Introduction
“The mission of public health is to fulfill society’s interest in assuring conditions in which [all] people can be healthy.” Institute of Medicine, The Future of Public Health, 1 1988.
Over the past two decades, public health professionals have expanded the understanding of the conditions necessary for health to include factors such as economic security, safe housing, food, transportation, and well-resourced schools — commonly referred to as the social determinants of health. Furthermore, these conditions are now recognized as ultimately created by those with the power to influence the social and political decisions forming the structural determinants of health.Reference Heller 2 The structural determinants of health encompass formal rules such as governance, law, policies, and resource allocation, as well as informal rules such as culture, institutional practices, norms, beliefs, assumptions, values, and worldview. 3 Underpinning both these formal and informal rules, as well as our subsequent access to health producing conditions, is power. 4 Therefore, attending to how power is created and maintained and how it influences the political processes that create the structural determinants serves to guide efforts to improve health outcomes.
How, or if, a community is able to exercise power through political processes determines their opportunities for health. Political scientist and international public health advocate Ilona Kickbush recognizes this dynamic within her own work: “Health is a political choice, and politics is a continuous struggle for power among competing interests.” Reference Kickbusch5 Advancing health equity and assuring all communities have an opportunity to be healthy therefore requires building the power to influence government, including civic and voter participation and policies, or the Political Determinants of Health as described by Daniel Dawes. Reference Dawes6 It requires analyzing the institutional and societal rules that are creating the conditions for health and developing partnerships that can effectively compete for power and create an inclusive, healthy democracy. Therefore, strengthening civic health — defined as, “the manner in which communities organize to define and address public problems” 7 — and promoting pathways for robust civic and voter participation is an emerging frontier for improving public health.
Health institutions and professionals can play an instrumental role in influencing civic health either by sustaining the status quo or strategically implementing efforts to improve health by promoting civic participation. For example, they can choose to democratize their practices and build networks and partnerships to build public understanding and exercise collective power. This article introduces the case for why practitioners in the health sector should prioritize strengthening civic and voter participation as a means to building the power to advance health equity and provides examples for how they can strategically incorporate this aim into their practices.
Civic and Voter Participation: The Connection Between Democracy and Health
Inclusive, representative communities with higher rates of civic participation are linked to better population health outcomes.Reference Nelson 8 Civic participation is described as how people engage with their communities and is evident through actions ranging from voting to participation in activities focused on influencing decisions and improving community conditions. 9 Research demonstrates that more inclusive opportunities for civic and voter participation are correlated with better community health outcomes while more restrictive policies limiting participation are correlated with worse outcomes.Reference Montez, Jason and Grumbach 10 This is an interdependent relationship where communities with higher civic and voter participation also have more power and influence over the decisions and conditions that improve health, such as funding for schools, parks, and healthcare, and can elect representatives who make health-impacting decisions. 11 The interdependent relationship between civic and voter participation and health outcomes is recognized as a reinforcing cycle where healthier communities are more likely to have higher voter participation and those communities experiencing greater health inequities and social barriers participate at lower levels and thereby have less power to influence policy. 12 Power, as exercised through voting and influencing policies that create the conditions for well-being, is therefore a key determinant of health. Embracing this understanding makes it clear that health is inherently political and that strengthening civic and voting participation are strategic approaches to improving population health.
