Priority 8 – Increase Health Equity, Eliminate Disparities, and Address Social Determinants of Health

The NC Title V Program is committed to increasing health equity, eliminating disparities, and addressing social determinants of health as cited in Priority Need 8. In previous MCH Block Grant applications, the NC Title V Program showed this commitment by working to apply an equity lens within each of the priorities related to population domains, but in the 2020 Needs Assessment, it was clear that a separate priority need specific to increasing health equity was required. While there are racial and ethnic disparities found in too many different maternal and child health outcomes, the selected SPM for this priority need, the ratio of black infant deaths to white infant deaths, is a sentinel measure. Unfortunately, while mortality rates for black and white infants both were at then historic lows in 2018 at 12.2 and 5.0 per 1,000 infants, respectively, NC has not shown any progress in reducing the Black:white disparity ratio over the past two decades. The ratio was 2.3 in 1999, was at its highest at 2.9 in 2009, dropped to its lowest point at 2.2 in 2015, and was 2.7 in 2020. The small gains made during this time were generally due to an increase in the white infant mortality rate rather than a decrease in the black infant mortality rate. In addition to being a SPM, reducing this disparity ratio is a performance measure in the DPH Strategic Plan, an overarching objective in the Perinatal Health Strategic Plan, a goal of the NC Early Childhood Action Plan, and an indicator in Healthy North Carolina 2030.

The WICWS houses several programs/initiatives (Healthy Beginnings, Healthy Start Baby Love Plus, Improving Community Outcomes for Maternal and Child Health, and the Infant Mortality Reduction Program) focused on reducing infant mortality and the Black:white disparity ratio as well as inequities between other racial and ethnic groups. Descriptions of these programs and their achievements and plans can be found in the Perinatal/Infant Health Domain.

DPH Health Equity Framework

The NC Title V Office, the WICWS, and the DCFW/WCHS are working on eliminating disparities and increasing health equity in various ways including providing staff training, creating health equity teams, and ensuring that data are analyzed by race/ethnicity and other demographics as much as possible. The Division’s Health Equity Committee developed a Health Equity Framework released in 2020 with these five priority strategies:

1. Utilize data, research, and evaluation to identify and respond to the causes and consequences of health inequity
2. Create opportunities for engaging priority populations in planning, implementing and evaluating DPH strategies
3. Collaborate with partners working to positively impact health of priority populations and the determinants of health
4. Build capacity of Division staff to advance health equity
5. Use tailored communication strategies to educate partners

While work on structurally embedding these strategies into the work of the NC Title V Program was limited in some ways during FY21 due to work assignments brought on by the COVID-19 pandemic, the need for implementing this framework or other health equity strategies was magnified due to the longstanding health inequities brought to light by the pandemic.

DPH Foundational Health Equity Training

The SDoH COIIN team, which was shepherded by a member of the WICWS and a colleague with the NC Chapter of the March of Dimes, developed a foundational health equity training module which was scheduled to be released to all DPH employees as a module in the Learning Management System (LMS) during FY21. The training uses components of the Health Equity and Environmental Justice 101 training created by the Colorado Department of Public Health and Environment’s Office of Health Equity as well as videos and other materials specific to NC. Due to a variety of reasons, mostly because of the pandemic workload, but also because of the reorganization plans for a new Office of Health Equity and the hiring of the Department’s first Chief Health Equity Officer, the training has not yet been approved for use by NCDHHS. The initial plan was for the training to be required of every DPH/DCFW employee, thus Objectives CCSB 8A.1. (% of NC Title V Program staff who complete the Health Equity Foundational Training annually will be at least 90%) and CCSB 8A.2 (% of NC Title V Program staff who complete the HE Foundational Training within 3 months of hire will be 100%) should be achievable and easily tracked and monitored in LMS once it is completed. After receiving the training, employees will be invited to participate in debrief sessions held by trained facilitators. It is hoped that this foundational training will ensure that all employees have a basic understanding of health equity principles, but that the learning will not stop with just this training. Other resources will be offered within the module, and the NC Title V Program will continue to encourage professional development and continuing education by staff members in this area.

While the foundational health equity training module has not been implemented, Unconscious Bias training modules were assigned to all Cabinet agency employees, which includes all NCDHHS employees, through LMS during FY21. The training included 14 e-learning modules totaling 75 minutes in duration. The modules covered a range of topics including: Why Everyone Has Unconscious Bias; Interrupt Your Bias in the Moment; and How Unconscious Bias Affects Your Work, Whether You Know It or Not.

