NACCHO HiAP Report Experiences from Local Health Departments Feb 2017

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1 in ALL HEALTH Policies Experiences from Local Health Departments WWW.NACCHO.ORG FEBRUARY 201 7

2 ACKNOWLEDGEMENTS This document was made possible through cooperative agreement 5UE2EH000956-05 between the Centers for Disease Control and Prevention and the National Association of County and City Health Officials. The content and methods used to develop this document are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. NACCHO would like to thank all of the listening session and key informant participants for taking the time to speak with us and providing their thoughtful comments based on their Health in All Policies (HiAP) experience. LISTENING SESSION AND KEY INFORMANT DISCUSSION PARTICIPANTS Janis Sayer Chicago Public Health Department, IL Jennifer Herd Chicago Public Health Department, IL Chicago Public Health Department, IL Jamie Dircksen Marie Curry Community Legal Aid Services, OH Monterey County Health Department, CA La’Quana Williams Monterey County Health Department, CA Krista D. Hanni Carmen Gil Monterey County Health Department, CA Monterey County Health Department, CA Patricia Zerounian Boston Public Health, MA Lisa Conely Carolyn Link Blue Cross Foundation Minnesota, MN Kristian Blessington Florida Department of Health - Sarasota County Geordie Smith Florida Department of Health - Lee County Richard Kirkwood Florida Department of Health - Lee County Ashley Caraccio Florida Department of Health - Pinellas County Jocelyn Howard Florida Department of Health - Pinellas County Megan Carmichael Florida Department of Health - Pinellas Countyy Allison Nguyen Florida Department of Health - Hillsborough County Beth Altshuler Raimi+Associates NACCHO would also like to thank the reviewers and contributors for providing feedback and direction during the report development. REVIEWERS Dr. Sandra Whitehead, National Environmental Health Association; Dr. Patricia Cummings, Harris County Public Health; Dr. Anneta Arno, DC Department of Health; and Nancy Goff, Consultant CONTRIBUTORS rm with expertise in urban and regional NACCHO hired Raimi + Associates, a nationally recognized consulting fi planning and Health in All Polices, to assist in conducting the qualitative analysis and to help with writing the report. Raimi + Associates analyzed the audio recordings and notes for themes, findings, and key quotations. NACCHO would like to thank Raimi + Associates for their support developing the findings of this report. NACCHO and staff that contributed to this report include Jennifer Li , Bridget Kerne r, Tiffany Huang. 2 Experiences from Local Health Departments Health in All Policies:

3 Contents EXECUTIVE SUMMARY ... 4 7 ... INTRODUCTION ... 8 Background 10 ... U.S. HiAP Context . ... 13 Methods 14 ... Summary of Findings ... 15 THEME 1. PARTNERSHIPS AND COLLABORATIONS 15 ... Community engagement is important for HiAP ... 16 Partnerships across government agencies and departments is fundamental for HiAP ... 18 Co-benefits help ensure investment in the success of HiAP across local government . 18 ... Formalness of cross-sector collaborations varies widely and may evolve over time. ... 22 THEME 2. WINDOWS OF OPPORTUNITY AND OPENINGS FOR INTERSECTORAL COLLABORATION ... 23 Local health departments are working to align efforts across government to accomplish shared goals 26 ... THEME 3. BUILDING CAPACITY FOR HIAP ... 26 HiAP provides multiple opportunities to redefine possible ways to impact health 27 ... Local health departments are working to increase understanding of how to implement HiAP within local government 28 ... THEME 4. EMBEDDING AND SUSTAINING A FRAMEWORK FOR CHANGE ... 28 Define how cross sector collaborations will move forward together is an essential step for HiAP Supportive administrative and political leaders are important for securing resources and helping to ... 30 define a vision for HiAP 30 ... HiAP initiatives can be a way to uncover and discuss health inequities Local jurisdictions are interested or are working towards adopting local ordinances or resolutions to ... 31 institutionalize HiAP ... 31 Local jurisdictions need to determine whether HiAP initiatives are effective at improving health ... 35 THEME 5. CHALLENGES TO IMPLEMENTATION ... 35 Local initiatives are challenged by limited resources and funding ... 37 Local health departments need more evidence of tangible outcomes and assistance in communicating about HiAP ... 37 Local health departments describe challenges with evaluating HiAP initiatives ... 40 MOVING FORWARD 40 ... Key findings from assessment ... 41 Promising HiAP strategies ... 42 Recommendations for supporting HiAP in local jurisdictions 42 ... Report limitations TABLES ... 10 Examples of HiAP initiatives across the United States ... 17 Reflections on cross-sector partnerships ... 20 Potential stakeholders to engage in HiAP ... 29 HiAP initiatives at local jurisdictions ... 32 Questions for identifying key assets to implement HiAP among cross-sector partners 33 ... Methods for measuring success of HiAP initiatives ... 36 Reflections on challenges with limited resources and funding to implement HiAP ... 38 Reflections on challenges with data and evaluation of HiAP initiatives FIGURES ... 9, 51 Graph depicting search results for “Health in All Policies” ... 13 Professional affiliation of listening session participants REFERENCES ... 45 Appendix 1: Listening session and key informant questions ... 46 Appendix 2: List of useful tools and resources ... 51 Appendix 3: Health in All Policies literature review

4 Executive Summary What is Health in All Policies? Five themes identified through the Local health departments (LHDs) have been qualitative assessment: working to affect the conditions in which people Theme 1 live, learn, work, and play that have positive Partnerships and collaborations are the impacts on community health. Health outcomes, cornerstone of HiAP. Partnerships across such as differences in life expectancy by race government agencies and departments promote or ethnicity, are the result of a confluence of the routine integration of health into policies and social, environmental, and behavioral factors the creation of structures and processes across simultaneously operating at different scales. These sectors necessary to support institutionalization. complex issues rarely have a singular solution Community engagement is critical for gaining the that can be implemented by one sector or perspectives of populations that are most impacted government agency. Health in All Policies (HiAP) by changes in policies and planning projects. is a framework for considering health in processes and decisions throughout government, and developing mechanisms that institutionalize these conditions. The National Association of County Theme 2 and City Health Officials (NACCHO) defines HiAP present possibilities Windows of opportunity as a “change in systems that determine how for intersectoral collaboration for health. This decisions are made and implemented by local, opportunistic approach focuses on identifying state, and federal governments to ensure that policy issues, policies, plans, or projects that can provide decisions have neutral or beneficial impacts on venues for cross-sector partners to work together 1 health determinants.” Across the country, health towards shared goals. departments have implemented HiAP to achieve health goals by working with cross-sector partners and engaging community members. Theme 3 is essential for HiAP practice Building capacity As a new and emerging field within the at local health departments. Cross-sector United States, HiAP poses both a challenge collaboration requires understanding how to and an opportunity for local governments work with partners across sectors and explicitly eager to tackle complicated health problems. HiAP incorporate health in sectors and policy arenas that is driven heavily by local context, and successful did not previously. initiatives in one place may not work in another. The absence of a step by step for implementing HiAP creates ambiguity for implementation Theme 4 and difficulty in communicating its outcomes or justifying the allocation of resources towards Embedding and sustaining a framework for these initiatives. However, HiAP also presents an requires integrating new ways of thinking change opportunity since community stakeholders and and culture shifts in how public agencies operate local governments have influence in defining locally and work together. Participants have expressed based and relevant solutions to priority concerns. different levels of comfort and familiarity with how to do this depending on their experience with Information identifying how, where, and with what HiAP and other cross-sector collaborations. success local governments have implemented HiAP is needed so that successes and best practices can be shared. In order to document current HiAP Theme 5 practice, NACCHO conducted listening sessions and key informant discussions with local health challenges Many inhibit health officials’ attempts officials leading or implementing such initiatives to implement HiAP. Challenges stem from the and partner organizations to capture the state difficulties associated with the nebulous and of HiAP practice at LHDs in the United States. undefined nature of HiAP practice and the variety of This report provides the results of the qualitative ways localities have implemented HiAP initiatives. assessment, along with best practices and recommendations for future research and practice. Experiences from Local Health Departments 4 Health in All Policies:

5 continued Executive Summary Key findings from qualitative assessment Promising HiAP strategies There is wide variation in the process, • New framework for public health. A new framework for public structure, and scope of local HiAP health practice, encapsulated by HiAP, represents a culture shift away from pursuing independent, topic-based, siloed interests to working initiatives across the country. While HiAP collaboratively across government to achieve common goals. in the United States is still in its formative stage and there is not a formal set of best Multiple models for HiAP implementation. HiAP requires an • practices to-date, local health officials understanding of the dynamic political landscape operating within are already pointing to the importance localities and a willingness to be flexible and responsive to local context of developing strong foundation for and community needs. Wide variations in HiAP initiatives exist, spanning practice. Listening session and key different levels of formality and scale. informant participants identified the following promising strategies: HiAP is a new and emerging field. • Many local HiAP initiatives are still very new, and participants express their struggle with how to intervene Start small. • HiAP is a process and an in complex and dynamic political systems. Education and training on investment in long-term outcomes. community health and how to work together to impact it are crucial for Setting achievable, scalable goals HiAP and can help to articulate the need for and rationale behind HiAP. provides partners with the flexibility to test ideas and evaluate outcomes. It is • Windows of opportunity are openings for collaborations. important for local health officials to Participants describe the need to be ready to take advantage of “window of start somewhere, no matter how small. opportunity” to engage in intersectoral collaboration for health. They also The work needs to take place across discuss uncertainty with how to progress with working across sectors. multiple fronts for HiAP efforts to be successful. While progress is neither Cross-sector partnerships and community engagement are • linear nor uniform, it is important to Community engagement and cross-sector essential for HiAP. establish a solid framework for scaling collaborations are essential to HiAP initiatives. Many participants are up future work across institutions exploring how to improve and build relationships with community and diverse communities. One of the groups or other public agencies and departments. Leading with co- biggest hurdles faced by participants benefits can increase investment in joint work and ensure the success is acknowledging that there is no of HiAP initiatives. “one-size-fits-all” approach and that HiAP efforts must be adaptive • The support of Cultivating leadership to champion HiAP. and responsive to local context and administrative and political leadership can assist with securing needed community needs. resources and articulating a vision of success. Changes in leadership can also hinder HiAP initiatives by disrupting momentum or changing the • Find champions at partner direction of the work. agencies or departments. Finding strong champions at • Participants consistently articulated Data and measuring success. partner organizations and making a the need to demonstrate the value of HiAP and how best to measure commitment to building trust can success. They also identified several challenges to understanding if fortify the organizational capacity and initiatives are accomplishing goals and whether health is improving or long-term sustainability of initiatives. worsening. Notable challenges include difficulty in measuring changes The process of building HiAP is in policies and government processes, lags in data collection, and fundamentally based on cross-sector barriers to creating a data-driven culture. partnership; local health officials Challenges. As a new and growing field, many challenges were • consistently noted that building identified in the implementation of HiAP, including limited resources, these relationships with cross-sector staff capacity, and needed funding and other resources to support champions strengthened the work. efforts. Participants struggle with how to evaluate and communicate the Develop measurements for • importance of building partnerships, which is central to HiAP work, and success. The ability to evaluate other outcomes that are difficult to measure. changes in health determinants and outcomes can serve as a powerful tool to guide priorities. 5 Experiences from Local Health Departments Health in All Policies:

6 Executive Summary continued Understanding how to measure systems change and Recommendations for supporting changes in outcomes are important for knowing HiAP in local jurisdictions whether progress is being made toward shared Listening session and key informant participants goals. The primary questions for most participants identified the following priorities to continue improving are what to measure and how. Local health officials HiAP at the local level: have used creative approaches to collecting data such as tracking the level of collaboration among Research. • More research is needed to evaluate cross sector partners over a specified time period, changes in health determinants and outcomes or tracking requests for the technical assistance from HiAP initiatives using both qualitative and from cross sector agencies. Considering meaningful quantitative data. Evaluation can help to demonstrate indicators of progress can strategically inform the impact of HiAP and the ability to improve health approaches and increase access to funding, support, in the short and long term. and other resources. Capacity building is a Developing the field. • Investing the time Prepare for the unexpected. • great need of the field. Trainings should focus on to prepare for unknown future circumstances is why HiAP is needed and include more specific important for success in HiAP. Participants identified topics, such as how to engage with cross-sector challenges with staff and leadership turnover and partners and determining potential strategies for working with limited capacity and resources, which implementation. Case studies can be used to share was prevalent in local government. While planning information on how HiAP initiatives have been for all contingencies is impossible, it is important to successfully implemented and how such initiatives consider ways to alleviate potential losses. HiAP can might be tailored to different jurisdictions. be an approach to mitigate potential risks of limited capacity and resources by facilitating the shared use Health equity. • The achievement of health equity of limited resources across agencies. is a central tenet for HiAP practice. HiAP initiatives should continue to elevate differential neighborhood Organizational integration and • conditions and unjust inequities in the distribution of One strategy for embedding institutionalization. health determinants and health outcomes. HiAP into current processes is to include integrating HiAP functions in job descriptions and develop an • Many Expanding outside of built environment. institutional home for cross-sector collaborations, early HiAP initiatives were focused on improving such as interagency councils or taskforces. community design and built environments. Dedicating staff to HiAP initiatives ensures support Opportunities also exist across multiple policy for collaborative efforts through administration, domains to improve health. Examples of other policy reporting, and communication support. Additional domains include criminal justice system, economic efforts can be implemented to formalize or development, and housing. institutionalize the work, such as the adoption of Creating opportunities to share success and • local ordinances, executive orders, and resolutions. Around the country, interest in HiAP challenges. is growing. Despite the wide variety of HiAP efforts at the local level across the country, local health This document was made possible through officials must share findings, successes, challenges, cooperative agreement 5UE2EH000956-05 stories, and lessons learned to continue to grow the between the Centers for Disease Control and Prevention and the National Association field. Experiences implementing HiAP can be shared of County and City Health Officials. The through conferences, webinars, and group calls. content and and methods used are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. References For more information, please contact NACCHO’s 1. NACCHO. (2015). Statement of Policy: Health in All Healthy Community Design team at Policies. Retrieved from http://www.naccho.org/uploads/ [email protected] or visit our website at downloadable-resources/Programs/Community- http://www.naccho.org/programs/community-health/ Health/12-01-health-in-all-policies.pdf healthy-community-design 6 Experiences from Local Health Departments Health in All Policies:

