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

The WCHS 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, WCHS showed this commitment by working to apply an equity lens within each of the priorities related to population domains, but in this year’s 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 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 2.4 in 2018. 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, a goal of the NC Early Childhood Action Plan, and an indicator in Healthy North Carolina 2030.

DPH Health Equity Framework

Each Branch in the WCHS is working on eliminating disparities and increasing health equity in its own 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 to be 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

The WCHS will assess where they are currently with implementation of these strategies during FY21 and identify additional ways they can them into their work.

DPH Foundational Health Equity Training

The SDoH COIIN team, which is shepherded by a member of the WHB and a colleague with the NC Chapter of the March of Dimes, has developed a foundational health equity training module which is 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. The training will be required of every DPH employee, thus Objectives CCSB 8A.1. (% of WCHS who complete the Health Equity Foundational Training annually will be at least 90%) and CCSB 8A.2 (% of WCHS 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. After receiving the training, employees will be invited to participate in debrief sessions held by facilitators that will be trained by members of the SDoH COIIN team. 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 WCHS will continue to encourage professional development and continuing education by staff members in this area.

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 WCHS plans to conduct this same survey in Fall 2020 with all of its staff members to get baseline data for the percent of WCHS 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 WCHS respondents who can appropriately define the terms health equity, health disparity, and determinants of health. The survey will then be conducted annually to measure whether there is improvement.

Additional WCHS Health Equity Plans and Activities

In the scope of work in the agreement addenda with LHDs for maternal health and family planning program activities, some of which are funded completely by Title V, the Women’s Health Branch 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 LHDs access good trainings, the WHB has posted a health equity training resource sheet on their website located here: https://whb.ncpublichealth.com/provpart/docs/6-11-20-APPROVED-HealthEquityResSheet-FINAL.

The WHB also continues to provide opportunities for staff to participate in the Phase I 2-day REI Foundational Training and REI 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 will be offered to the Maternal Mortality Review Committee along with providers through the Provider Support Network.

The C&Y Branch has convened a Health Equity Continuous Quality Improvement Team that will:

1. Promote the DPH Health Equity Foundational Training.
2. Encourage participation in and analyze results of C&Y Branch staff responses to the DPH Health Equity Survey to share back with the Branch.
3. Assign a Health Equity Team member to each Unit withing the C&Y Branch 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.

The NC ITP is prioritizing addressing issues of inequity within the Part C system. Currently, program leadership is consulting with the DHHS Diversity and Inclusion Office and the DPH Office of Minority Health 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 Perinatal Health Strategic and Early Childhood Action Plans. It also is a priority for NCDHHS as NC moves into Medicaid transformation. The WCHS 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 WCHS will continue to promote the use of NCCARE360.

Food Insecurity

WCHS 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 WCHS 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 (https://files.nc.gov/ncdhhs/SDOH-HealthyOpptys-FactSheet-FINAL-20181114.pdf). Proposals for these pilots were submitted to DHHS in February 2020, but evaluation of the proposals was suspended due to the state’s ongoing response to the COVID-19 pandemic and a new award date has not yet been determined.
• NC ECAP released in 2019 which has prioritized food security as one of ten goals. WCHS 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 WCHS. 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 WCHS 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.

For strategy CCSB 8B.2., the PNC in the C&Y Branch will increase training to child health staff around nutrition/food insecurity; create a training package; and identify audiences in WCHS and across 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.

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 will include the PNC working with WCHS leaders to assess needs and opportunities within the Section and throughout DPH as appropriate. This likely will be 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. WCHS 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, will continue in FY21 throughout the pandemic.