CHII Assessment -A Model Approach to Increase Capacity to Serve Individuals Living with a Disability

Siouxland District Health Department (SDHD) serves as the public health department for Woodbury County, Iowa (pop: 105,941).  Woodbury County is comprised of Sioux City (pop: 85,797) and 15 other rural towns making up the remaining 20,000 residents.  Sioux City is comprised of 68.3% white non-Hispanic, 19.6% Hispanic, 4.4% black and 3.4% Asian individuals.  Sioux City and Woodbury County sits on the tri-state border of Nebraska, South Dakota and Iowa, with large portions of South Dakota and Nebraska residents working, shopping, socializing and seeking medical care in Sioux City.

According to the annual County Health Rankings, Woodbury County continues to rank in the bottom quarter of the state for overall health outcomes and health factors.  Adult obesity is at 35% in Woodbury County and 27% of residents report limited to no physical activity.

Iowans with disabilities (IWD) are more likely to be inactive, have high blood pressure, and be obese. According to the CDC Disability and Health Data System, 35.7% of IWD are inactive  compared to 23% of adults without disabilities. Thirty-eight percent of IWD have high blood pressure compared to 25.2% Iowans without disabilities and 44.8% of adults with disabilities are obese compared to 33.3% of adults without disabilities.  According to the US Census, just over 10% (12,602) of Woodbury County residents have a disability, which again does not include individuals from neighboring counties or states that frequent our community.

The overall goal for SDHD was to strengthen disability inclusion efforts within our local health department and community partners by improving access to care and physical activity options to improve the health of  residents living with a disability by utilizing the Community Health Inclusion Index (CHII) Assessment tool.

Three objectives were set for this particular project:

Objective  #1: Increase Siouxland District Health Departments capacity to serve individuals with disabilities within Siouxland District Health Departments programs and services by implementing a minimum of four policy, system, or environmental (PSE) changes by July 15, 2022. 

Objective  #2: Increase Siouxland District Health Department's All Abilities Coalition's capacity to provide inclusive recreational opportunities for residents with disabilities by completing a minimum of two policy, system or environmental changes at a minimum of one recreational facility by July 30, 2022. 

Objective  #3: Increase Siouxland District Health Departments community partners capacity to reduce barriers and/or increase accessibility for individuals with disabilities by completing a minimum of two policy, system or environmental changes at a minimum of one location targeting the underserved by July 30, 2022. 

Several activities and outcomes were implemented and accomplished for this project:

Activities and outcomes for Objective #1.

SDHD completed an on-site Community Health Inclusion Index (CHII) onsite assessment and implemented a minimum of four PSE changes.

·         SDHD provided training to health department staff on disability and health and added training to new employee orientation. (system level change)

·         SDHD modified clinic exam rooms to become sensory friendly with the inclusion of: dimmer light switches, fluorescent light covers, weighted lap mats, liquid floor tiles and other sensory products, along with a wheelchair-accessible scale. (environmental change)

·         SDHD modified appointment requests both online and over the phone to require asking if special accommodations are required for the requested appointment (system level change)

·         SDHD reviewed and revised the health department's branding and style guide to ensure content in promotional materials (print and electronic) were accessible. (policy/system level change)

Activities and outcomes for objective #2

SDHD completed an onsite CHII assessment at the local bowling alley, Plaza Bowl and provided recommendations for PSE changes along with providing technical assistance to complete a minimum of two PSE changes.

·         Plaza Bowl secured a variety of adaptive bowling equipment including, a push button ramp, bowling ball pusher and retractable handle bowling ball (environmental change)

·         Plaza Bowl remodeled their women's bathroom to become fully accessible. (environmental change).

Activities and Outcomes for objective #3

SDHD completed an onsite CHII assessment at the Warming Shelter, a local nonprofit that houses homeless individuals during the day and overnight to prevent death from cold temperatures. SDHD provided recommendations for PSE changes and provided technical assistance to complete a minimum of two PSE changes.

·         The Warming Shelter installed a wheelchair charging station (environmental change)

·         The Warming Shelter replaced top loading wash machines with front loading machines (environmental change)

·         The Warming Shelter built a ramp at their emergency exit door (environmental change).

