A total of 206 of the 560 invited multisectoral representatives (response rate 37%) from northern Arizona participated in the RHES. Of those who participated, 64% (132/206) completed the entire survey, responding to the open-ended qualitative questions of interest about: (1) the root causes of health inequity that impact the health of the community they serve, and (2) strategies to address health equity. Among those that answered open-ended questions, half held government positions at the federal, state, county, and municipality level and one-third worked for non-government organizations, including community-based organizations, community groups or coalitions, faith-based organizations, and non-profits. Participants reported holding leadership positions such as county managers and department directors, chief of police, superintendents, presidents, CEOs, and executive directors. The demographic breakdown of all survey participants did not significantly differ for those that provided qualitative responses. Therefore, Table 2 provides participant demographics for the entire survey reflective of qualitative respondents.
Participants were primarily middle aged, predominantly white leaders, with slightly more female participations compared to male. Leaders were well established within their sectors with an average of 16 years in the field and stable in their positions with an average of 5 years in their current leadership role. All participants held leadership positions and largely reported they did not work directly with the community within their current role.
Table 2
Demographic Characteristic | Total Participants N (%) |
Gender | N=129 |
Male | 56 (43.4) |
Female | 69 (53.5) |
Other | 1 (0.8) |
Prefer not to answer | 3 (2.3) |
Race and Ethnicity | N=129 |
American Indian/Alaskan Native | 3 (2.3) |
Asian/Pacific Islander | 1 (0.8) |
Black/African American | 3 (2.3) |
Hispanic/Latino | 6 (4.7) |
White | 108 (83.7) |
Other | 3 (2.3) |
Prefer not to answer | 5 (3.9) |
Age in years | N=127 |
Mean (SD) | 49 (11.6) |
Position time in months | N=195 |
Mean (SD) | 5.3 (6.0) |
Sector time in months | N=194 |
Mean (SD) | 16.6 (11.1) |
County | N=206 |
Apache | 8 (3.9) |
Coconino | 94 (45.6) |
Mohave | 34 (16.5) |
Navajo | 28 (13.6) |
Yavapai | 42 (20.4) |
Organization | N=204 |
Government | 102 (49.5) |
Non-government | 57 (27.7) |
Private | 11 (5.3) |
Academic | 20 (9.7) |
Other | 14 (6.8) |
Work Directly with Community Constituents | N=192 |
Yes | 37 (19.3) |
No | 155 (80.7) |
Participants could identify with more than one sector. While all 13 sectors were represented, 95% of all participants identified with either health and human services (49%), education (26%), or community and economic development (20%) (Figure 1).
Community Demographics
Two questions elicited characteristics of the communities served, including survey questions regarding leaders’ perceived understanding of the distribution of resources and services within the community they serve and an open-ended question asking respondents to describe the root causes of health inequity.
Upwards of 75% of participants reported resources and services to unevenly or inequitably distributed across all sectors in the communities they serve (Figure 2). According to one quarter of survey participants, resources and services related to public safety and children’s education were perceived to be the most evenly or equitably distributed resources in the community.
Multisectoral Leaders Perceptions of Health Inequity
Participants were provided the definitions of the SDoH and root causes of health inequity outlined in Table 1 and asked to describe the root causes of health inequity in their community. Approximately 64% (n=132) of participants responded to this question, and of those respondents, 11.4% (n=15) provided a description that met the a priori definition of root causes of health inequity. The remaining participants provided an explanation that met the a priori definition of a SDoH and, in certain instances, leaders discussed other factors outside of the definitions applied for health inequity and SDoH. Exemplary quotes below are followed by the participant’s self-identified position and sector.
Root Causes of Health Inequity
When leaders described root causes of inequity, they articulated systemic factors affecting the communities they serve and primarily described discrimination and unequal allocation of power and resources.
