1. Health in All Policies September 16, 2015 Directors of Public Health Nursing 2015 Fall Conference Julia Caplan, MPH, MPP and Linda Rudolph, MD, MPH Public Health Institute

2. 2 Introductions and Overview

3. Today’s Goals Increased understanding of –Health in All Policies –Links between health, equity, and climate change Share tools for building cross-sectoral partnerships Ideas about how PHNs can use a HiAP approach in your own communities 3

4. Agenda 1.Introduction & Overview 2.Government Functions 3.Root Cause Mapping Exercise I Short break & map walk-about 4.Root Cause Mapping Exercise II 5.Collaboration & Communication 6.Cross-Program Opportunities 7.Discussion & Closing 4

5. Agreements Try on the process Step up / Step back There is no wrong way to do HiAP Have fun! 5

6. 6 Creating Healthy Communities

7. What is a Healthy Community? 7

8. A Healthy Community provides for the following through all stages of life: Meets basic needs of all – Safe, sustainable, accessible and affordable transportation options – Affordable, accessible and nutritious foods and safe drinkable water – Affordable, high quality, socially integrated and location-efficient housing – Affordable, accessible and high quality health care – Complete and livable communities including quality schools, parks and recreational facilities, child care, libraries, financial services and other daily needs – Access to affordable and safe opportunities for physical activity – Able to adapt to changing environments, resilient, and prepared for emergencies – Opportunities for engagement with arts, music and culture Quality and sustainability of environment – Clean air, soil and water, and environments free of excessive noise – Tobacco- and smoke-free – Green and open spaces, including healthy tree canopy and agricultural lands – Minimized toxics, greenhouse gas emissions and waste – Affordable and sustainable energy use – Aesthetically pleasing Adequate levels of economic, social development – Living wage, safe and healthy job opportunities for all, and a thriving economy – Support for healthy development of children and adolescents – Opportunities for high quality and accessible education Health and social equity Social relationships that are supportive and respectful – Robust social and civic engagement – Socially cohesive and supportive relationships, families, homes and neighborhoods – Safe communities, free of crime and violence

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10. Rudolph 2013 10

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13. Rudolph 2013 13 Social Determinants of Health

14. Education Income Inequality Race & ethnicity Early child experiences Social support Employment Social & cultural environments Built environment Housing Transportation Green space Food environment Stress Gender

15. “ It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural, and physical environment conspire against such change.” - Institute of Medicine Rudolph 2013 15

17. Place Matters 17

18. What are Health Inequities? Preventable differences in health outcomes that are the result of the systematic and unjust distribution of social determinants or conditions that support health. http://www.cdc.gov/healthycommunitiesprogram/overview/he althequity.htm 18

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20. Where’s Public Health? 20 Transportation Agriculture Arts Housing Community Development Transportation Labor & Workforce Energy Environment Public Works Public Health

21. We all have a role to play in creating healthy communities. Environments in which people live, work, study and play impact health Decisions made by “non-health” agencies play a major role in shaping environments Consideration of health allows agencies to make more informed policy and program decisions and to identify win-wins

22. a collaborative approach to improving the health of all people by incorporating health considerations into Health in All Policies is… decision-making across sectors and policy areas. Source: Rudolph, L., Caplan, J., Ben-Moshe, K., & Dillon, L. (2013). Health in All Policies: A Guide for State and Local Governments. Washington, DC and Oakland, CA: American Public Health Association and Public Health Institute. 22

23. Health in All Policies: 5 Key Elements 1.Promotes health, equity, & environmental sustainability 2.Supports intersectoral collaboration 3.Benefits multiple partners 4.Engages external stakeholders 5.Creates structural or process change 23

25. Co-benefits 25

26. California Health In All Policies Task Force 26

27. Report to the Strategic Growth Council Active transportation Housing and indoor spaces Parks, urban greening, and places to be active Community safety through violence prevention Healthy food Healthy public policy 

28. Active Transportation Co-Benefits 28

29. Active Transportation Co-Benefits Increases –Physical activity –Social capital Avoidable increases –Bike/ped injuries Reduces –Respiratory & CV disease –Diabetes & cancer –Depression & stress –Osteoporosis Reduces –Infrastructure costs –GHG emissions –Air pollution –Noise –Community severance 29

