Public Health Advisory Board as Public Health Ethics Committee: Authentic community input through an equity lens

Goals:

MCPHD partnered with the MCPHAB to house the public health ethics committee within the advisory board structure. The goal was to have broad community representation and input on all public health ethics deliberations, regardless of the topic.

The committee works through established public health ethics frameworks and has included an equity lens specific process in all deliberations. The second goal has been to expand on the questions of justice and distribution of burdens and benefits and examine each public health issue explicitly from an equity perspective.

Implementation:

MCPHAB agreed to include the function of public health ethics committee in December 2017. Charter, bylaws and training based on NACCHO materials followed.

Recruitment for MCPHAB emphasizes representation from all parts of our county and actively seeks members from racial and ethnic communities, seniors, youth, faith leaders, and business leaders.

Our current membership includes individuals with experience in hospital systems, the homeless/houseless populations, philanthropy, corrections, transportation and elder advocacy. Other members represent the Asian/Pacific Islander community, disability, faith and Latinx communities, unaccompanied minors, and a recent MPH graduate with local ties. 

Members of MCPHAB self-select for participation on the ethics committee. With 13 members total, a quorum consists of a minimum of eight members. They select a chair and vice-chair who serve on the executive committee, helping MCPHD staff to vet and shape questions for deliberation and identify additional stakeholders. They provide input on the type of content background needed for each question so that all may participate in the deliberation. With MCPHD staff support the committee has set up a structured process for identifying, refining, and presenting questions (including background and in-person deliberation). The chair facilitates each meeting with staff support, drawing on existing public health ethics framework(s) and including the equity lens 5P” process in each deliberation. 

Committee members and public health staff have co-created an evaluation plan described elsewhere.

Criteria:

Through an iterative process we have learned so far that the best questions to bring to our public health ethics committee are:

Open-ended (as opposed to yes/no)

Elevated through public health program staff to public health leadership

Approved by health department leadership as needing community input

Approved by the executive committee: chair, and vice-chair (both advisory board members) and MCPHD staff

Questions that represent a genuine opportunity for input

Timeframe and other stakeholders:

The first attempts at convening a public health ethics committee were in 2016. The version described here started in December 2017 with the most recent meeting in August 2019. 

The committee identifies and invites additional community stakeholders. Examples of stakeholders invited to specific deliberations include a representative of Latino Network (a local Latino-led education non-profit), members of the Future Generations Collaborative (a local Native-led effort to address alcohol-affected pregnancies), and colleagues from the Multnomah County Mental Health & Addictions Division.

Planning and implementation:

MCPHD leadership and the public health advisory board chartered the group together along with the evaluation process. The chair and vice-chair routinely vet questions for deliberation with MCPHD staff.  Committee members and MCPHD staff co-created the evaluation and improvement plan detailed elsewhere.

Collaboration with community stakeholders:

The desire for authentic community input into local public health practice led to a public health ethics committee that is primarily made up of community members, with public health staff, subject matter experts, and other stakeholders as needed. This approach differs from current NACCHO guidance suggesting primarily public health and program level participants with some community stakeholders. In the MCPHD model every question gets examined by a broad cross-section of community members, including those of color. This approach means program staff and subject matter experts must describe the issue in terms that non-experts can understand, one of the first steps of genuine community engagement.

The MCPHD supports community engagement by providing ethics training to new members and offering food and meeting incentives in the form of small gift cards to anyone who is on the advisory board so that they can attend meetings. Acknowledging the gift of time from our stakeholders has helped support attendance and engagement.

Finally, we apply principles of popular education and adult learning methods:

• Meetings open with a dynamic activity in which members intentionally connect with others to build an atmosphere of trust so members can share their ideas and experiences.

• Think, pair and share” allows members time for reflection, connection and dialogue with another member. Pairs then report out any highlights that came up during their discussion.

• Reflection activities in which members record their thoughts onto post-it notes in response to prompts. A gallery walk” allows everyone to see others' responses and note any similarities or differences.

