Office of Equity & Community Partnerships: A community-led and anti-racist approach to public health

Public Health Seattle & King County (PHSKC or Public Health”) is a large metropolitan health department in Washington State, serving over 2.2 million residents with over 1,400 employees. PHSKC reaches across 39 cities that span urban, suburban, and rural areas, and serves residents who speak over 100 different languages [1]. The Seattle and King County region has rapidly increased in population including racially and ethnic communities in recent years. The population in King County is 19% Asian, 10% Hispanic/Latinx, 7% Black, 5% Multi-racial, 1% Native Hawaiian/Pacific Islander, and 1% American Indian/Alaska Native. Over half of new residents since 2010 are foreign-born, with the top five countries of origin being India, China, Mexico, Vietnam, and the Philippines [2].

The rapid growth of Seattle and King County has led to gentrification in the area, pushing lower-income residents further from services and community, into the surrounding suburbs. These areas, often to the South, face barriers to transportation, furthering marginalization and lack of access to basic services and social support for these communities. Health inequities have widened in recent years, especially with the impacts of the COVID-19 pandemic, with disproportionately high rates of communicable and chronic disease health indicators in these communities.

During the first half of 2020, PHSKC and other King County departments established a community-facing branch and an equity team within the COVID-19 Incident Command Structure, led by a new Office of Equity and Community Partnerships (OECP, previously the Community Mitigation and Recovery Branch). The OECP within PHSKC promotes work both within the department, growing its equity and community-facing capacity, and externally, working to be anti-racist and co-create with community to shift power, develop pro-equity policies and systems, and ultimately address health inequities. The OECP works to sustain and routinize community- and equity-centered work within the department. The department is working to transition the COVID-19 one-time emergency funded investments made early in the pandemic to do anti-racist and community-centered work as core throughout the department. These changes are aligned to King County's 2010 equity and social justice ordinance (Ordinance 16948), the 201622 Equity and Social Justice Strategic Plan, which call for the use of a racial equity lens and community partnerships in public health and all county work, and the 2020 declaration by King County of Racism as a Public Health Crisis.

The OECP's approach is community-centered and multi-pronged and involved the creation and sustained efforts of new teams developed during the pandemic: the Pandemic and Racism Community Advisory Group, the Community Navigator Team, the Priority Populations Teams, the Language Access Team, the Equity Response Team, and a team of OECP leaders and community consultants working towards organizational development and building department capacity:

-          The Pandemic and Racism Community Advisory Group (PARCAG) works to identify, inspire, and mobilize bold solutions in response to the urgent, interconnected crises of COVID-19 and systemic racism. The public-private committee provides community insight and input on PHSKC's policy-making process, implementation of programs/services, and information needs for COVID-19 to King County residents. 

-          Community Navigators work with over 45 communities, representing those most impacted by health inequities. These are compensated community leaders who educate, equip, and serve as connectors to their communities by providing culturally responsive information and resources, addressing social determinants of health, and provide guidance to Public Health.

-          The Priority Population Teams consist of Public Health staff and community partners addressing health inequities in the following communities: Black, African Immigrant, Native/Indigenous, Latinx, Pacific Islander, Asian, South Asian, LGBTQ+, and people living with disabilities.

-          The Language Access Team provides translation and interpretation services to advance language access, working with 130 contracted community members and serving 44 languages. The team delivers meaningful language access assistance resulting in accurate, timely, and effective communications for King County's multilingual and linguistically diverse communities. Language access services are provided through staff trainings and certifications with provision of rapid, high-quality translations in response to community needs. The team's work includes to strengthening existing relationships and building new relationships with translators, other Public Health Language Access Liaisons, and integrating health literacy and plain language into Public Health work.  

-          The Equity Response Team addresses cross-cutting issues raised by the team and partner agencies through advocacy and guidance. As an internal think tank” for anti-racism and crisis response, this team examines and improves internal and community-facing programs, strategies and policies. They promote equity between community workgroups focused on Black, Indigenous and People of Color (BIPOC) populations and Public Health teams through advocacy and guidance by developing review processes such as equity checklists to address internal and external processes, programs and policies.

-          The OECP leadership team consists of three key OECP staff who work alongside community consultants and department leadership to create substantial and sustained changes to PHSKC human resources, contracting, budgeting and strategic planning, plus supporting work by divisions. The leadership team includes the Director of the OECP, the Deputy Equity Officer, and the Equity, Inclusion, and Belonging Manager.

Together, the OECP teams work to prioritize communities affected by structural racism, to support county leaders and staff to create better public health policies and decisions, and to address the root causes of health inequities including systemic racism.