This projected was successful due to support from SDHD's administration, having strong community partnerships in place through our All-Abilities Health and Wellness Coalition and funding from NACCHO.

The public health impact was to enhance local capacity to meet the needs of people with disabilities within health department programs by increasing accessibility and accommodation policies and procedures and expanding collaboration between local public health and organizations that serve the individuals with disabilities.

Community partnerships included in this project consisted of SIMPCO  - the Siouxland Interstate Metropolitan Planning Council that assisted with the CHII assessments, Plaza Bowl a local recreation bowling alley and the Warming Shelter, a day and night shelter for homeless individuals.

Our website is www.siouxlanddistricthealth.org

This practice is to highlight how the implementation of the Community Health Inclusion Index (CHII) onsite assessment tool can be utilized by local public health departments and community partners to advance health equity for those with a disability.

The target population for Siouxland District Health Department's CHII Assessment – A Model Approach for Local Public Health Departments and Community Partners to Increase Capacity to Serve Individuals Living with a Disability included:

• Siouxland District Health Department the local public health department for Woodbury County, IA
• Community partners that serve individuals with a disability that impact their physical health.

People with disabilities consistently report higher rates of obesity, lack of physical activity and smoking. Some also have higher rates of newly diagnosed cases of diabetes, and their percentages of cardiovascular disease are 3 to 4 times higher.  Although they have higher rates of chronic diseases than the general population, adults with disabilities are significantly less likely to receive preventive care. According to the US Census, just over 10% (12,602) of Woodbury County residents have a disability, which again does not include individuals from neighboring counties or states that frequent our community.

Individuals living with a disability have experienced a history of social, economic and environmental disadvantages over the years. They experience documented differences in health outcomes at the population level that relate to higher rates of unmet health care needs, unhealthy lifestyle behaviors, mental health and chronic diseases, and social determinants of poor health.

It is imperative to include people with disabilities in programs to prevent and manage chronic diseases and conditions. One of the recommended ways to address the health inequities that exist for people with disabilities is integration into community-based programs.

However, in order to effectively and successfully integrate, it is essential to be mindful of disability culture, which includes understanding of disability literacy, disability etiquette, and inclusion/accessibility challenges.

Up until six to seven years ago SDHD failed to acknowledge the need for inclusiveness and health equity needs in the community for those with a disability, not because we did not want to, but rather we were uneducated and ill equipped to do so.  We had a few community entities that worked in silos to address the needs of people living with disabilities (PWD), but it was not common practice to work on those issues together.   Once SDHD adopted the use of the CHII Assessment we were able to start adopting and implementing inclusion PSEs within the health department, but also with local community partners working through the All-Abilities Health and Wellness Coalition.

The All-Abilities Health and Wellness Coalition was formed shortly thereafter and continues to meet regularly today. It is comprised of several community partners. This coalition has jointly hosted several All-Abilities Day events, in which special accommodations or adaptive equipment has been used to showcase physical activity opportunities in our community for PWD. The coalition has also assisted in securing locations that serve PWD and those that do not, to complete CHII assessments. The purpose of the CHII is to access the degree to which a facility is inclusive. Medical facilities, faith-based facilities, recreational and a variety of food outlets have been accessed.  One way our work is advancing health equity is by building understanding and capacity among non-traditional public health partners to improve access to physical activity and healthcare for those with a disability through the completion of CHII on-site assessments.

What is nice about the CHII on-site assessments are that they are offered at no cost with no expectations of implementing report findings. It's been a resource that allows SDHD to begin conversations with partners about what inclusion is, and for partners to learn how through simple PSE changes they are able to positively impact the health of individuals with a disability.

The CHII was developed in partnership by the Center on Health Promotion Research for Persons with Disabilities, University of Illinois at Chicago and the National Center on Health, Physical Activity and Disability, University of Alabama at Birmingham & Lakeshore Foundation. The CHII is the first instrument to operationalize community health inclusion into a comprehensive assessment tool that can be used by public health professionals and community coalitions to examine the critical supports needed for improving healthy, active living among people with disabilities.

The CHII assessment is an 80-question tool that requires the use of a digital level, door pressure gauge and tape measure. The process takes two individuals about 1 – 1.5 hours to complete onsite and looks at such things as traffic calming, walking supports, transit accessibility, parking access, health promotion materials, reception area, bathrooms, menus, equipment, playgrounds, indoor navigation, etc. 

