GOALS AND OBJECTIVES
Public Health – Seattle & King County (PHSKC) is a large metropolitan health department that serves a county population of nearly 2.2 million people with over 100 languages spoken here. In the Environmental Health Services Division, our mission is to identify and sustain environmental conditions that promote healthy people and healthy communities in Seattle and King County. As an agency, we value the principles of community engagement and equity and social justice.
Under a five-year Cooperative Agreement (2017-2021) with the EPA, PHSKC leads this community-based institutional controls program for the EPA to promote the seafood consumption advisory for the LDW Superfund site. The long-term goal is to promote culturally appropriate, healthy actions that protect the health and well-being of fishing communities, especially pregnant women, nursing moms, and young children, from the contaminated resident seafood in the LDW Superfund site before, during, and after the cleanup.
Within the first few years, we established an innovative community participatory practice as the foundation for this new program. Our specific objectives for this practice were:
- To build the capacity of community members from priority fishing communities to become Community Health Advocates (CHAs) who raise awareness and promote culturally appropriate healthy seafood consumption actions.
- To support the CHAs in empowering themselves to influence programmatic decisions and relevant policy recommendations toward protecting the health of their fishing communities from the LDW contaminated resident seafood.
PROGRAM DEVELOPMENT ACTIVITIES
The following summarizes how this program evolved and the key stages and activities that were implemented to establish the community participatory practice.
Prior to the Cooperative Agreement (pre-2017)
PHSKC's Environmental Health Division had been involved in different pilot community projects and studies about the Duwamish fishing community and the seafood consumption advisory. We carried out our own limited outreach, as well as, served as an advisor on the projects or studies. During this time, we established working relationships with community organizations and gained some understanding of the Duwamish fishing community. We also recognized that there had been a lack of sustainable resources dedicated to promoting safe seafood consumption among the Duwamish fishing community since the advisory was issued in 2006.
Year 1 of the Cooperative Agreement (2017)
During the launch in 2017, we began establishing the internal program infrastructure and staff capacity (e.g., reporting templates, Federal Grant requirement trainings for staff, hiring a multi-lingual community engagement coordinator, set up community contracts/grants).
In addition, we began developing a draft curriculum with Just Health Action to train the CHAs in 2018.
Furthermore, we created new health promotion tools immediately, including:
- A program logo and brand based on input from four language groups (English, Spanish, Vietnamese and Khmer). Purpose of the logo is to attract the attention of fishers and tie all program materials and activities together.
- Digital story videos created by some community members as outreach tools. These brief videos feature their personal story related to the seafood contamination issue, as told through their own voice, photographs, images, music and text.
Year 2 of the Cooperative Agreement (2018)
In 2018, we partnered with the Environmental Coalition of South Seattle and Just Health Action to pilot the draft CHA training curriculum with members from the Cambodian, Vietnamese, and Latino fishing communities. After the training, the CHAs helped design and implement culturally appropriate tools and outreach to promote the health messages. Some CHAs also helped develop the EPA's draft institutional controls plan through participation in the Community Steering Committee (CSC).
During the first half of the year, we completed a 10-week training (interactive lessons, boat tours, expert panels, and field visits) that certified 23 CHAs from the Cambodian, Vietnamese and Latino fishing communities. Each CHA completed approximately 40 training hours.
We started with a lack of knowledge and confidence, but throughout the training we gained more knowledge... Also the community is more educated, so the conversation is getting easier and I'm able to deliver the message as well as answer questions. I started out nervous about ‘what if they ask questions?' but now I am able to answer all the questions and come back to the meeting and share that with Public Health.” —Vietnamese CHA, December 2018
After the training, the CHAs helped us create new multi-lingual tools that they recommended. These tools promote catching and eating only salmon from the Duwamish River and finding alternative fishing sites with safe seafood to eat in King County. The CHAs also helped to design layouts, develop content, recruit for pilot-testing, translate materials and star in the videos.
- Program Website: The multi-lingual website targets local fishing families, including the children who may research information for their fisher parents. Website includes an outreach page (in-language) for each CHA team.
- Go Fishing in King County” Guide: Fisher CHAs worked with Public Health's graphic designer to improve the design and messages so that the guide resonates better with fishers. The guide provides alternative fishing sites with safe seafood to catch in King County.
