The Ripple Effect: Ways to Make Health in All Policies Stick in Kansas and Beyond to Enhance Health and Equity

Understanding the Impact: Decisions and Health

Decisions made at all levels — organizational, governmental or public sector — not only shape how our community looks but also how we experience everyday life and the subsequent impacts on health. Many decisions are implemented through policies and regulations. Often, the potential connections between these decisions and their effects on health are not immediately clear. If questions about these connections are not asked and time is not taken to understand them, there is a risk of passing policies and developing projects that have an unintended negative impact on health, or that miss an opportunity to have a greater positive impact. Embracing and centering a Health in All Policies (HiAP) approach to decision making ensures that health considerations are integrated into the fabric of policies across all sectors, leading to more informed, equitable and sustainable outcomes that positively affect the well-being of all community members.

Transforming Public Health for the 21st Century: Bridging Theory to Practice is a blog series that will explore the challenges and opportunities faced by the public health sector and will introduce a roadmap for transformation. Sign up here to receive these summaries and more, and also follow KHI on Facebook, Twitter, LinkedIn, and Instagram. Learn more about the series on our archive page. Please feel free to share your feedback or suggestions with us by emailing info@khi.org.

Public Health’s Role and Essential Capacities in HiAP Implementation

One of the most challenging aspects of Health in All Policies is that public health cannot achieve this alone. Many of these decisions are made by partners in the community, such as economic development, recreation and parks, energy and utilities, transportation and housing. It’s essential for the public health community to understand the priorities of partners in other sectors and explore how the HiAP approach can help advance these priorities. Achieving this goal necessitates deep listening, consistency, full engagement and a dedication to understanding other sectors. It also requires time and effort to craft a vision that resonates with the unique characteristics of each community, informed by a comprehensive understanding of the decisions and policies that are being considered. For public health professionals, this could involve keeping a pulse on discussions at the city council, county commission, chamber of commerce and major local employers, as well as identifying ways to engage in the process and provide evidence-based information. Practically, this includes allocating staff time for meeting attendance, implementing systems to track decisions and using insights to inform action plans that can support cross-sector goals, thereby necessitating knowledge beyond traditional public health areas.

National Initiatives Driving Health in All Policies

Health in All Policies is not a new concept. At the national level, it is a cornerstone of Public Health 3.0,  10 Essential Public Health Services and strategic planning models such as Mobilizing for Action through Planning and Partnerships (MAPP) and PHAB’s standards and measures.

Numerous organizations, including the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, and SOPHIA: The Community of HiAP Professionals, work to advance the HiAP field. These organizations have been convening communities of practice, and developing and disseminating resources that offer a variety of examples and strategies which can be tailored and integrated at various levels.

Building Foundations and Implementing Health in All Policies in Kansas Communities

Over the past decade, Kansas gained valuable experience with various formal and informal approaches to implementing Health in All Policies. The program has advanced as communities began to recognize how the conditions in which we live, work, learn, worship and play shape our health and the role of policies in Kansas. Most recently, two specific efforts have assisted communities in building foundations to advance HiAP. At the state level, the Centers for Disease Control and Prevention’s Public Health Innovation Grant (PHIG) provided an opportunity for grantees to strengthen their public health infrastructure and workforce. As part of its overall plan for this grant, the Kansas Department of Health and Environment (KDHE) included a focus on HiAP. In the initial phase, KDHE brought together all three divisions of Public Health, Healthcare Finance and Environment in a workshop on HiAP facilitated by KHI to enhance capacity in the HiAP concept and determine the integration of it into both internal and external operations.

“KDHE embarked on HiAP to continue building its dedicated commitment and collaboration among its divisions,” KDHE Secretary Janet Stanek, said. “It has created an array of robust internal and external mechanisms that function to guide all decision-making, which ensures that policy, procedure, purchase and individual choices have neutral and beneficial impacts on the health and the environment of Kansans.”