30. 30 Role of Government

31. What does government do? (Policy or policy) 31

32. Government Functions Data Direct Service Provision Education & Information Employer Funding Guidance and Best Practices Permits/Licenses Purchasing, Procurement, Contracts Regulation Research & Evaluation Legislation & Ordinances Taxes/Fees Training and Technical Assistance 32

33. 33 Root Cause Mapping

34. Opportunity to identify, illustrate, and discuss: –key factors contributing to community health problems and methods for action –opportunities for change –overlapping roles that sectors play –frequent root causes –contributing factors with higher / lower health impacts Opportunity to identify and involve partner agencies 34

35. Why is Jason Sick? Why is Jason in the hospital? Health Canada 35

36. Why is Jason Sick? Why is Jason in the hospital? But why does he have an infection? Health Canada 36

37. Why is Jason Sick? Why is Jason in the hospital? But why does he have an infection? But why does he have a cut on his leg? Health Canada 37

38. Why is Jason Sick? Why is Jason in the hospital? But why does he have an infection? But why does he have a cut on his leg? But why was he playing in a junkyard? Health Canada 38

39. Why is Jason Sick? Why is Jason in the hospital? But why does he have an infection? But why does he have a cut on his leg? But why was he playing in a junkyard? But why does he live in that neighborhood? Health Canada 39

40. Why is Jason Sick? Why is Jason in the hospital? But why does he have an infection? But why does he have a cut on his leg? But why was he playing in a junkyard? But why does he live in that neighborhood? But why can't his parents afford a nicer place to live? Health Canada 40

41. Why is Jason sick? Why is Jason in the hospital? But why does he have an infection? But why does he have a cut on his leg? But why was he playing in a junkyard? But why does he live in that neighborhood? But why can't his parents afford a nicer place to live? But why...? Citation: © Her Majesty the Queen in right of Canada, represented by the Minister of Public Works and Government Services Canada, 1999. 41

42. Root Cause Mapping 42 Outcome Contributing Factor Root Causes Outcomes Behaviors Environment Policies

43. 43 Outcome Contributing Factor Jason is sick Cut on leg Infection Root Causes Playing in junkyard Lack of nearby playground Fell on jagged steps Unsafe housing conditions Parent’s lack of knowledge about wound care Lack of medical supplies to treat wound Poverty Low literacy No funds for purchase Lack of income Economic policies Rental prices Education Outcomes Behaviors Environment Policies

44. Root Cause Mapping: Example 44

45. “Real Life” Root Cause Maps 45

46. 46 Questions?

47. Root Cause Mapping Activity Instructions Small group activity Create maps showing the causal relationships between the upstream and downstream root causes for: –Not enough physical activity –Excessive consumption of sugar sweetened beverages 47

48. 48 Break & Map Walk-About

49. Root Cause Map Exercise II In pairs, discuss areas on the map where you are already working? 49

50. Report Back & Questions What was most interesting about what you learned from this exercise? What is one opportunity to expand current work? What is one area identified as important for impact, but where people are unsure they could address it? 50

51. 51 Collaboration & Communication

52. Health in All Policies Relationships Rely Upon… Trust Mutuality Reciprocity 52

53. Skit: “Public Health Reaches Out” 53

54. 54 Cross- Program Opportunities

55. Small Group Discussion – Break into groups of 2-3 –What is currently happening (or will be happening) in the county? –How can PH nurses support or leverage those efforts? Group Share 55

56. 56 Questions and Closing

57. Health in All Policies: A Guide for State and Local Governments What is HiAP and Why Do We Need It? The Nuts and Bolts of HiAP Getting Started Partners and Roles Working Together Across Sectors Structures to Support HiAP Creating Healthy Public Policy Talking about HiAP Case Study: California HiAP Task Force Appendices 57

58. Acknowledgements Public Health Institute California Health in All Policies Task Force California Strategic Growth Council California Department of Public Health With funding from: The California Endowment 58

59. 59 Thank You! Julia Caplan, julia.caplan@cdph.ca.govjulia.caplan@cdph.ca.gov Linda Rudolph, linda.rudolph@phi.orglinda.rudolph@phi.org