Problems and Purpose

Local public health departments (CCHS: Contra Costa Health Services) are in charge of promoting overall community health and wellness as well as addressing the underlying causes of disease and disability in Contra Costa, California, United States. The local health departments must collaborate with communities to find solutions to the most urgent health care problems of the day [1, 2], including chronic diseases (which are the leading causes of death), health disparities [1, 3, 13], and other complex community health issues, in order to achieve its goals after its establishment in 1973.

Contra Costa county has been facing a number of challenges in recent years, including: 

1. Lack of access to healthcare: Many residents in the county, especially low-income and minority populations, face barriers to accessing quality healthcare. 
2. Health disparities: There are disparities in health outcomes based on race, ethnicity, and socio-economic status in the county. 
3. Mental health crisis: The county has seen a rise in mental health problems, including depression, anxiety, and substance abuse (i.e. drug abuse).

To address these challenges, CCHS needs to work and partner with community groups to improve health outcomes for all residents in the county [3, 4]. The purpose of these partnerships is to collectively bring together community resources and expertise to: 

1. Increase access to healthcare services, especially for underserved populations. 
2. Address health disparities by providing targeted outreach and education programs.
3. Address the mental health crisis by increasing access to mental health services and resources. 

By working with community groups, CCHS aims to create a more equitable and effective health system for all residents of Contra Costa county in California.

This case study, which is based on years of experience in the Contra Costa county health department in California [7, 8, 9, 10], provides a conceptual framework for community involvement in public health. It strategies for integrating communities in both long-standing public health concerns using the Ladder of Community Participation framework [5]. The tactics used by Contra Costa Health Services in California to engage the community are highlighted in this case study. Based on the lessons learned, it offers suggestions to help other regional health departments improve their own operations by adopting the same strategy.

Background History and Context

Contra Costa Health Services (CCHS) is a public health department in California, USA. It was established in 1973 as part of the California State Health and Welfare Agency, with the mission to improve and protect the health of residents in Contra Costa county. CCHS provides a wide range of public health services, including preventative care, clinical services, environmental health, and emergency preparedness. CCHS works to improve the health and well-being of the community by promoting healthy living and preventing diseases. Since the establishment of CCHS as part of the California State Health and Welfare Agency it has been serving the community for over 47 years till date [7, 8, 9, 10]. 

The health organization is committed to improving the health and well-being of residents by providing access to quality health care services and promoting healthy lifestyles. CCHS works in partnership with other health organizations, community groups, and local governments to improve health outcomes and address public health issues in the community. Over the years, CCHS has implemented a number of initiatives aimed at improving the health of residents, such as improving access to preventive care, promoting healthy behaviors, and reducing health disparities [1, 3, 13]. The organization is governed by a board of supervisors, who are responsible for setting policies and allocating resources to support the work of CCHS. The board is committed to ensuring that residents have access to high-quality, affordable healthcare services and to promoting public health and well-being in Contra Costa county.

CCHS partners with community groups (i.e. for community engagement) to address public health issues in the community because CCHS realize that public health problems can be effectively solved as a shared collective responsibility of the health department and the community. Effective public health efforts require collaboration and coordination between public health organizations, community groups, and local governments. Partnerships with community groups are essential for CCHS to be able to understand the unique health needs of the community and to develop and implement effective public health strategies. Community groups have a unique perspective on the health issues that affect their communities and can provide valuable insights and input into public health efforts in solving them. 

Working with community groups also helps to build trust and credibility with the community, which is critical for the success of public health initiatives. Community groups help CCHS to raise awareness about public health issues, mobilize resources, and promote healthy behaviors, all of which are essential components of effective public health efforts. Overall, partnerships with community groups are a key element of CCHS's work to improve the health of residents in Contra Costa county and to address public health issues in the community. By collectively working together, CCHS and community groups can achieve greater impact and help to ensure that residents have access to the resources and support they need to live a healthy life.