The community has been very responsive to this allowing SDHD to complete over 25 CHII Assessments throughout Woodbury County. Following completion of the CHII, SDHD and SIMPCO summarize results into an inclusion facility report. This report identified the facilities current best practices, findings that are inconsistent with guidelines and recommendations for policy, system, or environmental changes that would improve inclusion or accessibility.

SDHD was awarded grants over the course of the last eight years that allowed them to provide minimal funding to some businesses to assist them with implementing recommendations outlined in the facility report. This has led to over 125 PPSE changes that have improved access to more physical activity opportunities, healthier foods and medical care. 

With our most recent project, SDHD's goal was to strengthen disability inclusion efforts within our local health department and for community partners to improve access to care and physical activity options to improve the health of residents living with a disability.

Objectives were: 

Objective  #1: Increase Siouxland District Health Departments capacity to serve individuals with disabilities within Siouxland District Health Departments programs and services by implementing a minimum of four policy, system, or environmental (PSE) changes by July 15, 2022.

Objective #2: Increase Siouxland District Health Department's All Abilities Coalition's capacity to provide inclusive recreational opportunities for residents with disabilities by completing a minimum of two policy, system or environmental changes at a minimum of one recreational facility by July 30, 2022.

Objective #3: Increase Siouxland District Health Departments community partners capacity to reduce barriers and/or increase accessibility for individuals with disabilities by completing a minimum of two policy, system or environmental changes at a minimum of one location targeting the underserved by July 30, 2022. 

Angela Drent, SDHD Health Promotion Specialist trained in the CHII assessment process along with Dawn Kimmel from SIMPCO completed the CHII assessment at Siouxland District Health Department, Plaza Bowl and the Warming Shelter. After the assessments were completed, an inclusion facility report was presented to each organization by SDHD.   SDHD staff then scheduled various meetings with each agency and provided technical assistance to them as they selected what PSE changes they wanted to implement after discussing things internally within their organization.

Internally at SDHD, Angela met with each program division to seek input on their services and how they could better provide services. An all-agency meeting was held that featured community residents who either had a disability or worked with people with a disability to provide additional input as to what could be implemented at SDHD to better serve people with disabilities. Angela also visited with departments who provide appointment type services to discuss what changes could possibly be made to scheduling platforms to capture if special accommodations would be needed for upcoming appointments. Angela visited with specialists who work with people with disabilities for recommendations for a sensory friendly exam room. Once the exam rooms were completed a special Siouxland Chamber ribbon cutting was held to showcase the sensory friendly rooms.  Our hope is that more facilities in our community will begin to replicate and adopt these PSE changes that can positively advance health outcomes for those living with a disability. 

Externally, working with Plaza Bowl and the Warming Shelter required a few follow-up meetings with the owner and executive director respectively.  Working with Plaza Bowl, decisions on what type of adaptive equipment would be best for the bowling alley and what needed to be done to make the women's bathroom more accessible. Once the adaptive equipment was manufactured and completed by a local company, Ability Tech, a special equipment unveil was held with local media covering the event. Signage promoting the availability of the adaptive equipment and reservation process has also been completed. Increasing access to adaptive equipment and facilities allows for more inclusive physical activity options in our community. 

The Warming Shelter quickly knew what they needed to focus on after being presented the findings. A handful of their sheltered individuals utilize wheelchairs and only their main entrance was assessible, while their back-emergency exit only had stairs. They built a ramp at the back exit and also installed a wheelchair charging station that allows the wheelchair users to charge their chairs quicker.  Health and wellbeing is also impacted by personal hygiene, however the wash machines at the shelter were top load only, and not conducive to those using a wheelchair.  Frontload washers now allow for more independence for these individuals.

SDHD, Plaza Bowl and the Warming Shelter had 6 months to focus on this project.  Funding from NACCHO allowed for PSE changes to be implemented at all three locations which were allocated roughly $4,000 each.  It needs to be noted that several additional PSE changes implemented at SDHD were also implemented at no cost. 

Siouxland District Health Department, the local public health dept for Woodbury County, IA continues to facilitate the All-Abilities Health and Wellness Coalition that helps support these partnerships in our community.

