Equit[y]-easer: A Card Game to Demonstrate Health Equity

Seminole County is in east Central Florida just north of Orlando. With an estimated population of 470,093 (as of July 1, 2021), according to the U.S. Census Bureau. Seminole County is also the most densely populated county in Central Florida with a total land area of 309.5 square miles. The county is comprised of seven cities and six unincorporated areas represented by 26 zip codes and 86 census tracts as of the 2010 Decennial Census. 52% of the population is female, 80% Caucasian and 78% non-Hispanic. The Florida Department of Health in Seminole County (DOH-Seminole) serves the community with a mission to protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

The Robert Wood Johnson Foundation defines health equity as everyone having a fair and just opportunity to be as healthy as possible. Over the past decades, health equity has become a framework and lens that public health at the local, regional, state, and national level has used to address health disparities, the disproportionate impact in health outcomes and disease, like COVID-19, and systemic barriers impacting the social determinants of health for at-risk, high-need, and priority populations. The Florida Department of Health in Seminole County has been a local leader in health equity through collaboration with grassroots community organizations like the East Goldsboro Council, through the advent of our Community Mobile Health Integrated Services, and through the legacy of systems-change work with our Health Equity Advisory Board.

In alignment with the Florida Department of Health's Office of Minority Health and Health Equity mandated Section 381.735 of Florida Statute, the Florida Department of Health in Seminole County is making health equity more actionable in practice through built capacity for an internal Health Equity team of Minority Health and Health Equity Liaisons, expanded partnership of the Health Equity Advisory Board to a Health Equity Taskforce, the creation of a county health equity plan, health equity training through Equit[y]-easer: A Card Game to Demonstrate Health Equity, and by creating a culture of health equity through operationalizing health equity awareness and implementation as a core employee performance expectation metric.

In April 2022, Equit[y]-easer: A Card Game to Demonstrate Health Equity was offered from the Office of Health Promotion and Education to all DOH-Seminole staff as a training exercise during our mandatory quarterly town hall for all programs. In November 2022, the card game was presented in the Ethics Roundtable format section at the American Public Health Association Annual Conference as a training tool for public health professionals to experience the ethical principles that help shape a culture and system of equitable service delivery to the communities we serve.

To measure the application of equity principles in daily activities, the Office of Health Promotion and Education in collaboration with the Office of Performance and Quality Improvement quantified health equity awareness and implementation through the creation and implementation of a health equity performance metric. The following measurement scale was created as part of employee performance expectations.

5 = Report activities addressing social determinants to achieve health equity related to Community Health Improvement Plan (CHIP) objectives; discuss at meetings on the inequities facing the community and the health department's role in health equity, participates in a health equity basic training provided by DOH-Seminole, and create a health equity profile for their program(s).

4 = Discuss at meetings on the inequities facing the community and the health department's role in health equity, participates in a health equity basic training provided by DOH-Seminole, and create a health equity profile for their program(s).

3 = Participate in a health equity basic training provided by DOH-Seminole and create a health equity profile for their program(s) shared on any internal DOH-Seminole committee meeting.

2 = Participate in creation of program(s) health equity profile(s).

1 = No documentation on health equity activities.

DOH-Seminole is making health equity more actionable in practice through training all staff on equity through an easy-to-understand family card game format, and then measuring the application of this tool's effectiveness in practice through standardizing health equity implementation in every department program. This internal cultural shift in infusing health equity across the board will allow DOH-Seminole to better acknowledge, understand, and address social determinant of health barriers that priority populations in Seminole County face through the integration of more lived experience perspectives, expanding partnerships, and the development of more systems thinking solutions.

The Florida Department of Health in Seminole County strives to achieve health equity through innovative approaches in the cultural competency education of our public health workforce. Populations experiencing health disparities are further disenfranchised and marginalized when their needs are met through an inadequate lens as opposed to one that liberates. Equit[y]-easer: A Card Game to Demonstrate Health Equity is an engaging and nonthreatening card game developed by the Office of Health Promotion and Education team at the Florida Department of Health in Seminole County that allows participants to confront and examine how society's response to individual differences in ability, advantage, and privilege can present personal and structural challenges. Through role play, the game offers public health employees an opportunity to translate beliefs regarding diversity, equity, and inclusion to experiencing belonging, dignity, and justice in practice. The activity is guided by four rounds of Equit[y]-easer: A Card Game to Demonstrate Health Equity that demonstrate how equality, inequity, equity, and liberation frameworks impact health disparities. Equit[y]-easer: A Card Game to Demonstrate Health Equity is an easily digestible educational and professional development tool for the public health workforce to examine our ethical response and approach to achieving more just health outcomes.