At the county level, the Pathways to a Healthy Kansas Initiative, developed and funded by Blue Cross and Blue Shield of Kansas (BCBSKS), assisted communities in building foundations and implementing HiAP efforts. Pathways combines community-wide, evidence-based solutions and practices to help Kansas communities improve active living, healthy eating and commercial tobacco prevention. Participating communities had an opportunity to select which areas they would be addressing throughout the four years of the grant period, with HiAP being one of them. Out of 24 funded communities, six communities selected HiAP as one of their areas of work. The section below provides an overview of the journey of four HiAP communities. According to Virginia Barnes, BCBSKS Blue Health Initiatives Director, the goal of Pathways has always been to make Kansas communities thriving, healthy places to live. “The Pathways program is built around addressing the social determinants of health and HiAP is one strategy to improve how health is considered in policy decisions in Kansas,” said Barnes. “Building HiAP into the Pathways work made sense because the Kansas Health Institute’s expertise in this area would help ensure long-term success for partnering communities.”

An integral part of the project involved communities identifying organizations that could collaborate with health coalitions on this effort. Securing a commitment through a signed pledge was a crucial first step. Subsequently, each community was tasked with passing a policy to lay a foundation for systemic change.

These policies could be implemented at both the organization and local government levels, encompassing city or county jurisdictions. Additionally, each community received comprehensive technical assistance from Seed 2 Roots with expertise in public health law, Wichita State University’s Community Engagement Institute with expertise in coalition development and KHI with expertise in HiAP.

KHI has a long history of focusing on HiAP, beginning with the launch of the Children’s Health in All Policies project in 2010. Since that time, KHI has conducted six Health Impact Assessments on policy areas ranging from casino development in Southeast Kansas to recycling municipal wastewater for beneficial purposes. KHI has developed tools such as the Health Impact Checklist (HI-C) and worked with communities to develop HiAP policies, launch initiatives like HiAP task forces and embed assessments in their processes to understand the potential impacts of decisions on health before they are made. To meet the needs of Kansas, KHI will continue this work and has recently launched a Health in All Policies Technical Assistance Hub. The HiAP Technical Assistance Hub will offer many services, including workshops, development and implementation support for HiAP processes, guest lectures to students and more. KHI hopes that our HiAP Technical Assistance Hub will further advance community efforts across the Midwest and beyond in evidence-based decision-making.

Strengthening the Foundation for HiAP Success: Insights from Kansas’ Experience

The HiAP journey of Bourbon, Cowley, Franklin and Riley counties in Kansas are featured in the vignettes here. Their journeys can demonstrate how HiAP can be operationalized and sustained.

While these communities are still in the early stages of advancing HiAP efforts, their experiences are helpful in understanding what needs to be put in place for HiAP to stick and succeed in the future. The communities featured in this blog had common elements, such as:

• Securing champions who embrace HiAP, both within public health and in sectors outside of health, played a crucial role in carrying out activities.
• Establishing mechanisms to support commitments made by partners, such as signing a pledge or passing a policy, ensured their ongoing commitment and provided a clear reference point.
• Developing a system and designating staff helped ensure that efforts went beyond just one-time activities and became part of the ongoing process. This system can take the form of a protocol or process that becomes integrated into operations and standard procedures.
• Focusing on effectively communicating the value of HiAP to partners and the broader community, including creating a narrative that resonates based on local context, ensured that they understood the purpose and knew how to engage in these processes.
• Experimenting with HiAP strategies and leveraging lessons learned sustained and advanced the work.

Although funding and technical assistance were beneficial, community and organizational readiness were critical in advancing the efforts further. Signs of readiness included the understanding and belief among organizations that championed HiAP efforts that conditions in the community shape health beyond just behaviors, genetics or access to care. Additionally, there was an understanding of the importance of affecting change through well-informed policies and systems, as well as collaboration across sectors. Furthermore, they invested in building this understanding among broader community members, such as Cowley County’s efforts in conducting a Data Walk or Riley County’s HiAP conversations across the community.