Like other socially driven conditions for health, access to the opportunity to vote is created through a set of formal and informal rules, policies, processes, and values. Therefore, it is imperative that the field of public health broaden its attention to include the conditions that create or hinder opportunities for an inclusive, representative democracy. A review of history reveals that each time we have expanded the electorate, health outcomes have improved. For instance, in the United States, when women gained the right to vote, child mortality rates improved by 8 to 15 percent.Reference Miller 13 Subsequently, the Civil Rights Movement and passage of the Voter’s Rights Act increased voter participation and ushered in more inclusive policies in education, housing, economic opportunity and health care, including the establishment of Medicare and Medicaid. 14 These policies improved health and well-being across the countryReference Hahn, Truman and Williams 15 and led to a decrease in disparities in health outcomes such as Black infant mortality.Reference Rushovich 16 States with more accessible voting policies are more likely to adopt health-supportive policies like Medicaid expansion.Reference Mahs and Bremer 17 A recent report exploring this relationship found that 100 percent of states with strong democracies — measured by how free, fair, and accessible electoral institutions are in a given stateReference Grumbach and Bitton 18 — expanded Medicaid by 2020, compared to only 37.5 percent of states with weak democracies. 19 The report found that states with stronger democracies were 3.72 times more likely to have expanded Medicaid, even after adjusting for state political environments, education, and income. 20
In 2021 a nonpartisan coalition of major public health and civic engagement organizations set out to understand and describe the relationship between the voting policy environment and population health outcomes. They published the Health & Democracy Index, 21 an analysis of 12 public health indicators, and the Cost of Voting Index (COVI).Reference Schraufnagel, Pomante and Li 22 COVI is a state-level measure of how difficult it is for people to vote; the higher the COVI, the less accessible voting is. First created in 1996, COVI is updated every four years to take into account changes in voting practices and whether those changes make voting more or less accessible. 23 The Health & Democracy Index shows a correlation between public health outcomes and voting access. For example, of the 10 healthiest states, eight restore voting rights to those convicted of a felony. By contrast, of the 10 least healthiest states, only one allows for such restoration. 24 Similarly, the 10 healthiest states all have programs that make registration of eligible voters more widely accessible, such as same-day registration and automatic voter registration. 25 Of the 10 least healthiest states, only two have such programs. 26 This relationship is especially evident for specific health indicators, such as premature mortality and neighborhood safety. 27 In addition, when looking at specific voting practices and comparing health outcomes across states, the pattern continues to demonstrate the relationship between the opportunity to vote and health outcomes. For example, states that allow people to vote at home, whether through the mail or via absentee voting, tend to be healthier. 28 Those that require additional documentation at the polls, such as photo ID even after voters have established their eligibility, tend to be less healthy. 29
Research inspired by the Health & Democracy Index found that reducing barriers to civic participation and strengthening democracy could support individual and community health, particularly for Black Americans. 30 A new study used national survey data and found that even after controlling for other factors known to be associated with health outcomes, like education, income, health insurance, age, gender, employment status, obesity, and exercise habits, people living in states with more restrictive voting rules were more likely to report being in only fair or poor health. The effect is especially strong for Black Americans. In states with restrictive voting environments, Black Americans report worse health than non-Black Americans. However, in states with less restrictive voting rules, there is no meaningful difference in self-reported health outcomes between the two groups. 31
This emerging recognition of the interdependent relationship between health and democracy has spurred the health sector to promote inclusive voting practices. In June 2023, voter participation was named as a “core objective” in the nation’s health goals, Healthy People 2030.Reference Blakey 32 Core objectives reflect high-priority public health issues that are associated with evidence-based interventions. In explaining its decision, the Office of Disease Prevention and Health Promotion (ODPHP) said: “voting offers a chance for people to contribute to decisions that can affect their communities and directly or indirectly impact their health and well-being.” 33 In addition, professional organizations such as American Public Health Association, 34 American Medical Association, 35 American College of Physicians,Reference Cline, Hilden and Beachy 36 and Society of Public Health Education 37 passed position and policy statements calling on members to prioritize civic and voter participation as an important pathway to improving health and advancing health equity.