Community groups have offered a range of services and support to CCHS that have made their partnership more profitable over time. Some of the key contributions that community engagement have made to CCHS include [5]:

1. Awareness raising: Community groups have helped to raise awareness about public health issues among their members and the wider community, which has helped to increase understanding and support for CCHS's work.
2. Resource mobilization: Community groups have helped to mobilize resources and support for CCHS's public health initiatives, such as fundraising, volunteer recruitment, and community outreach. 
3. Health promotion: Community groups have helped to promote healthy behaviors and lifestyles among their members and the wider community. This has included working with CCHS to develop and implement health education and outreach programs.
4. Advocacy: Community groups have been important advocates for public health and have worked with CCHS to support policies and initiatives that improve health outcomes for residents. 
5. Bridging gaps: Community groups have helped to bridge gaps in access to health services and to address health disparities in the community. This has included working with CCHS to improve access to care for underserved populations. 

These contributions have helped to make CCHS's partnership with community groups more profitable by increasing the impact and reach of CCHS's public health efforts and by improving health outcomes for residents. By collectively working together, CCHS and community groups have been able to achieve greater success in promoting public health and well-being in Contra Costa county.

Organizing, Supporting, and Funding Entities

For this case study, Contra Costa Health Services (CCHS) as the organizer, partners with the California Endowment and CCHS Writers Group and its community and organizational partners to support community groups in the county for actualization of community engagement in public health.

The California Endowment is a private foundation that funds and supports the community engagement in public health launched by CCHS health initiatives throughout the Contra Costa Health Services (CCHS). The California Endowment's mission for funding is to expand access to affordable, quality health care for underserved communities and improve the overall health of the State of California. In support of this mission, the California Endowment provides funding and resources to CCHS to support its initiatives with community groups in Contra Costa county. These initiatives include programs to increase access to healthcare services, address health disparities [1, 3 13], improve mental health outcomes, and promote health education and awareness in the community. The California Endowment's support of CCHS and its community partners is critical in helping to address the health needs and concerns of residents in Contra Costa county. By collectively working together, CCHS and the California Endowment are helping to create a healthier and more equitable community for all through community engagement in public health.

Participant Recruitment and Selection

Contra Costa Health Services (CCHS) typically involves community groups in its participant recruitment and selection process for the community engagement in public health through the following means such as: 

1. Outreach and education: CCHS conduct informational sessions, community meetings, and other outreach activities to educate members of the community about its programs and services, and to encourage participation.
2. Collaboration with community organizations: CCHS partners with local community organizations, such as faith-based organizations, schools, and health clinics, to reach and engage with community members. These organizations help to promote participation in CCHS programs and services and to provide support to participants. 
3. Surveys and assessments: CCHS uses surveys and assessments to gather information about community health needs, attitudes, and behaviors, and to identify potential participants. 
4. Referrals: CCHS also receives referrals from healthcare providers, community organizations, and other stakeholders. 

CCHS did not reveal detailed information and the total number of participants selected for the Community Engagement in Public Health case study project, it may be due to privacy and consent agreement which is not obvious to me but I reached out to Contra Costa Health Services but I have not received a response yet. But the selection of participants was based on criteria such as the individual's health needs, eligibility for the program, and willingness to participate. CCHS is committed to promoting health equity and ensuring that its programs and services are accessible to all members of the community, regardless of their race, ethnicity, income, or other factors during participants selection to avoid any kind of bias [13].

What is more obvious is that it depends on the specific program or study that CCHS is conducting. For some studies, CCHS may use random sampling to select participants, which helps to ensure that the sample is representative of the target population. In other cases, CCHS may use non-random selection methods, such as convenience sampling or purposive sampling, based on specific eligibility criteria or the needs of the study. Regardless of the selection method used, CCHS is committed to selecting participants in an ethical and responsible manner, and to ensuring that the rights and welfare of study participants are protected. This includes obtaining informed consent from participants, providing them with information about the study, and ensuring that they are free to withdraw from the study at any time which also apply to the Community Engagement in Public Health case study chosen for this write up.