7 Introduction Growing evidence on the social determinants of health has found the conditions in which people live, learn, work, and play contribute to their overall health and well-being. The World Health Organization (WHO) defines health as “the state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. This means that health is more than being free of disease or not feeling sick; it is also a state of physical, mental, and social well-being. 1 In the United States, This state can bring about such feelings as happiness, contentment, and security.” while an estimated 96% of health expenditures are directed toward health care, access to health care only accounts for 10% of a person’s health. Conversely, the environment and personal behavior, which is directly influenced by environmental conditions, account for nearly 70% of what determines a person’s 2,3 Unfortunately, many Americans do not live and work in communities that were designed with health. health in mind. This explains some of why certain Americans are healthier than others and why Americans generally are not as healthy as they could be. For example, Healthy People 2020 states that “a lack of options for healthy, affordable food or safe places to play in some neighborhoods makes it nearly impossible for residents to make healthy choices. In contrast, people living in neighborhoods with safe parks, good 4 schools, and high employment rates are provided with some of the key requirements to better health.” i AP H SOCIAL DETERMINANTS OF HEALTH NACCHO defines HiAP as a change in the system that The social determinants of health are “the structural determinants and determines how decisions are made and implemented conditions in which people are born, by local, state, and federal governments to ensure that 5 grow, live, work and age.” policy decisions have neutral or beneficial impacts on 6 health determinants. To address the social determinants of health, some communities have adopted a HiAP approach to decision making. HiAP provides a systematic way to address important factors that determine health: environment and behavior. By considering health in governmental operations and policy decisions, communities have the opportunity to improve health outcomes. HiAP explicitly recognizes that health and wellbeing are largely influenced by measures that are often managed by non-health department government agencies. In this vein, a HiAP approach focuses on changing systems of decision-making, rather than changing a single decision. Experiences from Local Health Departments 7 Health in All Policies:

8 Background of HiAP Practice The Rise 2011 2010 10 health ministers in South Australia hosts southeast Europe the Adelaide 2010 endorse HiAP in International Meeting The Banja Luka Pledge. on Health in All Policies. Adelaide Statement CDC funding opportunity on Health in All Policies announcement on is published. 2013 HiAP for five-year 2015 The Association of State cooperative agreement. California establishes and Territorial Health American Public nation's first statewide Officials adopts policy Health Association HiAP is endorsed in Health in All Policies Task statements on HiAP. dedicates its annual the Rio Political Force through an 1999 meeting to HiAP. Declaration on Social executive order. Gase et al. publish Determinants of Health. HiAP alluded to in an 2012 foundational review Vermont Executive Creation of the National European Union (EU) 2006 of emerging practices NACCHO Order No. 7–15 HiAP policies adopted Prevention, Health council resolution “to used to implement adopts establishes HiAP HiAP launched in several major U.S. Promotion, and Public ensure health protection HiAP in the HiAP policy Interagency more specifically cities and local health Health Council (National in all policies and 8 9 United States. statement. Task Force in the EU. departments. Prevention Council). activities of the EU.” Public health literature has identified seven interrelated strategies for incorporating HiAP into decisions and systems: (1) developing and structuring cross-sector relationships; (2) incorporating health into decision-making processes; (3) enhancing workforce capacity; (4) coordinating funding and investments; (5) integrating research, evaluation, and data 7, 8 systems; (6) synchronizing communications and messaging; and (7) implementing accountability structures. STRATEGIES These seven strategies ensure that policies and services Develop and for Implementing Health in All Policies 7 Structure from all sectors have beneficial or neutral impacts on the Cross-Sector Relationships determinants of health. Ensuring that health is considered Enhance Implement Workforce Accountability in the policy formulation process creates opportunities for Capacity Structures Synchronize Communications policy decisions to achieve the non-health agency mission and 7 Messaging and minimize or improve the policy’s impact on health. Integrate Incorporate Research, Health into Evaluation, and Decision-Making Data Systems Processes Coordinate Across the United States, local health departments have begun Funding and implementing the seven HiAP strategies to achieve their public health goals. investments However, data identifying how, where, and with what success health departments are implementing HiAP is needed to document successes and best practices. To document current HiAP initiatives, NAC- CHO conducted listening sessions and key informant discussions with local health officials leading or implementing such initiatives and partner organizations to capture the state of HiAP practice at LHDs in the United States. This report pro- vides the results of that qualitative assessment, along with best practices and recommendations for future research and practice. Because HiAP is still an emerging practice at health departments, more work is needed to track current HiAP initiatives, and evaluate the impact of HiAP on decision-making and, ultimately, community health outcomes. Experiences from Local Health Departments 8 Health in All Policies:

9 Background continued Over the last decade, HiAP has flourished by providing strategic approaches for embedding health in decision-making across non-health sectors. The increasing trend over time can be seen using search results from the PubMed database for of HiAP Practice The Rise the term “health in all policies,” as illustrated in Figure 1. 2011 2010 Number of search results by year for “Health in All Policies” in PubMed, through August 31, 2015 FIGURE 1. 10 health ministers in South Australia hosts southeast Europe the Adelaide 2010 endorse HiAP in International Meeting 30 The Banja Luka Pledge. on Health in All Policies. Adelaide Statement CDC funding opportunity on Health in All Policies announcement on is published. 25 2013 HiAP for five-year 2015 The Association of State cooperative agreement. California establishes and Territorial Health American Public nation's first statewide Officials adopts policy 20 Health Association HiAP is endorsed in Health in All Policies Task statements on HiAP. dedicates its annual the Rio Political Force through an 1999 meeting to HiAP. Declaration on Social executive order. Gase et al. publish Determinants of Health. HiAP alluded to in an 2012 15 foundational review Vermont Executive Creation of the National European Union (EU) 2006 of emerging practices NACCHO Order No. 7–15 HiAP policies adopted Prevention, Health council resolution “to used to implement adopts establishes HiAP HiAP launched in several major U.S. Promotion, and Public ensure health protection HiAP in the HiAP policy Interagency more specifically cities and local health Health Council (National in all policies and 10 8 9 United States. statement. Task Force in the EU. departments. Prevention Council). activities of the EU.” Number of Publications 5 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year and case examples often highlight the role of the health As the number of public health professionals who sector, especially local health officials as the convener recognize HiAP grows, the field is moving from describing 11,12 and facilitator for HiAP efforts. However, with a local To the “what” of HiAP to describing the “how”. approach also comes the recognition that the type of support these promising efforts, several capacity-building upstream intervention promoted by HiAP “cannot be resources and “how-to” guides have been published in 19 easily replicated from one context to the rest.” From Start recent years, including ChangeLab Solutions, to Finish: How to Permanently Improve Government through As HiAP moves from the “what” to the “how”, there Health in All Policies, Health in All Policies: A Guide for State is an increasing need for more rigorous evidence to and Local Governments, a joint publication of The California STRATEGIES 20-23 support implementation strategies. Recognizing Develop and for Implementing Health in All Policies Endowment, American Public Health Association, the 7 Structure that many HiAP initiatives are still in their infancy while Cross-Sector California Department of Public Health, and the Public Relationships interest in and implementation of HiAP approaches are Enhance Implement Health Institute, and the World Health Organization’s Workforce Accountability growing tremendously, HiAP remains in a developmental Capacity Structures 13-15 comprehensive Health in All Policies Training Manual. Synchronize Communications stage. Since HiAP is relatively new to the United States and Messaging Much of the literature summarizes case studies to provide compared to Europe and Australia, much of the literature Integrate Incorporate Research, Health into examples of HiAP implementation. U.S. case study is not specific to the U.S. context. As more initiatives are Evaluation, and Decision-Making Data Systems Processes Coordinate examples include Seattle/King County, WA, Richmond, established and existing initiatives evolve, additional case Funding and 16-18 CA, and the state of California. These training guides studies will be available to provide the evidence needed investments for implementation and evaluation. PURPOSE AND AUDIENCE The purpose of this report is to depict the state of HiAP practice, including challenges and best practices, at LHDs across the United States. The findings in this report are based on a thorough review of current HiAP literature, and subsequent qualitative data collected through listening sessions and key informant discussions. The target audience for this report is local health officials interested in using a HiAP approach in their community. Experiences from Local Health Departments 9 Health in All Policies:

10 U.S. HiAP Context HiAP approaches are maturing in the United States, creating some encouraging policy successes led by innovative public officials at local, state, and federal levels (see Table 1 for a sample of initiatives from across the country). To understand HiAP within the context of local communities across the United States, summaries of HiAP initiatives supported by NACCHO through funding, technical assistance, and/or training are provided below. Examples of HiAP initiatives across the United States TABLE 1. TYPE OF INITIATIVE HiAP INITIATIVE TYPE OF INSTITUTION FEDERAL National Prevention, Health Promotion, and Public Health Interagency Taskforce Multiple federal agencies Council (2010) STATE Executive Order/Legislation Vermont Health in All Policies Task Force (2015) Vermont California Health in All Policies Task Force (2012) Executive Order/Legislation California Government Office; Office of Equity (2015); Sustainable DC Transformation Order Washington, DC Executive Order Adoption of Health Impact Assessment Requirements for major Legislation Massachusetts transportation projects (2009) Governor's Interagency Council on Health Disparities (2006); Legislation Washington Board of Health - Health Impact Reviews (2014) COUNTY Health Equity Initiative (2007) Policy/Agenda Multnomah County, OR Passed an ordinance requiring all new planning projects to Policy/Legislation Prince George’s County, MD have a Health Impact Assessment (2011) King County Equity and Social Justice Initiative (2008); Policy/Legislation King County, WA Inter-Branch Team/Ordinance 16948 (2010) CITY Community Health Improvement Plan’s objective includes Strategy Denver, CO health considerations and analysis in city policy, processes, and planning Baltimore, MD Healthy Baltimore (2015) Policy Agenda HiAP strategy and ordinance adoption Richmond, CA Legislation Strategy/Interagency Fairfax, VA Partnership for a Healthier Fairfax (2010) Community Taskforce Mayor Healthy Hometown Movement Leadership Team (2012) Interagency Taskforce Louisville, KY Framework Publication White Paper on Health in All Policies (2013) New Orleans, LA Experiences from Local Health Departments 10 Health in All Policies:

11 continued Context U.S. HiAP DC MD PRINCE GEORGE’S COUNTY, MD WASHINGTON, DC In 2011, the county council in Prince George’s County, After attendance at NACCHO’s HiAP Leadership MD, passed an ordinance requiring the planning board Academy in May 2013, senior managers from the to refer site, design, and master plan proposals to the District of Columbia’s Department of Health (DOH) and Prince George’s County Health Department for a health the District Department of the Environment (DDOE), impact assessment (HIA) of the proposed development representing the District Government, realized that the on the community and the distribution of potential basic principles governing HiAP fit seamlessly with the Mayor’s Sustainable DC Plan. A shared vision of HiAP effects within the population. The planning board was and sustainability provide a path to fulfill this vision also required to provide recommendations for design and enhance the quality of life for District residents. components that increase positive health outcomes and 24 In November 2013, Mayor Vincent Gray positioned minimize adverse health outcomes on the community. the District to advance the vision of health equity by KY issuing Executive Order 2013-209, the Sustainable DC Mayor’s Order. Section 10 of the order established a LOUISVILLE, KY HiAP taskforce of 12 District agency directors, co-chaired In March 2012, the Louisville Mayor convened a newly by the directors of DOH and DDOE and includes key created Healthy Hometown Movement Leadership Team, 24, 25 external stakeholders and HiAP experts. modeled after the National Prevention Council. Chaired by the Director of the Louisville Metro Department of LA Public Health and Wellness, the Leadership Team brings NEW ORLEANS, LA together key leaders throughout the metropolitan government who oversee departments that impact Together with community partners, the New Orleans residents’ ability to make healthy choices in their homes, Health Department (NOHD) engaged in a community childcare facilities, educational and recreational facilities, health improvement planning process that began in workplaces, and neighborhoods. The Leadership Team fall 2011 and culminated in 2013 with the publication includes the Directors of Planning & Development, of the first city-wide community health assessment Public Works, Transit Authority, and Air Pollutions Control and community health improvement plan (CHIP) in over a decade. A key theme that emerged from the District. The purpose of this team is to dramatically improve the health of Louisville Metro residents through community health improvement planning process was the importance of addressing the social determinants the development and implementation of policies, programs, and practices that address the social and of health. While a multi-sectoral approach addressing health determinants was already underway for many of environmental determinants of health. As part of this the priority areas that the CHIP identified, this process initiative, Louisville has launched a “Healthy Louisville Community Dashboard,” which allows them to track helped set the stage for a more strategic and systematic 25 progress towards achieving health goals, and will include approach to HiAP in New Orleans. opportunities for community partners to communicate their ideas and efforts with the health department and 24, 25 each other. 11 Experiences from Local Health Departments Health in All Policies:

12 continued U.S. HiAP Context VA FAIRFAX, VA In February 2010, the Fairfax County Health Department convened the Partnership for a Healthier Fairfax (PFHF), a diverse community coalition of individuals and public, community, and business organizations that joined forces to promote change and improve community health. The PFHF uses a community-wide strategic planning process called Mobilizing for Action through Planning and Partnerships (MAPP), developed by NACCHO. The MAPP process brought together 89 stakeholders from 37 organizations across the local public health system, including government, non-profit, academic, faith, and business sectors. Over time, this coalition has grown to consist of over 300 members representing more than 80 different organizations, increasing opportunities for partnerships to promote healthier communities. In 2011, Fairfax County’s Department of Neighborhood and Community Services, working closely with the health department, received a Community Transformation Grant from the Centers for Disease Control and Prevention. This grant significantly supported the coalition’s efforts and accelerated the process of promoting and implementing change. Through grant funds, the coalition established the “Live Healthy Fairfax” initiative and completed a CHIP in September 2013. The five-year plan focuses on seven priorities: (1) healthy and safe physical environment; (2) active living; (3) healthy eating; (4) tobacco-free living; (5) health 24, 25 workforce; (6) access to health services; and (7) data. 12 Experiences from Local Health Departments Health in All Policies:

13 Methods This report used a qualitative methods approach, which included four listening sessions and four key informant discussions. The focus of the information collected was on local community-based HiAP initiatives, and represented the experiences of 21 individuals from Illinois, Ohio, Florida, Kentucky, Minnesota, Massachusetts, and California. The majority of participants were local health officials. Notes were taken of all the listening sessions and key informant discussions. Listening sessions and key informant discussions were conducted from November 2015 through July 2016. All identifying information, such as names of people, organizations, or places, have been removed from the data and the findings. This report presents findings from this process, which focuses on gathering insight into the successes, challenges, and best practices for advancing HiAP in local jurisdictions. FIGURE 2. P rofessional affiliation of listening session and key informant discussion participants 6% 11% Funder Non-profit 83% Local Health Department 13 Experiences from Local Health Departments Health in All Policies:

14 S ummary of Findings • • Windows of opportunity Embedding and sustaining a Five themes were identified during present possibilities for the qualitative assessment: (1) framework for change requires partnerships and collaborations; intersectoral collaboration integrating new ways of thinking for health. This opportunistic and culture shifts in how public (2) windows of opportunity agencies operate and work approach focuses on identifying and openings for intersectoral issues, policies, plans, or projects together. Local health officials collaboration; (3) building have expressed different levels of that can provide venues for cross- capacity for HiAP; (4) embedding and sustaining a framework for comfort and familiarity with how sector partners to work together towards shared goals. to do this depending on their change; and (5) challenges to implementation. These themes were experience with HiAP and other cross-sector collaborations. developed through an analysis of the is essential Building capacity • listening session and key informant for HiAP practice at local health departments. Cross- discussions. Challenges • exist for the sector collaboration requires implementation and evaluation understanding how to work Partnerships and of HiAP. Many of these stem from • with partners across sectors and the difficulties associated with the are the collaborations explicitly incorporate health in amorphous and undefined nature cornerstone of HiAP. Partnerships sectors and policy arenas that did across government agencies and of HiAP practice and the variety not previously. of ways local jurisdictions have departments promote the routine implemented HiAP initiatives. integration of health into policies and the creation of structures and processes across sectors necessary to support institutionalization. Community engagement is critical for gaining the perspectives of the populations that are most impacted by changes in policies and planning projects. The following sections each introduce a different overarching theme, explain subthemes using quotes taken directly from the listening sessions and key informant discussions, and discuss HiAP practice as it pertains to that particular theme. 14 Experiences from Local Health Departments Health in All Policies:

15 Theme 1 Partnerships and Collaborations Partnerships and collaborations are the cornerstone of HiAP. Partnerships between public health and non-public health sectors across government agencies are needed to integrate 26 Community health considerations into routine government processes and structures. engagement is critical for gaining the perspectives of populations that will be most impacted by changes in policies and planning projects. For the purposes of the following discussion, community engagement is distinguished from working collaboratively across sectors within local governments. and organizations improves local Whether formally or informally COMMUNITY ENGAGEMENT government’s understanding of defined, partnerships and community concerns and possible collaborations allow for an expanded Community engagement is the understanding of problems and solutions. As one listening session process of including community possible solutions. This theme participant noted, “It is a huge members or community- mistake for us to think we know all the discusses local health officials’ efforts based organizations in policy to engage with community members issues and solutions that a community and planning decision-making needs. We tend to think from our and partners across government processes. Engagement can take own perspective that we have all the sectors to implement HiAP. various forms, moving from answers.” The participant went on to informing and consulting with Community engagement is state that community engagement by communities to empowering government agencies is essential for important for HiAP. 27 communities to make decisions. increasing civic engagement through Local health officials discussed how community members’ participation engaging with community members in government decisions. Effective “We need more of an ability to get into the community with civic engagement. Help the community understand how they can have more of an impact on their environment... We need more education, engagement, and funding to get down into community, especially low-income communities to address barriers.” Experiences from Local Health Departments 15 Health in All Policies:

16 continued Partnerships and Collaborations Theme 1 community engagement requires “That’s an enormous step—to have people that don’t that when planning projects or policies, information needs to be normally engage in community design policy come forward clearly stated and relevant to multiple and read the policies, give recommendations, and support audiences, as another listening things that really are a shift in the way of thinking.” session participant observed. why intersectoral collaboration, some of the challenges with Other listening session participants noted that community engagement working collaboratively across local collaboration among multiple is difficult. Community engagment is sectors of government such as government. Many echoed the need time intensive for public agency staff transportation, planning, education, to not overly burden government partners and to ensure that the and requires dedication, resources, etc. is critical for HiAP. Some incorporation of health considerations and a commitment to the process. participants discussed their efforts to into non-health sector work is Community members often juggle partner across agencies, while others adding value and not detracting multiple priorities in their daily lives are struggling with how to do this. A listening session participant observed from it. Additionally, a participant and may not be able to participate in community meetings or other acknowledged the difficulty of relying that strategies for partnership might outreach events. More importantly, on the “good will” of partners if change over time depending on the political landscape, the issues there is no formal process in place government processes, such as policy that supports or directs intersectoral involved, and the level of comfort development and planning projects, collaboration. Local health officials of those engaging in cross-sector are opaque and difficult for lay efforts. Cross-sector partnerships audiences to navigate. Communities also expressed that each sector, also require a culture shift away from may require education, training, and whether transportation planning or public health, have their own working independently in silos to additional support to understand what culture and language or jargon that working collaboratively with other is being proposed or planned to fully can create barriers to cross-sector departments and agencies, which participate in public decision-making collaboration. Partnerships necessitate may be challenging. One listening processes. It is also an enormous step session participant noted that their for community members, especially a shared language and the ability to transcend differences in culture and those who have not traditionally health department is taking “baby steps forward.” taken part in these decisions, to feel ways of talking about similar issues. comfortable and empowered enough Table 2 discusses additional reflections Key informant and listening to participate. As one listening session regarding cross-sector partnerships. session participants discussed participant noted, “it is a shift in the way of thinking.” Partnerships across government agencies and departments is fundamental for HiAP. Local health officials discussed the value of working collaboratively across government sectors and 16 Experiences from Local Health Departments Health in All Policies: Theme 1

17 continued Theme 1 Partnerships and Collaborations TABLE 2. Reflections on cross-sector partnerships SUMMARY REFLECTIONS “I’ve been here for a year, and it’s just baby steps forward. Some of it is that there are a lot of partnership opportunities but figuring out how and when to engage.” LHDs sought out cross- – Local health official sector partnerships and are determining “Knowing which non-public health players have health on their radar. If you know someone how best to engage already doing a project around health; identifying those key partners.” their partners. – Local health official “How we engage with people in a way that is not burdensome to them...and that is a value added to their work? I definitely think that’s something we always need to keep in mind. Why are our partners at the table? Are we helping them? Are we just asking things of them? There is always that risk - that you become a burden. You are not trying to do that.” Working together in – Local health official partnership should add value. “Be humble. Particularly if you don’t have a policy, you have to rely on good will, learn about other areas of expertise...know how the department functions. Find ways to plug into other departments work.” –Local health official “When you get into policy and decisions around community design, a lot of people have to be at the table. Some people don’t think of it as their job and you have to understand the ins Partnerships require a and outs of political dealings with government...A lot of these things remain a huge challenge shift in thinking. when you bring others to the table...This is a huge step and shift in the way of thinking.” – Listening session participant “We are trying to fund collaborative projects. There are usually multiple organizations working together on a project to deal with capacity issues. We’re trying to creatively use Partnerships can help funding to get people to work across professional boundaries.” to align funding. – Listening session participant “Learning each other’s language was also another barrier to overcome.” Partnerships require a shared language. – Local health official “One challenge in any planning process is that residents are busy. How do we get them to the table and keep them engaged? In some places its super easy. In others you cannot convince people to come to a meeting on a weeknight.” Experiences from Local Health Departments 17 Health in All Policies:

18 continued Theme 1 Partnerships and Collaborations Co-benefits help to ensure new initiatives in which cross- C0-BENEFITS investment in the success of sector partners may be exploring and forming relationships with HiAP across local government. Co-benefits are positive impacts each other. One disadvantage other than improvements in Local health officials identified co- to an informal approach, as benefits as an important way to health that occur as a result of one listening session participant HiAP efforts. engage cross-sector partners. Co- noted, is the reliance on individual benefits can assist in shaping non- relationships that can be difficult Formalness of cross-sector health sectors’ understanding of to sustain long term. how their work impacts health and collaborations varies widely also help to accomplish their goals. and may evolve over time. Such positive impacts can include Local health officials discussed lowering energy costs from planting variations in the formalness of shade trees next to homes or their cross-sector partnerships. buildings, opportunities for economic Collaborations may range, in development from a transit-oriented “You never this regard, from a very formal development that focuses on partnership structure, such as a know who your increasing opportunities for walking taskforce or an interagency council, and bicycling, or cost savings as best partners are to less formal relationships between a result of increased efficiencies going to be. It’s individuals or ad hoc committees or from working collaboratively. A groups that meet for short periods good to take a listening session participant noted of time on a particular topic. Levels that working together is an efficient very cross-sector of formalness may also be fluid way to accomplish common goals approach. Don’t and evolve over time as initiatives by sharing staff time and resources themselves develop and change. underestimate across agencies. Some key informant and listening who could be a Listening session and key informant session participants observed that stakeholder.” remaining open to opportunities participants also highlighted how co-benefits can help to increase for HiAP allows for new allies and the perceived importance of partnerships to form and build and investment in cross-sector informally and organically over collaborations, especially when time. This is especially true for resources or timelines are stretched. As a local health official described, “We were able to leverage existing “At first... non-traditional agency relationships. This was very partners didn’t seem interested, important. The project ended up but when they noticed co-benefits, being a longer process, and we had to extend the timeline. We incurred they participated.” additional costs, but we were willing to take the hit. We saw the win-win.” 18 Health in All Policies: Experiences from Local Health Departments Theme 1

19 continued T heme 1 Partnerships and Collaborations DISCUSSION Findings from key informant discussions and listening sessions confirm that cross-sector collaboration and community engagement are foundational “I feel the inter-agency elements of HiAP. HiAP requires a willingness to work internally across council is a really government sectors and externally with communities toward collective goals. great place. It’s not Alliances across sectors and with community groups and residents can also super formal, but promote health and equity, increase efficiencies in the use of resources, and people participate. assist in identifying resources. They show up. They engage. They share Community engagement can help to shape local governments’ understanding ideas. And then of priority community concerns, disproportionate impacts and differential neighborhood conditions, and potential solutions to address these issues. those ideas become Community organizations and groups outside of government can help to something. That’s ensure that such initiatives are responsive and accountable to community really exciting!” needs. Community participation can also increase civic engagement of residents that would be most impacted by policy and planning decisions. Table 3 depicts potential stakeholders for HiAP. 19 Experiences from Local Health Departments Health in All Policies:

20 continued heme 1 T Partnerships and Collaborations Potential stakeholders to engage in HiAP TABLE 3. EXAMPLES TYPES Community Neighborhood associations, schools, faith- and community-based organizations and organizations and other community groups, local businesses residents Community clinics, hospitals and health systems Health facilities Local government Housing, public safety, public health, economic and community development, urban and regional planning, criminal justice system, school districts, transportation, agencies and parks and recreation, social services departments Regional Regional transportation and planning organizations government agencies Academic University researchers, undergraduate and graduate students, community colleges researchers Foundations, federal and state agencies, non-profit organizations, national Funders associations “The Health Department has a history of working across sectors, for instance the Interdepartmental Taskforce on Childhood Obesity. This task force involved working with schools and day care centers. The first big win as a result of this task force was a change to daycare licensing standards. This change at the city level led to change at the state level creating improved nutritional guidelines, physical activity and screen time for all daycare licensed owners throughout the state.” Experiences from Local Health Departments 20 Health in All Policies: Theme 1

21 continued heme 1 T Partnerships and Collaborations Local health officials acknowledge the need to understand the goals and functions of cross- sector agencies to identify “Downside of that [informal organic opportunities to incorporate health approach] is that it relies on particular considerations into their work. relationships. Relies on people who know Additionally, health concerns need other people and...we kind of get things to be owned collectively by all done by saying ‘Hey! How can we help?’... sectors of local government and the community at large, and the but we don’t necessarily have a system for responsibility to address health dealing with it.” problems and concerns should be shared by multiple sectors. HiAP initiatives should benefit more than one partner. Intersectoral collaboration works best when partners from all sectors identify shared gains, and co-benefits are essential for building a mutual vision and common goals. Using co-benefits as a strategy for engaging partners encourages support, establishes buy-in, and maximizes efficiencies by pursing multiple goals through the shared use of limited resources. Aligning goals across agencies and policy areas represents a shift from pursuing independent, siloed interests to collaboration in pursuit of a common purpose. “Bringing a HiAP lens helps give city planning departments and city governments in general the permission and rationale that city planning needs to address other social determinants in their work.” 21 Experiences from Local Health Departments Health in All Policies:

