Advancing Health Equity and Climate Change Solutions in California Through Integration of Public Health in Regional Planning

Climate change is a significant public health danger, with a disproportionate impact on low-income and communities of color that threatens to increase health inequities. Many important social determinants of health are at stake in California climate change policy-making and planning, and the distribution of these will further impact health inequities. Not only are these communities the most vulnerable to future health impacts due to the cumulative impacts of unequal environmental exposures and social stressors, they are also least likely to be represented in climate change decision-making processes. Therefore, it is imperative that public health and social equity advocates participate in climate change policy-making that protects and enhances the health and well-being of vulnerable communities. Regions have emerged as important policy-making arenas for both climate change and public health in California, because many drivers of climate change are also social determinants of health (e.g. land use, housing, and transportation planning); these play out regionally and are under regional governmental authority. However, the public health sector is not engaged adequately with climate change planning given the magnitude of risks and opportunities inherent for health. Examination of where public health and equity partners have engaged in regional climate change planning and policy-making may offer lessons for how to change the drivers of health inequities and climate change through this work. This dissertation examines why the public health sector in California is not more engaged with climate change work and regional scale planning given current threats to and opportunities for health, and whether and how public health and social equity stakeholders’ participation in climate change solutions and regional scale planning can improve health and inequities outcomes and decision-making processes. The overarching goal of this research was to inform efforts to increase public health work on climate change and regional-scale planning, strengthen partnerships between public health, social equity, and climate change stakeholders, and formulate strategies that address climate change and health equity. The first chapter of this dissertation was conducted in conjunction with a study at the Center for Climate Change and Health at the Public Health Institute, where we conducted semi-structured in-depth interviews (n=113) with public health and climate change professionals and advocates. I performed structured coding and conducted inductive-deductive thematic analysis within and across respondent groups. I found that individual-level barriers to public health engagement with climate change include perceptions that climate change is not urgent, immediate, or solvable, and insufficient understanding of public health impacts, connections, and roles. Institutional barriers include a lack of public health capacity, authority, and leadership due to risk aversion and politicization of climate change; a narrow framework for public health practice; and professional compartmentalization. Opportunities include integrating climate change into current public health practice; providing support for climate solutions with health co-benefits; and communicating, engaging and mobilizing impacted communities and public health professionals. In the second chapter, I conducted two case studies of Sustainable Communities Strategies planning to achieve greenhouse gas reduction targets through integrated regional land use and transportation planning under California Senate Bill 375 (San Francisco Bay Area and Southern California). I used in-depth interviews (n=50) with SCS planning participants, public document review, and participant observation. I analyzed interviews using thematic analysis in an iterative inductive-deductive process. In both regions, climate change planning was a major lever for increasing the language, consideration, funding, and measurement of health impacts into the SCS plans. Public health’s analytic skills and social determinants of health conceptual framework were valuable for both regional planning agencies and equity groups. Political context influenced the priority concerns, framing, and outcomes. Desire to improve public health was influential in both of these environments. In the Bay Area, a health equity frame promoted regional solutions that can improve health, equity, and climate change. In SCAG, a public health frame increased awareness, language, and future funding for active transportation. Public health was a less contested and commonly held value across diverse political jurisdictions that may be an entry point for future discussions of equity and climate change. In both regions, reform of regional governance processes was pursued to sustain institutionalization of health and equity concerns and improve regional democracy. I discuss implications and recommendations for engaging in multi-system integrated regional planning that can simultaneously improve climate change, health, and equity. In the third chapter, I analyze the same data as a case for understanding regional-scale public health, social equity, and regional planning staff efforts to slow climate change and improve social determinants of health and social equity. In both regions multi-year SCS planning processes, public health and equity stakeholder engagement was instrumental in getting health goals, targets, and indicators into plans. In the Bay Area, advocacy efforts yielded health and equity language in policies and implementation funding guidelines and changes to the basic governance structure. In SCAG, advocacy efforts yielded significant future funding for active transportation and more metrics to monitor the health and equity impacts of planning. Participants in the SCS planning process described their motivations for engaging at the regional level, the barriers to effective regional planning, the achievements of their engagement, and recommendations for improving future efforts. In the interviews, three main themes emerged related to the opportunities and challenges of working at the regional scale: (1) Building regional identity as a foundation for advancing health and equity; (2) The importance of governance structures for health and equity, and the need for regional governance reform; (3) The prospects and barriers of building regional coalitions both within public health networks and with regional equity partners. I discuss implications and recommendations for public health’s engagement with regional planning agencies, creation of coalitions, and reforming of regional governance structures to sustain better consideration of climate change, health, and equity