Assessment and Planning Processes as Pathways to Strengthening Civic Health
Overall community health conditions are impacted by a community’s civic health. Therefore, the field of public health can commit to improving health outcomes by expanding public understanding of this connection, strengthening community capacity for civic participation, and building collective power through all aspects of their work. Health organizations have a wide array of convening roles that serve as opportunities to strengthen relationships and organize, define, and address the conditions and policies that create health. A key example is the role public health agencies play in assessing, defining, and addressing community health threats and opportunities. Employing practices designed to expand participation and shared decision-making in these processes and intentionally strengthening relationships with communities and groups experiencing health inequities builds social capital and increases the power and ability of these communities to influence decisions. 38 Promoting civic and voter participation and supporting efforts to develop a shared understanding of the conditions that create health strengthens civic health. Assuring inclusive, representative decision-making is a path to advancing health and health equity.
Community Health Assessment and Health Improvement Planning Processes
A community health assessment (CHA) is a process by which a state, tribal, local, or territorial health department identifies key health needs and issues through systematic, comprehensive data collection and analysis. The assessment process is conducted at the state, tribal, local, or territorial level and is then used to develop a Community Health Improvement Plan (CHIP) for ther respective jurisdiction. 39 The Public Health Accreditation Board (PHAB) requires accredited health departments to conduct health assessments and health improvement plans to drive population health priorities. 40 In addition, some state and local jurisdictions require regular health assessments and planning processes to improve population health. 41 While PHAB uses “community health assessment” and “community health improvement plans” as generic terms, in public health practice, titles generally specify the jurisdiction covered (e.g. CHA/CHIP — local, state health assessment (SHA)/State Health Improvement Plan (SHIP) — state). In addition, with the passage of the Affordable Care Act (ACA), the IRS added a requirement to the Internal Revenue Code for non-profit health care entities/systems to conduct regular Community Health Needs Assessments and implementation plans. 42 These processes are conducted regularly at the national, state, and local level and should, ideally, work together and in alignment. At the national level, the health improvement plan is called the Healthy People Framework. When Healthy People 2030 named increasing voter participation as a core objective, 43 it paved the way for state and local health departments to prioritize promoting civic and voter participation across their health assessments, plans, and programs.
The health assessment and planning processes that governmental and non-profit health organizations conduct, and the reports and implementation activities these processes produce, exemplify important opportunities to strengthen civic participation and engagement. The process embeds an approach aligned with the aim of democratizing the community health assessment including supporting multisector collaboration and broad diverse community engagement; use of high-quality data, both quantitative and qualitative, from a diverse set of sources; transparency to improve community engagement and accountability; and establishing mechanisms to track and evaluate progress. 44
The formal and informal rules of how agencies conduct these processes establish norms for who is convened and what roles and influence the various parties play in the process — either reinforcing a status quo or presenting an opportunity to create a more inclusive, representative civic process. The data and community experience that is prioritized through the process expands the understanding of the impact of decisions. Convening a diverse cross-section of the community to discuss critical issues invites people to be part of understanding problems and finding solutions. Assumptions about conditions and community experiences can be explored and a broader set of perspectives can be considered. Shared values and aims can be identified collectively and can set the stage for accountability for outcomes. Democratizing these processes strengthens civic health and can build the public and political will for actions that improve the health opportunity for all.
The following sections include stories from two state health departments (Wisconsin, Minnesota) that have intentionally employed approaches to strengthen civic health through their health assessment and planning processes.
State Stories — Wisconsin
The Wisconsin Department of Health Services (Department) prioritizes civic participation through their approach to the development of the SHA and SHIP as well as by naming strengthening civic participation as an aim of the improvement plan. The Department’s SHA and SHIP processes build trust by demonstrating deep and ongoing engagement with partners and communities. Beginning in 2019 and 2020, local public health staff and community partners conducted 74 community conversations to inform the state health assessment. These conversations were held across the state and with a broad set of communities. The data was then used to inform development of both the local CHAs and the state-wide / state level analysis. These rich conversations resulted in a new recognition of underlying structural causes of the health challenges communities were experiencing being reflected in the SHA. Topical areas that have rarely emerged in the past as priorities for the state and local public health emerged with a new strength through this process for the first time. Some examples include access to economic opportunities and family-supporting jobs as a key driver of health, addressing inherent institutional biases as a change needed to improve health, and the need to include the voices of people most impacted by decision-making in governmental processes as a major health theme. Follow-up listening sessions were conducted in 2022 to inform the development of the SHIP. The follow-up conversations led to a new SHIP priority area on “social connectedness and belonging.” Addition of this priority focused planning on ways to promote and support civic participation to achieve a true sense of belonging.