King County Website: https://kingcounty.gov/depts/health.aspx

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References

[1] Public Health-Seattle & King County. About Us. https://kingcounty.gov/depts/health/about-us.aspx 

[2] Gene Balk, New milestone in King County: Immigrant population tops 500,000,” The Seattle Times, January 14, 2019, https://www.seattletimes.com/seattle-news/data/new-milestone-in-king-county-immigrant-populationtops-

500000/

Throughout the pandemic, epidemiologic and surveillance data indicated that there should be a stronger focus on populations of Pacific Islanders, Hispanics/Latinx, Black people, some Asian American groups, Native American residents, and residents of all race/ethnic groups who live in lower-income areas in South King County. The population in King County is 19% Asian, 10% Hispanic/Latinx, 7% Black, 5% Multi-racial, 1% Native Hawaiian/Pacific Islander, and 1% American Indian/Alaska Native [3]. Among the county's 2.2 million residents, COVID-19 cases were five times higher among Pacific Islanders than among White residents, almost four times higher among Hispanic/Latinx residents, more than twice as high among Black people, and almost twice as high among Native Americans [4].  

 In response to these inequities, demands from community to address system racism, and the persistent impact of racism on public health, King County declared Racism as a Public Health Crisis in June 2020. Part of the results to this declaration plus the critical equity and community work during the pandemic was the formation of the Office of Equity and Community Partnerships (OECP) by Seattle King County Public Health (PHSKC). The OECP's work began with a focus on combatting two major public health crises: the COVID-19 pandemic and systemic racism. The long-term strategy, however, is to permanently embed the work of the OECP into the Public Health department.

The OECP consists of 28 King County staff, 26 community navigators, and supports over 45 communities most impacted by health inequities. The OECP supports and works with Public Health divisions, county employees and leaders, and community partners to advance racial and health equity in King County. In 2022, PHSKC OECP and its teams partnered with more than 1,000 organizations and community leaders, focusing on Black, Indigenous and People of Color (BIPOC) communities and in places of the county where needs are greatest.

Community partnerships have been embedded in nearly all OECP teams and activities to center community voice in the design and implementation of COVID response activities. OECP teams have implemented activities to support community mitigation of COVID-19 impacts (interventions and services), improvements to information infrastructure, and improvements to organizational infrastructure. The OECP's approach advanced progress toward equity and social justice goal areas related to plans, policies, and budgets; workplace and workforce equity; community partnerships; and leadership, operations, and services in PHSKC processes and across other community settings.

The OECP's approach has provided a deep and impactful method to enact anti-racist public health practice, and to create a more equitable and socially just public health department. The OECP has worked to create a community-facing infrastructure which includes staff and stipends for advisory groups and task forces, implementation workplans that give time for community consultation and revisions, providing funding and technical assistance to community-based organizations that contract with the department, and a workforce at all levels of the organization that reflects the community.

This approach has created radical change within the department and county, and represents an innovative model, requiring the commitment and collaboration of county leaders and community at multiple levels.

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References

[3] Public Health-Seattle & King County. Racism is a Public Health Crisis: Transformation Starts Here. It Starts With Us. https://publichealthinsider.com/2020/06/11/racism-is-a-public-health-crisis/ 

[4] Public Health – Seattle & King County, COVID Vaccination Among King County Residents,

https://kingcounty.gov/depts/health/covid-19/data/vaccination.aspx

The OECP works with county employees and leaders, department divisions, and community partners. The office promotes co-creation with community-led processes, and meaningful involvement of community partners in programs and workgroups to improve the department's public health practices. The OECP's approach has three main objectives:

1. To co-create services, outreach, and programs with communities that have been marginalized through local Community Navigators, Priority Population Teams, the Language Access Team, and with community-based organizations and contracted community leaders;

2. To enact community-informed budgeting and policy changes led by the Pandemic and Racism Community Advisory Group (PARCAG), Community Navigators and the Equity Response Team; and

3. To provide anti-racist crisis response and organizational development to improve internal and community-facing programs, strategies, and policies through Equity, Inclusion & Belonging Managers, the Equity Response Team, and organizational consultants. 

