A Holistic Approach to Public Health: Using the Socio-Ecological Model to Address Health Disparities Associated with Sub

State: OR Type: Model Practice Year: 2010

The practice, using the socio-ecological model to holistically look at public health issues, in the Multnomah County Environmental Health example, addresses public health issues associated with substandard low-income housing, including, but not limited to: asthma, mold and mildew, pests and vectors, lead, household chemicals, and renters rights. Goal: Reduce health disparities associated with substandard housing by making connections between health and housing on each level of the socio-ecological model. Objective 1) provide and sustain targeted nursing and environmental in-home case management for families with children with asthma. (Individual and Interpersonal levels) Objective 2) guarantee housing code enforcement for all rentals in Multnomah County (Policy and Organizational level) Objective 3) provide education and outreach in culturally competent and empowering ways. (Community level) The practice of addressing public health issues using the socio-ecological model requires innovative solutions on each level of the model. Outcomes included: 1. Increased understanding of the multiple ways that housing influences health outcomes. 2. Greater asthma control and reduced ER visits for clients using Multnomah County Health Homes Services, as well as improved coordination and relationships with providers. Community needs have identified retention of the Healthy Homes comprehensive home visit program and the implementation of a new program that supports primary care providers to incorporate the home environment into their plan of care to support improved asthma control by providing the provider with environmental assessment results. 3. Increased enforcement of housing codes and greater protections for low-income renters 4. Delivery of empowering education and health promotion to residents of affordable housing. The data analysis and findings of these various initiatives are used to form public health policy.
Multnomah County Environmental Health is committed to looking at public health through an equity lens, with recognition that empowering communities to take greater control over their own environment is an essential value aimed at reducing and eliminating health inequities. Substandard housing is related to many public health issues, and by nature using the socio-ecological model (which addresses any public health issue on multiple levels: individual, interpersonal, organizational, community, and public policy) in a holistic approach means that many public health issues will be identified and addressed. Specifically, asthma morbidity is directly related to environmental health triggers in homes, which universally tend to be more prevalent in substandard housing. By focusing on just one chronic condition, through a holistic approach, and by intentionally viewing the illness through an equity lens, the practice of using a holistic approach impacts multiple contributors to health issues. At the individual and interpersonal level, we are working with families to empower them to take greater control over their individual home environments and making connections between health and the environment. By addressing housing code and enforcement, we are working at a public policy level to identify gaps in protections, and by looking at education and empowerment of residents, while also improving relationships between landlords and tenants, the model creates conditions by which community members can speak for themselves, under a premise that a "community that speaks for itself, can best protect itself. Multnomah County Environmental Health relied on several processes: 1. PACE-EH: community assessment that identified affordable housing issues, mold, lead, trash and feeling ignored and led to the creation of a community coalition that develops recommendations for the health department 2. Healthy Homes Summit: created recommendations and practical solutions, involving over 150 stakeholders, to determine best approaches to addressing substandard housing issues, and the health issues associated with housing in key areas: data collection, education and outreach, and policy. 3. The Quality Rental Housing Workgroup, the Gresham City housing ordinance and the public health initiatives to connect health with housing created the framework for setting policy recommendations for greater renter protections in the Portland area. The socio-ecological model addresses the issue by using a holistic approach to identify interventions, education, and policies that can best protect and benefit the community. Home case management results in greater asthma control and reduction of ER visits. The legislation and enforcement of housing codes provides greater protections for tenants and results in increased accountability for landlords and managers, and greater stability and health of the home for renters. Education and empowerment of tenants addresses the lack of community knowledge about the connections between our environment and our health. All together, the practice of a holistic approach to public health results in greater civic knowledge, improved dialogue and relationships between public health and housing providers, and reduction of health inequities associated with substandard housing. Jane Moore, Ph.D., RD Manager of Oregon Department of Human Services-Health Services describes the model as such: "The socio-ecological model recognizes the interwoven relationship that exists between the individual and their environment. While individuals are responsible for instituting and maintaining the lifestyle changes necessary to reduce risk and improve health, individual behavior is determined to a large extent by social environment, e.g. community norms and values, regulations, and policies. Barriers to healthy behaviors are shared among the community as a whole. As these barriers are lowered or removed, behavior change becomes more achievable and sustainable. 