In addition, the number of participants that can participate in Contra Costa Health Services (CCHS) through community groups depends on several factors, including the size and demographics of the community, the specific program or study being conducted, and the resources available to CCHS. For example, a larger community group may have a higher potential for participant recruitment, while a smaller community group may have fewer participants. Similarly, the eligibility criteria for a study or program may impact the number of participants, as only individuals who meet the criteria will be able to participate. It is difficult to provide an exact number of participants recruited for this case study without more information from the CCHS after I sent an email to them about the study being conducted for Community Engagement in Public Health. However, CCHS aims to maximize community engagement and participation in its programs and services, and to ensure that its programs are accessible to all members of the community who are eligible and interested in participating.

Methods and Tools Used

Ladder of Community Participation (i.e. A Framework Adopted by CCHS)

The "Ladder of Community Participation [5]" is being adopted to help local health departments (CCHS) engage communities in public health services. It provides a framework for considering the level of community and health department involvement, decision-making, and control in public health efforts. It's important to note that the ladder is a continuum, with different levels of community involvement and decision-making power, and that communication within the ladder is crucial for success.

CCHS utilizes the "Ladder of Community Participation" framework in its Community Engagement in Public Health to achieve its objectives by promoting a collaborative approach to public health services. The ladder provides a systematic way to assess the level of community engagement, allowing CCHS to tailor its approach to the specific needs and circumstances of each community it serves. By using the ladder as a guide, CCHS can evaluate the existing level of community participation and identify opportunities for further engagement. This helps ensure that communities have a meaningful role in the development and implementation of public health services, which leads to better outcomes. For example, if a community is at the lower end of the ladder, with minimal involvement in public health efforts, CCHS can work to increase engagement through education and outreach efforts. As the community becomes more involved and informed, CCHS can move towards a more balanced approach where the community and health department work collectively together to make decisions and allocate resources. The ladder also helps CCHS prioritize communication with the community and build trust. Effective communication is essential at every level of the ladder, as it allows CCHS to understand the needs and concerns of the community and work towards mutually agreed upon solutions. Furthermore, the ladder provides a clear understanding of the roles and responsibilities of the health department and the community, which helps prevent misunderstandings and conflicts. This results in a more harmonious working relationship and a greater sense of shared ownership of public health initiatives. In conclusion, the "Ladder of Community Participation" framework is a valuable tool for CCHS in its Community Engagement in Public Health services. It provides a systematic approach to engage communities, prioritize communication, and promote collaboration. The ladder helps CCHS achieve its objectives and ultimately improve public health outcomes in the communities it serves.

Certainly, here are some examples of how Contra Costa Health Services (CCHS) has put the Ladder of Community Participation into practice in public health: 

1. Information Dissemination: CCHS used traditional communication methods such as press releases, newsletters and flyers to keep the community informed about its activities. 
2. Consultation: CCHS held open forums and public meetings to gather feedback from the community on its programs and initiatives. The feedback was used to shape the programs and make them more responsive to the needs of the community. 
3. Involvement: CCHS created opportunities for the community to be involved in its initiatives. For example, it established community health worker programs that trained and employed local residents to provide health education and outreach to their peers. 
4. Collaboration: CCHS formed partnerships with community-based organizations to address health issues. For example, it worked with local faith-based organizations to promote healthy behaviors and increase access to healthcare services. 
5. Empowerment: CCHS provided training and support to community-based organizations to increase their capacity to address health issues. For example, it provided training on how to advocate for policies that support healthy communities. 
6. Inform and Educate: This level involves simply sharing information with the community about health issues, programs, and policies. 
7. Consultation: This involves soliciting feedback from the community on a range of issues and engaging community members in shaping department priorities.
8. Bridging: This involves engaging community members as conduits of information and feedback, both to the health department and from the health department to the community.
9. Power-Sharing: The power sharing involves the community and health department working collectively together to solve problems facing Contra Costa county. 
10. Community Initiates and Directs Action: This level involves the community making decisions and acting independently of the health department, with the health department having a limited role in the activity.