Some of the participants discussed the role discrimination plays in health and economic inequities in their communities. A few mentioned the type of discrimination, for example based on race, sex, or class. Often, participants discussed discrimination and racism at both institutional and systemic levels and included perspective on the deleterious effects on past and current policies perceived to be discriminatory, as articulated here:
“The root cause of health inequity is racism, systemic and institutional racism.” [Program manager, health and human services]
“The primary social conditions that impact the (housing and homeless) community I serve seem to be systemic racism and systemic poverty, which are, of course, inextricably related.” [Owner and research scientist, multisector]
“Many unincorporated townships passing laws stating the outright ban of “box stores” and other affordable/accessible services. Past policies around land distribution and land use disproportionately impacting Native communities. Infrastructure, or lack thereof, favoring higher income brackets and more able-bodied peoples: lack of sidewalks, elevators, handicap access, specialized services, etc. Classism affecting poor families, and especially families of color with childcare and early education opportunities being too expensive for most to afford. Free or reduced-price options fill up quickly with wait times being years long.” [Senior program coordinator, multisector]
Some participants described unequal allocation of power and resources. Most leaders who identified this phenomenon as a root cause of health inequity in their community gave robust explanations, providing examples of how this unequal allocation manifests as a complex interlocking of systems of power. Many leaders went on to describe how this contributes to inequity across SDoH and place specific communities, especially communities of color and people living in poverty, at a direct disadvantage. A regional director that identified as multisectoral and serves families with young children and higher risk populations identified root causes of health inequity and resulting effects as:
The root cause here is the same as it is anywhere - unequal distribution of money, opportunity and power. How that shows up in my community is: Essential services provided in population hubs where cost of living is too high for those who most need services. Virtually no public transportation, wage disparity, lack of entry level employment opportunities, social and geographic isolation, technology vacuums outside of population hubs - although about 95% of the population owns a smart phone, data services for their use is too expensive, or there is spotty/no service in many of the outlying rural areas. Very limited affordable housing. The most "affordable" housing is the furthest from services/food/socialization. Yavapai (county) has been identified as a mental health desert. Yavapai (county) has been identified as a food desert. Limited access to quality medical specialists. Not enough medical providers. Very limited services for families with children with special needs.
Social Determinants of Health
Approximately 75% of responses were categorized by the a priori definition of an SDoH. Guided by the SDoH specific code definition, we further categorized the types of SDoH leaders perceived as impacting the health of the community they serve. Based on these SDoH definitions, the predominate SDoH described by multisectoral leaders included community design, environmental quality, social justice, housing, social/cultural cohesion, economic opportunity, quality affordable food, community safety, transportation, educational opportunity, access to care, and health equity. These themes are summarized in Table 3 in order of frequency. [Insert Table 3 below]
Table 3
Description of Themes for Social Determinants of Health Codes in Order of Frequency
Code | Theme | Exemplar Quotes |
Economic Opportunity (N=90) | Themes included poverty, income inequality, high cost of living, unemployment, limited job opportunities, limited high-quality job opportunities, and struggling economies locally and regionally. Economic opportunity was often viewed as inextricably linked with other factors such as healthcare, education, and secure housing. Access to quality, high-speed internet impacted connectivity and access to services. | “We don't have a consistent permanent employment base that keeps our community growing, competitive, or sustainable. There is a lack a critical infrastructure (water, internet, educated human capital work force) that would entice industry or business to move here creating employment growth.” [Fire chief, health and human services] “Lack of affordable housing, lack of high paying jobs, lack of jobs that offer healthcare and other benefits to employees, lack of medical providers.” [Economic development coordinator, community and economic development] |
Access to Care (N=51) | Leaders described a lack of healthcare providers and healthcare services within their communities, particularly as compounded by rurality. Healthcare cost, insurance status and coverage, and distance to health services were stated as potential challenges to access to care. A small handful of the participants mentioned an unequal distribution of health services in the communities they serve but did not further elaborate on why that inequality may exist. | “The root causes of health inequity in our area are due to limited rural supportive of services with access to care for families/individuals in need. Often times barriers include education of services, transportation, and financial support.” [Community impact director, multisector] “Poverty, distances people need to travel to health practitioners or facilities. Difficulty to attract health professionals to the area. Lack of access to specialized care, i.e. speech therapists, oncologists. Language barriers for the Native American elderly, and many reside in areas without running water or electricity. High level of addictions and social problems exceeds the practitioners and facilities that can intervene with the care needed.” [Library district director, multisector] |