22 Theme 2 Windows of Opportunity and Openings for Intersectoral Collaboration Openings in the planning, policymaking, or initiative development 28 present a spectrum of processes, also called “windows of opportunity,” opportunities to highlight health and equity considerations in government decisions across an array of policy domains and sectors. The spectrum of opportunities for HiAP range widely and can vary in scale and complexity. For example, an LHD may be asked to review a proposed housing development for recommendations on how to increase options for walking and bicycling. Another opportunity might be to serve on an interagency council to respond to safety concerns in a low-income neighborhood of the city. Other opportunities may present themselves when the city or county updates their general or comprehensive plan. Taking advantage of these windows when they occur can present opportunities to engage in intersectoral collaboration for health. This approach focuses on identifying issues, policies, plans, or projects that can provide avenues for cross-sector partners to work together. COMPREHENSIVE PLAN A more specific example of a window of opportunity that occurs across the nation is an update of a city’s zoning code, which generally only occurs every A comprehensive plan, “also few years. Opportunities can arise throughout the goal-setting, planning, and known as a master or general public engagement stages of the zoning code update to discuss how land use plan, is a collection of information and the built environment impact community health. The zoning code can and materials designed to guide also be modernized to support positive health outcomes through tactics such the future development of a as limiting the concentration of alcohol outlets and fast food restaurants near schools or promoting walkability through improved land use designations. city or county. Such a plan can Ultimately, windows of opportunity present openings in government processes provide a community with a firm to align efforts across sectors towards shared goals. Theme 2 highlights local foundation for policy and action health official’s efforts to identify and act on windows of opportunity to work that will allow it to function more 29 across sectors and implement HiAP. efficiently and effectively.” Health in All Policies: 22 Experiences from Local Health Departments Theme 2

23 Windows of Opportunity and Openings for Theme 2 Intersectoral Collaboration continued Local health departments are COMPLETE STREETS POLICIES working to align efforts across Complete Streets policies are “laws, resolutions, agency policies, and government to accomplish planning and design documents establish a process for selecting, shared goals. funding, planning, designing, and building transportation projects Local health officials described that allow safe access for everyone, regardless of age, ability, income, opportunities to work with other 31 or ethnicity, and no matter how they travel.” sectors and government agencies to improve community health. Plans or initiatives such as an update to general plans, housing and economic development plans, or Complete Streets policies were identified as windows of opportunity to incorporate health and equity into a planning process. Community plans, 30 such as the CHIP, or public health accreditation identify health goals that usually require coordination and cooperation across multiple sectors to accomplish. Listening session participants also expressed the need to draw connections between the social determinants of health and downstream health outcomes to highlight opportunities for policy and planning interventions. 33, 34 HIA Local health officials strategy. In several other cases, key informant also noted that HIA trainings HIA is “a systematic process that and listening session participants provide a means to build capacity uses an array of data sources and identified HIA as a springboard for towards HiAP. Additionally, because analytic methods and considers HiAP. HIA brings together data, HIA has a structured process for input from stakeholders to expert knowledge, and public input engaging in policy development determine the potential effects to identify and examine the health and planning projects, participants of a proposed policy, plan, effects of proposed decisions in a noted that it can be an easier 32 program or project on the HIA advances step-wise fashion. entry point into HiAP for local health of a population and the a health promotion and protection health officials working to build distribution of those effects within approach toward planning and partnerships with other sectors. the population. HIA provides policy decisions and is seen as recommendations for managing one component of a broader HiAP 32 and monitoring those effects.” 23 Experiences from Local Health Departments Health in All Policies:

24 Windows of Opportunity and Openings for Theme 2 Intersectoral Collaboration continued Local health officials described the need to be ready to take advantage of windows of opportunity when they present themselves. This strategy has led to greater involvement in working with cross-sector partners and has opened up opportunities to discuss and incorporate health. HiAP APPROACH: “A HiAP approach is expected to be the standard. I think that’s the best way to maintain and to always be seeking opportunities. As an opportunity arises, how do we jump on it?” “I think it’s important to keep your mind open about what Health in All Policies is, you know? So that you find your ally.” OPPORTUNITIES FOR HiAP WITH CROSS-SECTOR PARTNERS: “We began to insert ourselves in the plans of other county departments. The more we did this, the better job we were able to do in incorporating healthy places for people. We were able to engage with developers in the planning stages of park design, school building, and lighting choices... Later we started working at the policy level. The county and one of the cities are currently working together on a policy. We continue to work on inserting the health department more into reviewing environmental plans.” “Where it’s not coming from top-down, put it on the table so it helps the administration see that HiAP can help meet their strategic goals and can put resources to it. If you talk about it, it’s likely to happen.” Health in All Policies: 24 Experiences from Local Health Departments Theme 2

25 Windows of Opportunity and Openings for Windows of Opportunity and Openings for Theme 2 continued Intersectoral Collaboration Intersectoral Collaboration continued “Often when presenting on HIA, HIA AS A STARTING POINT FOR HiAP: HiAP becomes part of the conversation. We “HiAP for us is an overarching goal. We use can talk about how HIA as one way to do it since we’re trying to inform policy.” they work together. That can help make the connection.” DISCUSSION Participants in listening sessions and key informant discussions discussed a variety of ways that they have been or are beginning to align efforts across their local governments and finding “windows of opportunity” to retool government processes to enhance health and wellness. Many also saw the value in seeking opportunities for new partnerships and cross-sector collaborations. For several of the health departments included in the analysis, this meant learning how to work with other government agencies and departments, which is new and uncharted territory for many. It also means staying open to opportunities and having a broad vision for health. While there were challenges along the way, local health officials described their ability to continue making progress and gain traction. 25 Experiences from Local Health Departments Health in All Policies:

26 Theme 3 Building Capacity for HiAP As HiAP is a new and developing field in the United States, local health officials noted the importance of and need for capacity building to engage in HiAP. HiAP initiatives can be implemented in a variety of ways, depending on the needs and political landscape of the community. As a result, participants struggled when communicating the utility of HiAP to their partners and to their leadership, distinguishing HiAP from other health initiatives or assessments, and determining a future course of action for intersectoral collaboration. Capacity building offers partners an opportunity to help build and strengthen their partnerships. Theme 3 examines how local health officials are working to build capacity around HiAP within their local jurisdictions and redefine possible ways local governments can impact community health. with other government partners HiAP provides multiple and community members opportunities to redefine to explicitly integrate health possible ways to impact health. “Traditional into sectors and policy arenas health department Local health officials noted that that did not previously. Cross- the traditional work of health work is changing. training opportunities about departments is changing and new The new generation the spectrum of HiAP activities opportunities are emerging for how of public health is and co-benefits can also work to to work in collaboration to influence focused on theories build support across government the multiple determinants of health. and a foundation for partners to that work with ” Listening session participants work together. ” outside organizations. noted that HiAP requires a focus on building new skills and an understanding about how to work “There’s a lot of education that needs to be done. In some circles, there may even be denial. It involves deconstructing the built environment—putting the toothpaste back into the tube.” 26 Experiences from Local Health Departments Health in All Policies: Theme 3

27 continued Building Capacity for HiAP Theme 3 Local health departments are working to increase “We have enough partner support that we’re understanding of how to just getting it going and seeing how it goes. implement HiAP within local I think they’d be on board, but there’s not government. enough information out there, so people Local health officials acknowledged don’t get it. We have really committed the changing dynamics within partners, but it’s a matter of educating them public health away from single- on what HiAP means.” issue health topics towards working collaboratively across governments. Many local jurisdictions are embracing this change, but want DISCUSSION more information about how to implement intersectoral collaboration HiAP is based on innovative approaches to improving community health. for health. Participants, especially Listening session participants and key informants expressed a need those still in the initial phases of their to build a base of understanding with cross-sector partners on what HiAP efforts, expressed uncertainty HiAP is and how it can be applied. HiAP requires reshaping existing about the best course of action. understandings of how to improve health and the role of non-health As HiAP does not have a singular sectors. It also demands a shift in how local government agencies and defined approach, listening session departments operate and work together. Education, training, and and key informant participants capacity building can serve dual purposes: enhance understanding of expressed challenges with this flexible how routine government processes and decisions affect health, and structure, but also expressed hope in assist in determining a course of action for cross-sector collaboration by being able to shape local initiatives building support for HiAP among local government partners. towards improving community health. Health officials are exploring options as the process moves along. As one participant described, “it’s like building a plane as I’m flying it.” Training and education have “One of the “Not many been used to clarify and increase staff within the challenges is understandings of how HiAP has local health educating partners been applied elsewhere and how department around policy similar strategies could be tailored to know or change. A lot of other local jurisdictions. Education understand organizations...don’t is an important tool in defining a HiAP.” ” common path towards achieving do policy change. shared health outcomes. Health in All Policies: Experiences from Local Health Departments 27

28 Theme 4 Embedding and Sustaining a Framework for Change Listening session and key informant participants noted that HiAP requires new ways of thinking and culture shifts in how public agencies operate and work together. Part of this involves defining a locally based HiAP framework for change, and participants have expressed different levels of comfort and familiarity with how to do this depending on their experience with HiAP and other cross-sector collaborations. One of the identified difficulties implementing HiAP, is that HiAP is not linear or “one- size-fits-all.” The success of HiAP initiatives varies according to local context and opportunities for change within communities. As such, it is important to consider the different experiences community members and local government staff bring to the table and the limitations they may face in terms of stakeholder participation, internal and external funding, resources, and political dynamics. This theme examines how local jurisdictions have been able to move forward collectively, cultivate administrative and political leaders, support health equity, use local ordinances or resolutions to institutionalize HiAP, and measure success. HIAP RESOURCES Defining how cross-sector collaborations will move forward together is an essential step for HiAP. Organizations such as NACCHO and the Association for State and Territorial Efforts by local health officials to build bridges and share knowledge with other sectors can help build trust and highlight opportunities Health Officials (ASTHO) have developed various resources for state and local for long-term partnerships. Although acknowledging the importance of doing so, participants also described their struggles with health departments to utilize when building a foundation for working collaboratively. Several LHDs are implementing HiAP. NACCHO developed implementing HiAP initiatives through trial and error. a HiAP factsheet outlining seven strategies for HiAP implementation at the local level, Listening session and key informant participants articulated wide and ASTHO recently developed a HiAP variation in their efforts to implement and operationalize HiAP efforts framework to serve as a foundation for all at the local level. Examples of HiAP initiatives include conducting 6, 26 levels of government to implement HiAP. HIA, conducting or attending trainings on HIA or HiAP, establishing Experiences from Local Health Departments 28 Health in All Policies: Theme 4

29 Embedding and Sustaining a Theme 4 Framework for Change continued an interagency council, and adopting local ordinances. These examples demonstrate the many ways that HiAP can be operationalized that vary in scope, scale, and complexity. As shown in Table 4, key informant and listening session participants described multiple HiAP initiatives working with communities in their local jurisdictions. TABLE 4. HiAP initiatives at local jurisdictions Local Jurisdiction Type of Initiative HiAP Activity Received HIA training and attended HIA conference Training and education ” Formal cross-sector partnership Established Healthy Chicago 2010 Interagency Taskforce Chicago, IL Established Interdepartmental Taskforce on Childhood Obesity Formal cross-sector partnership Working towards adopting a HiAP Resolution Legislation Provided education on social determinants of health using local Training and education data and information Engaged with developers in the planning stages of park design, Integration of health in planning projects school building, and lighting choices Monterey County, CA Health department reviewed environmental plans Integration of health in planning projects Conducted an HIA training Training and education Provided skill-building trainings on data literacy, laws, and Training and education advocacy ” Salinas, CA Integrated explicit language on culturally and linguistically inclusive Funding requirements community engagement in Request for Proposals Completed a health element as part of the County’s General Plan Integration of health in planning projects Santa Clara County, CA Outreach Conducted outreach as part of the CHIP Pinellas County, FL Included health in plans written by the Metropolitan Planning Integration of health in planning projects Organization Hillsborough County, FL Conducted an HIA with the Metropolitan Planning Organization Health assessments Established the Healthiest Weight Florida initiative to inform Informing policy development policies to improve the determinants of obesity Conducted Protocol for Assessing Community Excellence in Health assessments Lee County, FL Environmental Health (PACE-EH) Conduct HIA on Tice Community Connectivity and Health assessments Redevelopment Plan Experiences from Local Health Departments 29 Health in All Policies:

30 Embedding and Sustaining a Theme 4 Framework for Change continued to withstand changes in leadership cultivate supportive leaders that as well as ensure the longevity and understand the importance and “Top-down, bottom- sustainability of HiAP initiatives. value of intersectoral collaboration up, middle-out— for health. they all work. HiAP initiatives can be a All roads can lead Challenges can arise for HiAP way to uncover and discuss to HiAP. [It] doesn’t initiatives that do not have health inequities. matter where you leadership support. Local health start as long as it’s the officials discussed how they are Some listening session and key appropriate approach approaching these obstacles, informant participants emphasized for your community’s such as finding ways to work HiAP as a way to highlight health context.” with administrative leaders who inequities and discuss differential Supportive administrative “The leadership is engaged and supportive. It and political leaders are is important to have this leadership support important for securing so that one, the work can get done; and two, resources and helping to the leadership can be an outward facing define a vision for HiAP. spokesperson for this work.” Listening session and key informant participants observed that supportive administrative and political leaders can conditions in neighborhoods, are less receptive to HiAP efforts. provide a powerful pivot in clarifying although this sentiment was not Additionally, changes in political direction and defining a vision for expressed by many as central to or administrative leadership HiAP, securing resources for initiatives, their efforts. One local health official can hinder the work of existing and scaling up change. Leaders are partnerships by disrupting the observed that HiAP can present a also important for championing HiAP way for local governments to discuss momentum of initiatives and even and communicating that vision to altering the direction of the work. inequities related to health status various audiences. Participants also As some participants have noted, without alienating people. strongly identified with a need to enhancing staff capacity can help “It’s place by place. In some smaller communities it’s easier to engage elected officials and businesses because everyone knows each other... for city planning and for cities in general—they’ve often been so focused on only the physical—streets, zoning map, what you can build where, infrastructure. But those decisions have social and health implications that are far-reaching beyond the streets and the buildings, and do have impacts on education, criminal justice, safety.” 30 Experiences from Local Health Departments Health in All Policies: Theme 4