- Salmon Recipe Cards: Public Health learned that some community members do not know how to prepare salmon. The CHAs adapted their cultural seafood dishes to feature salmon.
After the trainings, the certified CHAs led their own community outreach efforts, such as living room chats, community kitchen cooking demos, boat tours, youth group discussions, and backyard gatherings. By the end of 2018, the CHAs conducted 46 outreach activities at homes, piers, community kitchens, farms, festivals and health fairs, reaching 1,015 community members. We also piloted survey tools at the outreach events. Of the 18 events where they surveyed the participants, we learned that the CHAs engaged with 38 fishers, 35 pregnant/nursing moms, and 43 parents/caregivers.
In June 2018, we established the CSC to capture the voices of representatives from the affected fishing communities, with the specific purpose to develop an institutional controls program plan for the EPA. During six CSC meetings, the 15-member CSC (made up of CHAs and their bilingual/bicultural team leads) created the program's logic model (or road map) and identified the targeted strategies and policy recommendations.
We conducted evaluation of the pilot trainings and the CSC process.
Year 3 of the Cooperative Agreement (2019)
We prepared the institutional controls report based on the road map and the information provided by the CSC in 2018. We finalized the report after considering the EPA's stakeholder comments with the CSC. The EPA approved the final report in August 2019, which can be found here https://www.kingcounty.gov/depts/health/environmental-health/healthy-communities/duwamish-fishing/about-us.aspx
Throughout 2019, the CHAs continued to lead their own culturally appropriate community-based outreach which included community talks, salmon cooking demos, living room chats, festival booths, and boat tours. In addition, the CHAs deepened collaborations between their three teams, community partnerships and created new and innovated outreach activities
Based on the monitoring data we have through September 2019, we learned that the CHAs:
- Conducted 42 community outreach events and presentations, reaching 589 community members
- Completed participant surveys at 21 events, showing that they promoted the program's message to 102 fishers, 183 parent and caretakers of young children and 184 recipients of locally caught seafood
Among these outreach events, CHAs explored new opportunities to present and engage multiple levels of stakeholders; this includes presenting at a graduate level seminar at the University of Washington, at a new partner Community-Based Organization all-staff meeting, at the EHS Division annual conference and a national webinar for ATSDR. The CHAs also represented community voices and participated in key stakeholder forums such as the EPA's Healthy Seafood Consumption Consortium and the EPA's Duwamish Cleanup Roundtable meetings.
For the past two years, we worked with the CHAs in making the Duwamish fishing rules and health video series (in partnership with WA State Department of Fish and Wildlife (WDFW), and University of Washington Superfund Research Program (UWSRP)).
WDFW had designed the framework for the short videos – steps that someone would take; learning the basic rules about fishing on the Duwamish River; types of gear needed for salmon fishing; and, how to prepare salmon at home in traditional dishes. We coordinated with the CHAs to work closely with the UWSPR's subcontracted videographer to integrate the Duwamish health messages, prepare for and shoot the videos. The CHAs will specifically use them as part of their outreach work and in the Duwamish Fishing Club's salmon fishing classes.
We repeated the evaluation of the community participatory process in December 2019, specifically related to the CHAs and the CSC. The analysis of the 2019 data has not been completed yet.
PROGRAM STARTUP COSTS
Since the Cooperative Agreement, we were able to build a dedicated PHSKC staff team (program lead, community engagement coordinator, program evaluator, supervisor and finance officer) for this program work. During this early startup phase, the staff resources started with 1.5 FTEs in year 1, then peaked at 2.5 FTEs in year 2, and down to a stable 2.0 FTEs in year 3. Year 2 required the most staff time because of substantial technical support provided to the CHA teams and the need to establish the program infrastructure (protocols, templates, processes etc.) to manage the activities, contracts and reporting.
Table 1 below provides an estimate of the total direct expenses since the Cooperative Agreement was established in January 2017 through the end of December 2019. The actual December 2019 expenses have not been compiled yet.
