Centers in Minority Institution
Regional Health Equity Assessment
Regional Health Equity Survey
social determinants of health
Southwest Health Equity Research Collaborative
Numerous people made significant contributions to the development and implementation of the work documented in this paper. In particular, the authors would like to thank the following members of our CAC: Amanda Guay, Emma Torres, Chelsey Donohoo, Emily Davalos, Candida Hunter, Stephen Julian, Mare Schumacher, Joyce Hamilton, Diana Gomez, Eric Wolverton, and Shepard Tsosie. This work was financially supported by the National Institute of Health (grant 1U54MD012388).
None declared.