The focus on civic participation was informed by Wisconsinites’ experiences and desire for greater social connection, but the processes also highlighted that it is necessary to build “the collective power of connected communities to create change” through actions such as “the creation of policies and building of systems and environments that can positively impact … health.” 45 For this reason, the Wisconsin State Health Improvement Plan for 2023–2027 tracks voting data and census participation as indicators for civic engagement and names increasing civic participation in government processes as a priority. 46 Wisconsinites also “want their communities to be more inclusive,” something that the improvement plan acknowledges is only likely when disparities in voting are addressed. In the 2020 elections, only 44 percent of eligible Black Wisconsinites, 42 percent of eligible Hispanic Wisconsinites, and 42 percent of eligible Asian Wisconsinites voted compared to 75 percent of eligible white Wisconsinites. The report also notes substantial geographic disparities in voting. In the 2022 general election, 57.1 percent of voting age Wisconsinites cast a ballot, though there was significant variability across counties. Voter turnout ranged from 37.8 percent of the voting age population in Menominee County (one of the Wisconsin counties with the highest poverty rates) to 72 percent of the voting age population in Ozaukee County (one of the Wisconsin counties with the lowest rates of poverty). 47 The Wisconsin SHIP opens the door for health organizations in the state to make efforts to strengthen voter participation as part of their work to address the social determinants of health and improve health outcomes.
To build trust and support ongoing influence of communities, there also must be a commitment to align resources and actions and create mechanisms of accountability. In 2023, the Department added an accountability stage to the SHIP prioritization process to provide ways for community and institutional partners to review the named priorities, strategies, and methods of measurement, and to track progress. In addition, the Department aligned funding through the “Mobilizing Communities for a Just Response” grant focused on supporting local action and policy change for health improvement and established the QualData grant program to increase capacity for qualitative data collection and improve local input into decision-making. The Agency’s commitment through the SHA/SHIP processes to assuring community participation builds trust and strengthens opportunities for communities and institutions to be long-term effective partners in problem solving.
State Stories — Minnesota
The Minnesota Department of Health (MDH) is similarly strategically focused on strengthening the civic participation of an expanded set of community groups and institutional partners.
This strategic focus was launched in 2012 when the Healthy Minnesota Partnership (Partnership) was intentionally expanded to include over 25 different organizations, 48 each representing a different stakeholder constituency — including universities; hospitals and insurance companies; the state Departments of Housing, Transportation, Corrections, Human Services, and Health; and various community and advocacy organizations, including organizations working directly with communities experiencing the greatest disparities in health outcomes. The Partnership was formed “to improve the health and quality of life for individuals, families, and communities in Minnesota.” 49 It was charged with developing the SHA and SHIP and engaging multiple sectors and communities across the state to implement the plan. Expectations were set early on, with members expected to actively participate in the Partnership, share information and collect information from their respective constituencies, and be prepared and focused in partner meetings.
This broad group of partners grounded themselves in the research and data regarding health, the determinants of health, and health inequities. Based upon an understanding of the conditions necessary for health, the Partnership directed the MDH to broaden the SHA to include indicators such as income, education, transportation, incarceration, environment, public safety, and housing. The Partnership also requested that MDH analyze the data by race, ethnicity, and income to deepen understanding of existing health disparities and to commit to addressing the underlying drivers of those disparities including structural racism — defined as “the normalization of … historical cultural, institutional, and interpersonal [dynamics] that routinely advantage white people while producing cumulative and chronic adverse outcomes of people of color and American Indians.”Reference Ayers and Peterson-Hickey 50 Working with a diverse and inclusive group of stakeholders to develop a shared understanding and analysis, and prioritizing data that reflected their communities’ concerns, was a critical step to building the public and political will for decisions and policies that could improve the opportunity for health for everyone.