The OECP works with multiple stakeholders to promote equitable programming and anti-racist public health practice. True equity work and community co-creation requires buy-in from department and county leadership, as well as county employees and community partners and members. Each of the following six teams within the OECP works together and with community partners towards a shared vision of health equity:

1.       PARCAG has 65 representatives from 25 organizations, with a specific emphasize on inclusion of BIPOC-led CBOs and institutions. Prioritizing Black and Indigenous communities, PARCAG includes a focus on membership and work that uplifts people with intersectional identities, and groups historically and systemically marginalized. The PARCAG has worked to meaningfully shift power from county staff to community, increasing community influence over time. For the first six months of work, PHSKC staff created meeting agenda and disseminated key information on COVID-19, consulting with community in order to adapt messaging. Over time, PARCAG moved to a more shared leadership model, upon request of BIPOC leaders, in order to center BIPOC community voice. An outcome of this shift was the creation of a Steering Committee comprised of five BIPOC community leaders and one PHSKC employee. The PARCAG Steering Committee is paid $3,600/year, and meet biweekly to set agendas, invite speakers, facilitate meetings, and steer the strategy of the group.  

2.       The Community Navigators work specifically to involve community partners, and to build towards stronger coalitions and community-led work and mobilization. The Community Navigator team includes 26 contracted community liaisons and leaders representing historically marginalized communities within King County. The team is engaged by three King County staff who manage the program's administration. Navigators meet bi-weekly to discuss community needs, share best practices, and consider the shared needs of their various communities. Navigators are paid at a rate of $2,700 per month for their work. The King County staff leaders work within and outside of King County to build partnership and coalition, set the strategic vision for the Community Navigators team, and to provide mentorship and consulting to other interested local jurisdictions.

3.       Priority Population Teams leverage the expertise of contracted Community Navigators and other key community leaders, and are organized by King County employees, but these are largely community-led endeavors. The work by the Priority Population Teams is tailored to each community's needs, and therefore the work varies group by group. Some examples of the variation include the Latinx Priority Population Team which focuses on community education and mobilization through bi-weekly meetings and radio spots, while the Black Community Priority Population Team builds coalition with community partners and supports a local BIPOC-led community space in Skykomish, and the Asian Priority Population Team has created a mini-grant program to support and build capacity with small CBOs in the community. Priority Population Teams have available funding for specific projects through the OECP, and contracted community partners are compensated for their involvement.

4.       The Language Access Team is comprised of four King County staff and 130 contracted community members who provide translation and interpretation services. These services include translation, community review, interpretation, voice over, and video development. The team was developed in response to COVID-19 pandemic in 2020, and the emerging community needs for translation and interpretation for public health messaging and communications. The Language Access Team uses Community Language Services Providers, contracted individuals and agencies, in order to root services in personal lived experience and community-based fluent language skills to provide high quality services. The model of community-based translation and interpretation in public health practice has been recognized as an important practice to promote community health and engagement across the department.

5.       The Equity Response Team (ERT) is comprised of community members, including tribal members and a bioethicist, as well as county staff. The ERT addresses cross-cutting issues raised by the team and partner agencies. The ERT provides King County Health and Medical Area Command and Public Health – Seattle and King County leadership with recommendations and actionable information to support communities most impacted by inequities, and communities experiencing hate and bias. Since its establishment in early March 2020, the ERT has had both short- and long-term impacts in King County, playing a role as thought partners in King County declaring Racism as a Public Health Crisis, the creation of an emergency response bill of rights, and providing feedback on emergency relief programs such as food and rent assistance. The ERT will continue to provide this type of support to the department for both crisis response activities, as it continues to do for the county's COVID-19 and 2022 MPOX responses, as well as for its non-emergency response operations (e.g., biennial budget preparation, etc.).

6.       Organizational development work is co-created with King County employees and community consultants. OECP is currently working with three consultants to reform King County's human resources, contracting, and budgeting. In addition, King County has committed to funding OECP leadership staff to promote radical strategic reformation in collaboration with the ERT and PARCAG, and informed by the work of Community Navigators and Priority Population Teams. OECP staff work to inform the Racism as a Public Health Crisis and Equity and Social Justice strategies, as well as the development of division-level internal racial equity strategies addressing anti-blackness and employee well-being.

Transforming public health departments into community-directed and anti-racist organizations is complex work that involves departmentwide change. The OECP has implemented an approach of six inter-related strategies described above to catalyze institutional change within the enterprise. Building on county government's commitment in 2010 to be a fair and just” local government, and with emergency response funding during the COVID-19 pandemic, Public Health is seeing transformation in a wide variety of public health programs across the department. Many routinely seek OECP and community guidance on programs, policy and budget decisions by engaging with one or more of the OECP structures described above. In 2022, for example, food security programs, many aspects of the COVID-19 response and the department's two-year budget were all shaped by community consultation supported by different OECP teams.