DPH Health Equity Survey

In January 2020, the DPH Health Equity Committee conducted the DPH Health Equity Survey using a stratified random sample sampling design with organization units as strata. This survey was designed to measure how Division staff members understand and practice health equity at work by measuring the extent to which they 1) recognized the influence of social factors on health, 2) had a knowledge of foundational terms and concepts, and 3) recognized DPH Health Equity Framework strategies as components of their own work activities. The survey was intentionally deployed prior to release of the DPH Health Equity Framework so that a true baseline of health equity knowledge and practices could be obtained. The survey, which was optional, not required, was sent to 408 employees and yielded a 55% response rate. Initial results showed that while 86% of respondents were knowledgeable about the term health disparity, only 53% were knowledgeable about the term health equity. With regard to the five framework priority strategies, respondents agreed that all were important to their roles (range from 51% for “Build capacity of Division staff to advance health equity” to 72% for “Collaborate with partners to impact the health of priority populations”), but not as many respondents thought that these strategies were actually a part of their role, in particular to “Build capacity of Division staff” (29%) and “Create opportunities to engage priority populations in planning, implementing, and evaluating strategies” (34%). In response to the question of “In your opinion, how much does DPH focus on addressing health inequities?”, 28% said the right amount, 32% said not enough, 1% said too much, and 39% said they did not know.

The NC Title V Program conducted this same survey in December 2020 with all of its staff members to get baseline data for the percent of NC Title V Program respondents to the DPH Health Equity Survey who agree that the five strategies are important to their work in DPH and also the percent of NC Title V Program respondents who can appropriately define the terms health equity, health disparity, and determinants of health. With an overall survey response rate of 48%, the results indicate that there is still much work to be done as only 51% of respondents could define health equity. More respondents (88%) could define health disparity, and while 90% or better identified income, employment, housing, education, and social supports as determinants of health, only 43% of respondents identified leadership as a determinant, and 47% identified political influence as one. Thirty-four percent of respondents thought that there is not enough focus on health inequities within DPH and 31% of respondents thought there was not enough focus within the NC Title V Program. The majority of respondents said that the DPH Health Equity Framework strategies were important to their work, with the highest percentage (78%) agreeing that two strategies (using tailored communication strategies to educate partners and collaborating with partners working to positively impact health of priority populations and the determinants of health) were the most important. As DPH has not conducted a follow-up survey as of yet, the NC Title V Program did not conduct a survey in 2021 and is determining how often the survey should be done internally.

Additional NC Title V Program Health Equity Plans and Activities

In the scope of work in the agreement addenda and contracts with LHDs, universities, hospitals, and community-based organizations for all programs in the WICWS, inclusive of maternal health, family planning, sickle cell, preconception health, TPPI, etc., some of which are funded completely by Title V, the WICWS includes the following requirement:

All staff, clinical and non-clinical, shall participate in at least one training annually focused on health equity, health disparities, or social determinants of health to support individual competencies and organizational capacity to promote health equity.

To help the funded partners access good trainings, the WICWS has posted the Resources for Promoting Health Equity – September 2021 training resource sheet on their website.

The WICWS also continues to provide opportunities for staff to participate in the Phase I 2-day Racial Equity Institute Foundational Training and Racial Equity Institute Groundwater Training, along with opportunities for small group discussions. In concert with two new federal grants, Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) and the state Maternal Health Innovation, implicit bias and other equity trainings were offered to the Maternal Mortality Review Committee along with providers through the Provider Support Network in FY21.

The DCFW/WCHS convened a Health Equity Continuous Quality Improvement Team whose mission was to:

1. Promote the DPH Health Equity Foundational Training.
2. Encourage participation in and analyze results of DCFW/WCHS staff responses to the DPH Health Equity Survey to share back with the Section.
3. Assign a Health Equity Team member to each Branch within the DCFW/WCHS to discuss the Health Equity Foundational Training and develop next steps in implementing health equity strategies in staff workplans.
4. Review contracts and LHD agreement addenda to incorporate health equity strategies.

Unfortunately, due to the COVID-19 pandemic, staff changes, and competing priorities, this specific CQI effort was put on hold. 

During FY21, the NC ITP prioritized addressing issues of inequity within the Part C system. Program leadership consulted with the DHHS Diversity and Inclusion Office and the DPH Office of Health Equity to explore resource availability and Departmental/Divisional support to embed diversity and inclusion within the program. The NC ITP plans to conduct a diversity audit to examine personnel and child/family data to explore disparities that exist in human resources and service provision within the program, respectively. In addition, the program plans to establish a Diversity and Inclusion entity to provide ongoing support for system equity explorations and also to provide recommendations for professional development strategies/opportunities, policy, practice, and system enhancements to address inequities.

Social Determinants of Health

As shared earlier, addressing SDoH is foundational to the NCDHHS priorities, Perinatal Health Strategic and Early Childhood Action Plans. It also is a priority for NCDHHS as NC moves into Medicaid transformation, particularly with the Healthy Opportunities Pilots. The NC Title V Program will continue to address SDoH as part of its programs and support the work being done by NCDHHS to launch Healthy Opportunity Pilots meant to address housing instability, food insecurity, lack of transportation, interpersonal violence, and toxic stress for eligible Medicaid beneficiaries. Additionally, the NC Title V Program will continue to promote the use of NCCARE360.