A process evaluation was completed, and our short-term goals of implementing a certain number of PSE changes internally and externally were met.  By utilizing the CHII onsite assessment tool, providing an inclusion facility report and suggesting PSE changes, and meeting with agencies and providing technical assistance, we were able adopt several PSE changes that will strengthen disability inclusion efforts within our local health department and with community partners to improve access to care and physical activity options to improve the health of residents with a disability.

Community Partners stated the inclusion facility report was very helpful in identifying PSE changes that could be implemented, and the technical assistance from SDHD assisted in the implementation process. PSE changes were tracked on an excel spreadsheet completed by SDHD. PSE changes that were implemented were identified by SDHD staff along with Plaza Bowl and Warming Shelter staff who shared those with Angela.

All PSE changes that were reported focused on improving services and access for individuals with a disability.  Internal staff at SDHD and external community partners have all reported verbally, that they have a better understanding of what they can do to their services to be more inclusive.

When it comes to health care, significant disparities exist among people with disabilities. People with disabilities face higher healthcare needs, more barriers to accessing services, and less health coverage, resulting in worse health outcomes. The hope of the CHII Assessment A Model Approach for Local Public Health Departments and Community Partners to Increase Capacity to Serve Individuals Living with a Disability will eventually lessen that disparity and barriers.  Angela Drent states, When it's barrier free you won't see the barriers, you won't see the struggles and that is what it's all about.” 

Training and educating more individuals on the CHII Assessment will help expedite the awareness of possible PSE changes that can be adopted by organizations.  Sharing accomplishments through media outlets, ribbon cuttings and coalitions is a way to spread knowledge of the benefits of the CHII. 

Funding for PSE changes is not always required and sharing the low cost no cost options can also benefit community partners.

Implementing PSE changes takes commitment, it takes time, and it takes funding.  In order to implement PSE changes at a local health department or within the community you have to have several champions who are passionate about it.  It also helps to have one or two people lead the healthy inclusive community work and have it added to their job description.   Another lesson learned is looking at your job responsibilities for additional opportunities that you can fit in healthy inclusive community work.  For instance, when reviewing policies, review and suggest  inclusive language be added. When doing an environmental scan, look at accessibility.

Another lesson learned is that it is best to include people with disabilities and on your coalition and these individuals need to commit their time to being an advocate.  Having a variety of community partners on your coalition is also beneficial.  This includes not only individuals with disabilities but also family members of individuals with disabilities. You will also want to consider bringing organizations and businesses who serve PWD to the table. Working with your local area agency on aging, metropolitan planning organization, senior center, day programs, residential facilities, city parks and recreation, health and fitness clubs, city transit, Special Olympics, Miracle League, and sports and recreation facilities, just to name a few.  Working with your coalition to develop a mission and vision is important to keeping coalition members engaged and working to develop an action plan that includes goals and objectives will help keep coalition members on track and working toward common goals.  All of these steps will result in change throughout your community.

We have also learned that if new projects, programs, or facilities are in the planning or development stage it is best to review the plans and services prior to implementation and to opening and offer to complete a CHII assessment at that time.  It is much easier to be inclusive and accessible from the beginning and it is often times more cost effective than doing it after the fact. 

Businesses and community-based organization want to provide quality services to all individuals in their community, including people with various types of disabilities. Unfortunately, they often just lack the knowledge and skills to do so.  Coalition members who have working relationships with other entities can contact and promote your coalition work and encourage others to have a CHII onsite assessment completed. 

Providing even minimal funding to businesses to implement PSE changes helps businesses agree to having the CHII onsite assessment completed, but often times businesses end up investing more of their own money to make additional PSE changes. 

Local health departments should seek out local grants and funding sources for healthy inclusive community work as most entities will provide funding for such important initiatives. It is often easy for people to rally around people with disabilities and hard for people to say no to making improvements for people with disabilities.

SDHD is fortunate to have the support of the All-Abilities Health and Wellness Coalition to sustain partnerships and awareness in the community for the CHII.  Community Partners that have already completed the CHII are now moving forward with additional PSE changes on their own as their eyes have been open to what needs to be done to improve access to care and physical activity for those living with a disability.  SDHD will continue to support community organizations wanting assistance in completing the CHII assessment.