Continuous assessment and evaluation are pivotal to OECP's work and success. In recent years, an evaluation strategy for a process and outcome evaluation was developed. The evaluation is currently in progress, with data collection and analysis underway.

The evaluation is focused on how the OECP approach and contextual factors contributed to capacity and services that address COVID-19 health inequities. This evaluation examines three key areas: PHSKC processes to carry out OECP-funded activities, the sustainability of grant-funded activities, and areas for growth and opportunities in PHSKC's engagement with community partners and community members.

Three main evaluation questions and data sources inform for the evaluation:

1.       PHSKC processes: To what extent are OECP teams incorporating existing Equity and Social Justice (ESJ) goals prioritized by PHSKC? Data source: Narrative Summaries, periodic reflections.

2.       Sustainability: How can PHSKC's work with equity and community partnerships be sustained? Data sources: Program Sustainability Assessment Tool.

3.       Community impact: How have BIPOC communities been affected by PHSKC's equity and community partnerships? Data source: Focus groups with community partners and recipients of services.

Evaluation questions for public health processes were designed to describe implementation of services; barriers and facilitators to carrying out activities; adaptations made to services in response to equity and social justice goal areas (e.g., leadership, plans policies and budget, workforce, community partnerships and communication), and areas for improvements. Sustainability of OECP activities is examined through surveys and discussions with each team to better understand what resources and commitments are needed to sustain the work, and how PHSKC can embed equity and community partnerships as part of routine practice. To identify growth opportunities in community engagement, the evaluation team aims to capture community perspectives on OECP's partnership approaches and success of services.

OECP teams submit quarterly reports of performance measures of mitigation activities, data and organizational improvements, and partnerships, as well as narrative descriptions of the team's progress, successes, and barriers. These data are leveraged for the overall evaluation, alongside qualitative data, for a mixed methods analysis.

Qualitative data are collected through group interviews with representatives from 16 OECP-funded teams. Iterative content driven analysis is applied with initial codes that are drafted based on the goals of the process evaluation and prioritized department equity and social justice goal areas. The evaluation team will create a codebook in collaboration with student interns to guide analyses, and will be conducted using Dedoose software. 

In addition to quarterly reporting and qualitative data collection, a modified Program Sustainability Assessment Tool (PSAT) was administered to teams to identify key areas of capacity needed to sustain the work of equity and community partnerships beyond temporary funding sources. Average scores for each domain of sustainability were calculated. A follow-up group discussion was held with participants to discuss PSAT results and capture additional information about how to sustain components identified as strengths and opportunities. The discussion was recorded, transcribed, and coded for themes.  

The evaluation has so far identified areas for further development toward sustainability and progress toward PHSKC's ESJ goals. Areas of strength described by representatives from the OECP teams include program adaptation; specifically, taking actions to adapt their programs to ensure its ongoing effectiveness. Another noted area of strength was environmental support; specifically, workplace setting, policies, and/or practices, as well as partnerships between the teams and community leaders. OECP teams and community provided recommendations for sustaining OECP activities, enriching community engagement, and prioritizing equitable evaluation. Areas of opportunity include the need for investment toward sustaining the work and mitigating disparities/inequities. The evaluation team will continue to share recommendations with leadership as they arise.

Work continues to collect and analyze data on the community impact of OECP work. The evaluation team continues to work with project leadership and community advisory groups to share learnings, collect feedback and scope the remaining evaluation question. Informed by community advisory groups and community partnerships, impact data will be collected through key-informant interviews and focus-groups. Community engagement has begun and will continue into 2023.

The evaluation team will also work with project leadership and community to finalize and implement dissemination plans for evaluation findings. The final evaluation report will include lessons learned based on evaluation findings and describe implications for similar teams in different settings or for the future success of the OECP approach within PHSKC.  

Pre-pandemic, PHSKC had a one-person Equity Director, which expanded after 2020 to an office overseeing six teams. Throughout the pandemic, the OECP worked with the public health department to support communities hardest hit by pandemic​​, to develop and implement policies that integrate equity and community voice, and to integrate anti-racist work into COVID-19 response and regular department business. Based on the progress made during the pandemic, the declaration of Racism is a Public Health Crisis and the department's Equity and Social Justice work, the OECP has been transitioning teams from COVID-focus to primarily anti-racism/racism is a public health crisis in support of all the department's work. OECP has been building capacity, systems of support, and accountability, as it advances an integrated approach to racial equity and community partnerships across the department.

