Session
Promoting Health through Systems Change
APHA 2022 Annual Meeting and Expo
Abstract
Cross-partnership initiative engaged in cultivating sustainable systems change for equitable public health systems
APHA 2022 Annual Meeting and Expo
We are at a pivotal moment for public health and health equity in the United States. COVID-19 cast a harsh light on health disparities throughout our communities—but these disparities existed long before the pandemic. With an influx of federal funds and heightened public awareness, we now have an opportunity to create long-term change toward achieving health equity in our communities.
Public health practitioners understand sustainable systems change efforts are necessary to ensure long-term impact and break down barriers causing health inequities. This approach requires adjusting and transforming the policies, practices, power dynamics and social norms that have allowed health inequities to persist, despite laudable field efforts.
Beginning in late 2021, the Strategies to Repair Equity and Transform Community Health (STRETCH) Initiative, a collaborative effort between the CDC Foundation, the Association of State and Territorial Health Officials (ASTHO) and the Michigan Public Health Institute (MPHI), partnered with 10 state public health agencies (SPHAs) and their community partners to engage in systems change work aimed at creating more equitable public health systems.
The STRETCH Initiative created a new framework, stretching previous models and expanding them to fit today’s health conversations. The STRETCH framework focuses on addressing the root causes of health disparities, including racism and the current and historical context of communities. Together, the project partners and the 10 SPHA teams are using the STRETCH framework as the basis for developing action plans to create sustainable systems change efforts in five domains: community-led approaches, place-based initiatives, workforce development, data-driven mechanisms and finance systems.
Throughout the project’s implementation, the STRETCH Initiative is assessing how the STRETCH framework has aided the 10 participating SPHA teams in learning from one another and embedding equity principles in their specific strategic priorities, policies and community partnerships.
Quarterly all-state convenings and monthly workshops allow regular touch bases with the state teams providing opportunities for peer learning and process check-ins. Individual technical assistance coaching provides specific support for the project focus areas as well as cross-learning. Evaluation of the STRETCH initiative and framework includes development of evaluation questions aimed at exploring influencing factors for broader systems change and whether the initiative is contributing to more equitable public health systems. Key informant interviews, focus groups, surveys, outcome tracking and other methods will provide evidence to explore these questions in depth.
Abstract
Advancing Equity through Systems Change: Building Capacity Across Oregon’s Public Health System
APHA 2022 Annual Meeting and Expo
Background: With an audacious goal to eliminate health inequities by 2030, Oregon Health Authority is committed to address complex public health problems through a nimble, community-based and equity centered public health system. As a part of their public health modernization commitment, OHA’s Public Health Division (PHD) has catalyzed intentional work across the public health system’s levels – including local public health (LPH), the Public Health Advisory Board (PHAB), and within the Division itself – to build capacity to advance health and racial equity through systems change approaches.
Implementation: With Health Resources in Action (HRiA), a national, non-profit public health institute, PHD engaged its leadership and staff, as well PHAB members, which include local public health leaders in series of health and racial equity capacity building sessions. While sessions were separately held for each audience, they aimed to build a shared vision and language for health and racial equity first across PHD and PHAB members, followed by LPHs; while providing space to explore the distinct perspectives and roles that each level plays to advance health equity in the state. Beyond conceptual understanding, sessions aimed to bridge head knowledge with heart work and foster personal and organizational commitments; examine and transform policies and practices that hold inequities in place; and intentionally challenge and reimagine a public health system and organizational culture that allow all people to flourish.
Lessons Learned: The work in Oregon continues with the next phase of capacity building for LPHs; but so far, capacity building sessions have led to important examinations of workplace culture and tangible systems changes. This session will explore the successes, challenges, and lessons learned with aligning multiple players in OR’s public health system to advance health and racial equity. Specific lessons learned include:
•The importance of the state health authority using its’ voice, resources and policy setting power to lead by example.
•The importance of structuring health equity capacity building with an explicit focus on race and racism.
•The importance of integrating foundational equity concepts into practical applications (such as local health equity assessments and strategic planning) through the implementation of public health practice standards.
•The importance of developing internal systems to integrate staff energy and motivation to push for change as they emerge from capacity building sessions.
•The importance of external partners and volunteers (on advisory boards) amplifying the same messages and approaches through their networks and advocacy channels.
