Staff Focus Groups and Survey

We conducted focus groups with different segments of staff at the local health department, which included the senior CHD leadership team (four participants), the expanded CHD leadership team (nine participants), and two focus groups with other CHD staff members who are not part of leadership (seven participants and three subsequent participants). Focus groups were mixed race, with the majority of all participants being white. We recruited staff through an email sent by the university team asking for voluntary participation. Focus groups were facilitated by the authors with the goal of having at least one white-identifying and one Black-identifying facilitator at each session. Focus groups focused on three main topics: (1) a vision for equity at the health department five years in the future, (2) perceptions of readiness to work toward that vision, and (3) perceptions of where the health department is on its path toward anti-racism. All focus groups were recorded, transcribed verbatim, and analyzed thematically.

Our data collection and analytic process were informed by the interpretive description approach that is focused on pragmatic knowledge-creation from qualitative data to improve health outcomes (Thorne et al., 1997; Thorne, 2016). Practically, this meant that we sampled people (community members and certain CHD staff) who could provide the most useful information to the research question, developed an interview guide for the focus groups in collaboration with leadership at the CHD to help provide useful information, and analyzed the data using strategies that kept the focus on questions such as “What is happening here?” and “What am I learning about this?”

All focus groups expressed some level of fatigue that undermined their ability to engage in anti-racism. While many participants felt anti-racist values were present, they also felt there wasn’t knowledge of how to operationalize those values and incorporate anti-racism into everyone’s portfolio. Hiring practices along with the restrictions, protections of union contracts, and county rules that superseded CHD policies often came up as examples of gaps between CHD values and practices. Moreover, CHD leadership and staff with longer tenures tended to be more pessimistic about the department’s progress around racial equity than newer staff because they had seen variation in progress over the years.

The staff survey was sent to all 160 staff members at the CHD by the university research team, with CHD leadership encouraging survey completion at staff meetings and via email. The survey was anonymous but included questions on participant demographics, characteristics of roles, attitudes related to race and racism, and perceptions of health department practices related to racism and equity. The 88 participants who completed the survey identified as follows: 12% Black or African American, 66% White, 2% American Indian or Alaskan Native, 7% Asian/Asian American, 2% Native Hawaiian or Other Pacific Islander, 3.5% Middle Eastern/North African, 5.8% Hispanic/Latinx, and 1% not listed. To ask about attitudes related to race and racism, we adapted items from the Pew Race in America scale (Menasce Horowitz et al., 2019). To ask about perceptions of health department practices, we adapted the Health Equity and Social Justice discussion guide to ask about 11 different domains of practice and rank the health department (1 to 4) on equity (Bloss et al., 2018).

The survey revealed that most staff think the CHD is moving toward more equity and anti-racism. Consistent with the focus group findings, survey findings indicated that equity practices that appeared to be stronger were focused on the domains of “leadership” and “values” but less so on “community partnerships” and “hiring/retention.”

Community Involvement

Guided by community-based participatory research (Fleming et al., 2023), the meaningful inclusion of community members has been a key aspect of our work with the CHD. As such, we planned on including community focus groups as part of formative data collection. We began our community engagement efforts by meeting with an established group of community advocates convened by the CHD and modestly compensated for lending their time and perspectives to the group. This group is composed of individuals from six communities within the county that disproportionately experience poor health outcomes. These communities are primarily, but not exclusively, composed of people of color, and many of the poor health outcomes they experience are due to the structural racism that has economically and socially disadvantaged these neighborhoods.

An initial meeting with the community advocates’ group revealed that the group was hesitant to recruit community members to our focus groups. The predominant reasoning was that they had previously shared concerns about racist practices at the CHD and did not feel like there was meaningful action afterward. They expressed frustration with what they perceived to be a purely extractive process with no returns on their investment of time and insight. The group’s experiences reflect long-standing problematic practices in the history of university-based research in communities and marginalized communities in particular (Dempsey, 2010; Lane et al., 2022). In the group’s response to our request, our team was reminded that we were implicated in that history by virtue of our university affiliation and we had to attend to that history and do more to earn this group’s trust and sufficiently learn about the history of racial equity at the CHD. In response to the feedback we received, we pivoted toward trust-building by meeting with individual community members as well as attending community events. Slowly we were able to learn more specifics about the challenges the group faced in their work with the CHD. As a result, our team did due diligence by first listening and then believing what we were hearing from the group about their past experiences with the CHD. Deep listening and cultivating belief led us to do more background research by looking into documents and talking with CHD staff and other community members about the relationship between the CHD and the community. We also made regular updates to the group about how we were following up on their guidance and what we were learning in the process. We measured the success of our efforts by how the engagement of the community advocates’ group changed over time. The more we met with the group, reported back on our efforts, and displayed a growing understanding of the community and CHD relationship nexus, the more eager group members were to engage and support the next phase of the project.