31 Embedding and Sustaining a Embedding and Sustaining a Theme 4 Framework for Change continued continued Framework for Change Local jurisdictions are interested or are working towards adopting local ordinances or resolutions to institutionalize HiAP. Several local health officials described considering or working towards adopting a local ordinance or resolution as a way to formally institutionalize HiAP. These participants expressed their local jurisdictions’ desire to move beyond more informal efforts towards integrating health into government processes through legislation. Local ordinances or resolutions create Local jurisdictions need to opportunities to improve the health of a top-down policy-directed HiAP determine whether HiAP residents and ensure that government agenda that guides HiAP initiatives. initiatives are effective at agencies and departments improving community health. Since participating in this analysis, collaboratively work together. the Chicago Department of Public Local health officials consistently Health has assisted the City of articulated a need to measure Chicago in passing a HiAP resolution the success of HiAP in order to “My direct supervisor in May 2016. The resolution understand whether initiatives is very supportive ... recognizes that major policy issues have been effective at improving but the division have health implications and community health. Several manager is a little establishes a HiAP approach towards participants also discussed an more old-school and program and project development interest in sharing data and data hasn’t really embraced throughout all government agencies analysis across government agencies 35 these new approaches and departments. The resolution and departments. Additionally, to public health.” creates a HiAP Task Force made up of participants agreed that evaluating all City departments to identify new HiAP initiatives is challenging “Leadership is important, but you also need representation from the people doing the work. You need integrated capacity, and multilevel representation at meetings because the people doing the work tend to stick around longer than the departmental leadership.” 31 Experiences from Local Health Departments Health in All Policies:

32 Embedding and Sustaining a Theme 4 continued Framework for Change because many HiAP objectives, such as changes in systems and policies “The goal is to have a HiAP policy in place, but for right now and building cross-collaborations, we are working on a HiAP resolution. The resolution is the are difficult to measure. Challenges first step toward institutionalizing this work.” to evaluating HiAP initiatives will be elaborated upon in Theme 5. develop relationships with cross-sector partners and communities, and create a DISCUSSION 12 momentum towards larger goals. HiAP requires an integrated effort Relationships with cross-sector partners and community stakeholders, across sectors and with community informational resources such as health data, personnel resources such as members to determine shared values and work together to accomplish staff time and supportive leadership, funding resources, and legal resources such as local ordinances or resolutions can help establish and sustain HiAP common goals. Listening session and 24 initiatives over the long term. key informant participants noted a Partnerships and collaborations, as discussed in great deal of uncertainty in how and Theme 1, are necessary to build the foundation for HiAP, while dedicated staff with whom to get started. One useful resources and funding are important to sustain joint efforts. Local ordinances tactic is to identify “low-hanging and resolutions can provide political support and direction for HiAP, and fruit,” or small easily achievable steps informational resources, such as data and measurement tools, can aid in to get started that create progress evaluating the impacts of changes in policies or planning projects on health toward a longer-term goal. Early wins determinants and health outcomes. Table 5 outlines questions for identifying or successes can build morale, help to key assets for implementing HiAP across government sector partners. TABLE 5. Questions for identifying key assets to implement HiAP among cross-sector partners QUESTION CATEGORY What skills can people contribute (i.e. professional, technical, advocacy)? People Are staff available to support cross-sector efforts? What types of technologies or data are available and can they be shared? Resources and data What other types of resources can be leveraged? What are potential opportunities to work across sectors? What are potential co-benefits of cross-sector collaborations? Cross-sector partnership and What types of opportunities can be used to inform, educate, and exchange community engagement knowledge with community stakeholders (i.e. workshops, curriculum development, and technical assistance)? Are there grants or other funding opportunities to support multi-sector collaboration? Funding Are there opportunities to adopt local policies, resolutions, or ordinances that are Legislative and/or Executive supportive of HiAP? Branch options Are there opportunities to issue an executive order? 32 Experiences from Local Health Departments Health in All Policies: Theme 4

33 Embedding and Sustaining a Embedding and Sustaining a Theme 4 continued Framework for Change Framework for Change continued An evaluation of short- and long-term changes in cross-sector collaborations and changes in health determinants and outcomes are important for “It’s been a safe way for understanding whether progress is being made toward shared goals. Table cities and counties to 6 highlights evaluative strategies and tools for measuring outcomes of HiAP start talking about race efforts. These include creating local rating systems and healthy community and racial inequities. checklists, conducting a community health assessment, and evaluating the The health outcomes impact of HiAP initiatives. and disparities that you see are really a manifestation of TABLE 6. Methods for measuring success of HiAP initiatives racial inequities in MEASUREMENT our policies that are DESCRIPTION STRATEGIES AND historic and ingrained, TOOLS but alive and well. Developing healthy community design It’s a good way to talk indicators. Developing health indicators Rating systems and about differential indicators of short-, intermediate-, and longer-term conditions and start measures. the conversation Developing a snapshot of baseline existing without scaring health conditions of the community, including people about race.” Community health health outcomes and neighborhood conditions assessment by geography and race/ethnicity and socioeconomic factors. Tracking and measuring processes, including Process evaluation identifying number of partners engaged and number of participants in a project. “We drill down to specific projects, like number Monitoring changes in health determinants and health outcomes. Examples include of partners engaged, changes in healthy community infrastructure Outcome evaluation number of participants investments and changes in chronic disease in a project—things rates due to increases in physical activity. helping us understand if we’re increasing impact or trending towards a more positive impact.” “We need to do more work around institutionalization. [We] need a policy change through ordinance.” Experiences from Local Health Departments 33 Health in All Policies:

34 Embedding and Sustaining a Theme 4 continued Framework for Change role in the implementation of The listening session and key HiAP. As LHDs possess the legal informant participants described how “... [W]e have been working supportive leaders strengthened local authority and responsibility to with the Department of protect and promote the public’s HiAP efforts. Supportive leaders can Building on data sharing help to define a vision for HiAP and health, they are natural leaders and lead exposure. It mobilize resources toward collective for defining and directing these wasn’t always clear to the 23 efforts. efforts. Additionally, leaders receptive Local health officials Department of Building why have an understanding of priority to HiAP can help to develop an the Health Department was health issues in the communities explicit focus on equity within HiAP requesting data sharing. they serve and are more likely to initiatives, as HiAP can be a way to However, explaining HiAP have a better grasp of the multiple explore equity concerns, identify upstream determinants of health policy solutions, and adopt changes in terms of the social that are impacting identified within local government that can determinants of health health concerns. This knowledge, support improved health outcomes and focusing on the root combined with expertise in for communities and populations causes has helped to experiencing disproportionate epidemiology and health data, validate the data sharing impacts. can assist health departments in requests specifically with the leading local HiAP efforts. Department of Building.” Among local government departments and agencies, health departments can provide a leadership 34 Experiences from Local Health Departments Health in All Policies: Theme 4

35 Embedding and Sustaining a Framework for Change continued Theme 5 Challenges to Implementation Listening session and key informant participants noted significant challenges to HiAP implementation, such as limited resources and funding, communicating tangible outcomes to decision-makers, and difficulty evaluating HiAP initiatives. Many of the challenges stemmed from the undefined nature of HiAP practice and the variety of ways localities have implemented HiAP initiatives. Participants also described other barriers, such as educating administrative leaders and policy decision-makers on the value of HiAP beyond measureable outcomes, struggles with gaining the support of partners and defining a coherent path, difficulty with instituting systems change, and restrictions on LHDs and other public agencies to engage in advocacy and lobbying. This theme identifies and discusses many of the notable challenges to implementing HiAP raised by listening session and key informant participants. commitment of a very few dedicated and departments. One local health Local HiAP initiatives are staff members, which can result in official noted that it was a challenge challenged by limited resources activities ending when there is staff to communicate a sense of shared and funding. turnover or burnout. A local health responsibility for funding joint work HiAP efforts are challenged by limited official described her experience across all agencies. resources and funding, as many working on HiAP after losing key staff key informant and listening session as, “something like a hobby.” Additionally, as HiAP is by nature participants have noted. From staff intersectoral and crosses siloes, it turnover, competing priorities, and Funding is also an enormous doesn’t have a specific institutional the limited of funding, HiAP can be limitation for HiAP initiatives. Local home. Stretching HiAP across sectors difficult to implement and sustain and silos can add challenges for health officials reported having to over time. Health department do more work with fewer resources identifying resources and staff to put staff capacity to take on additional (e.g. dedicated staff time) and towards these efforts. Challenges responsibilities or duties is not always funding over time. Local health also arise if the overall initiative is possible when health departments not owned by a specific agency officials, also described having are in “survival mode,” as one to search for funding to start or or department that can champion local health official described, and continue collaborative efforts. change and direct resources towards especially when HiAP-related tasks are accomplishing goals. Table 7 Several times, participants reported added to LHDs’ already full workload. that intersectoral collaborations summarizes reflections regarding Moreover, some participants limited resources and funding to require creativity and a willingness described HiAP projects that were implement HiAP. to leverage resources across agencies highly dependent on the work and Experiences from Local Health Departments 35 Health in All Policies:

36 Challenges to Implementation continued Theme 5 Reflections on challenges with limited resources and funding to implement HiAP TABLE 7. SUMMARY REFLECTIONS “Time is a challenge. HiAP gets added to people’s plates.” “Not fully implemented because it’s not been prioritized in the administration. It’s hinging on the work that [one individual] does.” LHDs have limited “Other challenges [include] staffing in smaller communities that are in staff capacity to survival mode. Getting residents involved is pretty difficult. Getting implement HiAP. staff and elected officials to shift their to-do list when they’re in survival mode can be a challenge, [as is]...getting other departments to support the work.” “We can develop goals and health indicators but tomorrow something else comes up that is urgent.” “In my department...we have to be very smart about how we dedicate the limited resources we have. When we get into a neighborhood, we do good stuff, but we can’t be everywhere.” LHDs are challenged with prioritizing “We’d rather prioritize doing a good job in the communities we are in limited resources. than a mediocre job in more communities...We’re a little under the gun, but we’re losing people and constantly having to do more with less. We’re keeping up, but can’t expand.” It is challenging to “Having the working group together made future grant opportunities request that partners easier but when you are asking other departments for resources, it’s more difficult—how is health going to fund this? Health shouldn’t have to fund invest financial all of this. A challenge has been having partners invest financial resources.” resources. Searching for “Identifying grant opportunities. Constantly looking for grants. We funding to support have unique challenges in grant funding, but the good thing is we do have great collaborations. It’s a synergistic effect. A lot of people really HiAP initiatives is a do want to help.” continuous effort. 36 Experiences from Local Health Departments Health in All Policies: Theme 5

37 Challenges to Implementation continued Challenges to Implementation continued Theme 5 Local health departments need more evidence of [The] process takes even longer than policy “ tangible outcomes and change usually does in public health. Even assistance in communicating about HiAP. getting a sense of the framework takes time. It’s a big cloudy thing for Health in All Local health officials noted that Policies. It’s a very lengthy process. I was HiAP is challenged by the difficulty concerned after a year that I had no concrete communicating tangible short-term benefits and outcomes, especially deliverables to show—and I think that’s why when compared to other similar it’s hard to get leadership buy-in.” health initiatives like HIA. HIAs are structured step-wise assessments of health impacts and typically aim to impact near-future decisions of a policy, plan, program, or project. Local health departments describe challenges with evaluating HiAP initiatives. Local health officials described their struggles communicating with Local health officials described the importance of measuring the success of administrative and political leaders HiAP efforts. However, several participants also reported challenges with data about the value of HiAP objectives, collection and evaluation of HiAP initiatives. As noted by several key informant such as building partnerships, and listening session participants, measuring policy change is difficult. It is engaging with communities, and also equally difficult to attribute any changes in health outcomes to a policy other outcomes that are difficult to or planning intervention, since as one listening session participant noted, quantify and describe. Participants “Health affects everything and everything affects health.” A participant also also noted that challenges observed that data is often not timely and significant lags in data can hinder a communicating about the outcomes real time accounting of changes in health determinants and outcomes. Table and benefits of HiAP created 8 describes challenges with data collection and evaluation of HiAP initiatives. difficulties getting buy-in from administrative leadership. Right now, the outcomes include partnerships. “ So for example, we had never worked with the “[I am]... in favor of MPO (Metropolitan Planning Organization) HIA because it’s more and now we’re doing an HIA. So partnership tangible, but HiAP is so has been a great outcome, but it’s not far a lot of education something you can necessarily put on the and relationship- building, and there’s no table. But, some of our senior leadership is tangible outcomes.” recognizing that the partnership is a success.” 37 Experiences from Local Health Departments Health in All Policies:

38 continued Challenges to Implementation Theme 5 Reflections on challenges with data and evaluation of HiAP initiatives TABLE 8. SUMMARY REFLECTIONS “Some of the things we do are very difficult to measure. You just have confidence to know you’re doing the right thing, but we struggle to find ways to measure it.” It is difficult to measure changes “Measuring the effect of policy is very difficult [and] challenging, because we can see the changes, but are not necessarily measuring it in policies and or can’t get the data.” systems changes. “It is difficult because health affects everything and everything affects health. It is hard to measure cause and effect.” “People are really up against some significant barriers here...when the data is that far behind...we are constantly growing at one of the highest Data is not timely. rates of the country...it’s not that helpful.” “You have to become a data-driven community where people are willing to share and are okay talking about real data outcomes. We sometimes It is challenging to stray away from measuring things because if we don’t succeed and the shift thinking about data shows that, people freak out. Being data-driven has to become how data can be part of the community culture or else it becomes a punishment tool. It’s a political issue, and it needs to stop being seen that way. Other used to improve communities are doing this better, and it has a huge impact. When they community health. see data that doesn’t say good things, they can use that to improve. We don’t do that here.” DISCUSSION There are many challenges with implementing HiAP initiatives, which often stem from HiAP being a new and emergent field in the United States. HiAP necessitates cross-sector partners to intervene in complex and dynamic political systems that involve a range of local government and community stakeholders and rely on specialized knowledge and language. HiAP is also an approach that may be difficult to communicate to various audiences and even more difficult to evaluate. Experiences from Local Health Departments Health in All Policies: 38 Theme 5

39 Challenges to Implementation continued Challenges to Implementation continued Theme 5 Specific HiAP activities are defined However, the flexibility is also an by local context and priorities. opportunity because community HiAP initiatives in one jurisdiction stakeholders and local governments may not be as effective in another have a great deal of influence in outlining locally based strategies to location. This can be very difficult address priority concerns. for local governments as there is no one recipe or model for success, Additionally, there are several best which can be seen as either a practices outlined in the next section challenge or an opportunity. Local that can be used by any community governments can be hesitant to interested in HiAP. While there is engage in HiAP without knowing no one recipe for success, learning the potential outcomes or definitive more about how other jurisdictions strategies to accomplish goals. The have implemented HiAP initiatives flexible nature of HiAP initiatives will give local health officials is challenging because there is no examples to draw from when one ‘right’ way to implement it. implementing their own initiatives. 39 Experiences from Local Health Departments Health in All Policies:

40 Summary of Key Findings Moving Forward : Improving health through cross- As a new and • • Windows of opportunity are Challenges. sector collaboration brings with it growing field, local health officials openings for collaborations. many opportunities to build new implementing HiAP initiatives face Participants describe the need to be bridges and reinforce innovations many challenges including: limited ready to take advantage of “windows in expanding the public health resources, funding, and staff capacity of opportunity” to engage in system. This shift in practice to support efforts. Listening session intersectoral collaboration for health. impacts how public health and key informant participants Opportunities for engagement professionals coordinate efforts in reported struggling with how to present openings in government communities, and in many cases, evaluate and communicate the processes to align efforts across transforms organizational strategies importance of building partnerships, sectors towards shared goals. for local governments. The key which is central to HiAP work, and findings from the qualitative other outcomes that are difficult to The success of HiAP rests on effectively assessment are listed below. measure. integrating a wide spectrum of practices, programs, and policies with • Cross-sector partnerships and the aim of improving community community engagement are health. There is no one model or Local health essential for HiAP. KEY FINDINGS FROM THE approach to HiAP, as community officials described how they are context, funding, partners, leadership, QUALITATIVE ASSESSMENT exploring ways to improve and and other factors powerfully shape build relationships with community • A new framework for public learning and how initiatives unfold. groups and other public agencies A new framework for public health. In working across sectors, one of and departments. Leading with a health practice, encapsulated by the biggest hurdles identified by clear definition of co-benefits can HiAP, represents a culture shift away participants was, “learning each increase buy-in and joint investment from pursuing independent, siloed other’s language.” There is a steep in cross-sector work. interests to working collaboratively learning curve in the implementation across government to achieve of HiAP; from working with partners Cultivating leadership to • common goals. to sharing resources to building Administrative champion HiAP. cross-sector initiatives. These are new and political leadership can support Multiple models for HiAP • relationships that need to be defined articulating a vision of success for There is no implementation. and supported. Several participants HiAP and securing needed resources. singular local HiAP framework acknowledged their HiAP efforts were Changes in leadership can also because of dynamic political still very young, and it was still an hinder HiAP efforts by disrupting the landscapes operating within ongoing process. momentum of initiatives or change localities and a need to be flexible the direction of the work. and responsive to local context and community needs. Key informant Evaluation and measurement • and listening session participants of success. Listening session described variations in their local and key informant participants HiAP initiatives that span different consistently articulated the need levels of formalness and scale. to demonstrate the value of HiAP and how best to measure success. • HiAP is a new and emerging They also identified several Many local HiAP initiatives are field. challenges to understanding if still very new, and participants have HiAP initiatives are accomplishing struggled with how to intervene the goals set out and whether in complex and dynamic political health is improving as a result. systems. Education and training Notable challenges included on community health and how to difficulty in measuring less work together to make an impact quantifiable changes in policies are crucial for HiAP and can help to and government processes and articulate the need for and rationale development of partnerships behind HiAP. across agencies. Experiences from Local Health Departments Health in All Policies: 40

41 continued Moving Forward Organizational integration and Find champions at partner PROMISING Hi AP institutionalization. Strategies for agencies or departments. STRATEGIES integrating HiAP include integrating Finding strong champions at There is wide variation in the process, functions into job descriptions and partner agencies and making a structure, and scope of local HiAP developing an institutional home commitment collectively to build initiatives across the country. While for cross-sector collaborations, trust can fortify organizational HiAP in the United States is still in such as interagency councils or capacity and long-term its formative stage and there are no taskforces. Dedicating staff to HiAP sustainability of HiAP initiatives. formal HiAP best practices to-date, initiatives strengthens collaborative The process of building HiAP is key informant and listening session efforts by providing administrative, fundamentally based on these participants noted several promising reporting, and communication cross-sector partnerships; listening strategies that can help to develop a support. Additional efforts can session and key informant strong foundation for practice. be implemented to formalize or participants noted that building institutionalize the work, such as these relationships with cross- the adoption of local ordinances, sector champions consistently Start small. HiAP is a process and executive orders, and resolutions. strengthened the work. an investment in long-term strategies. Setting achievable, scalable goals Develop measurements for These building blocks provide a provides partners with the flexibility success. The ability to evaluate platform for partners to learn and to test ideas and evaluate outcomes changes in health determinants educate one another on the principles along the way. It is also important and outcomes can serve as a of HiAP. In addressing issues of equity, for local health officials to start powerful tool to guide priorities. accountability, and advocacy, it is somewhere, no matter how small. For Understanding how to measure necessary for partners to be flexible HiAP efforts to be successful, the work systems change and changes and to grow comfortable with rapidly needs to take place across multiple in outcomes are important for changing conditions. fronts. While progress is neither understanding whether progress linear nor uniform, it is important to HiAP is an innovative and emerging is being made toward shared establish a solid framework for scaling practice that brings many goals. The primary questions for up future work across institutions opportunities to improve health many local health officials are what and diverse communities. One of through multi-sector collaboration. to measure and how. There are the biggest hurdles identified by Wide variation in the formality and already many creative approaches participants was acknowledging there scale of HiAP initiatives showcases to collecting data. Considering is no “one-size-fits-all” approach and the diversity of strategies across meaningful indicators of progress that HiAP efforts must be adaptive the country. Many strategies exist can strategically inform approaches and responsive to local context and to support joint government work; and increase access to funding, community needs. however, participants in our analysis support, and other resources. also expressed a great deal of barriers Prepare for the unexpected. and challenges to implementing Investing time to prepare for HiAP. Priorities for future efforts to unknown future circumstances support HiAP at the local level ought is important for the success to focus on articulating the benefit of HiAP. Local health officials of a whole government approach to identified challenges with staff and improving health, building capacity leadership turnover and working for cross-sector collaboration to in environments with limited engage in HiAP, and sustaining capacity and resources, which are initiatives over time. prevalent challenges across local government. While planning for all contingencies is impossible, it is important to consider ways to alleviate setbacks. Health in All Policies: Experiences from Local Health Departments 41

42 Moving Forward continued While many public health across multiple policy domains RECOMMENDATIONS professionals identify HiAP as to improve health. Examples of FOR SUPPORTING Hi AP innovative, it is important to other policy domains include IN LOCAL JURISDICTIONS recognize that public agencies and criminal justice system, economic departments across government development, and housing. There are many opportunities to outside of health departments may continue to support the field of • Create opportunities to share already be working to improve HiAP at the local level based on success and challenges. neighborhood conditions and the reflections of listening session Around the country, interest in quality of life, but haven’t had a and key inform-ant participants. HiAP is growing. It is important to framework for articulating how their Participants prioritized the share findings, successes, challenges, work supports health. By staying following recommendations. stories, and lessons learned to open and flexible to how health and continue to grow the field. Local its impacts are defined, partners can health officials can share their find ways to secure resources and • Evaluation. More evaluation is experiences implementing HiAP take advantage of opportunities to needed to understand changes in through conferences, webinars, align efforts in ways that generate health determinants and outcomes and group calls. meaningful change to improve from HiAP initiatives using both health and wellbeing. qualitative and quantitative data. Evaluation can help to demonstrate REPORT LIMITATIONS the impact of HiAP and the ability of these initiatives to improve health in This report has limitations that should the short and long term. be considered when reviewing and interpreting the recommendations. Developing the field. • Capacity The following considerations may building is a great need of the field. limit the ability to make definitive Trainings should focus on why HiAP statements or conclusions about HiAP is important and include more efforts across the country. specific information, such as how to engage with cross-sector partners • The geographic locations or how to determine potential of participants were not a strategies for implementation. representative sample of HiAP Case studies can be used to share efforts across the United States. information on how HiAP initiatives A limited number of listening • have been successfully implemented sessions and key informant and how a strategy might be discussions were conducted, with a tailored to different jurisdictions. small number of total participants. The achievement Health equity. • Despite these limitations, the of health equity is a central tenet assessment and findings establish for HiAP practice. HiAP initiatives an important understanding of the should continue to elevate health emerging field and progress towards inequities and differences in HiAP at the local level. It is intended neighborhood conditions and to identify initial accomplishments, work toward improving the developing themes, and promising health of communities facing areas for further growth of the field disproportionate impacts. and research. The findings and Expanding outside of built • recommendations presented can also inform future efforts, facilitating environment. Many early continued progress of HiAP in local locally based HiAP initiatives were jurisdictions. focused on improving community design and built environments. Additional opportunities exist Health in All Policies: Experiences from Local Health Departments 42

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44 References continued NACCHO Request for Proposals. (2014). Health in All 34. J. Collins and J. P. Koplan. (2009).Health Impact 24. Assessment: a step toward health in all policies. Policies at Local health Departments. JAMA: The Journal of the American Medical Association. 25. Yuen, T. (2014). Health in All Policies: Local Health 302(3): 315-317. Departments Driving Systems Change to Improve 13 (2): 18-19. Communities. NACCHO Exchange. City of Chicago. (2016). Mayor Emanuel’s ‘Health in 35. All” Resolution To Ensure that Health of Communities Association of State and Territorial Health Officials. 26. is At the Core of All Cities Policies. Retrieved from (2016). Health in All Policies: A Framework for State https://www.cityofchicago.org/city/en/depts/cdph/ Health Leadership. Retrieved on October 20, 2016 provdrs/healthychicago/news/2016/may/mayor- from http://www.astho.org/HiAP/Framework/. emanuel-s--health-in-all--resolution-to-ensure-that- health.html. 27. International Association for Public Participation. IAP2’s Public Participation Spectrum. Retrieved on October 20, 2016 from http://www.iap2. org/?page=A5. 28. Rudolph, L., Caplan, J., Ben-Moshe, K., & Dillon, L. (2013). Health in All Policies: A Guide for State and Local Governments. Washington, DC and Oakland, CA: American Public Health Association and Public Health Institute. 29. Iowa State University, University Extension. (2001). Land Use Series: The Comprehensive Plan. Retrieved on October 20, 2016 from http://www.rdgusa.com/ crp/ellis/ISU_Comprehensive%20Plan.pdf. Community health improvement plans (CHIP) 30. identify priority issues from the community health assessment, develop and implement strategies for action, and establish accountability to ensure measureable health improvement. NACCHO. Community Health Assessment and Improvement Planning. Retrieved from http://www.naccho.org/ programs/public-health-infrastructure/community- health-assessment. 31. Smart Growth America. (2016). The best complete streets policies of 2015. Retrieved October 20, 2016 from https://smartgrowthamerica.org/resources/best- complete-streets-policies-of-2015/. National Research Council of the National Academies. 32. (2011). Improving Health in the United States: The Role of Health Impact Assessment. Retrieved October 20, 2016 from https://www.nap.edu/catalog/13229/ improving-health-in-the-united-states-the-role-of- health. L. M. Gottlieb, J. E. Fielding, and P. A. Braveman. 33. (2012). Health Impact Assessment: Necessary but Not Sufficient for Healthy Public Policy. Public Health Reports. 127(March-April): 156-162. Health in All Policies: Experiences from Local Health Departments 44

45 | Appendix 1 Listening Session/Key Informant Questions Partnerships Opening Questions Based on your experience, how did HiAP begin at 1. 1. What new partners were formed (e.g., academic- your LHD or if you are not with an LHD, please talk practice partnership?) How involved were these about your experience with HiAP in communities? partners during the HiAP implementation? (Only ask if you are speaking with LHD) 2. How has the project affected relationships with your Did you have training on HIA or HiAP training before 2. partners outside of the HiAP work? you began the project? Please discuss the training to preparation activities that took place before you began the project. Outcomes 1. What were the outcomes of the HiAP process? 3. How was your HiAP funded (grant funded, LHD (Policy change, partnerships, new initiatives, etc.) funded, etc...)? 2. How did you measure outcomes? How did leadership in your LHD or within the HiAP 4. project that you contributed to engage in the 3. Would you consider the HiAP process successfully implementation? implemented at your LHD or in your community? Why or why not? Changes in Public Health Practice What tools and resources have you identified as your 1. Sustainability needs for working on an effective HiAP project before 1. How has momentum been sustained throughout the project? your HiAP work? How did your LHDs capacity change over time while 2. 2. What advice would you give to other local health working on HiAP? departments of similar size who are interested in getting started with a HiAP project for the first time? Challenges What are/were the biggest challenges during the 1. HiAP project and how are/were they overcome? Experiences from Local Health Departments APPENDIX 1 Health in All Policies: 45

46 | Appendix 2 List of HiAP Tools and Resources List of HiAP tools and resources for local health officials: AUTHOR TITLE DESCRIPTION TYPE Guide or Primer This document informs local health departments and other NACCHO Health in All Policies agencies and stakeholders about HiAP. The FAQs defines what (HiAP): Frequently HiAP is, how it is different from other health policies, gives a brief Asked Questions history of HiAP, how health equity and environmental health play (N/D) in HiAP, and defines terms related to HiAP. NACCHO, The webinar, hosted by NACCHO and PolicyLink, focuses Webinar Implementing PolicyLInk specifically on why equity is critical to HiAP and Health Impact Equity in Health in Assessments (HIAs), and specific strategies to implement and All Policies & Health ensure equity. The speakers discuss principles and frameworks Impact Assessments: for the inclusion of equity, as well as present examples of the From Concept to principles in practice. Action (2013) Tool NACCHO This Environmental Health in All Policies Meeting-in-A-Box Environmental presentation is a modifiable PowerPoint presentation that can be Health in All Policies used to educate leadership, community members, or local health Meeting-in-A-Box department staff on HIAP. The presentation is broad so it can be (2013) adapted for a wide audience. Although it is meant to serve as a guide, it should be tailored to reflect the local context and what is feasible, given the community’s needs. King County Model King County adopted the King County Strategic Plan 2010 King County, Ordinance 16948 - 2014 and included a fair and just principle that serves all WA ordinance or (2010) EO residents of King County by promoting fairness and opportunity and eliminating inequities. County leaders passed this ordinance in order to define and systematize the implementation of the fair and just principle. Getting started Li Ka Shing Guide or Primer This document is a review of identified literature describing with “Health in All international examples of health equity-focused HiAP. A total of Knowledge Policies”: A resource Institute 4,833 scholarly articles and 501 sources of grey literature were pack (2011) gathered and screened. This report is a conceptual framework describing the initiation and implementation stages of HiAP approaches, a discussion of comparisons and trends found in the case studies uncovered through the literature search. APPENDIX 2 Health in All Policies: Experiences from Local Health Departments 46