Forging Ahead: Cultivating an HIAP Culture

As communities embark on or continue their HiAP journey, it’s crucial to focus on creating a culture where HiAP is not just a workshop or a one-time activity, but rather becomes a part of the culture and operational practices. This entails making health and equity considerations an integral part of the decision-making mindset, asking, “What about the impacts of this decision on health and equity?” This also necessitates a willingness to act upon the findings, potentially requiring adjustments to initial plans and the adoption of different approaches to budgeting and resource allocation. By strengthening the foundation for HiAP in more places, communities can build an infrastructure that ensures decisions more consistently promote the health and well-being of the community and effectively address health barriers.

Health in All Polices: Journeys of Kansas Communities

Four Kansas communities — Bourbon, Cowley, Franklin and Riley counties —navigated the implementation of various Health in All Policies (HiAP) strategies via the Pathways to a Healthy Kansas initiative, developed and funded by Blue Cross and Blue Shield of Kansas (BCBSKS). Each community passed a policy under the Pathways initiative, committing to continued work on HiAP over the course of five years. By describing their paths, the intention is to illustrate the practical application and long-term sustainability of HiAP approaches. The communities received comprehensive technical assistance in Health in All Policies from the Kansas Health Institute and in policy development from Seed 2 Roots.

A Spotlight on Bourbon County: HiAP Task Force

In Bourbon County, HiAP efforts were focused on creating the Bourbon County HiAP Task Force and were jump-started by the Healthy Bourbon County Action Team, Inc (HBCAT), which saw the strong value of intertwining HiAP concepts with economic development efforts. According to Jody Love, president and CEO of HBCAT, “At the Healthy Bourbon County Action Team, we are committed to building collaboration and community trust. The health policy task force is a way to enhance multi-agency communication, engage community members and coordinate efforts around a common vision.”

One initial challenge encountered when proposing the HiAP policy was navigating the political landscape. Initially, not all county commissioners were on board, prompting HBCAT to change their approach and pursue a memorandum of understanding (MOU) between other incorporated towns and the school district. Subsequently, as HBCAT continued to build buy-in among countywide stakeholders, it successfully secured the county commissioners’ signatures on the policy.

The Task Force operates under the MOU executed between the City of Bronson, City of Fort Scott, USD 234 and HBCAT. One of the goals of the group is to enhance access to previously unavailable opportunities and resources, specifically aiming to improve overall health outcomes and address health disparities in Bourbon County. To support these efforts, the Task Force, in collaboration with its members, will apply for grant opportunities that benefit various communities in Bourbon County. The Task Force also will work to provide recommendations on the health impacts of decisions to city and county commissions; identify local policies or codes that may hinder a healthy environment; foster communication and collaboration among governmental entities, businesses and community members; assist organizations in using data from community health assessments and improvement plans for informed decision-making; and seek joint funding opportunities to support health improvement initiatives.

A Spotlight on Cowley County: Implementing a Tool That Connects Decisions to Health

The City-Cowley County Health Department (CCCHD) centered their HAIP efforts on ensuring that the potential effects on community health and well-being are considered when community-wide decisions are being made. An opportunity to explore and implement this concept emerged as one of the cities in the county began to contemplate a new housing development. At a city commission meeting, CCCHD recommended conducting a health impact assessment before finalizing the decision. Consequently, CCCHD utilized the Health Impact Checklist, developed by the Kansas Health Institute, to evaluate the health impacts of the proposed Sleeth Addition Housing Project in Arkansas City. The team evaluated the development’s impact on housing stability and environmental conditions in the area, and considered development features, such as a proposed splash pad and the lack of a storm shelter. The findings and ways to maximize positive health impacts and address negative health impacts were shared with the city commission for consideration and any necessary action. Although CCCHD originally intended to spend more time building HiAP capacity before completing its first HI-C, it decided to dive right in to provide valuable information to decision-makers. Working and learning simultaneously wasn’t ideal, but ultimately, it led to a far greater appreciation for the depth and scope of HiAP.

Moving forward, CCCHD is committed to continuously informing decision-making by providing this type of assessment and information. To gather community suggestions on which decisions to assess, it created an HiAP page on its website. CCCHD also is establishing internal processes and protocols to stay informed about various community decisions and provide evidence-based information for future decision-making.