Challenges to community engagement in research have been well documented (Akintobi et al.,2020; Holzer et al., 2014; Weerts & Sandmann, 2008). Our study is designed to contribute to that literature with a research model that is iterative and responsive to the voices of the community. As such, we outline a few challenges encountered in the process thus far.

• Confusion between perceptions of community input versus cocreation: When initially encountering the community group to introduce and begin engagement in the project, many members preemptively assumed that we wanted input on a finished product despite our insistence that the product was not developed and would not be developed without the involvement of the community. They were accustomed to research processes that were largely extractive and, as a result, it took many months of intentional effort to build trust and repair relationships before the community came to understand and, more importantly, trust our desire to collaboratively engage.

• Internal staff resistance from constant criticism of COVID-19 response as racist: We partnered with the CHD in the midst of the public health response to the global COVID-19 pandemic. By the time we began initial data collection with staff, burnout and frustration associated with the CHD’s COVID-19 response were apparent. In particular, talk of anti-racism did not land well with some staff, including staff of color, who felt that the CHD and its employees were unfairly criticized for COVID-19 initiatives, such as the vaccine rollout campaign, in the county. These staff felt that anti-racism had been weaponized against them and they seemed concerned that engaging in our anti-racist project would only open them up to further criticism.

• Lack of acknowledgment and transparency of historical engagement with community: When the research team began engagement with the community group, the group expressed frustration and concern about historical practices of alleged partnership with the CHD. Group members noted past projects in which information was collected but substantive follow-up never occurred. As a result, the research project started with inherited distrust from previous engagement practices.

• Insufficient understanding of equity and diversity: Despite working toward increasing the staff’s knowledge base around diversity, equity, and inclusion (DEI), an increase in DEI training, and political will from leadership, some staff still did not understand the value of a diverse workforce and the benefit of power-sharing with community groups. For example, some white senior staff struggled with how to integrate DEI into core CHD processes such as hiring and portfolio management. These staff noted that they were unsure whether they should hire the candidate who displays the best “fit” for the job and organization or “the most diverse” candidate, indicating their belief that these two characterizations are mutually exclusive. Seeing diversity as antithetical to hiring the best candidate and hiring for “fit” are both examples of how racism impedes the development of more equity-focused hiring practices and outcomes. The individual viewpoints of these senior white staff contribute to the overall organizational beliefs of the CHD and, left unchallenged, will hinder any potential cultural shift at the CHD.

Cocreation of the Racial Justice Impact Assessment Tool

With these challenges in mind, the research team proceeded with successful trust-building practices and data collection with the community group and CHD staff. After data collection, we shared the results with the health department, shared what we had accomplished to date with the community, and planned for the next phase of the project. The goal of the next phase is to cocreate a tool to help examine CHD processes, programs, and policies for alignment with anti-racist principles. We have developed a framework to guide this, called the “Four Ps of Anti-Racist Practice,” which include preconceptions, people, power-sharing, and policies. This framework mirrors our conceptual model, with one notable difference: the removal of “programs” and the inclusion of “preconceptions.” This change reflects what we learned in our survey and interview data about the importance and impact of individual and collective ideas and opinions about racial equity on organizational progress at the CHD. In addition to the input of the CHD staff and community partners, the four Ps framework is also informed by other frameworks such as the Racial Equity Impact Assessment (REIA) used by the organization Chicago United for Equity (CUE) and the Government Alliance on Race and Equity (GARE) (Brar, 2023; Chicago United for Equity, 2023; Government Alliance on Race and Equity, 2023). The Board of Health in this CHD’s locale declared racism a public health crisis and committed to the “dedication of Department resources to deepen this work in solidarity with social movements for racial justice and in accordance with the Health Department’s vision and guiding principles for health equity”(Washtenaw County Board of Health, 2020). With this commitment in mind, the work of the Racial Justice Impact Assessment tool is to help align practices and policies with these stated commitments.

The outcomes of this work are yet to be known since this process is at its midpoint. The plan in this work is to bring together a group of six community leaders who represent different neighborhood groups’ experiences around health inequities and six health department staff members who are instrumental in program planning and policy development. This small working group will come together for a total of 12 facilitated hours of cocreation that will begin with relationship- and trust-building among the group-level setting around the concepts of racism, white supremacy, and related topics; cocreation of the tool; feedback from other community members and staff; piloting the tool on a program or policy; and disseminating the tool to staff and community members. We view the process as important as the outcome.

The tool will ultimately be able to formally identify the bounds of anti-racist action as well as the opportunities. It is this work that will help staff and community hold leadership accountable to not only seize opportunities but also act as advocates for addressing the structural barriers that are constraints to progress. For example, in the information-collection phase, we frequently heard about union contracts as a barrier to equitable hiring practices because seniority was prioritized over and above everything else. In this example, the tool will help to identify the changes in hiring practices that would help move the health department toward anti-racist principles and name the constraints in place so that they could attempt to address them. It is within this process that institutions can break the current cycles of inequity and better target those structural barriers in future actions.