The process of developing a shared analysis and plan across sectors and with a broad set of partners was designed to strengthen civic health and build the collective capacity of communities to create their own healthy futures, and it quickly had an impact. Partnership members began to build on this shared understanding and organize to improve health outcomes for their respective communities. For example, organizers used data about the relationship between unemployment and health in a successful effort to pass a “Ban the Box” state law prohibiting potential employers from asking about arrest history on initial application forms. Building upon this success, partners asked MDH to analyze the health impact of increasing the state minimum wage and successfully used the analysis to advocate for higher hourly wages and a state increase in minimum wage. Community advocates further built upon these successes to improve working conditions for cleaning subcontractors of big box stores and other low-wage workers. Groups then asked for an analysis of paid leave and health policies, beginning a years-long effort advocating for paid leave ordinances in various cities and workplaces until it was successfully passed into a state-wide law in 2023. 51 Minnesota’s regular SHA planning process now routinely includes “policy profiles” on topics such as tree canopy coverage and universal broadband access in response to community interest and direction. 52
In Minnesota, committing to an inclusive, representative decision-making process has strengthened the influence of communities experiencing health inequities. A continuous commitment to supporting relationships with community and institutional partners is critical to building trust through pathways of accountability. 53 Recognizing this as an ongoing process has led to changes in formal and informal rules and processes within MDH. For example, Partnership members asked housing agency partners to disaggregate data on home ownership and housing by race. While this was not standard practice at the time, after some conversation the housing agency agreed to this request. Once disaggregated, the data revealed significant disparities for African American and American Indian communities in homeownership, which provided insight on how this one disparity impacted a wide array of programs and services. For example, MDH was able to use the disaggregated data to identify health and racial inequities in the design of the radon reduction and environmental hazard tracking programs. While these programs were designed to provide support and remediation services to homeowners, less than a quarter of Minnesota’s black population own their own homes, in contrast to three-quarters of the white population — an example of how structural racism contributes to differing opportunities for health for different communities. In recognition of these inequities, MDH staff began to explore ways to address the needs of renters as well. Disaggregation of this data is now becoming a standard practice.
MDH incorporated the priorities and lessons from the Healthy MN Partnership into its work across various service and program areas to support more inclusive decision-making processes — from grant-making to data collection to service delivery. An example of a change from within the department is the Sickle Cell Disease Trait Testing in the Newborn Screening Program. As part of a regional collaboration with colleagues from other newborn screening programs, staff learned that the MDH Public Health Lab was doing less than neighboring states when it came to informing parents and providers when newborn screening tests revealed an infant to have a sickle cell trait. This realization led the lab to ask questions such as, “Do parents want to know their child’s trait status, when the infant does not currently have sickle cell disease? And what is important in how that information is given back to families? How would medical providers need to change their approach to meet this need?”
Laboratory staff realized they could not answer these questions without direct input from impacted communities. The lab then developed relationships with parents in the Twin Cities African American and West African communities as well as with medical providers who were concerned about alarming parents when there was a trait but no detectable disease. Together, they developed an understanding of what information would be most helpful and who should receive the information. In 2015, the MDH lab began informing both parents and providers of a newborn’s trait status, which means over 1,200 Minnesota families each year are being directly notified of the trait result of their newborn and can work with their provider to ensure the healthiest outcomes for their children. In addition, a Minnesota Sickle Cell Collaborative was formed and has provided insight and recommendations to improve services for the Sickle Cell community. 54
Through all these experiences, staff learned that being accountable to, and in ongoing relationship with, communities can lead to changes in core institutional practices. That is, as a result of health agencies facilitating civic participation to strengthen the civic health of Minnesotan communities, those communities developed the power to make decisions and advocate for themselves, leading directly to changes in those formal and informal rules that shape the conditions of health.