Data, such as findings of the 2021 Public Health Workforce Interests and Needs Survey, highlight the indispensability of workforce support and the need for practical applications of ideologies that often remain too conceptual. Understanding of health equity must begin with the workforce. Ultimately, the communities we serve benefit from our knowledge. Public Health, through our work of delivering services in the field and meeting people where they are, is primed to deliver equitable services. There exists, however, a demonstrated lack of knowledge and understanding of what equity is and how it can be implemented in standardized tasks.  

The planning and implementation process for the game was informed by principles of health equity, as defined by the Institute of Healthcare Improvement (2018). We incorporated three principles in particular:

1. Everyone gets to play a part.   

            The instructions are easy to understand, and participants of all ages are invited to play.

2. We need to see with new eyes the barriers that exist.  

            Players are often thrown for a loop” by the game. In past games, players reported experiencing new feelings in scenarios that were unfamiliar to them.   

3. This is a personal journey that needs to be undertaken as a group.

            Each player's involvement and response to the game is personal. The nature of the game allows for self-reflection prompted by probing questions meant to be discussed with the entire group. The dynamic of the group influences the personal experience of each player.

The Florida Department of Health recognizes the need to build capacity within its workforce and, subsequently, communities. Mandatory, as well as optional, trainings address health disparities and cultural competency. The Equit[y]-easer: A Card Game to Demonstrate Health Equity functions as a complementary aide to the trainings already in place. The Equit[y]-easer: A Card Game to Demonstrate Health Equity is innovative to the field of public health. It is entirely interactive, relying on teams of participants to deliver instructions and carry out tasks. The game maintains its relevance not only through the timely content being delivered, but also through its appealing and modern designs. It is flexible yet consistently generates meaningful impact and honest discussion. Although it is recommended that the game be conducted with a maximum of 10 players, that number can be easily expanded. Adding a facilitator for every 10 people allows for separate games to be played simultaneously. The application of Equit[y]-easer: A Card Game to Demonstrate Health Equity is unlimited. The concepts, and instant reactions, go beyond public health. Themes of equality, equity, inequity, and liberation are explored through prompts meant to inspire creativity and resourcefulness. The facilitator encourages players to implement these skills in personal and professional settings. Detailed instructions, including discussion prompts, accompany the game. Therefore, no formal training or facilitation experience is required to lead a group. Lastly, and arguably most important, Equit[y]-easer: A Card Game to Demonstrate Health Equity is fun. A truly enlightening and enjoyable experience is guaranteed every time the game is played.

In our effort to make Health Equity actionable, DOH-Seminole established two main goals, each with objectives:

1.      Develop Equity Training Tool (March - October 2022)

a.       Train DOH-Seminole staff on equity in practice through developing a game simulation that allowed participants to confront and examine how society's response to individual differences in ability, advantage, and privilege can present personal and structural challenges for communities.

2.      Measure Equity Implementation in Practice (November 2022 – present)

a.       Measure health equity implementation in every departmental program through developing a standardized health equity employee performance evaluation metric.

The activities for developing an equity training tool included creating card game scenarios, images, reflection questions, and game instructions that demonstrated equality, inequity, equity, and liberation in practice, receiving feedback from small test cohort of staff on game's effectiveness, presenting Equit[y]-easer: A Card Game to Demonstrate Health Equity at DOH-Seminole's all staff town hall, presenting Equit[y]-easer: A Card Game to Demonstrate Health Equity at the 2022 American Public Health Association's Annual Meeting in Boston, and creating pre-test and post-test questionnaires to measure Equit[y]-easer: A Card Game to Demonstrate Health Equity goal to build workforce capacity of understanding of equity by public health professionals. In the Office of Health Promotion and Education, the Health Equity team is also collaborating with Human Resources to ensure that all new employees, staff, interns/trainees at DOH-Seminole receive health equity training by integrating Equit[y]-easer: A Card Game to Demonstrate Health Equity as part the new employee orientation experience.

The activities for developing a standardized health equity employee performance evaluation metric that measures the equity training tool's impact included developing a measurement scale via collaboration between the Office of Quality Performance and Improvement and the Office of Health Promotion and Education Health Equity team, presenting the performance metric to DOH-Seminole's Management Advisory Council to issue it into effect, and developing a health equity profile template for DOH-Seminole programs to use as a guide to fulfill performance standards. These activities are DOH-Seminole's innovative approach to infuse and integrate health equity into every area of our community health department's operational structure. Following the equity training tool's yearly training exercise, the DOH-Seminole Health Equity team will host quarterly reflection discussions with departmental programs to discuss lessons learned in their efforts to implement health equity into practice. The DOH-Seminole Health Equity team also remains a collaborator in each departmental program's health equity profile creation to provide on-going technical assistance on identifying priority populations, identifying social determinant of health barriers to departmental program services, and expanding internal and external partnerships to address social determinant of health gaps that create disparities.