Table 1 – Total Cost of Direct Expenses (January 2017- December 2019)
Direct Expenses | Total Direct Costs 2017-2019 | Percent of Total Direct Costs |
PHSKC staff Salaries & benefits | $706,827 | 48% |
Community Contractors & Grantees Community Health Advocates, CBOs, minority/women-owned businesses | $601,610 | 41% |
PHSKC Direct Operation Expenses | $79,897 | 5% |
- Travel (mileage, parking)
| $1,325 |
|
- Supplies (outreach, office)
| $8,410 |
|
- Printing (outreach materials)
| $3,718 |
|
- Staff Training (Community-Based Social Marketing, InDesign and Adobe Illustrator)
| $2,441 |
|
- Registration Fees (conferences)
| $2,394 |
|
- Gift Cards (for pilot-testing focus groups)
| $5,440 |
|
- Other direct operational costs (contracts management, financial services, IT, facilities)
| $56,169 |
|
Total Direct Expenses (2017-2019) | $1,388,334 |
|
FOSTERING MEANINGFUL INVOLVEMENT & COLLABORATION WITH THE CHAs
Sharing power and decision-making with PHSKC
Meaningful involvement is the mutual learning and collaborative process by which both community and agencies can work together – sharing power and decision-making - toward the program goal and objectives. Each partner brings to the table unique expertise that collectively informs programmatic decisions. It requires flexibility and continuous feedback to adapt to community input during program design, implementation, monitoring, and evaluation.
As part of our practice, we center the community voices of those who are most affected by contaminated seafood at the LDW Superfund site. CHAs and other community representatives (fishers, moms, and people who eat local seafood) bring expert knowledge about their cultures, fishing practices, and community. Their ideas and input guide programmatic work and inform agency decisions at multiple levels:
- On the ground: CHAs lead their own community outreach efforts to meet the program goal and strategic objectives. While engaging with their communities, they capture additional feedback and recommendations to share with PHSKC, the EPA, and other stakeholders.
- Program design: CHAs collaborate with PHSKC and its consultants to design health promotion tools, from the conceptual stage to content development to the broader community pilot-testing stage. They help ensure that the tools will be useful to and resonate with the program's target audiences.
- Program guidance: CHAs as part of the CSC will help monitor the progress of the program's implementation before, during, and after the cleanup. The CSC and PHSKC will review the evaluation findings to identify recommendations for changes to the EPA's institutional controls program plan over time.
Overall, a community participatory practice is meaningful only if community input is captured in a timely manner that helps to inform certain decisions, products, or actions by Public Health, the EPA, or other agencies. Thus, a key objective for meaningful involvement is to support CHAs in empowering themselves to influence programmatic decisions and relevant policy recommendations toward protecting the health of their fishing communities from contaminated LDW seafood.
The program has four areas that CHAs and community partner grantees can meaningfully inform and participate in:
- Community Steering Committee (CSC): The CSC serves as our community advisory group to provide input on ways to adaptively manage the program, including reprioritizing efforts as needed based on community feedback and evaluation results. Established in 2018 with some CHAs and their facilitators to develop the initial institutional controls plan, the CSC will evolve over time to include additional community members from other priority ethnic fishing communities. The EPA will continue to be involved in the CSC workshops to ensure that updates on the cleanup process and decisions made by the EPA related to the program work are shared in a timely manner. The CSC recently re-chartered themselves after the completion of the institutional controls plan was finalized and approved by the EPA.The members see the value of the CSC to coordinate around collective actions to advance the plan's strategies and recommendations. We will also report on evaluation results to the CSC so that we can adaptively manage and reprioritize (if needed) the program's work.
- Tools Development: Design of health promotion tools and activities must involve those whom the program is trying to reach with the tools. Such involvement is a best public health practice. We define these tools as products that can support healthy actions and are not simply informational materials. Ideas for tools originate from the community, including the CHAs. When designing a program tool, we begin by consulting with CHAs to capture, at a high level, the messaging or design elements that are important to include. Before finalizing a robust new tool, we may carry out a pilot-testing phase among community members who represent the target audience. All tools will be available in multiple languages. The EPA has final review and approval of program tools.
- Healthy Seafood Consumption Consortium (HSCC): The consortium brings together agencies, organizations, and the CHAs to discuss and collaborate on efforts that promote healthy seafood consumption in the fishing community. It is a venue in which the CHAs have directly engaged with stakeholders by presenting to them their community recommendations.