Additional State Stories
In addition to these examples from Wisconsin and Minnesota, several additional states have named civic participation in their most recent SHA/SHIP. A sampling includes:
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• Connecticut: Includes civic participation as part of their social conditions section. The SHA displays data on voter participation disaggregated by race and briefly discusses how voter participation is connected to health. 55
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• Delaware: Civic Muscle is part of the Vital Conditions Framework Delaware uses in their SHA. The SHA reports on voter participation from 2020 for the state and select counties compared to the national average. 56
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• Louisiana: Includes voter participation in their state health assessment data dashboard. 57
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• Massachusetts: Includes voter participation rates in the SHA data dashboard by county and compared to the national average. 58
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• Michigan: Names civic participation in their description of the social and community context but does not include any data on participation. 59
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• New Hampshire: Includes voter participation as a measure of civic engagement in the SHIP. 60 The SHIP includes statewide adult voter participation data and data for those over the age of 65. 61
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• Rhode Island: Includes the statewide voter participation rate and compares it to the national average and bordering states. The SHA also includes a write-up of why this is an important measure, who is affected, and interventions (including policy solutions) to improve participation. 62
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• Tennessee: The SHIP data write-up includes a measure of voter participation under social capital and cohesion; however, there is not a data dashboard to better understand how the SHIP displays or measures this data. 63
State Stories Summarized
The stories shared in this article demonstrate an approach to strengthening civic health by strategically expanding representation and participation in the community health assessment and planning processes. Democratizing health assessment and planning processes builds trust and positions public health practitioners to make a meaningful impact as an ally in creating accountable, inclusive decision-making systems. The strategies to strengthen civic participation described in the article can be employed across the entire field of public health practice by:
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• Reviewing an organization’s existing scope of responsibilities, including convening authority, program and policy development; service delivery and implementation; and methods of accountability to identify opportunities to create change.
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• Examining existing processes and the formal and informal rules, including the norms, values, and assumptions that are creating the context for the organization’s work and decisions.
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• Considering who and what groups are routinely convened, consulted and influencing decisions and what interests they represent.
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• Developing relationships with groups representing communities experiencing health inequities and designing processes to more effectively build the power to impact decisions.
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• Identifying spheres of influence and ways to increase accountability to the community — especially to communities experiencing the greatest health inequities.
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• Expanding the understanding of health to include the conditions that are creating opportunities for health, including how various policies, rules, and investments influence civic and voter participation.
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• Building and supporting a diverse network of relationships and working in partnership to strengthen collective power of communities to directly impact decision makers.
Conclusion
When the field of public health expanded the understanding of health to include the social determinants of health, it opened pathways to improving decisions across a broad set of policy sectors such as education, transportation, housing, environment, economic security, and public safety. However, real progress on the aim of “assuring the conditions for health for all” 64 now requires the field to go beyond describing the social determinants, to actually committing to building an inclusive, representative democracy. The call to champion an inclusive, representative democracy and promote civic and voter participation is grounded in an understanding that the opportunities for health are determined through political decisions and predicated on the power and influence of the groups represented in the decision-making process. Who does and does not have access to the health conditions and who is ultimately healthy or not healthy is a result of political decisions that are influenced by the power a community does or does not have. To effectively advance health equity it is imperative that communities experiencing the greatest impact of health inequities be included in and build the power to influence decisions that determine their opportunities for health. Civic participation and voting are key ways power is exercised in a democracy. Public health therefore has a role in advocating for inclusive voting policies and representation, as higher rates of civic and voter participation are clearly linked to better population health outcomes. Centering civic participation and being a champion for inclusive, representative, and democratic processes serve as a foundation for strengthening civic health and advancing health equity.
Disclosures
Support for this manuscript was provided by the Institute for Responsible Government.