The integrated approach and model provides core equity capacity, connections to community through community partnerships staff and Community Navigators, and language access capacity to make communications accessible to diverse communities. By working closely with other teams in the Office of the Director, like Communications and Policy, the department is now able to co-create on policies and communications. At the same time, by working with the department's divisions, this approach can be integrated to different programs and units. The goal is to have all priorities for the department include strong community-centered and equity approaches.

OECP funding is blended with local, state and federal funding, plus grants, with the long-term plan of creating a sustainable and permanent model. Some of the core staff is supported on-going with King County funding, while much of the rest of teams are funded through one-time funding such as two federal grants from Centers for Disease Control and Prevention (CDC) and Health and Human Services (HHS) and COVID-19 funds. New and longer-term funding from the Washington State Department of Health for some of the activities, like in the area of Community Partnerships, will allow activities like PARCAG and Community Navigators to continue for years to come.

There are additional efforts to support the teams with new and longer-term funding sources, including from Washington State Department of Health. Importantly, part of the strategy to make OECP programs on-going is to have department divisions and programs build in services from OECP into budgets and plans. For example, the Tuberculosis program has been supporting and funding a group of Community Navigators, and many programs have been funding language access and translation projects with their own budgets. Increasingly, to achieve sustainability and have equity integrated throughout the department, programs will need to build in these capacities as part of the costs and needs of conducting regular public health business.

As OECP sits within the Director's Office for PHSKC, the Office works a great deal on partnering with different parts of the department to make regular practice more community-informed and intentionally anti-racist. Also, the lessons learned and practices from the last few years led by OECP are models and strategies that the rest of the department can implement.  These change to previous business and public health norms are supporting the department in meeting its own internally set equity and social justice goals.

The OECP has been working to create institutional change by leveraging funds and building on community and employee voices, especially those most experiencing inequities. One lesson learned has been that this approach requires the buy-in and trust of the community, as well as the workforce supporting this work. It has impacted community trust as well as employee morale to be faced with budgetary constraints and diminished investments by pandemic-era supportive stakeholders and systems. The community and workforce require continued support and adaptive leadership to sustain trust and commitments; this must be balanced with sustaining support from decision-makers who are balancing limited and restricted funding, different pressures and interests, and a budget that does not meet the needs of community, especially as part of a chronically underfunded public health system.

An important lesson learned has been the need to be transparent and accountable in leadership and decision-making. With PARCAG and Community Navigators, for example, there has been important input and feedback to the design of programs and policies. For example, community groups and leaders have helped shaped policies like the Vaccine Verification Policy, the Principles for Equitable Vaccine Delivery, new programs around stipends for workers and rental assistance, and the overall Public Health budget. As part of these efforts, Public Health teams work with community to provide inputs, focusing especially on the needs of and impacts on BIPOC communities, and then the department reports back to share what input was incorporated, what was not, and why. This process is critical in becoming pro-equity and building trust and relationships with community leaders and representatives.

Related to the previous, another community engagement lesson learned as has been the need for leadership to keep community partners engaged in and abreast of evaluation findings and programmatic changes. OECP staff and community members requested leadership to identify actionable next steps to support the work and sustainability of community engagement and partnerships established. When asked what is needed to sustain program adaptation of the OECP approach, OECP members most frequently described environmental support. This environmental support was described as needing more leadership understanding of how much time is needed to carry out community engaged work with quality and centered on equity. Furthermore, staff and community members described a need for more organizational capacity; specifically, more full-time staff to support activities on an ongoing basis. 

Considering the significant challenges posed by budgetary constraints, local stakeholders have remained supportive of this approach, and continue to work with the OECP to find more sustained infrastructure for it. Recently, the department was awarded a 5-year CDC grant specifically aimed towards building public health infrastructure. Many of the key outcomes align with OECP's work, and some teams have been built into regular programming.

While PHSKC has not conducted a formal cost-benefit analysis, there have been efforts to evaluate the benefit of this work. Utilizing the Community Navigator model as well as the Priority Population model allowed PHSKC to support the community through part-time contracted work; this approach allowed for a more diverse pool of community consultants who can be compensated to serve their communities while continuing their respective careers. Furthermore, this approach includes the widespread support of multiple divisions and teams, allowing for minimal financial commitments from any one division.

The OECP prioritizes investments to build and strengthen internal infrastructure and mobilize community partners to address COVID-19, health inequities, and future emergencies and crises. PHSKC and the OECP continue to invest and strengthen an emerging community-facing infrastructure that supports staff who can co-design strategies with affected groups who are close to both the issues of concern and the solutions.