Social and Cultural Cohesion (N=34) | Included lack of support for mental health and lack of support systems and supportive relationships, families, and homes. Social and cultural cohesion was linked to or contributed to high rates of poor mental health, abuse, and childhood or family trauma, substance use, and stigma related to substance use and other health conditions like HIV. Fewer described topics such as language barriers and lack of opportunities to be engaged in the community. Both social and physical isolation were considered a function of rurality and the unique challenges rural communities face, including limited services and resources and lack of connection across sectors. | “High proportion of low-income jobs. High proportion of jobs without benefits. Use of illegal substances disproportionate to the size of the population. Children at high risk due to early traumas and dysfunctional families. Distance to specialized medical services.” [Superintendent, education] “My community has a higher cost of living with limited job opportunities and low pay. The youth lack support services and safe places to go. Community resources are limited and mental health resources are lacking.” [Health educator, multisector] |
Educational Opportunity (N=31) | “Lack of education” or just “education” were commonly listed with no further explanations. Some of the participants noted the lack of secondary education opportunities and support in their communities. Multiple participants also mentioned that low education status and low education standards is interlinked with the low employment within their communities. | “A lack of the education necessary to obtain a long term career.” [Regional director, early childhood development] “Lack of education, lack of money to attend school after free public education, lack of role models, lack of teamwork / communication for benefits of community, poor food options at the local store (soda, chips, candy), unhealthy lifestyle decisions.” [Superintendent, education] |
Transportation (N=26) | A lack of transportation (both personal and public transportation) was a major issue in leader’s communities. Multiple participants mentioned distance to services and rurality being contributing factors in transportation issues. Some tied their community’s transportation challenges to issues with the ability to work, and access to food and health services. | “Much of our ridership is comprised of seniors, the disabled, tribal residents and low income families dependent on public transit to travel to medical appointments, the pharmacy and grocery store and government services. Public transportation is primary in alleviating one of the major root causes of health inequity; without a reliable mobility service, the health and welfare of our communities are significantly impacted.” [Grants and transit manager, transportation] “Economics and the high cost of living also many of the residents live out in the country where transportation is difficult.” [Public defender, law, justice, and public safety] |
Housing (N=24) | Included lack of adequate and affordable housing, both to rent and buy, limited housing options, and homelessness in leader’s communities. Housing was often compounded by other factors, particularly by lack of economic opportunities. | “We have relatively low unemployment but do have a lot of low income citizens. Affordable housing seems to be a big cause of some of our issues. People have to pay more towards their living conditions so takes away from other issues such as health care. [Director, health and human services] “Lack of affordable housing, transient population, inability to maintain job security.” [CEO, health and human services] |
Community Safety (N=16) | Included domestic violence, child abuse, felony convictions, and substance (drugs and alcohol) abuse. Participants also mentioned homelessness, mental health challenges, and lack of safe places for youth. | “Mental health challenges (depression, helplessness, anxiety, stigmas) high levels of poverty, low levels of education minimal job opportunity, somewhat closed off community, high rates of alcohol, drugs, suicide, STIs, violence, domestic violence.” [Public health nurse, health and human services] “Homelessness in the community which relates to economics. Drugs and alcohol affect families and especially the children. Number of individuals in jail. Not enough mental health providers.” [President, multisector] |
Social Justice (N=12) | Themes of incarceration policies and practices, including convictions and the criminalization of substance use in lieu of treatment for substance use disorders; historical and generational trauma, lack of intergenerational wealth, land distribution policies that disproportionately effect Native Americans; lack of cultural and community representation in local and county policy; structural and institutional racism and discrimination, including how these are barriers for policy goals. | “The root causes of health inequity in the community I serve is the criminalization of people who use drugs. There is also institutional racism, sexism, and other stigma tied to this. The separation of mental health disorders from substance use disorders feeds this as well.” [Programs director, multisector] “Wealth inequity and the lack of generational wealth that sustains generations. Housing market that predominantly serves college residents and the tourism market. Racism and discrimination remain a significant problem for all policy goals.” [Public affairs director, policy] |
