For many years, the public health field focused on individual behaviors—like a nutritious diet, regular exercise, and a tobacco-free lifestyle—as the key determinants of good health. But more recently the field has increasingly recognized that where we live, learn, work, and play also impacts our health. There is growing evidence that unequal access to clean air, healthy food, good schools, and safe communities lead to worse health outcomes. And the people who most often lack access to those things are people with lower incomes and people of color. According to some estimates, these health disparities cost the United States up to $309 billion annually in health care costs and, if eliminated, would prevent up to 80,000 early deaths each year.
This shift in the public health field has brought more attention and energy to the goal of health equity, a commitment to reduce and ultimately eliminate disparities in health and strive for the highest possible standard of health for all people. Health equity is concerned with creating better opportunities for health and giving special attention to the needs of those at the greatest risk for poor health.
More and more, philanthropic, nonprofit, and government partners are focused on promoting health equity. The Affordable Care Act (ACA), signed into law in 2010, marks one great stride in taking action towards achieving health equity. Most people know how ACA has expanded access to health insurance for millions of Americans. Less well known is a requirement that nonprofit hospitals conduct a Community Health Needs Assessment (CHNA) every three years to determine the overall health needs—not just the health care needs—of the community served by the hospital. These hospitals must also create strategies to address the needs identified through their CHNA. This approach encourages hospitals to assess the health of traditionally underserved individuals including low-income, minority, or geographically isolated communities, in addition to privately insured hospital patients who are in their offices and clinics.
In 2015, Harder+Company worked with hospitals and public health departments in six regions across California, from Sonoma and Marin to San Bernardino and Long Beach, to conduct county-wide Community Health Needs Assessments in response to these requirements. These communities span the vast geographic, economic, and cultural diversity that characterizes the Golden State. Across these projects, we found several things essential to promoting health equity through the CHNA process:
- Place community engagement at the core of the CHNA process. It is essential that CHNAs use quantitative health data to paint a complete picture of health in a community, but prioritizing community voice is equally important. Residents know what they need. Focusing on community engagement ensures that the experiences of residents and key stakeholders are included as you identify and prioritize health needs.
- Meet people where they are. People with the greatest health risks are often the hardest to engage. To meaningfully include underserved and low-income populations, and communities of color in the data collection process, we talk to people in underrepresented communities, not just those who typically try to speak on their behalf. Collaborating with community partners who are already trusted and respected in a neighborhood is a great way to leverage existing relationships and develop new ones.
- Examine health indicators in at-risk populations. It is important to push beyond county level indicators to identify disparities for vulnerable groups within your community. Resident and stakeholder input can also help identify groups that face greater risk of specific health issues. Examining health indicators by zip code, race/ethnicity, age, gender, or income can shed light on important disparities in health, and help identify strategies that can address top health concerns.
- Use the CHNA as an opportunity to start a conversation about race and health, place and health, and inequities present in your community. Collecting data and identifying health needs with equity in mind is only the first step in using the CHNA requirement as an impetus to move towards health equity in your community. The data can be a resource to all groups working towards a healthier community, as well as a starting point for important and challenging conversations about structural and historical barriers to health.
Looking across the CHNAs that we’ve conducted in California, we can see how partners who really embraced these principles have been able to extend their reach by engaging community stakeholders and examining data in a way that goes beyond measuring individual health issues to a broader understanding of drivers of health and health equity. As these hospitals and community health partnerships identify strategies for investing community benefit dollars, they are well-positioned to focus on the most vulnerable groups in their community and build stronger, healthier places for everyone.