These are just a few examples of how CCHS has used the Ladder of Community Participation to engage the community and make its program more effective in community engagement in public health [5]. The following section shows how the tool (Ladder of Community Participation) was utilized. In addition, by using this framework, Contra Costa Health Services is able to involve the community in a meaningful way in their public health efforts, leading to improved health outcomes and a more equitable and responsive health care delivery system.

Fig 1 The ladder of community participation in public health services at CCHS

Tools Used: How the Ladder Utilized in the Community Engagement in Public Health

The ladder consists of various components, each representing a higher level of engagement and responsibility for the community. The framework is used by CCHS to guide community engagement and empower community members to take a more active role in participation in the Community Engagement in Public Health (CEPH) [6, 7].

1. Health Department Initiates and Directs Action: In the public health emergencies, the local health department plays a crucial role in leading decision-making and actions. The health department involves the community in the development of emergency response procedures in order to build trust and increase the likelihood of the community following public health directives during an emergency. This approach is representative of a lower level on the Ladder of Community Participation, where the health department initiates and directs action but the community handles the development of emergency response procedures.
2. Health Department Informs & Educates: The Health Department Informs & Educates involves one-way communication from the health department to the community. This approach takes the form of printed materials, electronic media, and in-person instruction from trained health professionals to the community. 
3. Community Input/Consultation: The community input/consultation involves soliciting occasional input from the community on specific, predefined issues. This input is then used to inform decision-making about interventions. Community feedback is gathered through methods such as surveys, interviews, focus groups, or community forums.
4. Shared Decision Making: The CCHS uses a shared decision making characterized by an equal partnership between the local health department and the community, with joint responsibility for decision-making and problem-solving. This approach requires a substantial investment of time and resources, including dialogue and collaboration, and is typically implemented in the context of community-based participatory research aspects of the CEPH.
5. Bridging: The bridging strategy in the project involves using trained community members as intermediaries to facilitate communication and information exchange between the health department and the community.
6. Power Sharing: The power sharing helps in the collaboration between the community and local health department to solve problems collectively which requires more commitment of time and staff resources. 
7. Community Initiates and Directs Action: is one of the higher levels of the Ladder of Community Participation and represents a situation where the community takes the lead in identifying health problems and creating solutions, with limited involvement from the health department. This level of participation can result in innovative and effective solutions that are tailored to the specific needs of the community. However, it can also be challenging for the health department to support and coordinate such initiatives effectively. Nevertheless, this level of participation is important for promoting community empowerment and building trust between the community and the health department.

What Went On: Process, Interaction, and Participation

The Ladder of Community Participation as a framework utilized by CCHS and that describes different levels of involvement of communities in the CCHS community engagement in public health which help in decision-making processes that positively impact community lives in Contra Costa county. It provides a roadmap for CCHS and the communities to collectively work together to achieve desired outcomes. The ladder typically consists of seven steps, with each step representing a higher level of engagement and decision-making power. 

The levels of the ladder mentioned above highlights the dynamic nature of community engagement in real-life situations of CCHS in public health. In many cases, community engagement evolves and progresses over time, with different levels of participation being more appropriate at different stages of the process. In the fig 1, the level of participation started with Health Department Initiates and Directs Action, then moved to the level of Inform and Educate, and finally reached the Community Initiates and Directs Action ladder level, where the community leaders and the health department collectively worked together to address the problem of public health. This interaction demonstrates the importance of being flexible and responsive to the changing needs and circumstances of the community, and of having an approach to community engagement that is adaptable and inclusive and also to increase community participation and influence in decision-making processes.

Influence, Outcomes, and Effects

The influence, outcomes, and effects of community engagement in public health after CCHS successfully utilized the ladder of community participation in public health and the following shows the influence, outcomes, and effective impacts [6].