Incorporating popular education principles into our deliberations breaks down the dominant culture norm of having large group discussions that may only allow for more assertive voices. Each activity also allows members to connect in different ways which has often prompted further thought and dialogue. 

Funding considerations:

The MCPHAB public health ethics committee estimated budget is approximately $4,000 per quarter ($16,000 annually). 

The majority of the cost is staff time including the Health Officer, Public Health Division Deputy Director, a Public Health Project Manager and an Executive Specialist.

Staff prepare and refine questions and materials with the executive committee, support meeting logistics, scheduling, communication, deliberations, trainings, membership, and incentives.

Staff time total = 63 hours quarterly = $3,550

Public health project manager = 15 hours quarterly (includes meetings, logistics, communications, preparing other materials)

Health Officer = 6 hours quarterly (question identification and refinement; meeting facilitation)

Public health deputy director   = 30 hours quarterly (question identification, refinement, meetings with the executive committee)

Executive specialist = 12 hours quarterly (meeting and logistics support)

Incentives quarterly = $300 

Food quarterly = $150

Quarterly Total = approximately $4,000 

Yearly Total = approximately $16,000 

To what extent were goals met?

MCPHD partnered with the MCPHAB to house the public health ethics committee within the advisory board structure. The goal was to have broad community representation and input on all public health ethics deliberations, regardless of the topic.

The committee works through established public health frameworks and has included an equity lens specific process in all deliberations. The second goal has been to expand on the questions of justice and distribution of burdens and benefits and examine each public health issue explicitly from an equity perspective.

Outcome:

Four out of four deliberations to date have directly influenced MCPHD policy or practice.

They include:

Deliberation July 18, 2019 regarding school vaccine requirements. The committee examined the question How can we use school vaccine requirements to keep disease from spreading in schools, preserve parental rights and keep kids in class?” After a robust examination of assumptions and different public health goals of vaccine requirements, the committee gave helpful recommendations related to prioritizing vaccine access and setting a high bar for vaccine exemption. MCPHD has since identified opportunities to improve availability of vaccines in certain parts of the county and among minority communities with disproportionately low 2 year old up-to-date rates.

Deliberation November 28, 2018 regarding scarce resource allocation. The committee examined the Centers for Disease Control & Prevention (CDC) influenza vaccine prioritization scheme during an influenza pandemic. The committee looked at types of prioritization schemes, with some sharing personal experiences related to scarce health resources. The committee essentially ratified the scheme, although with scrutiny of critical  functions,” noting that some critical infrastructure workers may telecommute and that the definition itself would need to take equity considerations into account. They also put all healthy adults, including those 65 and over at the bottom of the list. Consultation with our ethics committee is now part of our region's Cities Readiness Initiative stated process for "allocating and targeting critical workforce groups for vaccination in accordance with CDC guidance for a pandemic influenza scenario.”

Deliberation August 23, 2018 regarding a health department proposal to move from opiate focused work to an all substances approach with a desire for community input regarding what issues to consider as we frame this work. The committee engaged in traditional ethics framework questions like what are the public health goals, what is the distribution of benefits versus burdens, and does the public health approach respect individual choices. The equity lens component raised a strong mandate related to culturally responsive and trauma-informed approaches. The committee ultimately emphasized that root causes, prevention and intervention cannot and should not be separated by substance. 

Deliberation May 24, 2018 regarding different funding opportunities related to reproductive health, and in particular  abstinence only” approaches that are generally at odds with MCPHD's current sex positive programs and messages. This two-part deliberation considered the role of government in people's lives, the symbolic value of expressing local public health priorities even if it means forgoing funding, and how to incorporate different approaches to reproductive health that are culturally specific and responsive to community needs. The final consensus can be summarized as follows: while we recognize the importance of abstinence and the members of the community who endorse it, we also want to provide a broader view of other options available and be more comprehensive in our curriculum.