Food (N=8) | When food was highlighted as a concern in leader’s communities, food deserts, access to nutritious food, food insecurity, and poor nutrition were described. Similar to other SDoH, food systems were often talked about in synchrony with other factors affecting the community’s overall wellbeing and health, such as economic opportunities and transportation. | “We serve the poorest and neediest senior over 60 and those under with a disability. These clients are do not make enough money on their Social Security to afford housing, food, and health. If a client is just 5 dollars over the limit for AHCCCS [Arizona Health Care Cost Containment System, Arizona’s Medicaid program] they can't afford food.” [Client services manager, health and human services] “Low employment opportunities, vast low-income neighborhoods, diet-related disease, lack of transportation i.e.: valley-wide transit line, diminished access to healthy food with widespread food desert.” [Executive director, multisector] |
Environmental Quality (N= 6) | Defined as lack of basic and critical utilities such as lack of running, drinking or wastewater and electricity. These were often described in connection with economic opportunity and living in rural or tribal lands with limited access to resources compared to cities and more urban areas of the region. | “The root causes of health inequity in our community have to do with access, many of our community live in very rural areas that require travel of great distances to get access to care. There is also in the same vein a very poor population that live without even basic necessities like electricity, running water and internet service.” [County manager, policy] “Agricultural challenges due to heat & environment.” [Executive director, multisector] |
Community Design (N=3) | Community design as a cause of inequity was defined by lack of infrastructure, including limited land development, lack of physical infrastructure such as streets and sidewalks, and little interest in improving or developing infrastructure. A couple examples described how insufficient physical infrastructure affects leader’s communities and made connections between community design and inequity. | “[My] county is a politically conservative community and there is little interest in improving and building infrastructure needed to address the environmental inequities (neighborhoods with paved and unpaved streets, no sidewalks, etc.).” [Director, health and human services] “Topography, high desert with little infrastructure. Limited land development and ownership.” [Economic development manager, multisector] |
In our analysis, two themes emerged beyond the a priori SDoH, including geographic location and local political context.
Geographic Location (N=27)
Given the rurality of the region of northern Arizona of focus, it was no surprise that many leaders identified rurality was a cause of inequity in their community. Participants talked about rural, remote, or isolated areas and a lack of connection as a function of rurality. For instance, rurality was considered to compound a lack of or limited access to various services and resources, such as limited healthcare services often due to long distances to travel to care, lack of affordable housing, with the most affordable housing being in more rural and isolated areas, and unfunded and underperforming schools. A few participants who discussed rurality noted the disparities between rural and urban areas in their communities, observing that rural areas experienced greater challenges compared to urban areas due to limited access to essential social services and goods.
“The disparity between rural and urban areas in the county. Lack of infrastructure: broadband, available land for private use, water, and other support utilities. These conditions negatively affect opportunities for economic development and mobility, and access to health.” [Assistant facilities management director, multisector]
“Economic disparity in rural communities across the region, combined with isolation from needed services (social, healthcare). Additionally, rural Arizona's political attitudes of self-reliance, does not provide adequate support for needy populations.” [Transit planner, transportation]
Political Context (N=10)
A number of participants voiced their thoughts on how politics play a role in health inequities. The most common mentioned topics related to politics were about vulnerable and lacking infrastructures, discrepancies between political leaders’ decisions and the community’s needs, lack of trust and confidence in the government, and unfair tax systems.
“Historic and continued lack of representation at the local and county level being anything other than white, male dominated.” [Senior program coordinator, multisector]
“Rural area with low education standards, underfunded and underperforming schools, and lack of economic opportunities. General apathy towards education, along with a desire to live ‘off the grid’ and away from real or perceived government intervention. Perception that taxes and government interventions are already too high.” [Assistant county manager, policy]
Strategies To Address Root Causes Of Health Inequity
Approximately 63% (n=130) of participants identified key strategies they considered essential in addressing health inequities in their local communities and in society as a whole. Leaders described strategies that fell into ten broad categories, including 1) build community knowledge and capacity; 2) develop economic and workforce infrastructure; 3) activate collaboration and partnerships; 4) establish referral and resource systems; 5) provide direct services; 6) ensure flexible, fair, and equitable access; 7) conduct community outreach and engagement; 8) engage in advocacy and policy change; 9) be culturally and community responsive; and 10) utilize evidence-based practices (Table 4). Several strategies were oriented towards working directly with the community, such as building community capacity and engaging the community to work together towards something positive. Leaders also described strategies in response to community needs, such as establishing resource systems, directly providing needed services, and making sure access to services is flexible, equitable and culturally relevant. Importantly, participants also discussed strategies for advancing health equity through activating partnerships, using evidence-based practices to make decisions, and promoting health, and engagement in advocacy to effect policy and systems change. [Insert Table 4 below]