Abstract
Applying community-based system dynamics to support collective action for healthy and fit kids in Milwaukee, Wisconsin
APHA 2022 Annual Meeting and Expo
Background: Increasingly, coalitions are focused on addressing child health equity, emphasizing systemic determinants through cross-sector collaboration, acknowledging past harms through restorative justice practices that elevate community voice, and engaging collectively on timely, relevant social issues to repair and transform communities. Little is known about the process or outcomes of community coalitions pursuing child health equity using system approaches. Community-based System Dynamics (CBSD) is an approach for engaging groups to model complex systems using system dynamics conventions, which emphasizes development of modeling capabilities within that group. This translational study examined one community coalition’s participation in an intervention that used CBSD and highlights the transformative learning that occurred among coalition members.
Methods: The intervention included the following activities: sharing mental models of past, present, and future drivers of healthy weights in children 0-5 years; examining hopes and fears about the intervention; developing Causal Loop Diagrams (CLDs) to illustrate the complexities of variables that influence child weight and brainstorm action; and examining evidence to inform and prioritize collective action. A web-based survey (n=13) to assess transformative learning, and interviews (n=11) to assess perspective shifts around childhood obesity prevention were implemented pre- and post-intervention (timeline 6 months) from a community coalition in Milwaukee, Wisconsin.
Results: Overall, 7 of 13 coalition members shifted their primary focus away from healthy eating and active living as primary drivers of children not achieving a healthy weight pre-intervention, and towards more systematic drivers such as structural racism (n=4), affordable housing (n=3), and generational trauma (n=3) post-intervention. This shift is amplified by the resultant causal loop diagram that included dynamics related to racism and the gap between family needs and family resources.
Conclusion: These study findings contribute to the existing body of scholarship which supports the important role of a community coalition's collective engagement in identifying systemic drivers that need to be addressed to promote child health. The coalition continues to work collaboratively on these drivers. Building upon insights from the intervention, the group successfully secured a CDC 2111 grant to develop a “Social Determinants of Health Accelerator Action Plan in Milwaukee and contributed to renewed foundation funding to sustain and expand interventions nationally.
Abstract
Reimagining the public health ecosystem: Programs, policies and systems for strengthening community health
APHA 2022 Annual Meeting and Expo
Background. Public health leaders have long envisioned a future in which multiple sectors work together to promote shared aims of community health and wellness, ensuring every American has the opportunity to thrive. Yet, misaligned incentives prioritize sickness care at the expense of public health, and politicization has created the conditions for public health systems to fail. Agency leaders face a decades-long backlog of funding, a global pandemic, ongoing chronic disease epidemics, the growing threat of climate change, and pervasive inequities that threaten our health, longevity, and trust in government, not to mention a burnt-out workforce. These challenges are not new – but new approaches are needed if we are to overcome them.
Objectives. This study aimed to identify: 1) public health leader perspectives on the current state of public health systems and the principal levers to drive community health system improvement, 2) obstacles to community health innovation, 3) promising practices and 4) a theory of change for public health system transformation.
Methods. We conducted an environmental scan which included a literature review and 35 semi-structured interviews with public health leaders in government, academia, nonprofits, and philanthropy. Transcripts were coded for themes and analyzed using a grounded theory approach. Findings were synthesized to delineate a theory of change for public health system transformation, and to develop a set of indicators to monitor progress against these aims.
Results. Our findings show that a future in which all Americans can be healthy will require shifting from a clinical paradigm focused on individuals to a health-promoting paradigm focused on communities, where goals extend into a longer time horizon to create a legacy of caring for future generations. Results distinguish six mutually-reinforcing dimensions of public health system transformation, and actionable strategies at the local level to approach these aims: 1) ecosystem partners working toward shared goals, 2) funding and incentives aligned with prevention, health promotion, and wellness, 3) shared data across sectors in real-time, 4) a shared value proposition, 5) a resilient, robust, and multi-disciplinary workforce, and 6) centering health equity.
Conclusions. Lingering deficiencies in our community health ecosystem are due to lack of collective purpose and political will. With workforce enhancements and ample discretionary budgets, local health departments can serve as leaky reservoirs for a culture of health. The future of public health hinges on strengthening local public health capacity to support effective, multi-sector partnerships for better health and greater equity.