Evaluation:

To date, four out of four deliberations have influenced MCPHD practice.

In February 2019, MCPHD staff and ethics committee executive membership co-developed an evaluation survey.

The total number of respondents was six:

All were satisfied with the use of the equity lens tool, and all believed that the equity lens 5P” tool helped think of and consider other perspectives.”

A majority were very satisfied” with the deliberation process.

All felt that the deliberation process helped them engage in conversation.

Almost all felt we had included the right stakeholders in the process to date.

All agreed the deliberations had been relevant, interesting, substantive and diverse.

Because of the low number of respondents, we devoted the February 28, 2019 meeting to a group evaluation process. In general, the committee felt that the process and use of the equity lens 5Ps” worked well for deliberations, although needed some refining depending on the question. They liked that all members got to think through each P” with time for discussion in small groups before the full group facilitated discussion.

Consistent themes related to improvement included giving more context for where deliberation questions come from and making sure to provide follow up of each topic and how committee input was used. 

Specific action items from the evaluation included:

• Background one-pager development for future deliberations (now current practice)

• Allow additional committee members to join leadership phone meetings to help further refine questions (now current practice)

• Include regular equity & empowerment training to the whole board and for new members (now current practice)

• Provide previous ethics committee meeting minutes to new members as part of orientation process (now current practice)

• Follow up with the committee to provide updates about the impact of their deliberations (now current practice)

Each meeting closes with a paper meeting evaluation to support continued learning about how to refine questions and deliberations to make the most of everyone's time and wisdom. Those who participate by phone receive the same evaluation in electronic survey form. The meeting evaluations provide both quantitative and qualitative data. Members assess the meeting using meeting success indicators identified by the executive committee:

• The meeting had a clear and meaningful purpose

• The right people were invited and included in the meeting

• Meeting participants were willing to speak up and offer their input without fear of retribution

• Meeting participants are able to gain mutual understanding on key topics, issues and decisions

Members also rate the presentation and logistics of the meeting on a 4 point Likert scale. Results are compiled by staff and reviewed at the monthly executive committee meeting with an action plan developed for necessary improvements. 

(The) Ethics Committee is essential to carrying out the MCHD/PHD/MCPHAB commitments to inclusiveness.  There is opportunity to gain perspective at every discussion. Community members get to learn about the dimensions of public health policy and practice and the complexities of determining the right strategies to address issues important to them and their communities.  Public health staff hear chronicles of real life impacts of what we are doing and what we are not doing to protect and promote public health.” -Suzanne Hansche, Chair, MCPHAB

Lessons learned:

As a result of convening the MCPHAB public health ethics committee and using a structured equity lens process, MCPHD practice is increasingly reflective of community values.

This novel approach allows community members to learn about the inner workings of their local public health authority. It also allows for a fresh perspective and real input on multi-dimensional ethical questions.

Looking forward to future ethical deliberations, it is important to identify the right type of question and create brief, informative materials for a community-based public health ethics committee.

MCPHD must also regularly circle back to deliberations to articulate back to the committee where their input has influenced policy and practice.

Equity work and authentic community engagement take time and effort - and are well worth it.

Sustainability:

Our advisory board members have the opportunity to participate in other committees, but some only attend ethics because they want to engage in a structured process where they can provide input on issues that deeply affect their community. The majority of current ethics committee members have served for over one year and at least half have served for at least two years. The  Chair and Vice Chair for the full advisory board serve on the ethics committee and participate in the planning meetings.

MCPHD leadership has prioritized public health ethics committee staffing and financial support in upcoming budgets. Our deputy director points out the role that MCPHAB Ethics has played is key to our commitment to community participation, guidance and transparency.”  

Furthermore our executive committee has generated potential public health ethics topics for future deliberation, including:

The role of the local public health authority in protecting the immediate environment

Year over year budget planning and how to stagger service changes in light of moving to a Public Health 3.0 role

Questions related to youth tobacco access