Impact 1

The Contra Costa Health Services has applied the principle of community involvement in emergency situations. By incorporating input from a broad segment of the community in the health emergency preparedness activities, CCHS was able to develop more effective and inclusive response plans for the avian flu outbreak in Contra Costa county. Also, the input from organizational and agency stakeholders in the preparation for an avian flu outbreak highlights the importance of involving the community in emergency planning and response efforts. 

Impact 2

The Community Wellness and Prevention Program by Contra Costa Health Services' has effectively employed the ladder as a strategy through the Asthma Community Advocates program. The ACAs provide education to community members in various settings, such as in day care centers, churches, and homes. By including a bilingual ACA and a health plan nurse in the home visiting team, CCHS was able to increase its ability to serve monolingual families and expanded its focus on preventive care education. This approach represents a lower level on the Ladder of Community Participation, where the health department is primarily responsible for informing and educating the community.

Impact 3

Contra Costa Health Services' Family Maternal and Child Health Programs employed the creative approach of the ladder as strategy with the “Picture This Photovoice” project [11]. Through Photovoice, community residents were trained to take photos reflecting their views on family, maternal and child health assets and concerns in their community and report this back to CCHS and while CCHS take effective measures for appropriate intervention.

Impact 4

CCHS' Environmental Health Services (EHS) Division has been implementing this strategy through their involvement in the Richmond Community Green Space Project. EHS staff has been working in partnership with community residents, environmental organizations, and other government agencies to improve the health of the community through the development of green spaces. The project uses a collaborative approach that includes community residents in all phases of the project, from identifying health problems, setting priorities, and developing solutions, to implementation and evaluation. Through this community engagement program, EHS has been able to develop a deeper understanding of the community's health needs and to identify innovative solutions that address their needs in a sustainable way.

Impact 5

CCHS has implemented this same strategy through programs like the Bay Point Promotoras Program, where monolingual Hispanic/Latino residents are hired and trained as lay health educators. These Promotoras provide culturally and linguistically relevant health information to the community and bring back information about community needs to the health department, leading to improvements in the healthcare delivery system. An example of this is the establishment of a shuttle service to a local health center and cultural sensitivity training for clinic appointment staff, in response to feedback from the Promotoras.

Impact 6

CCHS's Developmental Disabilities Council is also an example of this strategy in action. It's a voluntary advisory group made up of clients, families, service providers, and advocates of the developmentally disabled community. The Council works with the health department to advise on services and advocate for the healthcare needs of the disabled community. A successful example of this collaboration is when the Council, along with the health department, successfully fought budget cuts for disabled services, resulting in restoration of program funding.

Impact 7

The Monument Community Partnership (MCP) is an example of how a local health department, Contra Costa Health Services (CCHS), participates in a community-initiated and directed effort. The MCP and CCHS were funded by The California Endowment’s Partnership for the Public’s Health Initiative in 2000, and even after the funding ended, the MCP has continued to thrive and grow. By being present at partnership meetings, CCHS staff can help MCP develop organizationally and identify ways CCHS can contribute to and further the community’s health agenda. CCHS has provided various forms of support to MCP, such as neighborhood-level data analysis, training and staffing for resident-led projects, and assistance with neighborhood safety issues. This type of collaboration is a great example of how a health department can work with a community-initiated effort to help improve the health and well-being of the community.

Analysis and Lessons Learned

Engaging communities in public health initiatives help create healthy communities through public health [6]. The communities are actively involved in the planning and implementation of public health initiatives, they understand and support the efforts, which leads to increased trust and credibility in the health department (CCHS). Additionally, involving a collective diverse range of community members, including those who have been historically absent from the planning process, helps to ensure that the perspectives and needs of all members of the community are taken into account [6]. The positive results seen in Contra Costa county, such as increased community understanding and appreciation of public health, facilitated involvement of traditionally absent communities, and the creation of a broad constituency to advocate for community health concerns, demonstrate the value of community engagement in public health initiatives. By continuing to prioritize collective community engagement and involving residents in the public health process, local health departments (CCHS) create a more inclusive and effective approach to promoting health in their communities.