For Cowley County, one critical piece of building a foundation for HiAP was conducting a robust community engagement event it called the “Data Walk” in collaboration with RISE Cowley County. This approach helped the community connect the dots between a broad range of environmental, economic, educational and social conditions and health, identifying areas for improvement.  Echoing the significance of these efforts, Tom Langer, administrator of the public health office at CCCHD noted, “To fully understand and address community-wide health conditions affecting children in Cowley County, a purposeful examination of health indicators was conducted through a Data Walk. Participants questioned what could be done to address the systemic issues identified. Adopting HiAP across multiple sectors, such as local government, education and private industry, was seen as the best approach for focusing efforts on providing long-term solutions.” Data and analysis for the Data Walk were provided by KHI. Since Cowley County, KHI has supported data analysis for three more Data Walks across Kansas.

A Spotlight on Franklin County: Health Lens Analysis

The Ottawa Recreation Commission, with support from Live Healthy Franklin County, took the lead in implementing HiAP. The commission was undergoing a strategic planning process for the years 2024‒2028, carried out by PROS Consulting and commission staff with input from the community. It commissioned a Health Lens Analysis to ensure that the strategic plan thoroughly incorporates health and equity considerations and strategies for maximizing services for all community members — particularly those facing barriers to health. According to Levi Meyer, executive director of the Ottawa Recreation Commission, “We made the decision to embark on Health in All Policies to ensure our strategic planning process was equitable toward the needs of our entire community. Our goal is to serve the community as a whole, and the HiAP process helped ensure we were taking into consideration the needs and interests of all individuals within our community.” The analysis was conducted by KHI, with support from the Live Healthy Franklin County Coalition and a faculty member from Baker University.

The analysis led to over 50 recommendations for the Strategic Plan, all aimed at enhancing the community’s engagement and inclusivity within programs, services and policies. PROS Consulting integrated recommendations from the analysis throughout the Plan. Among these recommendations were strategies including the integration of community engagement elements into future commission decisions regarding services, programs and policies; equipping staff with the necessary skills to work effectively across diverse cultures, backgrounds and languages; ensuring services are designed to meet the varied needs of community members; and ensuring that marketing and communications about programs and services are accessible to all community members.

As a result of this process, the commission feels more adept at incorporating the Health Lens Analysis approach into its various operations and decision-making. Making Health Lens Analysis a standard part of regular procedures will ensure the consistent consideration of health and equity. Currently, the commission intends to use some of the insights gained as it explores the feasibility of developing an inclusive and accessible playground and acquiring a communication board designed to meet the linguistic and cultural needs of the diverse community members.

Baker University will host a guest lecture on Health in All Policies, delivered by KHI. It is considering integrating this topic into the class curriculum, which will strengthen local capacity and workforce skills.

A Spotlight on Riley County: Embedding HiAP in Existing Groups and Policies

Since its inception, Flint Hills Wellness Coalition has approached all of its work from an HiAP perspective, so it was natural for it to select this Pathways package. Initially, the coalition spearheaded the HiAP initiative by focusing on training individuals who are already well-connected within various groups to assist in embedding health and equity considerations into decision-making processes. These individuals engaged with various groups to build a foundation for HiAP efforts. Additionally, the coalition developed an HiAP policy for the Food and Farm Council of Riley County and the City of Manhattan, encouraging the council to adopt the HiAP approach in the development and implementation of all projects.

While the coalition continues to build buy-in among public entities for the adoption of formal policies, such as resolutions, it also continues to identify opportunities to insert HiAP into the conversation. The most recent example is the inclusion of HiAP in the proposed update of the Riley County Comprehensive Land Use Plan, both in the sections on housing and health. Furthermore, the coalition is convening a larger cross-sector community in Riley County to enhance its understanding of HiAP and will provide mini-grants to public entities or nonprofit organizations with the hope that the organizations will adopt resolutions or policies within the next several months.