Agency Community RolesThe LHD should have a role in assessment , development and implementation of community efforts at the multiple layers that constitute a community: Example- community members, policy makers, organizations designed to serve a healthy and empowered community. Additionally, public health practice should demonstrate broad-based involvement and participation of community partners (e.g. healthcare professionals, governmental partners, local residents, the business sector, academia, etc.). This practice demonstrates the public health role of leading and convening internal and external organizations and community members to form and storm community practice that improves health outcomes. The LHD role has been to educate and advocate internally by coordinating with safety net providers to incorporate referrals to housing interventions, inform about the linkages between health and environment, staff coalitions, create culturally competent educational tools, facilitate the acquisition of resources and coordinate the voices that have changed public policy to improve disenfranchised populations.Multnomah County Health Department is investing in the “Health Promotion Framework” that encompasses the socio-ecological model as a core function of the work. Environmental Health has been a leader in this process, as our work showcases how a holistic approach can address health inequities. Multnomah County Environmental Health has used several processes to plan and implement the use of the socio-ecological model, and stakeholders and our partners have played key roles. Starting with PACE-EH, the entire process was driven by community and organizational partners/stakeholders. Upon identification of housing issues, MCEH convened a healthy homes summit comprised of public health, academia, community members, CBO’s and elected officials to identify strategic directions for implementation of programs, policies and interventions. We have worked with Community Development Corporations to partner around education and empowerment of residents (individual, interpersonal, community level), and have worked with local and state policymakers to help facilitate Medicaid reimbursement for our in-home case management work (policy/community levels). At all stages of our work we engage with stakeholders and our partners who play a critical role in determining direction, best practices, and policy advocacy. Costs and ExpendituresUsing the socio-ecological model to address public health concerns requires focused acquisition of funding to implement multiple intervention strategies addressing each level of the model. It is imperative that leaders believe in the value of each sphere of the socio-ecological model and are willing to take a "leap of faith" and assure sustainable resources follow in the footsteps of the assessment and identified needs. It is not ethical to initiate a community engagement process without the commitment to actively address the issues. Implementation: PACE-EH: was initially funded from general funds from three distinct sections in Multnomah County Health Department (Administration, Planning and Development, Environmental Health) and supported by NACCHO at start-up. Using the socio-ecological model, which requires a holistic approach to addressing public health issues associated with housing, there were multiple programs and multiple funding sources: Individual and Interpersonal: Home visit services provided to high risk children with asthma to identify triggers, implement interventions, provide education, information and referral resulting in improved asthma control and reduced health care costs; funded by Housing and Urban Development grant, general funds and Medicaid reimbursement. Community: Development of Healthy Homes Coalition to identify comprehensive community concerns and multi-agency interventions resulting in the acquisition of grant funding for multiple community partners providing various housing assets along the continuum of need. Development of Healthy Affordable housing project to educate, empower and engage tenants and landlords to address health issues in affordable housing, funded by CDC grant and general funds. Organizational and Policy: Convened housing summit to identify strengths and gaps in the current housing policy and committed multiple organizational resources to addressing the policy gaps between housing and health resulting in adoption of two additional housing code ordinances. Created linkage strategies between providers of direct health care and knowledge of individual environmental triggers in the home; funded by general funds and other agency resources. ImplementationTo achieve a holistic approach to health and housing, MCEH had to develop a framework upon which we would operate. In our case, our first task was to use the PACE-EH model as a driving force to determine the direction of our work. From there, it was imperative to use the assessment as a basis for developing community action steps that required cooperation but not increased resources and submitting grant concepts that would be able to address issues on each level of the socio-ecological model. From in-home case management focusing on the individual and interpersonal control of asthma and of single units of housing, to grants that provided funding for policy analysis and advocacy, MCEH was intentional about being task oriented around funding and accountability to the model. Timeframe: In the case of Multnomah County Environmental Health, this has been a 10 year process. It really required a strategy where we have moved, as in the socio-ecological model, from the individual focus to the policy focus, and have worked to create sustainable models.