Table 4
Strategies to Address Root Causes of Health Inequity (n=130)
Strategies | Definition | Exemplar Quotes |
Build Community Knowledge and Capacity | Providing general education and raising awareness across a range of topics; ensuring appropriate framing and messaging is used when sharing information; supporting and equipping people with tools to be successful | “Education and awareness building to support people to become their own advocates.” [Regional director, multisector] “Honest education regarding risk/benefits of chosen lifestyles that contribute to long term poor health and poor quality of life.” [Registered nurse, health and human services] |
Develop Economic and Workforce Infrastructure | Developing the local economic and physical infrastructure, including employment opportunities and professional development; expanding existing services; and seeking funding for further development | “We have been trying to attract some different types of businesses that could employ people who have little or no secondary education.” [City manager, multisector] “Economic development efforts, development of regional transit service.” [Community development director, community and economic development] |
Activate Collaboration and Partnerships | Actively search for opportunities to collaborate across organizations, sectors, and with community; build partnerships and capitalize on existing partnerships; network, share resources, align priorities, and fill gaps to achieve health equity | “Collective community collaborations, sharing of resources among community agencies, looking for avenues to partner with others.” [CEO, health and human services] “Community partnership to tackle infrastructure challenges together versus in silos. Strength is in numbers and joining forces is critical for funding and future enhancements.” [Chief information officer, other sector] |
Establish Referral and Resource Systems | Connect individuals to and provide assistance in navigating needed resources and services; raise awareness of and encourage engagement in existing resources and service | “Linking people to community resources is the best strategy I see to help individuals and families address the challenges they face and find support to overcome many of the problems that occur.” [Faculty, health and human services] “The school district provides a full time RN to services our students. She provides referrals as needed.” [Superintendent, education] |
Provide Direct Services | Address health equity by directly providing services and resources that respond to community needs | “Delivery of services which are responsive to these challenges.” [Director, health and human services] “Provide as much food as possible so no one goes hungry.” [Soup kitchen supervisor, food systems] |
Ensure Flexible, Fair, and Equitable Access | Provide services and resources to everybody regardless of financial or other barriers; ensure resources and services are free of cost or low cost and accessible; meet people where they are by providing services where they are needed | “Meeting clients where they are. Coming to them.” [Health educator, food systems] “Providing services to all regardless of income or ability to pay; hiring compassionate, non-judgmental, knowledgeable service providers.” [Division manager, health and human services] |
Conduct Community Outreach and Engagement | Having an active presence in the community, building rapport and trust with communities, conducting outreach via various communication means to connect with the community, listening and responding to the need, and learning from the community to work together towards health equity | “Putting a 'face' to local government--helping residents see that public servants are not part of a nameless machine, rather they are friends, neighbors and live in the same communities.” [Assistant county manager, policy] “Work with positive community members that want to help students, participate in local radio show in the past to give positive messages, newsletters, open listening, focus decisions on what is best for students, try and recruit positive role models for children.” [Superintendent, education] |
Engage in Advocacy and Policy Change | Advocating and lobbying for resources, services, and policy changes based on community needs; raising awareness of issues and influencing decision makers to advance health equity | “Provider groups banding together to lobby for change.” [CEO, multisector] “Advocating for system review/change. Push for outcomes vs outputs. Asking 3 questions: How much did you do, how well did you do it and is anyone better off?” [Director and chief health officer, multisector] |
Be Culturally and Community Responsive | Recognizing and honoring the uniqueness of different cultures and communities; providing services and resources that are grounded in the culture and community | “Our organization tries to bring together professionals from a range of sectors, help ensure that prevention strategies are culturally, linguistically, and age appropriate, and that they match people’s health literacy skills, provide internet skill-building courses to help residents find reliable prevention services.” [Executive director, multisector] “Acknowledgment of historical trauma and focus on resiliency building for children and youth.” [Executive director, multisector] |
Utilize Evidence-Based Practices | Staying informed on and implementing evidence-based practices into strategies used to address health equity | “Being informed on evidence-based practices and incorporating them into our strategies. Updating policies to prioritize addressing root causes, rather than how we ‘feel’ about them.” [Chief probation officer, multisector] “Working with community residents and partners, achieving agreement on proposed service delivery models, implementing evidence-based programs, and monitoring/providing feedback on program results. When supported, adopt public health ordinances to promote health (i.e., smoking ordinances, texting while driving ordinances, etc.).” [Deputy director, health and human services] |