It is great to learn that Contra Costa Health Services is committed to engaging communities in promoting community health and addressing health disparities [13]. Sharing their experiences and knowledge with other local health departments is a valuable contribution to the public health services in the county. The Ladder of Community Participation framework and the community engagement serve as a useful tool and inspiration for other health departments looking to advance their community engagement efforts. Collective continuous learning and improvement are important in addressing complex public health issues and disparities [13]. By seeking feedback and sharing information with others, health departments build on their strengths, learn from their challenges, and create more effective strategies for promoting community health. The local health department learnt within the program initiative that it is important to collaborate with communities and other stakeholders in addressing health disparities and creating healthy communities. By collectively working together, health departments and communities can create a more inclusive and effective approach to promoting health and addressing health disparities in their communities [13].

See Also

Community Engagement

Public Health

Ladder of Community Participation

References

1 Davis, R., Cook, D., & Cohen, L. (2005). A community resilience approach to reducing ethnic and racial disparities in health. American Journal of Public Health, 95(12), 2168-2173.

2 Farquhar, S. A., Michael, Y. L., & Wiggins, N. (2005). Building on leadership and social capital to create change in 2 urban communities. American Journal of Public Health, 95(4), 596-601.

3 Hennessey Lavery, S., Smith, M. L., Esparza, A. A., Hrushow, A., Moore, M., & Reed, D. F. (2005). The community action model: a community-driven model designed to address disparities in health. American Journal of Public Health, 95(4), 611-616. 

4 Centers for Disease Control and Prevention. (1997). Principles of community engagement. Atlanta, GA: CDC/ATSDR Committee on Community Engagement athttp//www.cdc.gov/phppo/pce/(Accessed February 2006).

5 Chess, C., Hance, B. J., & Sandman, P. M. (1988). Improving dialogue with communities: a short guide for government risk communication (p. A11). Trenton, NJ, USA: Division of Science and Research, New Jersey Department of Environmental Protection. CCHS adapted this framework from Rutgers’ individual-oriented Ladder of Citizen Participation (to make it more conducive to a population level approach to public health promotion).

6 Morgan, M. A., & Lifshay, J. (2006). Community engagement in public health. California Endowment under the sponsorship of Contra Costa Health Services (CCHS), 1-8. https://cchealth.org/public-health/pdf/community_engagement_in_ph.pdf 

7 Morgan M. Health Departments and Communities Mobilize to Prevent Chronic Disease: A Case Study from Contra Costa Health Services. https://cchealth.org/prevention/pdf/case_study_2003.pdf 

8 Rattray, T., Brunner, W., & Freestone, J. (2002). The new spectrum of prevention: A model for public health practice. Contra Costa Health Services, Public Health Division. 

9 McKetney C, Freestone J. (2005) Maintaining Effective Community Coalitions. Contra Costa Health Services. 

10 Leung Y, Morgan M, Smith D. (2011) Contra Costa County Tackles Chronic Disease. California County. Volume 17. https://cchealth.org/public-health/pdf/tackles_chronic_disease.pdf 

11 Wang, C. C., & Pies, C. A. (2004). Family, maternal, and child health through photovoice. Maternal and child health journal, 8, 95-102.

12 Brunner, W. (2001). Community-based public health: a model for local success. Community-based Public Health Policy & Practice, (1), 2-3.

13 Nelson, A. (2002). Unequal treatment: confronting racial and ethnic disparities in health care. Journal of the national medical association, 94(8), 666. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2594273/pdf/jnma00325-0024.pdf 

External Links

Contra Costa Health Services 

California Health and Human Services Agency 

The California Endowment 

https://cchealth.org/publications/articles.php 

Notes