- Grant-Making Process: We manage a grant-making process that have involved CHAs in reviewing funding applications submitted in response to our Request for Proposal (RFP) or Request for Application (RFA). We completed our first RFA process in late 2018 for a community-based organization to manage the Latino CHA team. The Latino CHAs helped to review the written applications and interview the candidates in Spanish (including developing interview questions and scoring the candidates). A similar team will be assembled to select community partners to implement the program's strategies.
Applying an equity and social justice (ESJ) lens to the CSC process
Due to the diversity of voices on the CSC, we had to be intentional with every detail of the CSC meetings so that the space feels comfortable, accessible, and meaningful for all of those participating. In addition to the multiple interpreters, all handouts and materials are translated, PowerPoints are visual, and seating is arranged to create the feel of a collective, rather than a presentation.
We did not want this to be set up in a traditional format where there is only one person at the front of the room speaking. We really wanted to create a space that felt like a collective and everyone could share their perspective.
In addition to the space itself, we held meetings on Saturdays to ensure that those who work during the week be able to show up. While this is often perceived as not convenient for government staff, we believe it was essential if we wanted to truly set up an advisory group where fishing community members' voices are highlighted.
The work is not easy. But if it's easy, it's probably not equitable. Our staff view the entire program through an equity and social justice (ESJ) lens, which often means slowing down, practicing humility, and learning to be creative within existing structures and systems.
Examples of how we have applied the ESJ lens into our engagement with the CHAs:
- ESJ is represented in how we show up and engage with the CHAs – where we respect and honor the expertise they bring to the table.
- ESJ is represented in the trust that we have built with the CHAs – they are able to speak their truth with us.
- ESJ is represented when government staff recognize the community's own empowerment and accepts that we can share power” with community.
- ESJ is represented by the CHAs who are still engaged in this program work – doing work that they feel proud of.
As the first local health department to organize and run an EPA-funded community participatory practice to address contaminated seafood consumption at a Superfund site, we stumbled along the way, yet gained many lessons learned (see section on Sustainability for more information). We now serve as a model for other health departments and EPA offices looking to build a similar program at other Superfund sites.
Community Feedback
We have received extensive positive feedback from the CHAs and their team leads that reflect a commitment to partnering with this program. We capture these through the formal evaluation process as well as moments of written reflections during the CSC meetings.
Khmer CHA Team:
I have felt empowered because we received education from the organizations [so] that I'm able to communicate to the community and also take feedback from the community to the organization. I feel empowered in that process.”
I feel very fortunate to be able to join this CSC group. I feel that I am being valued to be able to express and make decisions around the subject that matter to human life. I am valued and my voice is being heard—to make decisions and inputs to protect people's health around contaminations in the Duwamish. Being here at CSC, we provide the inputs, strategies, and tools to reach out to most affected groups, to have a plan to help protect their health. We create strategies, tools, and plans for fishers to have healthy alternatives to help protect their families' health. At CSC, we are being empowered to be power in the communities.”
Vietnamese CHA Team:
I do feel we are empowered because now we have knowledge about the river. To me, what empowerment looks like is to be able to go out and talk with people about what we just learned and being knowledgeable about something and wanting to share that knowledge. I like learning new things and finding people who have done those things, like learning about the river and finding someone who fishes there and make a connection. To me that's empowerment.”
In the group [Community Steering Committee], everyone's voice has been heard. Whenever we have something to say the other organizational leaders listen to us. I feel that my voice and thoughts are valued. Everyone in the group is very understanding and supports each other's opinions.”
Latino CHA Team:
When I see people interested in learning more and when I see them again, they start talking about the information we shared with them. That's when I feel like we are doing the right thing.”
My time in the CSC has felt very rewarding. Not only have I learned so much, I have also been able to build a better and stronger relationship with my coworkers from all three teams …. I have also been able to see how we come from different ethnicities and backgrounds, yet in one way or another we have many similarities. We come together and there are no differences between us …. We are all here for the same reason/purpose: to bring our community a voice.”
All of the processes, they [Public Health] have always included us in the process. They make us feel important, we are united, and it's always been that way—they ask us to be part of everything, every step. We are making history, since it's not seen elsewhere. Normally, a decision is made in an office and that is it, but not here. They've included us, since we are the community—kind of like for the community, by the community.”