47 Appendix 2 | continued List of HiAP Tools and Resources AUTHOR TITLE TYPE DESCRIPTION The “Discussion Paper on Intersectoral Action on Health: WHO Guide or Primer Discussion Paper A Pathway for Policy-Makers to Implement Effective and Intersectoral Action Sustainable Intersectoral Action on Health” was developed by on Health: A Path the World Health Organization. It provides a brief primer on for Policy-Makers to intersectoral action for improving health and then provides an Implement Effective overview of 10 steps necessary to implement intersectoral action. and Sustainable It closes with a few case examples from around the globe. Intersectoral Action This discussion paper is especially useful for local jurisdictions on Health (2011) looking for a brief, concise description of one approach toward advancing HiAP in a community. 7th Global “Moving Forward to Equity in Health” is a document that was Moving Forward Conference prepared for discussion at the 7th Global Conference on Health to Equity in Health: Promotion, “Promoting Health and Development: Closing the What Kind of Implementation Gap” and discusses how working across sectors Intersectoral Action is can help form cohesive policies that addresses health as whole, Needed? An approach which is a key objective of HiAP. This document can serve as to an intersectoral to resource to educate those who are unfamiliar with the HiAP typology (2009) concept and spur discussion on how to implement HiAP through cross-sectoral collaboration in their communities. WHO Guide or Primer This document is a guide that policymakers can use to promote Intersectoral Action intersectoral health initiatives in their jurisdictions. The guide on Health: A Path discusses about two overall strategies for intersectoral health, for Policy-makers to including HiAP, and provides real-examples of multi-sector health implement effective initiatives. and sustainable action on health (2011) Guide or Primer The Adelaide Statement on HiAP is to engage leaders and Government Adelaide Statement policymakers at all levels of government - local, regional, of South on Health in All national, and international. It emphasizes that government Australia and Policies: Moving objectives are best achieved when all sectors include health and WHO Towards a Shared wellbeing as key components of policy development. Governance for Health and Wellbeing (2010) NACCHO Exchange The Spring 2014 issue of NACCHO Exchange, NACCHO’s NACCHO Guide or Primer Spring 2014 Issue quarterly magazine, highlights HiAP efforts across the county. focused on HiAP This issue contains the following feature stories: How Community (2014) Health Improvement Process Helped to Build Momentum for HiAP Approaches in New Orleans; Greening Mid-Michigan: A Health in All Policies Approach for Mid-Size Local Governments; King County: Building Health, Equity, Fairness, and Opportunity with a Health in All Policies Approach; Integrating Health in All Policies: Two Case Studies from San Francisco; and Health Policy beyond the Health Department. NACCHO Guide or Primer The factsheet provides an overview of seven strategies that Local Health can help jurisdictions implement HiAP, with a focus local Department health departments. The seven strategies are grounded in a Strategies for comprehensive literature review of academic and grey literature Implementing Health and a review of case studies. in All Policies (2014) Health in All Policies: Experiences from Local Health Departments 47

48 Appendix 2 : List of HiAP Tools and Resources continued Appendix 2 continued List of HiAP Tools and Resources Appendix 2 | TYPE DESCRIPTION AUTHOR TITLE NACCHO The webinar showcased the implementation of HiAP in three Webinar Implementing U.S. cities – Houston, Baltimore City, and San Diego - with Health in All the aim of discussing how local health departments and Policies at the Local their partners are implementing HiAP approaches in their Level: Experiences communities, successful strategies and tactics to implement from Local Health HiAP, and lessons learned from their experiences engaging in Departments (2014) this work to improve the health of communities using a multiple determinants of health framework Guide or Primer In this discussion paper, the authors define the HiAP concept, Health in All Policies: Institutes of explain the need for HiAP approaches to confront complex Medicine Improving Health and current health challenges in the population, and provide Through Intersectoral Roundtable an overview of California’s pioneering experience with cross- on Population Collaboration (2013) sector collaboration to address the social determinants of Health health. The paper includes an analysis of key challenges and Improvement opportunities likely to arise when communities undertake health in all policies efforts. Introduction to HiAP This factsheet provides a general overview of HiAP by providing Guide or Primer ASTHO information on the National Prevention Strategy, the role of state (N/D) and territorial health agencies, and HiAP key messages. This resource aims to educate and empower public health leaders Guide or Primer ASTHO Health in All Policies: to promote a HiAP approach to policy-making and program Strategies to Promote development. A description of the National Prevention Strategy is Innovative Leadership enclosed along with key talking points to explain a HiAP approach to (2013) other leaders in your state or locality’s government, characteristics of successful cross-sector collaboration, and a collection of state stories. The stories are organized based on the following characteristics of successful cross-sector collaboration: creating shared goals, engaging partners early/ developing partner relationships, defining a common language, activating the community, and leveraging funding/ investments. This document provides an overview of the dependency of HiAP Guide or Primer ASTHO Health in All Policies: approaches on collaboration. Because collaboration is essential for Collaboration (N/D) integrating HiAP, strategies for successful collaboration, as well as sample agenda for a partnering meeting, are included in this guide. This document provides an overview of implementation strategies Guide or Primer ASTHO Health in All Policies: that include elements of collaboration, education, assessment, Implementation consultation, program development, and policy. Strategies (N/D) This guide was written by the backbone staff of the California HiAP Health in All Policies: PHI, APHA, Guide or Primer Task Force and is geared toward state and local government leaders A Guide for State and CDC, and who want to use intersectoral collaboration to promote healthy Local Governments CDPH environments. This guide provides a broad range of perspectives (2013) and examples. The authors reviewed the published peer-reviewed and grey literature and interviewed people working in formal and informal intersectoral collaborative government processes to promote health at local, state, and national levels. Experiences from Local Health Departments APPENDIX 2 Health in All Policies: 48

49 Appendix 2 : List of HiAP Tools and Resources continued continued Appendix 2 | List of HiAP Tools and Resources Appendix 2 | continued List of HiAP Tools and Resources TITLE AUTHOR TYPE DESCRIPTION Sustainable DC Model District of Washington DC created the Sustainable DC Plan and includes Transformation Order ordinance or Columbia principles that establish sustainability as a priority in the (2013) EO operations of District government agencies, which includes coordination across agencies to embed practices to improve public health. The order creates a HiAP Task Force, which is tasked with developing recommendations to advance health equity among District residents and strengthen the vitality of all communities. This document is the summary of a workshop convened in Institute of Applying a Health Guide or Primer September 2013 on Population Health Improvement to foster cross- Lens to Decision Medicine sectoral dialogue and consider the opportunities for and barriers Making in Non-Health to improving the conditions for health in the course of achieving Sectors (2014) other societal objectives. The workshop engaged members on three core issues: supporting fruitful interaction between primary care and public health; strengthening governmental public health; and exploring community action in transforming the conditions that influence the public's health. This report is a discussion of health in all policies approaches to promote consideration for potential health effects in policy making in many relevant domains, such as education, transportation, and housing. This document is a training resource to increase understanding of WHO Guide or Primer Health in all policies the importance of HiAP among health and other professionals. The training manual material will form the basis of 2- and 3-day workshops. (2015) ASTHO's position statement supporting HiAP recommends working ASTHO Position Health in All Policies across sectors to improve public health and recommends HiAP as statement Position Statement a strategy for moving state and territorial health agencies and their (2013) partners closer to the goals of health equity and addressing the social and environmental determinants of health. NACCHO support HiAP, and this policy statement advocates that Position NACCHO Statement of Policy: local health departments are best positioned to implement HiAP statement Health in All Policies in their local jurisdictions. LHDs can choose from a variety of (2012) strategies that advance HiAP. The document provides a foundation and a framework for how Health in All Policies: ASTHO Guide or Primer different sectors and levels of government can implement HiAP, A Framework for State and includes examples of successful outcomes from using a Health Leadership HiAP approach. (N/D) The model policies are specifically designed to help communities ChangeLab Model Health in All Policies institutionalize a HiAP approach, ensuring that structural change Solutions ordinance or Model Policies (2015) is sustained over time, even when there are shifts in staffing and EO leadership. The three models offer options for communities at different stages of readiness, or that face different opportunities to create change: model ordinance, model resolution, and HiAP in General Plans. The presentation illustrates the connection between our health, Tool A Health in All Policies ChangeLab public policy, and the environment. The presentation calls for a Presentation (2015) Solutions collaborative approach to policymaking to improve the health of a community. The presentation can be tailored to include local community examples. Health in All Policies: Experiences from Local Health Departments 49

50 Appendix 2 Appendix 2 | List of HiAP Tools and Resources continued DESCRIPTION TYPE AUTHOR TITLE This comprehensive toolkit provides a guide with tools and resources ChangeLab Guide or Primer From Start to Finish: and best practices for implementing HiAP. The toolkit includes a Solutions How to Permanently guide, which is an introduction to HiAP and outlines 5 key strategies Improve Government for effectively adopting a more formalized HiAP initiative. Through Health in All Policies (2015) This toolkit includes tools and resources that have been developed Environmental Health Tool NACCHO and used to help local decision makers educate and raise awareness in All Policies Toolkit about HiAP and environmental health policy. (2016) The webinar examines HiAP initiatives and how they have been Health in All Policies Webinar APHA developed and implemented. and the Law (2015) The City of Richmond passed the HiAP resolution in 2014. The Model Richmond, City of Richmond strategy sets a framework of collaboration within city departments as CA ordinance or Health in All Policies well as with community-based organizations and other government EO Ordinance (2014) agencies to address community health, equity, and sustainability in Richmond. The publication addresses the ways in which health perspectives Guide or Primer Ministry of Health in All Policies: can be incorporated into public policies in practice. The main Social Affairs Seizing opportunities, emphasis is on national policymaking and on issues related to health and Health, implementing policies promotion and social determinants of health, although HiAP is a Finland, (2013) broader concept that encompasses all levels of policymaking and health systems functioning. The Framework sets out six key components that should be Guide or Primer WHO Health in All Policies addressed in order to put the HiAP approach into action: establish (HiAP) Framework the need and priorities for HiAP, frame planned action, identify for Country Action supportive structures and processes, facilitate assessment and (2014) engagement, ensure monitoring and evaluation, and build capacity. These components are not fixed in order or priority. Rather, individual governments can adopt and adjust the components in ways that are most relevant for their specific governance, economic, and social contexts. APPENDIX 2 Health in All Policies: Experiences from Local Health Departments 50

51 List of HiAP Tools and Resources continued Appendix 2 | | Appendix 3 Literature Review Similarly, NACCHO defines HiAP generally as, “a change in The purpose of this literature review is to provide an overview the systems that determine how decisions are made and on trends in both peer-reviewed and gray literature relating implemented by local, state, and federal governments to to Health in All Policies (HiAP) in the United States, with a ensure that policy decisions have neutral or beneficial impacts focus on local government. This review is partially built on 2 on health determinants.” the work of Gase et al published in the Journal of Public Health Management and Practice in 2013, which thoroughly reviewed literature published on HiAP implementation.1 Gase Incredibly, over the last decade, HiAP has flourished by et al defined HiAP as, “incorporating health into decision providing strategic approaches for embedding health in 1 making by (or working with) non-health sectors.” decision making across non-health sectors and developed To review into a public health subfield. The increasing trend over time literature based on this broad definition, Gase et al included the of the search results using the PubMed database for the term following search terms in the review: “health in all policies”, “health in all policies” is illustrated in the graph below: “healthy public policy”, “inter-sectoral action on health”, “social determinants of health”, and “cross-agency/cross sector efforts”. In an effort to build on and update this review NACCHO used the same. FIGURE 1. Number of search results by year for “Health in All Policies” in PubMed, through August 31, 2015 30 25 20 15 10 Number of Publications 5 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year 51 Experiences from Local Health Departments Health in All Policies:

52 Appendix 2 List of HiAP Tools and Resources continued : Appendix 2 continued Appendix 3 | Literature Review 6 operationalize HiAP. There is a lack Intersectoral action Healthy Public Health in All of differentiation between HiAP and Policy: for health: Policies: other inter-sectoral strategies, but less integrated approaches can make Efforts by the Characterized by A horizontal, attempts at providing guidance health sector an explicit complementary for evaluating implementation less to work concern for policy-related strategy rigorous; Shankardass et al note that, collaboratively health and equity with a high potential with other sectors in all areas of to contribute to “existing literature rarely describes of society to policy and by an population health. ISA [inter-sectoral action] initiatives achieve improved accountability for The core of Health in that address midstream or structural health outcomes health impact All Policies is to determinants typically addressed by examine determinants 7 of health, which can HiAP.” be influenced to improve health but Definitional issues aside, as are mainly controlled by policies of sectors the number of public health other than health. professionals that recognize HiAP grows, the field is moving from describing the “what” of HiAP, to 4 6,8 Patterns in the literature describing the “how”. Jurisdictions within the United States have been slower to adopt HiAP than The trend depicted above also exists for the search term, “social in other countries. Finland, Australia, and New Zealand were determinants of health” (SDOH) where interest increased after all early adopters of HiAP at the national level, yet to date, the World Health Organization (WHO) Commission on Social there has been no nationwide movement in the United States. Determinants of Health published their final report titled, 3 Although, federal interagency efforts to integrate policies do “Closing the Gap in a Generation” in 2008. exist that were spurred in part by the Affordable Care Act’s As a result, the scope of this review is limited to using a 9 (ACA) National Prevention Strategy. The U.S. Department typology of integrated public health policy (IPHP) approaches, 4 of Housing and Urban Development, for example, embraced as described by Kickbusch in 2010. This typology the call to collaborate across agencies, examples of such differentiates between three waves of IPHP approaches, efforts include the Neighborhood Revitalization Initiative and from the less integrated “inter-sectoral action”, to “healthy 10 the Sustainable Communities Partnership. However, federal public policy”, to the most integrated approach, “health in efforts are complicated by political barriers, including repeated all policies”. Kickbusch cautions that these terms are often 4 efforts to repeal the ACA and attempts to significantly decrease used interchangeably. However, using this continuum allows 11 5 the Prevention and Public Health Fund. Despite political different interpretations to coexist. Therefore, all three terms difficulties, however, recognition of HiAP continues to expand. were used in the PubMed search for peer-reviewed literature and in Google for gray literature. Because the intent of this To support these promising efforts, several capacity-building review is to focus on HiAP in the United States with a focus on resources and “how-to” guides have been published in recent local government implementation, the results were limited by years, including ChangeLab Solutions, “From Start to Finish: removing case studies focused primarily outside the United How to Permanently Improve Government through Health States, unless they specifically address an aspect of HiAP at the in All Policies”, “Health in All Policies: A Guide for State and local level. Local Governments”, a joint publication of The California Endowment, the American Public Health Association, the As noted above, defining HiAP remains inconsistent in California Department of Public Health, and the Public Health the literature. “Health in All Policies” is one of a number Institute, and the World Health Organization’s comprehensive of integrated policy approaches, but is often used either 12, 13, 14 “Health in All Policies Training Manual”. as an umbrella term for all integrated policy efforts, or interchangeably with other terms. Authors such as Hendriks Much of the literature summarizes case studies to provide et al have attempted to address these inconsistencies by using examples of HiAP implementation. U.S. case study examples “defining characteristics” and “operational criteria” as a means include Seattle/King County, Richmond, California and the state of sorting through the myriad of definitions offered in order to Experiences from Local Health Departments APPENDIX 3 Health in All Policies: 52

53 Appendix 2 List of HiAP Tools and Resources continued : continued Literature Review Appendix 3 | continued Literature Review Appendix 3 | 15,16,17 of California. These training guides and case examples CONCLUSION often highlight the role of the health sector, especially local This review demonstrates that while interest in and health departments as the convener and facilitator for HiAP implementation of HiAP approaches are growing tremendously, 12 efforts. Internationally, “Healthy Cities” initiatives are a HiAP remains in a developmental stage. As noted above, common approach at the local level, with health sectors taking terms used to describe various inter-sectoral approaches are 12,18 a leadership role. As Rantala et al state, local governments often used interchangeably, thus making it challenging to are able to directly influence urban determinants of health differentiate what distinguishes HiAP from other strategies as well as elicit citizen participation, making them unique – a limitation of this review itself. In addition, since HiAP is 19 arenas for inter-sectoral approaches. Though, with a local relatively new to the United States compared to Europe and approach, also comes the recognition that the type of upstream Australia, much of the literature is not specific to the United intervention promoted by HiAP “cannot be easily replicated States context. As more initiatives are established and existing 20 from one context to the rest”. initiatives evolve, more case studies will be available to provide more evidence for implementation and evaluation. The next As HiAP move from the “what” to the “how”, there is an section will explain the methods used to identify participants increasing need for more rigorous evidence to support and collect qualitative data about local level HiAP initiatives 21,22,23,24 implementation strategies. Several challenges have across the United States. limited evaluation efforts. Bauman et al identified the following concerns; the need to move beyond process/implementation REFERENCES evaluation toward outcomes evaluation; evaluation results Gase, L. N., Pennotti, R., & Smith, K. D. (2013). “Health 1. from initiatives, such as South Australia; often focus on process; in All Policies”: Taking Stock of Emerging Practices to and one review of public policy literature on “joined-up Incorporate Health in Decision Making in the United States. government” approaches found no empirical evaluations for 19,25 Journal of Public Health Management and Practice, 19(6), HiAP. Researchers are beginning to propose evaluation tools 25,26,27 529-540. and frameworks for both process and outcome measures. Recognizing that many HiAP initiatives are still in their infancy, 2. [Fact All Policies NACCHO Fact Sheet. (December 2014). Storm et al developed a maturity model enumerating six http://archived.naccho.org/topics/ sheet}. Retrieved from stages of HiAP in communities, depending on how many of environmental/HiAP/upload/factsheet_hiap_dec2014-1.pdf 28 14 characteristics they exhibit. Efforts to evaluate outcomes, “Closing the Gap in a Generation” in 2008. Marmot, M., 3. as opposed to process, can be hindered by the long-term Friel, S., Bell, R., Houweling T. A., Taylor, S., & Commission nature of HiAP approaches; potential improvements to health on Social Determinants of Health. (2008). Closing the gap 19 outcomes may take years to come to fruition. Greaves and in a generation: health equity through action on the social Bialystok also note that evidence about HiAP “is generally determinants of health. The Lancet, 372(9650), 1661-1669. correlative and descriptive”, rather than causal, further reiterating the challenges of empirical evaluation; when Kickbusch, I. (2010). Health in all policies: where to from 4. applying an inter-sectoral approach to obesity, Hendriks et al Health promotion International, here? 25(3), 261-264. identified a lack of scientific evidence about effective solutions 5. Peters, D., Harting, J., van Oers, H., Schuit, J., de Vries, N., 29, 30 as a barrier to collaboration. & Stronks, K. (2016). Manifestations of integrated public health policy in Dutch municipalities. Health promotion international, 31(2), 290-302. 6. Hendriks, A. M., Habraken, J., Jansen, M. W., Gubbels, Definitions (What) J. S., De Vries, N. K., van Oers, H., ... & Kremers, S. P. (2014). ‘Are we there yet?’–Operationalizing the concept Health policy, 114(2), of Integrated Public Health Policies. 174-182. Implementation Guides (How) 7. Shankardass, K., Solar, O., Murphy, K., Greaves, L., & O’Campo, P. (2012). A scoping review of intersectoral action for health equity involving governments. Evaluation (Why) International Journal of Public Health, 57(1), 25-33. Experiences from Local Health Departments Health in All Policies: 53

54 : continued List of HiAP Tools and Resources Appendix 2 Appendix 2 Literature Review continued Appendix 3 | 21. 8. Carey, G., Crammond, B., & Keast, R. (2014). Puska, P. (2014). Health in all policies—from what to how. 24(1), 1-1. The European Journal of Public Health, Creating change in government to address the social determinants of health: how can efforts be improved?. 9. Institute of Medicine Annual Report 2014. (2014). 14(1), 1. BMC Public Health, http://www. Retrieved August 19, 2016, from surgeongeneral.gov/priorities/prevention/advisorygrp/ 22. Shankardass, K., Renahy, E., Muntaner, C., & O’Campo, . index.html P. (2014). Strengthening the implementation of Health in All Policies: a methodology for realist explanatory case 10. Bostic, R. W., Thornton, R. L., Rudd, E. C., & Sternthal, czu021. Health Policy and Planning, studies. M. J. (2012). Health in all policies: the role of the US Department of Housing and Urban Development and 23. Bert, F., Scaioli, G., Gualano, M. R., & Siliquini, R. 31(9), 2130- Health Affairs, present and future challenges. (2015). How can we bring public health in all policies? 2137. Journal of public health Strategies for healthy societies. research, 4(1). 11. Eyler, A. A., Chriqui, J. F., Moreland-Russell, S., & 24. Brownson, R. C. (n.d.). Prevention, policy, and public Ollila, E. (2011). Health in all policies: from rhetoric to health. action. 39(6 suppl), Scandinavian Journal of Public Health, 11-18. ChangeLab Solutions. From Start to Finish. How to 12. Permanently Improve Government Through Health 25. Bauman, A. E., King, L., & Nutbeam, D. (2014). http://www. 2015. Available from in All Policies. Rethinking the evaluation and measurement of health in . changelabsolutions.org/publications/HiAP_Start-to-Finish all policies. (suppl 1), Health promotion international,29 i143-i151. Rudolph, L., Caplan, J., Ben-Moshe, K., & Dillon, L. (2013). 13. Health in All Policies: A guide for state and local governments. Baum, F., Lawless, A., Delany, T ., Macdougall, C., 26. American Public Health Association. Williams, C., Broderick, D., ... & Popay, J. (2014). Evaluation of Health in All Policies: concept, theory and World Health Organization’s comprehensive “Health 14. application. (suppl 1), Health promotion international, 29 World Health in All Policies Training Manual” (2014). i130-i142. (2015). Health in all policies: training Organization. manual. Shankardass, K., Renahy, E., Muntaner, C., & O’Campo, 27. P. (2014). Strengthening the implementation of Health 15. Wernham, A., & Teutsch, S. M. (2015). Health in all in All Policies: a methodology for realist explanatory case policies for big cities. Journal of Public Health Management Health Policy and Planning, studies. czu021. and Practice, 21, S56-S65. 28. Storm, I., Harting, J., Stronks, K., & Schuit, A. J. (2014). 16. Corburn, J., Curl, S., Arredondo, G., & Malagon, J. (2014). Measuring stages of health in all policies on a local Health in all urban policy: city services through the prism Health Policy, level: the applicability of a maturity model. 91(4), 623-636. of health. Journal of Urban Health, 114(2), 183-191. Polsky, C., Stagg, K., Gakh, M., & Bozlak, C. T. (2015). 17. Greaves, L. J., & Bialystok, L. R. (2011). Health in all 29. The Health in All Policies (HiAP) approach and the law: policies–all talk and little action?. Canadian Journal of The preliminary lessons from California and Chicago. Public Health/Revue Canadienne de Sante’e Publique, 407- 43(s1), 52-55. Journal of Law, Medicine & Ethics, 409. World Health Organization. (2014). Health in all policies: 18. 30. Hendriks, A. M., Kremers, S. P., Gubbels, J. S., Raat, H., Geneva: Helsinki statement. Framework for country action. de Vries, N. K., & Jansen, M. W. (2013). Towards health WHO. Journal of in All policies for childhood obesity prevention. 19. Rantala, R., Bortz, M., & Armada, F. (2014). Intersectoral obesity, 2013. Health action: local governments promoting health. promotion international,29 (suppl 1), i92-i102. World Health Organization. (2015). Health in all policies: 20. training manual. Health in All Policies: Experiences from Local Health Departments APPENDIX 3 54

55 continued Appendix 2 : List of HiAP Tools and Resources Appendix 3 | Literature Review continued Experiences from Local Health Departments Health in All Policies: 55

56 The National Association of County and City Health Officials (NACCHO) represents the nation’s nearly 3,000 local governmental health departments. These city, county, metropolitan, district, and tribal departments work every day to protect and promote health and well- being for all people in their communities. 1100 17th St, NW, Seventh Floor Washington, DC 20036 P 202-783-5550 F 202-783-1583 WWW.NACCHO.ORG

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STATE OF NEW YORK 2 0 1 9 T E N T A T I V E A S S E S S M E N T R O L L PAGE 1 VALUATION DATE-JUL 01, 2018 COUNTY - Niagara T A X A B L E SECTION OF THE ROLL - 1 CITY - North Tonawanda TAX MAP NUMBER ...

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clp en

Guidance on the Application of the CLP Criteria – July 2017 1 Version 5.0 G U I D A N C E Guidance on the Application of the CLP Criteria Guidance to Regulation (EC) No 1272/2008 on classification, la...

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ERP 2019

ERP 2019

Economic Report of the President Together with The Annual Report of the Council of Economic Advisers M a rc h 2019

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Justification Book

UNCLASSIFIED Department of Defense Fiscal Year (FY) 2019 Budget Estimates February 2018 Office of the Secretary Of Defense Defense-Wide Justification Book Volume 3B of 5 Research, Development, Test & ...

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me bpd eng

2017–18 Estimates Parts I and II The Government Expenditure Plan and Main Estimates ESTIMATES ESTIMATES

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StateoftheClimate2017 lowres

STATE OF THE CLIMATE I N 2017 Special Supplement to the Bulletin of the American Meteorological Society Vol. 99, No. 8, August 2018

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tsa4

tsa4

i i “tsa4_trimmed” — 2017/12/8 — 15:01 — page 1 — #1 i i Springer Texts in Statistics Robert H. Shumway David S. Sto er Time Series Analysis and Its Applications With R Examples Fourth Edition i i i ...

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mar19 medpac entirereport sec

mar19 medpac entirereport sec

MARCH 2019 Report to the Congress: Medicare Payment Policy REPOR G RESS T TO THE CON Medicare Payment Policy | March 2019 Washington, DC 20001 425 I Street, NW • Suite 701 • (202) 220-3700 • Fax: (202...

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World Report 2018 Book

A M U H N S T H G I R C W A T H D R E P O O R T| 2 0 1 8 W R L S 7 0 2 O 1 T N E V E F

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17 8652 GSR2018 FullReport web final

17 8652 GSR2018 FullReport web final

RENE WA BL E S 2018 GLOBAL STATUS REPORT A comprehensive annual overview of the state of renewable energy. 2018

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Fannie Mae 2017 Form 10 K

Fannie Mae 2017 Form 10 K

UNITED ST ATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 Form 10-K O SECTION 13 OR 15(d) ANNUAL REPORT PURSUANT T ACT OF 1934 OF THE SECURITIES EXCHANGE For the fiscal year ended Decem...

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283100

283100

Country Reports on Terrorism 2017 September 2018 ________________________________ United States Department of State Publication Bureau of Counterterrorism Released 2018 September Country Reports on Te...

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WEF GGGR 2017

Insight Report The Global Gender Gap Report 2 017

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Art & Finance report 2017

Art & Finance report 2017

Art & Finance Report 2017 th edition 5 REFUGEE ASTRONAUT II © YINK A SHONIBARE MBE (2016), PHOTOGRAPHER: STEPHEN WHITE

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VAM Book

VAM Book

                                                 

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