Goal: Use the socio-ecological model to reduce health disparities associated with substandard housing by making connections between health and housing. provide and sustain targeted nursing and environmental in-home case management for families with children with asthma.Improved Asthma Control Test (ACT) scores over a 6 month period for more than 200 families, improved environmental assessment status resulting in a reduction of asthma triggers, reduction in emergency room visits, improved medication ratio (appropriate use of control medication and reduced use of rescue medication) 1) ACT scores, conducted by certified asthma educator, in this model, a community health nurse. 2) Environmental Assessment: conducted by Community health worker. 3) Emergency Room Data: CARE Oregon (primary managed care provider) tracks ER data for all clients with Medicaid insurance 4) Medication ratio: CARE Oregon tracking use of daily, control medicine/rescue medication Data is collected at each visit over a 6 month period, with an emphasis on baseline (first visit) and 6 month outcome (last visit). A follow-up evaluation is done within 6 months after completion to determine sustainability of asthma and environmental control. MCEH provides list of clients to CARE Oregon who compares ER visitation records 12 months prior and 12 months after in-home intervention is completed. Program staff conducted weekly chart reviews, and continually worked to improve the effectiveness of the program, and improve the assessment and documentation of environmental triggers. A program evaluator worked to compile and assess data, and quarterly reports were submitted to funding agency: HUD. The Healthy Homes Team developed a database which was used to run queries informing the program about supplies, visitation frequency needs (case load), and recruitment. MCEH also hired an additional bilingual community health worker after evaluation determined 70% of clients in program were Spanish speaking, and developed protocols that prioritize the most severe asthma cases in order to have the greatest impact. Short-term: 1) Better asthma control based on ACT scores (18.17 to 22.13) and reduction of asthma triggers in the home 2) Emergency Room visits reduced by 2.5. Long term: increased knowledge of families for greater asthma control, empowered families with increased knowledge of environmental triggers, tenants’ rights, and improved self-efficacy. Guarantee housing code enforcement for all rentals in Multnomah County Housing code adopted in Unincorporated Multnomah County. 1. Informational interviews with surrounding city rental housing inspection programs, participation on City of Gresham and City of Portland rental housing inspection program advisory groups in development of and revision of current housing codes, collection of rental housing property information with Taxation and Assessment office, housing complaints for city of Portland (number and type of complaint) and Gresham, community stakeholder feedback in pubic meetings and Advisory Group meetings, data/literature review of various inspection programs nationwide collected by policy analyst. 2. Field assessment of a statistically sound sample of rental properties was conducted by a housing specialist. The national research on housing codes, informational interviews and participation in city rental housing advisory groups occurred within a twelve-month period in July 2008 – July 2009. A Stakeholder Advisory Group was formed and met three times within three months in 2009. Five public meetings occurred with impacted stakeholders within a three month period in 2009. The field assessment of approximately 200 properties occurred within a three month period in the end of 20009. Policymakers, impacted community members small landlord and property management association, multi-family member organization, tenant advocacy organization, Oregon Law Center, various environmental health organizations, Portland and Gresham Ho
There are several ways that the commitment to using the socio-ecological model is being ensured. First, Multnomah County Health Department is broadly adopting a Health Promotion Framework which incorporates the use of the socio-ecological model and empowerment as a core function of our work, and part of an institutional commitment. Multnomah County Environmental Health has a continuing Healthy Homes partnership committed to this ongoing effort to improve health and housing conditions. Multnomah County Health Department is developing a Health Promotion Framework that will use the socio-ecological model as a quality improvement tool, and be incorporated into all of our work. Finally, through years of relationship building, there is a community of housing and public health advocates who recognize the importance of maintaining safe, affordable, quality housing as an effort to reduce and eliminate health inequities. Multnomah County Environmental Health has been working with CARE Oregon to insure Medicaid reimbursement for our in-home case management work to create a sustainable model of funding for the continuation of this program, and cost avoidance from decreased emergency room visits. Our Healthy Homes partnership, which includes stakeholders from community non-profits, government agencies, and private and public housing providers continues to meet and strategize about funding and advocacy positions to address housing at a policy and community organizing level. Finally, with codes and a complaint-based enforcement model, Multnomah County Environmental Health sustains the protections for tenants in unincorporated Multnomah County.