According to the Top Training Needs of the Governmental Public Health Workforce” in the Journal of Public Health Management and Practice, workforce development in governmental public health has historically focused on discipline-specific skills. However, as the field of public health has evolved, cross-cutting skills have become critical” (Bogaert et al, 2019). The results of this study reveal that the largest area of training need, regardless of supervisory status, was in budgeting and financial management, with a large gap in systems and strategic thinking” (Bogaert et al, 2019). Thus, Equit[y]-easer: A Card Game to Demonstrate Health Equity is addressing the public health need for workforce capacity. The purpose of the evaluation is to measure Equit[y]-easer: A Card Game to Demonstrate Health Equity's effectiveness in training the public health workforce in Seminole County to apply an equity thinking lens and systems driven design to their scope of work.

The evaluation plan is built around two evaluation questions.

Does the Equit[y]-easer: A Card Game to Demonstrate Health Equity training provide baseline foundational knowledge for applying equity in practice?

Is the health equity performance evaluation metric an accurate measure of each departmental program's awareness and implementation of equity?

The primary data sources used in this evaluation plan is a pre-test and post-test questionnaire before and after the Equit[y]-easer: A Card Game to Demonstrate Health Equity game is played, respectively, as well as the health equity employee performance metric. The secondary data sources used in this evaluation plan include data collection from FloridaCharts that look at health disparities, chronic diseases, social determinants of health, and health outcomes. Secondary data sources will also include departmental program data like Women, Infants, and Children utilization rates and Vaccine & Immunization rates. DOH-Seminole's Customer Satisfaction survey data will continue to be monitored to evaluate client and community perception on success in equitable service delivery. Primary data sources will be used to conduct internal process evaluation of Equit[y]-easer: A Card Game to Demonstrate Health Equity distribution, delivery, and application, as well as its causal effect on more equitable and systems driven service delivery by departmental programs. Secondary data sources with a particular emphasis on departmental program level data will be used to limitedly measure Equit[y]-easer: A Card Game to Demonstrate Health Equity and the health equity employee performance metric's impact on access, utilization, and DOH-Seminole's success in addressing priority population needs. At this time, no impact evaluation can be shared or concluded, as these efforts still exist in the developmental stage. After only a few months of establishing this model practice preliminary results and findings reveal a central theme of increased capacity to address community population needs through this prioritization, focus, and infusion of health equity in DOH-Seminole's culture and operations.

The sustainability of this model practice was profoundly built and produced with intention to its longevity. The Health Equity team is collaborating with DOH-Seminole's Public Information Officer and legal team to explore trademarking Equit[y]-easer: A Card Game to Demonstrate Health Equity. This will provide our agency with the opportunity to expand health equity capacity in our county and throughout our region by providing a DOH-Seminole branded and trademarked family card game and extensive training on equity implementation in practice. In addition to ownership and branding, DOH-Seminole has standardized health equity practice through performance measurement, quality improvement, and human resource management practices, all through the creation and distribution of Equit[y]-easer: A Card Game to Demonstrate Health Equity as the first step to provide the public health workforce with foundational tools to build equity driven systems of care and service. The card game's instructional packet was created to serve as a train-the-trainer guide to equip any Equit[y]-easer: A Card Game to Demonstrate Health Equity game master with a kit to adeptly train its players about equity in practice. In addition to internal training, DOH-Seminole's health equity team is contributing to the sustainability of this practice through a commitment to present and share Equit[y]-easer: A Card Game to Demonstrate Health Equity at different conferences and meetings across the country. The health equity team has also been recognized by the Florida Public Health Association for presenting Equit[y]-easer: A Card Game to Demonstrate Health Equity at the American Public Health Association.

The extent of funding costs is still being actively analyzed, but thus far have been minimal. The Health Equity team will work with the business office to conduct a cost benefit analysis to better quantify how this cultural shift in health equity standardization can positively contribute to health care and public health expenditures in Seminole County. Minimal costs include trademarking costs, material and supply expenditures, printing costs, and health equity team personnel salaries already included in the Office of Health Promotion and Education's daily scope of work.