Food Insecurity

The NC Title V Program sees working in the area of food insecurity with a focus on healthy equity and access to healthy food as a priority for the MCHBG and as a NCDHHS priority. Even before COVID-19, many actions at the state and division level have occurred since 2019 to elevate this to an even greater priority. This includes NCDHHS’s work on:

• Food Insecurity screening (required through Medicaid and voluntarily encouraged for all providers) https://www.ncdhhs.gov/about/department-initiatives/healthy-opportunities/screening-questions
• Food Insecurity (and other SDOH) referral and follow up through NCCARE360 – a Statewide Coordinated Care Network online platform https://www.ncdhhs.gov/about/department-initiatives/healthy-opportunities/nccare360
• Medicaid Transformation through the Healthy Opportunities Pilots which includes a focus on food insecurity and healthy food access.  As reported in the Child Health Domain Annual Plan, the PNC is providing technical assistance on Food and Nutrition services being offered through the Healthy Opportunities Pilot.
• NC ECAP released in 2019 which has prioritized food security as one of ten goals. The NC Title V Program has adopted the goal (CCSB 8B) from this plan which includes that by 2025, the percent of children living across North Carolina in food insecure homes will decrease by 6% from 20.9% to 17.5% according to data provided by Feeding America and cited in the NC Early Childhood Action Plan.

The two strategies to address this food insecurity objective complement interest and staffing within the NC Title V Program. NCCARE360 was launched in 2019 and became available statewide in June 2020, six months ahead of schedule. LHDs are natural partners to be enrolled in and using NCCARE360, but they may not all have integrated food insecurity screening, referral, and follow up (outside of their Medicaid populations) or may have experienced other challenges due to COVID-19. Therefore, strategy CCSB 8B.1. states that the NC Title V Program will work with NCCARE360 partners to identify how food insecurity screening, referrals and follow up being tracked in NCCARE360 and conducted through LHDs can be enhanced. The PNC did submit and was accepted by ASPHN to record a Poster Session titled MCH Title V State Actions to Reduce Food Insecurity: North Carolina Experience which was presented in June 2021. Due to the impact and length of COVID and the prioritization of state and local public health to address COVID, this food insecurity activity (CCSB8.B.1) had very little other activity. The PNC did consult with the NCDHHS staff person who manages NCCARE360 data from the Departmental standpoint, and it was determined that at that point (May 2021), LHD data would be under-represented because LHDs had not been brought into NCCARE 360 as of FY21 and likely wouldn’t be brought in until FY23. Other confounding variables may mean that this strategy may need to be revised in future action plans.

For strategy CCSB 8B.2., the PNC in the DCFW/WCHS will increase training to child health staff around nutrition/food insecurity; create a training package; and identify audiences across DCFW/WCHS and DPH that would also benefit from these trainings and materials. This strategy fits well with prioritized food insecurity work that the PNC has already been doing as part of the MCHBG since FY18 and because of the exponential rise in food insecurity due to COVID-19. Due to the impact and length of COVID and the prioritization of state and local public health programs to address COVID, this food insecurity activity also had to be modified. The PNC continued to provide resources and some select trainings for state and local staff on food insecurity, but a formal training package was not feasible for FY21 or FY22.

These food insecurity strategies can also be aligned with work by the DPH Health Equity Committee and Framework where feasible and reasonable. Initial work in both strategies in FY21 included the PNC working with NC Title V Program leaders to assess needs and opportunities within the Program and throughout DPH as appropriate. This was accomplished through a Food Security team of interested staff members with lived experiences of food insecurity, expertise, and/or passion to plan for, address and evaluate this issue. Sensitivity and awareness around racial equity issues and systems that affect food insecurity will also be incorporated into plans developed by this team.

COVID-19 has caused so much stress and hardship for individuals, children and families in North Carolina, with a disproportionate burden on historically marginalized populations. Food insecurity has increased, especially among children. The NC Title V Program will continue to work with multiple partners to ensure innovative ways to feed children and families during this pandemic. The Title V Director co-chaired the Governor’s Education and Nutrition workgroup with the Department of Public Instruction, working with so many partners, volunteer organizations and advocates, to develop innovative strategies to ensure children across North Carolina and their families could access food with schools closed to in-person instruction. NC requested multiple waivers and quickly implemented USDA-approved flexibilities across programs such as WIC, Child Nutrition Programs (CACFP and School Nutrition Programs), SNAP and P-EBT. This critical work, as part of the overall COVID-19 response in North Carolina, continued in FY21 and into FY22. One purpose of creating the DCFW was to bring together the federal nutrition assistance programs administered by NCDHHS which includes WIC, CACFP, SNAP and SNAP-Ed into closer alignment and synergy to address whole child and family health and nutrition (including food/nutrition security).